burns 37 (2011) 790–793

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journal homepage: www.elsevier.com/locate/burns

Blood loss during extensive escharectomy and

auto-microskin grafting in adult male major burn patients

Gaoxing Luo a,1, Hua Fan a,b,1, Wei Sun a,1, Yizhi Peng a, Lang Chen a, Junsheng Tao a,
Jun Li a, Sisi Yang a, Xianchang Li c, Mark Fitzgerald d, Jun Wu a,*
a
Institute of Burn Research, Southwestern Hospital, State Key Lab of Trauma, Burn and Combined Injury, Third Military Medical University,
Chongqing 400038, China
b
Department of Burn and Plastic Surgery, Second Affiliated Hospital of Beihua University (the General Hospital of Jilin Chemical Group CO),
Jilin 132022, China
c
Harvard Medical School, Transplant Research Center, Beth Israel Deaconess Medical Center, Boston MA 02115, USA
d
Trauma Service Center, Alfred Hospital, 55 Commercial Road, Melbourne,VIC 3004, Australia

article info abstract

Article history: Purpose: To improve the accuracy of blood loss estimation during extensive escharectomy
Accepted 24 January 2011 and auto-microskin grafting on extremities in adult male major burn patients.
Method: All adult male major burn patients admitted to our center who underwent exten-
Keywords: sive escharectomy and auto-microskin graft on extremities for more than 10%TBSA during
Burn the period 1 January 2008 to 31 December 2009 were involved in this study. The blood loss
Blood loss during the operation was estimated by the surgeons or calculated according to the changes
Extensive escharectomy in hemoglobin levels.
Microskin graft Results: The average burn and escharectomy areas for the 64 burn patients included in the
study were 74.16  16.96% and 30.27  15.63%TBSA respectively. The auto-microskin donor
area was 3.81%TBSA. The volumes of intra-operative calculated and estimated blood losses
and transfused blood during the operation were 0.47 ml/cm2, 0.13 ml/cm2 and 0.20 ml/cm2
surgical area 77.29 ml, 20.51 ml and 32.83 ml per 1%TBSA), respectively. Within two weeks
after injury surgical blood loss appeared to be greater the later the operation was carried out.
Within the first week after injury the mean proportional blood loss was increased with area
excised.
Conclusion: In this study the average calculated blood loss for the operation of extensive
escharectomy and microskin graft in adult male major burn patient was 0.47 ml/cm2
(77.29 ml per 1% TBSA). This result will help us to predict expected blood loss more
accurately.
# 2011 Elsevier Ltd and ISBI. All rights reserved.

Precise estimation of blood loss before and during operation is
essential to ensure completing a major surgery. There are a
few papers addressing the blood loss in ordinary burn surgery
[1–6]. It is still a great challenge to repair the extensive wound
and rescue the life of the major burn patient. Auto-microskin
grafting has become a routine for major burn patients in China
[7,8]. Auto-microskin grafting is usually combined with
extensive eschar excision and alloskin or xenoskin covering
[7,8]. This approach is believed to contribute to the high
recovery rate of the severe major burn victims in China.
However, there are no studies delineating the blood loss for
this operation in major burn patients.

* Corresponding author. Tel.: +86 23 68752688; fax: +86 23 68752688.

