Dr. Philip Fidler Shares Best Practices for Early Excisional Debridement

Get ready for another episode of Deep Cuts with special guest, Dr. Philip Fidler, Director of Education for Burn and Reconstructive Centers of America. Listen as Dr. Roselle Crombie, general and burn surgeon from CT Burn Center, Yale New Haven Health System, speaks with Dr. Fidler on the blade movement he credits with being able to avoid any uneven staggers in the tissue, and how his excision approach is tailored in anticipation of central line access.

The opinions expressed, and techniques described, herein are general in nature and based on the clinical experience of the presenting physician. Physicians should use their own professional judgment and consider patient-specific factors in treating their own patients.

Dr. Crombie has a consulting relationship with Integra LifeSciences. Neither Dr. Crombie nor Dr. Fidler was compensated for their participation on this podcast.

Visit the Tissue Technologies blog to learn more.

Transcript

Dr. Crombie:

Today we have the privilege of somebody that's near and dear to my heart as the mentor that inspired me to come into burn surgery, Dr. Phil Fidler. Tell us a little bit about yourself. 

Dr. Fidler:

I trained in general surgery in Brooklyn. And I did some fellowship work in trauma and critical care as well as burn surgery. I've been at burn care for, I guess, about 23 years now as an attending. And I've enjoyed a wide variety of trauma, critical care and chronic wound care related practice.

Dr. Crombie:

Think back to when you were a new burn surgeon. What surprised you the most about debridement in terms of what you learned back then and how you think about it now? And how that evolved throughout your career?

Dr. Fidler:

I like to start with the idea of, we take care of people and not wounds. So it's important to compare the clinical circumstance to, I don't love this term, but the aggressiveness of the excision. It's very important to make it a goal, to make good study of what tissue has to be removed urgently. What tissue is worth allowing some to time to determine, because a wound is not a static thing. 

Over the years, you become better and better and better because you have more and more opportunities to file these nuanced ideas. “This needs to go for sure. This is worth salvaging or isn't worth the bother because in the end, it's not going to change the patient's outcome.” I think discerning how much, when, is still a big part of becoming more and more expert at debridement.

Dr. Crombie:

What do you specifically look at in the wound bed? To know that needs to go or doesn’t need to go? What are you seeing there? 

Dr. Fidler:

If I am looking at a large burn wound volume, then I know its very presence has a physiological detriment on the patient. And so now, it's a matter of gauging how much has to come off in order to mitigate shock. We're talking about a large burn.

I'm talking about a smaller burn wound where the physiological risk to the patient is not too significant, say an awful grease burn on the forearm. Clearly, tissue needs to be excised, but my interest or my push to get questionable tissue off is less. I'm more willing in that circumstance to see how they recover. And to the earlier point, we take care of people, not wounds. Is this a physiologically sound, otherwise healthy person? Because obvious to you and I, you can wait to see if the patient will recover that.

If the person is physiologically disadvantaged—elderly, poor circulation, poor nutrition—then we know that it's important to remove that tissue before it becomes a bigger problem like a wound infection. 

Specifically reading the tissue, I suppose a couple of things come to mind. One is healthy fat. If I'm just going to really drill down right to a healthy fat, you learn over time is a very pale color. It's pale yellow and yellowish. If it looks great, like golden fat, it's probably compromised. So it's not great.

When I look to the level of the dermis, now we're becoming more superficial, find it helpful to pay attention to the character of the dermis, not only in terms of the color, should be sort of pearly white, but also whether or not it has, what I always presume was a bit of lymphatic obstruction. Does it have the milky consistency when you excise it? And if it does, it's also a bit questionable. So you don't want to see any sort of milky transudates or exudates in that dermis to trust it for your subsequent coverage plan. And it's very hard to hear it or read it and acquire these nuances. You really have to see as many as you can. And see them and follow up.

Dr. Crombie:

What are the things that you've learned over the years that has changed the way that you practice based on how you're attacking or preserving that wound bed?

Dr. Fidler:

I've become a little more patient with my subsequent closure. The commonest thing done in burn surgery is eventually some form of typically a split thickness skin graft. I've become much more willing and much more compelled to wait a little longer, to make sure as best possible that that skin graft is going to take, and take as well as I and the patient hope. I think earlier in my career, I was much more satisfied with even a 90% take or something. And then you start to realize those subsequent operations are impact or morbid to a certain extent. So while it can be unavoidable. Based on so many circumstances, again, especially in the larger injured patient. Sometimes maybe apply that skin substitute again, just not quite ready yet.

And this is something I learned very early because we had very good teachers. That patient's nutrition is important to look after. That patient's circulation is important. We tend to over focus on manipulating the wound.

And I liken it to, and obviously respecting patients are not plants. But that concept where if you have a plant that's not doing that well, you are more focused on the soil for success, not the leaves.

Think of that a lot on the surface of the skin, especially the chronic wounds.

A little different. But you really want to make sure that you're improving the host, because skin is built to heal. It ought to heal it. That's what it does. So we have a lot of leeway with that, but I wouldn't forego doing our best to set that patient up for success by fixing their physiology. Diabetes under control, their circulation, their dialysis needs to be on time. These kinds of things are really important.

Dr. Crombie:

What lessons about excision did you learn and then transition to teaching that's have stuck with you over the years? 

Dr. Fidler:

So that pale yellow fat comes to mind, that non-milky dermis comes to mind. In terms of actual techniques, stabilizing the tissue, you certainly learn with practice.

