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Estimation of blood loss during adult burn surgery

B. Farny 1 , M. Fontaine 1, * , J. Latarjet, J.C. Poupelin, D. Voulliaume,

F. Ravat
Burn Intensive Care Unit, Saint Joseph Saint Luc Hospital, 20 quai Claude Bernard, 69007 Lyon, France

article info abstract

Article history: Introduction: Large burns excision and graft can produce major blood loss. The main objective
Accepted 27 April 2018 of this study is to evaluate the blood loss in relation with the excision size in square
Available online xxx centimeters (cm2) in adults.
Patients and methods: We conducted a monocentric, observational, prospective and open
study in a burn intensive care unit. Patients aged-over 18 with burn wounds excision and
Keywords:
autografting covering at least 5% of total body surface area (TBS) were enrolled. Blood loss
Burn surgeryblood
was evaluated with Mercuriali formula.
Blood loss
Results: 139 procedures were evaluated: median graft size was 1637cm2, median blood loss
was 0.8ml/cm2 excised and grafted skin and median total blood loss was 1444ml. 84
procedures (i.e. 60.4%) required transfusion. 66 procedures concerned upper limbs, 75 lower
limbs, 17 head and 72 trunk. 126 procedures used tangential excision, 10 used fascia excision
and 3 used the two techniques. Patients with comorbidities (ASA score 3 or 4) had more
bleeding (p=0.001).
Conclusion: The results that were obtained, i.e. approximately 0.8ml/cm2 of excised and
grafted skin, are similar to those of other published studies, which concerned specific
populations such as pediatrics. Determining blood loss in one centre can help physicians to
calculate the excisable area without any transfusion. However, blood loss can vary widely
between patients and one must consider individual clinical situation to provide safe surgery.
© 2018 Elsevier Ltd and ISBI. All rights reserved.

1. Introduction loss, using to the formula developed by Mercuriali for

orthopedic surgery [6].
Burn surgery is highly hemorrhagic [1]. In order to improve It is very difficult to find accurate and usable data to
blood sparing strategies in burn surgery [2], we evaluated blood evaluate the perioperative blood loss for burned patients. Most
loss in the burn intensive care unit of Saint Joseph Saint Luc available studies are old, related to specific populations, such
hospital (Lyon-France). as the pediatric population [7–9], and are difficult to apply in
Blood loss during skin grafting procedures is difficult to clinical practice. Moreover, surgical techniques, such as
assess and is frequently underestimated by observers [3]. tourniquet, tangential excision, can modify blood loss.
This problem is not unique to burn surgery [4,5]. Most A meta-analysis of 10 studies designed to assess the effect
authors rely on the measurement of hemoglobin and of local vasoconstrictors on blood loss in skin grafting
hematocrit rates pre and post surgery to calculate blood procedures was unable to compare blood loss, due to a lack

* Corresponding author.
E-mail address: mfontaine@ch-stjoseph-stluc-lyon.fr (M. Fontaine).
1
These authors contributed equally to this research.
https://doi.org/10.1016/j.burns.2018.04.019
0305-4179/© 2018 Elsevier Ltd and ISBI. All rights reserved.

