Addressing the Pain: Making the Case for Using a Silicone Dressing in Burn Wound Management

    The primary goal for burn wound management is to excise the devitalized tissue and close the wound as soon as possible. Secondary goals of wound care are to promote healing and to maintain function of the affected body part. These goals are accomplished by excising devitalized tissue, preventing wound infection and graft loss, and maintaining correct positioning and splinting throughout hospitalization.

    In children, scald burns are common and in young children are best managed with conservative treatment for 2 to 3 weeks, which allows the wound either to heal or to present as a third-degree wound in need of surgical intervention. Once surgical intervention is determined to be necessary, special consideration must be made regarding children to prevent graft loss. Most graft loss is from friction or shearing. Preventing graft loss can be challenging in the adult population - it is almost impossible in the pediatric population.

    Historically, graft fixation has been achieved by suturing (which is time-consuming) or stapling (which is painful when removed). Removing staples in children requires large amounts of analgesics and, at times, conscious sedation or general anesthesia. Usually, the patient returns from the operating room in a position that is maintained for 3 or 4 days. Any interaction with the patient during this time of graft immobilization requires creativity and care in order to prevent shearing of the graft. Children, who are usually active, cannot comprehend what is happening or why part of their body is immobilized, and become easily frustrated with the situation. Obtaining their cooperation for graft fixation and to prevent graft loss is next to impossible.

    They frequently react by pulling and tugging on their dressings. The graft also may be displaced during dressing changes for obvious reasons.

    Studies have shown that graft fixation and dressing materials for split-thickness skin grafts must be porous to allow drainage of serosanguinous wound exudates and remain nonadherent to the graft. Ideally, the dressing material also should allow a care provider to view enough of the surgical wound to assess for infection. One particular dressing material (Mepitel, Molnlycke Health Care, Newtown, Pa.), which consists of a polyamide net impregnated with silicone gel, has proven to be an effective wound covering.

Case Report

    Miss L is a 14-month-old African American child who received a 3% scald burn to her right lower extremity on October 25, 2003. She received a split-thickness skin graft to this area on November 24, 2003. The graft was meshed 2:1 and fixated in the OR without staples or sutures. The new silicone polyamide dressing material was placed over the graft and donor site and covered with an antimicrobial dressing (Acticoat, Smith and Nephew, Largo, Fla.). Burn compress dressings then were applied and Robnel catheters (red rubber catheters with small holes placed all along the catheter to allow solution to flow through) were placed medial and lateral to the lower extremity sand on top of the current dressing. The entire leg then was wrapped with Kerlix gauze (Tyco Health Care/Kendall, Mansfield, Mass.) and a posterior splint was made and secured with an ace wrap. The wound then was soaked with approximately 20 mL of 5% sulfamylon solution every 4 to 6 hours utilizing a Toomey syringe. The first dressing change was performed at 48 hours.

    The dressing was removed down to the silicone dressing layer November 26, 2003, and the wound was assessed as healing normally without infection. The wound was redressed using the antimicrobial dressing (per manufacturer recommendations) over the silicone dressing and wrapped again with Kerlix gauze, posterior splint, and ace wrap. The sulfamylon soak was not utilized at this dressing change.

    The next dressing change was performed 48 hours later. The silicone dressing was easily removed and replaced, covered with the antimicrobial dressing per manufacturer recommendations, and covered with a Kerlix dressing and ace wrap. The wound was healing and the patient was allowed to go home without the splint. The mother changed the outer dressing at home daily and inspected the wound for infection as directed. The patient returned to the outpatient burn clinic 2 days after dismissal or 6 days postop and was healed.

Discussion

    The split-thickness skin graft was 100% adherent to the wound 48 hours post-op and continued to heal. No wound infection or graft displacement occurred. Removal of the outer dressing was achieved with little analgesia and no type of anesthetic. Removal of the silicone dressing required no analgesia and the wound was healed completely on post-op day 5.
The silicone dressing was easy to change and dressing change was relatively painless, even after healing occurred, and was accomplished without disturbing the wound bed. Fixation of the graft was effective and easier than other methods; OR time was reduced as well.

    Because the application of a silicone dressing for fixation of split-thickness skin grafts requires a margin of healthy skin around the wound, use is limited to smaller surgical areas. Also, the area grafted in this case report was convex. Further study is needed to evaluate the feasibility of use in concave areas such as the neck, axilla, and groin.

Conclusion

    The silicone dressing proved to be an ideal wound covering in this case, providing the advantage of relatively painless removal, easy effective graft fixation, and reducing operative time because no staples were needed for graft placement. This case report of successful fixation of split-thickness skin graft using silicone dressing underscores the need for further study of this product in the burn care arena. 

Addressing the Pain is made possible through the support of Mölnlycke Health Care, Newtown, Pa.