Optimal Timing and Approaches for First Tangential Excision in Patients With ≥70% Total Body Surface Area Burns: Insights From a Retrospective Cohort of a Mass Casualty Incident.

OBJECTIVE

We aim to determine the optimal timing and approaches for the first tangential excision (TE) of severely burned patients with ≥70% total body surface area (TBSA).

BACKGROUND

Early TE is the gold-standard surgical therapy for full-thickness burns. However, there are debates about its optimal timing and approaches for severely burned patients with ≥70% TBSA.

METHODS

This study included 185 patients in the Kunshan factory explosion. We focused on surgical timing, surgical area, and main wound covering method for the first TE. We determined the optimal cutoff values for surgical timing and area using R language "surv_cutpoint" and "surv_categorize" functions and utilized the Kaplan-Meier survival analysis to investigate their influences on patients' overall survival (OS). Then, we utilized multivariate Cox regression analysis to identify independent factors and performed subgroup analyses to find confounding factors. Finally, we employed a 10-year single-center cohort of 144 patients with burn injury ≥70% TBSA for external validation.

RESULTS

Performing first TE in >3 days (hazard ratio = 2.37, 95% CI = 1.05-5.40, P = 0.039) and surgical area >48% TBSA (hazard ratio = 2.41, 95% CI = 1.46-4.00, P < 0.001) were independent risk factors in the Kunshan cohort for OS of patients with ≥70% TBSA, and were associated with a higher rate of complications. Subgroup analysis revealed that the timing and TBSA of the first TE were influenced by several treatment and complication factors (hemodynamic status and types of hospitals). Main wound-covering methods were a significant confounding factor. Patients with more autograft showed better OS than those with more extensive use of temporary skin substitutes in the Kaplan-Meier survival analysis ( P < 0.001). However, main wound-covering methods are influenced by the severity of injury, availability of autologous skin source, as well as medical resources. In addition, external validation demonstrated consistent results and acceptable calibration.

CONCLUSIONS

This study identified the optimal timing and approaches for first TE, validating them as independent prognostic factors for patients with ≥70% TBSA. However, considering the various confounding factors, treatment for each patient should be tailored.