A Pilot Study Using a Collagen/Oxidized Regenerative Cellulose Dressing for Split- Thickness Skin Graft Donor Sites to Reduce Pain and Bleeding Complications

Split-thickness skin grafting (STSG) is a common and effective reconstructive option for trauma and burn-related skin loss. Techniques for STSG have been well-established in the literature; however, management of the donor site has not been defined. Though the focus is on healing the recipient site, patients often report more pain associated with the donor site.¹ Multiple systematic reviews have been published on treatment of the donor site.^2-4 These reviews compared moist and dry dressings. Variables examined in these studies have included the following: pain, infection, healing rate, healing quality, and cost without determining a superior dressing for the donor site.⁴

Traditionally, donor site dressings following skin graft harvest include fine-mesh dressings impregnated with emollients (eg, Xeroform; Covidien).⁵ These types of dressings dry and adhere to the wound, which can cause significant pain for the patient when they are removed. Other dressings categorized as “moist” (eg, Aquacel; Convatec Inc) retain a moist wound environment and are nonadherent to the donor site. There is no clear practice guideline dictating the choice of wound care products, and it is routinely left to surgeon discretion. Comparisons of moist and dry donor site dressings have demonstrated greater reported pain with dry dressings.⁵ 

Additionally, donor site wound care can be complicated by bleeding or drainage from the donor site. Among a certain group of patients, particularly those who require anticoagulation, complications from bleeding can make it necessary to change the donor site dressings earlier and more frequently (Figure 1). Most donor sites fully epithelize within 14 days, and frequent disruption of the site can slow down the healing process and subject the patient to multiple, painful procedures. Reports vary on what type of donor site dressing best promotes reepithelization, with some studies claiming that moist dressings are better while others report no difference.⁵

In an attempt to assess the morbidity associated with conventional donor site dressings, the authors trialed a collagen/oxidized regenerated cellulose (C/ORC) matrix (eg, Promogran; 3M) on the donor sites of patients requiring STSG (Figure 2). The C/ORC matrix was chosen as it is known to facilitate healing of complex wounds by donating cytokines, inactivating matrix metalloproteinases, and promoting hemostasis.⁶

The authors hypothesized that the collagen matrix would decrease bleeding-related complications, reduce pain, and foster reepithelization of donor sites. The purpose of this pilot study was to report patient outcomes following C/ORC matrix application to donor sites at 2 large Level 1 Trauma Centers.

C/ORC protocol. All patients on the emergency general surgery service and trauma surgery service who presented with acute wounds were evaluated for surgical debridement and closure. Those patients with large wounds that would require a prolonged time to heal were selected to undergo closure with STSG. Donor site preparation was standardized among involved patients. The planned donor site was clipped of excess hair and then cleansed with a standard antiseptic solution (eg, povidone-iodine or chlorhexidine). The site was wiped clean with normal saline before the skin and the dermatome were lubricated with mineral oil. The dermatome depth was set to 0.011 to 0.015 inches, depending on the location, and consistent light pressure was applied as the dermatome was passed over the donor site to harvest the skin for grafting.

Hemostasis was achieved at the donor site using either topical thrombin spray or agents of the health care professional’s choice, in combination with firm pressure with a moist lap sponge. Following hemostasis, the C/ORC matrix was applied to the donor site with minimal overlap on the healthy surrounding tissue. The donor site was then covered by an absorbent, nonadherent foam (Tielle; 3M+KCI) dressing and secured completely with an adhesive transparent film dressing. The donor site dressing was assessed daily for signs of fluid accumulation. If completely saturated, the absorbent dressing and outer film were carefully changed while avoiding disturbance of the C/ORC matrix. Minimal saturation or leaking was controlled by reinforcement with ABD pads.

Study protocol. To assess the effectiveness of the C/ORC matrix, the authors performed a 2-center pilot study of patients treated with donor site C/ORC from May 2017 to January 2020. The two hospitals involved in this study were both Level 1 trauma centers treating 2000 and 4000 trauma patients per year, respectively. The study protocol was approved by each hospital’s institutional review board, and patients provided informed consent before their participation. Chart review was used to obtain patient demographics, including age and sex, comorbid conditions, and anticoagulation status. Operative reports were used to record donor site measurements and locations. Donor site dressings were removed on postoperative days 4 to 7 in coordination with the first dressing change for the recipient site.