E-mail address: logxw@yahoo.com (J. Wu).
1
These authors contribute equally to this study.
0305-4179/$36.00 # 2011 Elsevier Ltd and ISBI. All rights reserved.
doi:10.1016/j.burns.2011.01.021
 burns 37 (2011) 790–793
Auto-microskin grafting is usually performed early follow-
ing burn [7,8]. Blood loss is reduced significantly by utilizing
gas-filled tourniquets applied to the involved extremities.
However, although patients were assessed carefully for intra-
operative blood loss, anecdotally we found that the estimated
and prepared blood units were frequently inadequate and that
some patients developed significant acute anemia after
operation. Therefore this study was performed to prospec-
tively survey the blood loss during extensive eschar excision
and auto-microskin graft.
1. Materials and methods
1.1. Patient enrolment
With the approval from the ethic committee of the Southwest
Hospital, the Third Military Medical University, Chongqing,
China, all the burn patients admitted to the Burn Center of the
Hospital, from the beginning of 2008 to the end of 2009 were
enrolled in the study. The inclusion criteria were:
Adult male patients.
1. Age between 18 and 65 years old.
2. Burn area more than 30%TBSA.
3. Extensive eschar excision and micrograft surgery within 2
weeks of burn.
4. Eschar excision area more than 10%TBSA in one operation.
5. Coagulation profile normal before surgery.
Exclusion criteria were co-existing hematological disease,
diabetes, vascular disease and other diseases which were
considered to influence bleeding and coagulation.
2. Methods
Surgical planning occurred once the patient was resuscitated
and the patient’s circulation and other conditions restored
acceptable ranges. The donor site and operative area were
carefully plotted before operation. Under general anesthesia
gas-filled tourniquets were applied to involved extremities. The
donor sites and surgical burn areas were disinfected sequen-
tially. 0.22 mm thickness split skin was harvested from the
donor site and was cut into micro particles smaller than 0.4 mm
in diameter by scissors or by a low-speed mince machine.
Depending on the wound depth the necrotic burn area was
carefully excised to a viable depth with a scalpel or roller knife.
The debrided wound was thoroughly washed and hemostasis
achieved with diathermy or ligation. The auto-microskin was
then seeded onto the completely debrided burn wound and
cadaver skin (alloskin) was used to cover the entire area. If
alloskin was unavailable other biomaterial such as fresh
porcine skin was used to provide a suitable microenvironment
for the survival and growth of the seeded microskin. The ratio of
donor and grafted area was usually around 1:8–10. In our
institute, the major burn patient would be transfused when his/
here Hb level was found lower than 100 g/L, though there are
still some controversies on the criterion for blood transfusion in
China.
791
2.1. Data collection and analysis
The patient’s weight and height before injury were recorded on
admission. Based upon these indices whole blood volume and
absolute total body surface area were calculated. The total body
surface areas were obtained according to the modified
Stevenson’s formula based on body weight (W) and height (H)
for Chinese: total body surface area (TBSA, m2) = 0. 0057  H
(cm) + 0. 0121  W (kg) + 0.0882 [9]. With the TBSA and the
relative surgical area (%TBSA), the absolute surgical areas were
calculated. For statistical analysis, the cases were grouped
dependent on the surgical areas and surgical time after injury.
Blood loss was determined by three methods: (1) blood
transfused-the volume of blood transfused as determined
from the anesthesia records; (2) estimated blood loss-opera-
tive blood loss as determined by consultation between the
principle surgeon and first assistant; and (3) total blood loss-
calculated according to Nadler’s formula: the hemoglobin (Hb)
level (g/L) was assayed just before operation (Hb0) and checked
again at 24 h post operation (Hb1) when the circulating volume
had been restored. The blood volumes were assumed equal
before and after the operation. According to Nadler’s formula
the blood loss was calculated using the following [1,10]:
Total blood loss ðmLÞ ¼ 75  body weight ðkgÞ  ðHb0Hb1Þ
Hb0 þ
transfusion blood ðmLÞ
T test including paired T test and two-sample T test was
used for statistic analysis in this study.
3. Results
3.1. Demographics
Sixty-four male (64) patients met the inclusion and exclusion
criteria and during the study period and were enrolled in this
study. The average age of these patients was 41.24  9.18 years –
the oldest 62 and the youngest 23. The average burn area was
74.16  16.96%TBSA. The full thickness and deep partial thick-
ness burn areas were 39.55  24.36% and 30.26  14.57%TBSA
respectively.
3.2. Surgical interventions
The mean escharectomy area per operation was
30.27  15.63%TBSA. The auto-microskin donor area was
3.81  1.24%TBSA. The ratio of donor site area and eschar-
ectomy area was 1:7.94. The average procedural time was
2.28  0.94 h.
3.3. Intra-operative blood loss
Both the estimated blood loss and the blood transfusion
amounts during the operation were lower than actual blood
loss ( p < 0.01) (Fig. 1). Even though tourniquet application was
routine, average blood loss was 0.47 ml/cm2 (77.29 ml per
1%TBSA) during extensive escharectomy and auto-microskin
transplantation. Based on the patient’s absolute surgical area
the absolute values of calculated blood loss, estimated blood
loss and blood transfused during the operation were 0.47 ml/
cm2, 0.13 ml/cm2 and 0.20 ml/cm2 respectively.
792 burns 37 (2011) 790–793
[()TD$FIG]
Table 2 – Blood loss with different surgical area operated
in the first week after burn.
Escharectomy Number of Blood loss
area (%TBSA) the patients (ml/cm2)
10–20 13 0.41  0.18
20–30 12 0.46  0.21
30–40 10 0.42  0.17
40–50 23 0.51  0.15
More than 50 4 0.56  0.24

