Tumescent Infusion for Split Thickness Skin Grafting

Abstract

Current literature indicates a significant decrease in operative blood loss with the usage of a hemostatic agent for auto-graft sites.11, 12 Tumescence, the localized infiltration of subcutaneous solution to prepare auto-graft donor site, builds counter pressure under the dermatome, which is a mechanical device that allows for harvest of a uniform thickness split thickness skin graft. Tumescent infusion can be done manually or by a device. The process of manual injection through a syringe is operator dependent and divides the total volume of the infusate into several aliquots, which limits delivery efficiency. Additionally, when manually injected through a syringe, limitations exists for temperature management and infusate distribution. Recently our group modified a roller pump setup for tumescent infusion upon request by our hospital’s trauma and burns surgeon. A novel aspect of our setup over existing machine-operated tumescent infusion systems was the incorporation of a heat exchanger to warm the infusate. This alternative method of using Roller pump – heat exchanger device delivers a constant rate of infusate without any pauses, and simultaneously warms the infusate to assist with intra-operative thermoregulation. After conducting a retrospective chart review for patients at Banner University Medical Center, for patients who underwent split thickness skin grafting from September 2016 to May 2017 we found that mean post-operative temperatures in the machine aided tumescence (MAT) n = 43 group with surgeon 1 (MD1) was 36.6, which represents a mean -0.18 degree C decrease from pre-operative temperatures. Comparatively, the manual tumescence (MT) group with surgeon 2 (MD2) (n = 19) post-operative temperature was 35.6 degrees and represent a mean -1.36 degrees C change. (p ≤ 0.0001) For calculated blood loss and transfusions, MAT/MD1 (n = 20) was found to have significantly higher blood loss and transfusion requirements than the MT/MD2 (n = 13) group with a mean of 1.1 ± 0.98 mL/cm2 and 276 ± 316 mL pRBC transfusion requirement, whereas the MT/MD2 group demonstrated a mean 0.55 ± 0.54 mL/cm2 CBL and 43.5 ± 94.3 mL pRBC transfusion requirement. (p=0.08) In a prospective in-vitro analysis, it was determined that mean infusion duration for 0.7 L of tumescent solution at an average infusion rate of 150 mL/min, was 1156 seconds with MT. (n=15) Comparatively MAT (n=15) accomplishes the same volume infusion in 280 seconds, which was a 76% decrease in infusion duration. (p ≤ 0.0001) Results indicated that infusion duration was significantly lower for MAT compared to MT. Intraoperative temperature change was significantly less for MAT/MD1 than MT/MD2. Calculated blood loss and transfusion requirements were significantly higher for MAT/MD1 compared to MT MT/MD2. Overall, infusion duration and intraoperative temperature management favored MAT/MD1, while blood loss and transfusion requirements favored MT/MD2. Negative outcomes for increased blood loss and transfusion requirements may suggest that tumescence with MAT/MD1 was not suitable for all patients. However, decreased infusion duration and superior temperature management may outweigh adverse effects in blood loss for patients that are more susceptible to clinical hypothermia.