Clinics in plastic surgery
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Early excision of the burn eschar has been one of the most significant advances in modern burn care. Historical advances in understanding of the pathophysiology of burn injury and the systemic inflammatory response fueled by the burn wound, and refinements in the techniques of tangential and fascial excision, have led to earlier excision and grafting of the burn wound with improvements in morbidity and mortality. Efforts to control blood loss, and good operative planning and attention to special areas, can lead to the safe excision and grafting of large burns.
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Although definitive closure of the excised burn wound using split- or full-thickness autografts is the gold standard, permanent closure of larger defects may not be immediately feasible, especially if the presence of large burns limits the availability of donor sites. Newer temporary and permanent membranes can serve as adjuncts in some cases. Someday, burn surgeons may be in a position to close virtually any wound they generate using an immediately available, permanent, synthetic or laboratory-derived autologous composite.
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Smoke inhalation injury, a unique form of acute lung injury, greatly increases the occurrence of postburn morbidity and mortality. In addition to early intubation for upper-airway protection, subsequent critical care of patients who have this injury should be directed at maintaining distal airway patency. High-frequency ventilation, inhaled heparin, and aggressive pulmonary toilet are among the therapies available. Even so, immunosuppression, intubation, and airway damage predispose these patients to pneumonia and other complications.
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Increased capillary permeability and reduced plasma colloid osmotic pressure following burn injury result in hypovolemia and development of edema in the burn and nonburn tissues. Replenishment of the intravascular deficit with crystalloid fluid has been the mainstay of resuscitation for the better part of four decades. A progressive but as yet unexplained trend toward provision of resuscitation volumes well in excess of those predicted by the Parkland formula, associated with numerous edema-related complications, has been repeatedly observed recently. Correction of this phenomenon, called fluid creep, will likely revolve around several strategies, which may include tighter control of titration, re-emergence of colloids and hypertonic salt solutions, and possibly the use of adjunctive markers of resuscitation other than urinary output.
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The number of cases of mortality after burn injury continues to decline, in part because of advances in respiratory, fluid, and sepsis management. However, care needs to be exercised in the application of these new techniques and technologies, many of which have never been assessed or have been incompletely studied in patients who have burn injury. Use of any of these advances in critical care needs to be individualized for any given patient and altered based on the patient's response to therapy. Future advances in the critical care of burns will require multicenter prospective trials at dedicated burn centers to define the optimal therapy for the patient who has burn injury.