planed. However, anecdotally patients frequently developed

Fig. 1 – Blood loss and transfusion during the operation. anemia which indicating that the blood loss during operation
was underestimated and intra-operative blood transfusion
inadequate. Blood availability was determined by predicted
operative blood loss.
Table 1 – Intra-operative blood loss and operative Researchers have attempted to establish a precise, rapid
staging. and practical way to quantify the blood loss during
Operation day Number of Blood loss extensive eschar excision and micrograft surgery [2–4,11–
post injury the patients (ml/cm2) 13]. Various methodologies have been promulgated, includ-
Day 3 11 0.46  0.19 ing measuring weight changes of the swabs and gauzes
Day 4 28 0.44  0.22 utilized [2–4,11–13]. However, edema or body fluid exudates
Day 5 13 0.49  0.12 during escharectomy affect the results significantly. Other
Day 6 5 0.51  0.23 researchers have used red cell colorimetric [2,3] and
Day 7 5 0.55  0.26 radioisotope techniques to determine intra-operative blood
After day 7 2 0.62  0.27
loss [4,11,12]. The radioisotope method was abandoned as
imprecise, in addition to safety and practice concerns. Non-
3.4. Intra-operative blood loss and operative staging radioactive methods to survey the blood loss during the
operation using red cell labeling with biotin have also been
Most of the patients (81.25% of total, 52/64) were operated on undertaken [13].
day 3 to day 5 after burn. Two (2/64) patients were operated day Although there is minimal literature regarding blood loss
9 and day 13 after injury [the first suffered multiple during eschar excision, the reported losses vary [1–6,14]. In
complicated injuries and the second was admitted on day Budny’s study the mean blood loss for 1 percent of burn
10 post injury]. Blood loss was greater if surgery was delayed excised or split skin donor site harvested was 117 ml in the
(Table 1). adult burn patient [5]. The mean excised area was 8.7% in their
study. The authors conceded that the blood loss during the
3.5. Blood loss and excision area operation was significantly underestimated to between 57%
and 87% of the calculated blood loss. They also used the swab
As shown in Table 1, the two patients underwent operation collection method with that technique predicting 51% of the
after day 7 had much more blood losses. Only the other 62 calculated blood loss. Steadman and his team found that the
patients’ blood losses during operations performed within the blood loss in excision and grafting of adult burn patients was
first week postubrun were analyzed with the excision area. as high as 387 ml per 1%TBSA [6], whilst Warden reported an
Predictably, blood loss increased proportionally per cm2 average blood loss during early excision of 1 ml/cm2, or 170 ml
excised (Table 2). per 1%TBSA for a adult burn patient [14].
In our study the mean excised eschar area was 30.27%TBSA
and the average calculated blood loss during the operation was
4. Discussion 0.47 ml/cm2 TBSA (77.29 ml per 1%). Extremity tourniquets
were applied routinely which may explain why the blood loss
During the severe re-attack of a major operation upon critical in our study was lower than previously reported. However, our
trauma, it is very important to maintain enough circulating estimated blood loss was 26.5% of the actually blood loss –
blood in the body to ensure normal functions and structures of which indicates significant underestimation and is very
cells, tissues and organs. Tissue oxygen delivery, end-organ dangerous for the extensive burn patients during or after
function and wound healing are dependent on adequate the operation.
circulating hemoglobin. Though there are still some contro-
versies in the criterion for blood transfusion, we like to keep
the major bun patient’s Hb level over 100 g/L by blood 5. Conclusion
transfusion in our institute. Blood volume is preserved and
intra-operative blood losses are reduced with tourniquet In this study the average calculated blood loss during the
usage. Extensive eschar excision and micrograft surgery takes operation of extensive escharectomy and microskin graft in
as short as approximately 2 h when well organized and adult male major burn patient was 0.47 ml/cm2 (77.29 ml per
 burns 37 (2011) 790–793
1%TBSA). This result will help us to predict expected blood loss
more accurately.
Conflict of interest
All authors listed in the paper of ‘‘Blood loss during extensive
escharectomy and auto-microskin grafting in adult male
major burn patients’’ state that there is no any financial
and personal relationships with other people or organizations
that could inappropriately influence (bias) our work.
Acknowledgements
This work was supported by the National Natural Science
Foundation of China (30672174, 30973116), ‘‘863’’ project in China
(2006AA02A121), the State Key Laboratory of Trauma, Burns and
Combined Injury (SKLZZ200808) & (SKLZZ200820), CQSTC
(2005BB5044), Military medical programe (06H031, 06-Z-054).
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