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of data. It compared rates of transfusion, which are an indirect PRBC: packed red blood cells.Total blood loss=blood loss
and imprecise estimation of blood loss [10]. +transfused volume
Yet, many authors are interested in the transfusion needs We use 57 as the average amount of hemoglobin per PRBC in
of these patients as it is usually very high [2,11–13]. We find that grams, according to the data provided by the EFS Rhône-Alpes
there is an increasing number of researches done on blood (regional blood bank) for 2014–2016.
saving strategies for burned patients [2,10,12,14–19]. Total blood loss, expressed in millilitres (ml) of whole blood,
The main objective of this study is to evaluate blood loss is compared to the excised and grafted surface area in cm2 to
that results from the excised and grafted surface area in square establish an average loss per cm2. We also take into account
centimetres (cm2) in our burn unit. surgery time and laps of time in days between initial injury and
surgery.
Baseline characteristics of patients, pre and post-operative
2. Material and methods rates of hemoglobin and results of other studies are described
using medians with interquartile ranges (IQR) and security
We conducted a monocentric, observational, prospective and end-points with frequencies and associated percentages.
open study in a burn intensive care unit. This study is done on
patients aged over 18 with burn wounds excision and
autografting covering at least 5% of the TBS (total body surface 3. Results
area). Exclusion criteria are patients aged under 18 and less
than 5% TBS skin excision and autografting. From January 2014 to September 2016, 139 skin grafting
Informed consent was collected from patients once they procedures were included in the study that involved 112 pa-
were interviewed and received a written informative docu- tients, 65 male patients and 47 female patients (some of whom
ment. This study has received a favourable opinion from ethics were enrolled several times for different skin grafting
committee. procedures). The median age was 58 (41–74) (Table 1). The
The initial burned area is estimated using a specialized free average time between burn and surgery was 12days (9–15). The
software [20]. Excised and grafted surface area is assessed by initial median burn area was 15% TBS, and the median excised
surgeons as a percentage of TBS and in cm2, by direct and grafted surface area was 9.5% TBS, corresponding to
measurement of wound size or compare to a paper sheet 1637cm2 of excised and grafted skin.
with known area (A3 paper sheet 1250cm2, A4 paper sheet The median total blood loss was 1444ml, corresponding to
625cm2, A5 paper sheet 313cm2). For less than 313cm2, it was a 0.8ml for 1cm2 of excised and grafted skin (Fig. 1). 84 proce-
direct measurement. dures required red blood cell transfusion (60.4%) and the
Epinephrine-soaked gauzes are used for hemostasis (epi- median number of transfused PRBC transfused was 2 units
nephrine concentration of 100mg/ml). Pressure is applied to all (Table 2). 66 procedures concerned upper limbs, 75 lower
sites for a minimum of 10–15min. Electrocautery is used to limbs, 17 head and 72 trunk. 126 procedures used tangential
coagulate individual punctate hemorrhage and pressure excision, 10 used fascia excision and 3 used the two
reapplied as necessary. Hemostasis is achieved before graft- techniques.
ing. For extensive or deep burns, excision is essentially We found a positive correlation between the length of
performed tangentially by excising the skin down to the procedure (time between anaesthesia induction and recovery)
fascia. No tourniquets are used in the burn unit. and blood loss in ml/cm2, with a cut off at 240min (0.70 versus
Anaesthesia could be general or locoregional. Temperature 1.01ml/cm2 if the procedure was over 240min, p=0.0002,
of the operative room is kept at an average of 24
C, and Table 3). Fig. 2 shows the relation between procedure duration
hypothermia is prevented by forced-air warming (Bair and blood loss in ml/cm2. We found a positive correlation
1
Hugger ). Low molecular weight heparins used for venous between initial area burn and blood loss in ml/cm2 (p=0.0318,
thromboembolism prophylaxis are stopped the day before Fig. 3), and between ASA score and blood loss in ml/cm2
surgery. Transfusion is decided by the anaesthetist during the (p=0.0001, Table 4).
surgery. Hemoglobin threshold use for transfusion in our unit There was no correlation between blood loss and the delay
is approximately 70–80g/l for patient with no comorbidities between burn and surgery in our study (Table 5). There is a
and approximately 90–100g/l in case of vascular disease or correlation between size of the operation and procedure length
hemodynamic instability. To help the anaesthetist to decide
1
transfusion, capillary hemoglobin measurement (HemoCue )
is used, as per-operative estimation of bleeding. Table 1 – Demographics and baseline characteristics of
Blood loss is evaluated with the Mercuriali formula [6], patients.
using pre-operative and post-operative rates of hemoglobin
Number of patients n= 112
and hematocrit (Hte), and transfused blood volume. The Number of procedures n= 139
calculation that resulted from this study is as follows: Male, no. (%) 65 (58%)
Blood loss=[EBV*(pre-op Htepost-op Hte)]/pre-op Hte Age, median years (Q1–Q3) 58 (41–74)
ASA score, median (Q1–Q3) 2 (2–3)
EBV: estimated blood volume, approximately 70ml/kg in Weight (kg), median (Q1–Q3) 70 (57–80)
Height (cm), median (Q1–Q3) 170 (162–175)
men and 65ml/kg in women [21].Transfused volume=(num-
Estimated blood volume (ml), median (Q1–Q3) 4875 (3900–5600)
ber of PRBC*57)/post-op Hb Initial area burn (%), median (Q1–Q3) 15 (10–24)