The Numerical Rating Scale (NRS) was administered before, during, and 5 minutes following donor site dressing removal to assess the amount of pain experienced by the patient. The change in pain (∆pain) experienced by the patient was calculated for the periods before to during dressing change, during to after dressing change, and before to after dressing change.

The assessment included percentage of healing as determined by epithelialization, signs of infection, and any wound complications. After removal of the dressing, the donor site, which had absorbed the C/ORC matrix, was cleansed with saline and patted dry before having an oil emulsion and a clean dry dressing (eg, ABD pad) applied. Following the initial dressing removal, patients had daily dressing changes to both the donor and recipient sites.

A total of 39 patients were treated with the C/ORC protocol; of these, 28 were male (71.8%). Median age was 58 years (interquartile range [IQR], 33.5-73.5). Among all patients, the most common comorbidity associated with delayed wound healing was smoking (n = 14; 35.9%), followed by peripheral vascular disease (n = 12; 30.8%), diabetes (n = 4; 10.3%), malnutrition (n = 4; 10.3%), steroid use (n = 1; 2.6%), and immunodeficiency (n = 1; 2.6%). Only 9 patients (23.1%) had no associated comorbid diagnosis (Table 1). Most patients (n = 35; 89.7%) received anticoagulation therapy during the treatment period. Three patients (7.7%), 2 of whom were receiving dual anticoagulation, had some bleeding noted during their first dressing change, but there were no significant bleeding events among any of the study patients. All patients were also assessed for signs of infection at each dressing change, including erythema or purulence; no incidences of infection were observed during the study period.

The width and length of the donor site was documented in 31 patients. The median donor site width was 7 cm (IQR, 4-9 cm), and the median donor site length was 14 cm (IQR, 12-19.5 cm). The average donor site area was 123.8 cm2 (range, 20-528 cm2; Table 1). Healing was documented by the treating provider and was defined by the percentage of epithelialization of the donor site wound bed at each dressing change. One patient had 100% epithelization of the donor site at the time of the first dressing change. Among the remaining patients, healing was 95% in 15, 90% in 10, 85% in 1, 80% in 3, 60% in 1, 50% in 4, 30% in 1, and 10% in 2; in 1 patient, healing was documented as 0%. For the patient with 0% healing, objective rating of the percentage of epithelization was limited by slough on the donor site, leaving the provider unable to adequately assess healing. For the purpose of this analysis, the authors considered healing categories of ≥95% (n = 16), 90% to 94% (n = 10), and <90% (n = 13). The overall prevalence of comorbid conditions appeared to be similar among each of the healing categories (P = .37).

The donor site dressing was removed on postoperative day 4 to 7 with no patients requiring premature dressing changes. Few patients reported increases in pain associated with the donor site dressing. Using the NRS, patients were asked to rate their pain from 0 to 10, with 0 being no pain and 10 being the worst pain. The median pain level reported by patients before, during, and after dressing removal was 0. Twenty-three patients (59%) reported no pain while the dressing was in place, 20 patients (51.3%) reported no pain during the dressing change, and 24 patients (61.5%) reported no pain once the dressing was removed (Table 2). The median ∆pain from before to during dressing change, during to after dressing change, and before to after dressing change was 0 (IQR, 0-0). Twenty-five patients (64.1%) reported no change in pain during their dressing change, and 5 patients (12.8%) reported that pain decreased during the dressing change. Among the 9 patients (23.1%) who reported an increase in pain, the median ∆pain was 3 (IQR, 1-3). Following dressing change, 24 patients (61.5%) reported no change in their pain level while 8 patients (20.5%) reported that pain decreased and 7 (17.9%) reported that pain increased by a median ∆pain of 2 (IQR, 1-6; Table 3).

