51 Relationship of Early Dressing Change, Ambulation, and Early Discharge in Lower Extremity Grafted Burn Wounds
Authors: Toledo Sandor , Blome-Eberwein Sigrid , Barros De Souza Cesar , Shi Harry , Watanabe Miname , Anderson Morgan 
Published: May 2023

Abstract

Introduction
Split-thickness skin graft (STSG) healing follows the imbibition, inoculation, and revascularization healing model. The stage of imbibition takes approximately 48-72 hours and requires direct contact with the wound for success. Prior to revascularization the graft is at increased risk for damage from shear stress. Many of the protocols in place are based on pathophysiology of wound healing and few published data exist on the timing and logistics of mobilization after lower extremity STSG for burns. There is discordance in the Burn community as to when it is safe to start ambulation with patients after lower extremity skin grafting. The timing of the first dressing change may accelerate or delay ambulation and increase time to hospital discharge.

Methods
Retrospective chart review of burn patients regardless of age, admitted to burn service with grafted burns to lower extremities, whether they had other concomitant burns with/without grafting to determine if earlier first postoperative dressing changes (≤ 3 days) to grafted lower extremity burns lead to earlier ambulation and shorter hospital stays. Secondary endpoints will be evaluation of the ideal time to change the dressing after initial STSG grafting of the lower extremity without increasing graft failure rates.

Results
The groups were even in time from surgery to 1st dressing change (1st DC) (167 had a 1st DC in ≤3 days post-op, and 163 had a 1st DC &gt;3 days post-op). Demographics and medical history were nearly identical between the two groups, indicating there may be no association between the demographics or medical history collected and earlier dressing change. Median time from surgery to the 1st DC was 3 days (IQR: 3-5) in the entire sample, and from surgery to staple removal was 5 days (IQR: 4-6). The median length of hospital stay in the entire sample was 10 days, and this slightly differed between groups: those with a 1st DC of ≤3 days had a shorter hospital stay (9 days [IQR: 6-13]) than those with a 1st DC of &gt;3 days (11 days [IQR: 7-16]), this is exemplified in Figure 2. 80.3% of patients were discharged home in the sample, with a greater proportion of patients discharged to a facility when they had a 1st DC &gt;3 days post-op (24.5%) than if they had a 1st DC ≤3 days post-op (15%). A greater proportion of patients were discharged walking (47.6% vs 32.7%) when they had an earlier 1st DC than those who did not. Graft failure was seen in 6 patients with 5 of them needing re-STSG. Four due to graft loss and two due to cellulitis.

Conclusions
Patients who had 1st DC ≤ 3 days after surgery saw an earlier hospital discharge by 2 days without risk of graft loss due to hematoma or seroma regardless of comorbidities.

Applicability of Research to Practice
The data gathered will be used to establish a clinical based approach to lower extremity dressing changes. We hope to delineate a timeline based on tailored patient factors that can be used as guideline to safely expedite ambulation and minimize hospital stays without increasing graft failure rates.