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Fig. 2 – Total blood loss (ml/cm2, y-axis) and procedure length

Fig. 1 – Total blood loss (ml/cm2, x-axis) for all procedures (min, x-axis). Data from 139 procedures.
(number of procedures, y-axis). Data from 139 procedures.

This study was based on a pediatric population, with larger

and between size of the operation and total blood loss in ml but burn size (over 40% TBS), and time lapse between burn and
there is no correlation between size of the operation and blood surgery was very short (less than 36h). Blood loss has long been
loss in ml/cm2. We did not found correlation between age and known to be smaller in the first two days following the burn [8]
blood loss in ml/cm2 (p=0.8504, Fig. 4). Because of the lack of because the skin has not been infected and surgical hemosta-
data, we are not able to conclude about the operative site sis is more easily achieved on a non-infected skin. A recent
(2 procedures concerned only the head, Table 6), or operative study done on adults [16] resulted in a lower blood loss but the
technique (only 10 procedures excised the skin down to the surgical operation was not as extensive (maximum size of
fascia, Table 7). excised and grafted skin was 450cm2, versus 1637cm2 on
average in our work) and blood loss was estimated with the
weight of soiled swabs, which can underestimate the total
4. Discussion amount of blood loss [3].
It is unfortunately impossible to take into account
As in previous studies, we found that blood loss was dilution following crystalloid infusions but dilution can
significant, even though populations were different. A pediat- be considered insubstantial on the postoperative fifth day.
ric study conducted 25 years ago [8] reported a blood loss of Choosing the postoperative fifth day in this study means
0.8ml/cm2, 2–16days post initial burn, with a burn injury that we did not evaluate exclusively the blood loss during
superior to 30% of TBS. In Hart’s study [9], blood loss was lower. surgery but took into account the bleeding that ensued

Table 2 – Results.
Procedures characteristics n =139
Excised and grafted area, % (Q1–Q3) 9.5 (7–13)
Excised and grafted area, cm2 (Q1–Q3) 1637 (1212–2342)
Total blood loss, ml (Q1–Q3) 1444 (850–2523)
Total blood loss (ml/cm2 excised and grafted), median (Q1–Q3) 0.8 (0.5–1.3)
Procedures with transfusion, no. (%) 84 (60.4%)
Number of packed red blood cells transfused, median (Q1–Q3) 2 (0–3)
Procedure duration, min (Q1–Q3) 220 (170–270)
Time between burn and skin grafting procedure, days (Q1–Q3) 12 (9–15)
Hemoglobin D 1, median (g/dl) (Q1–Q3) 11.0 (10.0–12.0)
Hematocrit D  1, % (Q1–Q3) 33.0 (30.0–37.0)
Hemoglobin D + 5, median (g/dl) (Q1–Q3) 10.0 (9.0–11.0)
Hematocrit D + 5, % (Q1–Q3) 30.0 (27.0–32.0)

D  1: one day before surgery. D + 5: five days after surgery.

Table 3 – Surgery length and total blood loss.

Duration of surgery Under 240min Over 240min p-value

Number of procedures 83 56
Total blood loss, ml/cm2 (Q1–Q3) 0.70 (0.40–1.10) 1.01 (0.70–1.66) 0.0002

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Fig. 3 – Total blood loss (ml/cm2, y-axis) and initial area Fig. 4 – Total blood loss (ml/cm2, y-axis) and age (years,
burned (% of total body surface, x-axis). Data from x-axis). Data from 139 procedures.
139 procedures.