Donor sites from skin graft harvests are often-underappreciated large wounds that must be taken into account when caring for a patients requiring STSG. The pain associated with these wounds is often overlooked because the focus is on the recipient site, but these donor sites can often be a significant source of discomfort for patients who underwent skin grafting.⁷ In the present study, the authors reported on the perceived pain levels, bleeding complications, and percentage of epithelization experienced by patients undergoing STSG at 2 large Level 1 trauma centers. The application of a C/ORC matrix to STSG donor sites resulted in no bleeding complications and excellent pain control among the included patients. The degree of reepithelization was varied, but, based upon provider report, appeared to be equivalent to other treatment modalities. The expected rate of epithelization was difficult to quantify because prior studies reported anywhere from 4 to 35 days for reepithelization of the donor site.⁸Additionally, no donor or recipient site infections were seen in any patients during dressing change. This observation supports the authors’ conclusion that the dressings are an effective infection control barrier.

Among acutely ill trauma and general surgery population with difficult-to-manage wounds, one of the challenges of patient care is pain control. For these patients who undergo numerous painful procedures, decreasing the pain associated with dressing changes should be a goal. Persistent episodic pain can lead to sensitization of pain receptors and the development of chronic pain, which is prevalent among trauma patients.⁹ Because the C/ORC matrix is absorbed by the body during healing and there is no dressing adherent to the wound bed, dressing changes have the potential to be pain free for the patient.⁶ Enhanced healing associated with C/ORC dressings is also associated with fewer dressing changes, which correlates with improved patient satisfaction.

Regardless of the pain associated with wound care products, there has been extensive debate about what constitutes a “superior” donor site dressing. It is generally agreed that the dressing should promote healing and be impervious to infection.^4,5Collagen-based dressings have been widely studied in chronic wound healing given their effects during the hemostasis, inflammation, and repair stages of wound healing. The matrix absorbs wound exudate and promotes granulation tissue formation, which effectively aids in the healing of hard-to-manage wounds.¹⁰ C/ORC matrixes have also been shown to improve reepithelization when comparted to wounds dressed only in hydrocolloid dressings.¹⁰ Given all of these properties, C/ORC should also be effective in healing acutely created donor site wounds.

After demonstrating success with the C/ORC matrix, the authors initiated a policy change among the providers who perform skin grafts. While instituting this change, they developed the “RAPID” mnemonic to highlight the benefits of this dressing. Application of the C/ORC matrix to donor sites has been associated with reduced bleeding complications, avoided early dressing changes, promoted wound healing, improved patient satisfaction, and decreased pain.

This study has several limitations. First, despite being piloted at more than 1 site, the authors only reported on patients treated at 2 institutions. A larger multicenter study will be required to validate these findings. Second, pain scores are subjective and can be affected by other wounds or injuries and underlying conditions. The authors attempted to control for this by using a standardized pain scale and by assessing pain at discrete times during the dressing change process, as well as by asking patients to focus on the pain at the donor site only. Finally, the outcomes associated with the C/ORC protocol was not compared with the pain associated with other standard dressings, such as petroleum jelly gauzes. However, given the success of pain reduction using the C/ORC technique, it would be inappropriate to prospectively randomize patients to receive treatments known to increase pain.

In conclusion, donor sites from STSG harvests are new acute wounds that can complicate patient care and cause significant distress to the patient. The authors found that the application of a collagen/oxidized regenerated cellulose matrix directly to the donor site wound bed following hemostasis after graft harvest led to no bleeding complications, improved pain control, and appropriate levels of epithelization for patients undergoing STSG at two Level 1 trauma centers.

Emily C. Alberto, MD¹; Richard J. Caplan, PhD²; John R. Getchell, RN, BSN, BS¹; Luis Cardenas, DO, PhD^1,3; and Kathy E. Gallagher, DNP, APRN-FNP, CWS, WCC, FACCWS³

¹Department of Surgery, Christiana Care, Newark, DE

²Institute for Learning, Leadership and Development, iLEAD, Christiana Care, Newark, DE

³Wound Specialist Coordinator, Acute Surgical Wound Service, Department of Surgery, Christiana Care, Newark DE

Address all correspondence to: Kathy E. Gallagher, DNP, APRN-FNP, CWS, WCC, FACCWS, Wound Specialist Coordinator, Acute Surgical Wound Service, Department of Surgery, Christiana Care, Newark, DE 19718; email: kathy.e.gallagher@gmail.com

none disclosed

none