Selective Early Excision Versus a Conservative Surgical Approach. Management of Deep Burn Injury in a Resource-Restricted Setting: A Prospective, Observational Study.

Abstract

Operative intervention for deep burn injury confers a survival advantage compared to healing by secondary intention and dressings alone. Mortality benefits from early surgery may not extend to resource-restricted environments. There are major deficiencies in the delivery of advanced burn care in low-resource settings. This study aimed to compare two different operative approaches in the same setting for deep burn injury. We conducted a prospective, observational study at Grey's Hospital in Pietermaritzburg. The first system applied a triage strategy to ensure priority patients received early excision, while the second system provided no excision and performed skin grafting only once spontaneous eschar separation had occurred. The primary outcome was mortality. The Priority System included 191 admissions with 158 operative admissions. The Conservative System included 199 admissions with 174 operative admissions. The groups were similar in age, total body surface area and sex. Mortality was higher in the Priority versus Conservative System (10.8% vs. 4.6%, p = 0.039), with significantly higher acute kidney injury and ICU admission rates but lower sepsis rates. The time from injury to first surgery, and injury to discharge were significantly longer in the Conservative System. In a single, low-resource institution, spontaneous eschar separation and delayed skin grafting improved mortality outcomes compared to a triage system providing early excision and subsequent grafting for a group of high-risk patients. Conservative surgical approaches should be considered where resource restrictions prevent early excision and simultaneous closure. Early excision without immediate closure does not provide mortality benefit.