As in Wu’s study [13], a greater initial area burn is a

during the days post-surgery. We consider this most predictive factor of major blood loss and age is not. There is a
interesting for physicians because we measured the total positive correlation between a greater ASA score and total
bleeding volume involved in a burn surgery. In this study, blood loss in ml/cm2 (Table 4), indicates that patients with
more than half of transfusions occurred at D0 (day of the more comorbidities have more important risk of bleeding.
surgery) and D1 (one day after surgery). The correlation between procedure duration and blood loss
Another bias in this research is the measurement precision in ml/cm2 indicates that reducing time of surgery can be an
of hemoglobin, hematocrit rates and red blood cells quantity effective blood saving strategy. Several hypotheses can
(the average value is given by the regional blood bank). This explain this result, such as: hypothermia induced by the
bias can explain that few patients have a negative blood loss length of the procedure, the volume of crystalloids used during
after surgery (Fig. 1), although we enrolled patient who anaesthesia, and the greater area excised and grafted.
underwent autografting covering at least 5% of the TBS. We Hypothermia is involved in hemostasis disorders, and it is
choose 5% as threshold because it is very rare to transfuse for a known that coagulopathy improve blood loss in burn surgery
procedure on a smaller area [22]. [13]. There is no temperature threshold to avoid hemostasis
A few patients in our study underwent excision down to the disorder, but an orthopedic study observed a significant
fascia. Other studies [11,23] have used this protocol– as it can increase in per-operative bleeding with a decrease of 1.6
C
minimize blood loss – but the results we obtained can be in central temperature [24].
explained because we reserved this strategy for the more Dilution by crystalloids may be more important, even if the
serious patients. In this work, it is impossible to conclude measurement of post-operative hematocrit and hemoglobin
about operative site. was realized five days after surgery. The dilution caused by
This study did not show a significant impact of delay crystalloids in per-operative can generate coagulopathy, and
between burn and surgery, contrary to Hart’s study [9] which hypothermia aggravates effect of dilution [25].
shows lower blood loss after 12 days. Furthermore, as no A greater area excised and grafted induces major blood loss,
patient in our study underwent surgery in the first 36h and it may be involved in hemostasis disorders by consump-
following burn, we were not able to conclude on early tion and can generate hypothermia. In fact, hypothermia,
excision. resuscitative hemodilution and acidosis known as the lethal

Table 4 – ASA score and total blood loss.

ASA score 1 2 3 4 p-value
Number of procedures 20 54 47 18
Total blood loss, ml/cm2 (Q1–Q3) 0.63 (0.25–0.90) 0.70 (0.38–1.03) 1.00 (0.60–1.30) 1.35 (0.83–2.13) 0.001

Table 5 – Delay between burn and surgery and total blood loss.

Delay between burn and surgery Under 12 days Over 12 days p-value
Number of procedures 66 73
Total blood loss, ml/cm2 (Q1–Q3) 0.90 (0.60–1.40) 0.80 (0.35–1.25) 0.1540

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Table 6 – Operative site and total blood loss.

Operative site Number of procedures Total blood loss, ml/cm2 (Q1–Q3)
Head 2 4.6 (4.1–5.2)
Trunk 21 1.0 (0.5–1.4)
Upper limbs 9 1.5 (0.4–2.0)
Lower limbs 33 0.5 (0.2–0.9)
Lower limbs + upper limbs 17 0.8 (0.3–1.1)
Trunk +upper limbs 22 0.9 (0.6–1.2)
Trunk +lower limbs 13 0.7 (0.5–1.4)
Trunk +upper limbs +lower limbs 7 0.8 (0.7–1.4)
Head +trunk 4 1.6 (1.1–1.9)
Head +upper limbs 3 1.0 (0.9–1.1)
Head +lower limbs +upper limbs 3 0.8 (0.7–1.0)
Head +trunk +upper limbs 3 1.5 (0.6–1.6)
Head +trunk +upper limbs + lower limbs 2 1.1 (0.7–1.5)

Table 7 – Type of excision and total blood loss.

Type of excision Tangential excision Excision down to the fascia p-value

Number of procedures 126 10
Total blood loss, ml/cm2 (Q1–Q3) 0.80 (0.50–1.30) 1.15 (0.60–2.37) 0.1789

triad, may generate hemostatic disorders and improve per- =0.007184*W^0.425*H^0.725, with W=weight (kg) and
operative and immediately post-operative bleeding [26]. H=height (cm).
There are numerous and various blood saving strategies Therefore, and according to our results, you can use 1444ml
in burn surgery. For instance, skin grafting procedures of total blood loss for 9.5% of excised and grafted skin, i.e.
generate a significant coagulopathy, which is not corrected 152ml for 1%, and the initial formula becomes:
by the transfusion of blood products [27]. Tranexamic acid
postoperative Hb ¼ ð1  ðblood loss=EBVÞÞ  preoperative Hb
could also be used in burn surgery [28]. It has indeed been ¼ ð1  ðð152=EBVÞ  XÞÞ  preoperative Hb
proved effective and almost safe for many indications [29–
31], and a clinical trial is in progress in France to test X=excised and grafted surface (%).
tranexamic acid in burn surgery (clinical trial NCT03113253). For instance, if you planned to excise and graft 10% on a
Other blood saving strategies can be reducing time of surgery man weighing 70kg, which a preoperative hemoglobin of 120g/
within two hours (decreases risk of hypothermia, coagul- l, predicted postoperative Hb=(1(152/(70*70) *10))*120=83g/l.
opathy, and size of the excision), the use of epinephrine- This formula also enables you to estimate excisable surface
soaked gauzes or tourniquets, and the excision to fascia (but without transfusion (threshold 80g/l).Y=(1(80/preoperati-
with poor esthetic results). ve Hb))/(152/EBV).
Knowledge of median blood loss for 1cm2 in excised and If preoperative Hb=130g/l, excisable surface=12.4%.
grafted skin can enabled us to estimate the total blood loss for There are several limitations in this study. Sample size is a
one procedure and therefore predict postoperative hemoglo- major one, we only include 139 procedures because of missing
bin. With knowledge of the patient comorbidities and data and ongoing study. Because of lack of data, we are not able
acceptable hemoglobin level, we could be able to estimate to conclude on the operative site (only 2 surgeries concerned
red blood cell need before surgery, and calculate the excisable only the head) and the operative techniques. Another one is
area without blood transfusion. This work also led us to initiate the generalization of these results. They depend of surgical
to reduce blood transfusion in our unit, toward a restrictive techniques and per-operative resuscitation, and blood loss can
transfusion strategy. vary widely between individuals (interquartile range for blood
We propose the following formula: loss in our study is 0.5–1.3ml/cm2, Table 2). It is important to
remember that careful attention to individual patient param-
postoperative Hb ¼ ð1  ðblood loss=EBVÞÞ  preoperative Hb
¼ ð1  ð0:8  cm2 excised=EBVÞÞ  preoperative Hb eters is essential in providing safe surgery. Our burn unit used
a formula to estimate blood loss with weight, height and size of
burn injury to be excised and grafted. Its aim was to verify there
EBV=65ml/kg for women, 70ml/kg for men. was enough blood products in the local blood bank before the
Blood loss in our unit=0.8ml/cm2 of excised and surgery begins. This work also helped us to see that this
grafted skin. formula overestimates the median need but has a consequent
The surface in cm2 of excised and grafted skin can be easily safety margin which in combination with a liberal transfusion
calculated with the E-burn application [20]. Otherwise, one can strategy could have led us to overtransfused our patients, as
use the DuBois formula [32]. In this formula, TBS (m2) the post-operative hemoglobin levels demonstrate (Table 2).

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