We still use often a sharp blade by hand. Just a technical thing that I commonly feel like I correct or certainly my habit, is to actually oscillate, move the guard faster than you advance. I see a lot of newer surgeons, newer excisors feel they need to push the blade—almost in the way you use a cheese slicer.

But if you think of the dermatome, the pneumatic, how fast it goes and how effective it is by cutting. I think a longer, steadier, and slightly faster oscillation. While you advance slowly, keep that forward pressure on that blade so that you don't get those little staggers.

Or next level techniques that you can't always just notice, but you've seen, "Oh, your excision looks so clean." And then there's might be have those little staggered steps.

Dr. Crombie:

So when you're talking about the excision of the blade, you're specifically talking about the Goulian blade? And the Weck blade?

Dr. Fidler:

Sure. Goulian blade or any of the longer blades, they go by a number of different names, Humby. Yeah, just move faster forward and back and less fast as you advance. And I think your excision will be cleaner. 

Dr. Crombie:

A large injured burn patient. How do you make a decision about timing of when to take that person to the operating room?

Dr. Fidler:

That's a discussion about an adequate resuscitation. And so some amount of judgment needs to be put into evaluating a patient's readiness for general anesthesia, which we know infamously challenges a patient's cardiovascular system.

The most pressing and the commonest one that we know is adequate fluid. You don't want to take a badly dehydrated patient to the operating room.

If the patient is adequately resuscitated from a volume standpoint, there are no acute issues related to their pulmonary condition, certainly would want to make sure airway is functioning well, there's no plugs in the airway, which happen rarely, but not never early. That a person is got all their bells and whistles. I'm sure there's a foley catheter to evaluate urine output. Make sure that's adequate. Check their electrolytes. Make sure that they're all correct. This shouldn't take more than a couple of hours at most.

Dr. Crombie:

Why is that? Tell me a little about that.

Dr. Fidler:

Well, because again, excising the skin in and of itself is not physiologically that dangerous to the patient, but you have to be thinking again, this is a person.

And their heart, their lungs, their kidneys need to do well for them to do well. That's important, that you are making the patient as resistant to the detriments of anesthesia as possible. And then with that comes the risks of some blood loss. So you need to know the patient's hemoglobin ahead of time. If they need blood available in the operating room, it should be made available. I'm a strong advocate for excising with a tourniquet.

The reason I mention those other colors is because they are present with or without blood flow. For those folks that have not practiced excising a burn using a tourniquet, they're very dependent on seeing punctate bleeding. I'd rather not see bleeding.

Keep the blood in the patient, if you can. But you need to be confident that you have excised enough that were the tourniquet to be removed, it would bleed. So these are the things that experience brings you. In terms of timing, as soon as you reach that circumstance where you feel there's nothing else to add to the patient.

In terms of these other preparatory maneuvers, you can go, it could be the same day of the injury. Quite frankly, I think it's okay. There is a school of thought and some folks feel better waiting some period of time, to some people it's the next day, to some people it's even a few days. They want to see the swelling maximize and then recover. My experience, excising the burn tends to mitigate the shock a good bit. So as I said, as soon as those parameters are met, I don't see a strong reason to delay. I would recommend going in.

Dr. Crombie:

Yeah, I remember when even you taught me that back then, we didn't necessarily have that evidence well-documented about early decision and grafting. I do distinctly remember having a patient with you where we got everything up. For whatever reason, the timing worked out, the physiology was good. They were safe in the OR and we got all the burn off and it was almost as if they didn't have that burn shock [inaudible] because they flew through their resuscitation because we were able, to your point, to get all that devitalized tissue off.

You talked a lot sort of the coordination of the timing – you want to keep someone under for about two hours.  

What are the techniques that you use to minimize blood loss? So you mentioned tourniquet, but I also remember other things that you taught me about to minimize, because you want to minimize that excise as much as you can, but minimize the blood loss in a short period of time so that we can get the patient off the table.

Dr. Fidler:

Well, in that early phase of a badly burned patient, the best way to improve their outcome is to remove as much as you safely can, right? And because just this sheer volume of burn tissue on the patient is going to favor their inflammatory response, which is a whole basis of burn shock, right?

With that thought in mind, some compromises are made. For example, in my own practice, I often will not excise under the area where the tourniquets are, knowing that from a pure reconstructive standpoint, that creates a little bit of a headache because you've left a portion in that region. But for the benefit of not having to transfuse a patient early on in their burn shock in my practice, and reasonable folks can see it differently.

That's what I would do. So you would find under areas of tourniquet, maybe the upper thigh and the upper arms.

Dr. Crombie:

Eschar.

Dr. Fidler:

Eschar, potentially. At least after the first case. I like to do as much as I can with the patient while they're supine. Again, in that first operation, it's the safest position to operate on people. We have access to all the lines.

 Early on, I like to spend some autograft some donor site, right? Assuming it's not a 99% burn, but let's say 60% burn, large injury, where you have some donor. My personal practice is to early try to prepare for central line access. And even a tracheostomy can be likely. So I often will excise and autograft in the areas of anticipated central line. It's like the subclavian and internal jugular regions. And even in anticipation of a tracheostomy. And while again, central lines and tracheostomies are allowed to be put through eschar. My personal practice is to try to mitigate that complication, that set up for either line sepsis or erosion. That's a technique that I would have those listening strongly consider.

I've had some good luck with that and I would recommend it. The second trip to the operating room on a large burn patient is where I feel they've had now a couple days to settle in. We've taken a good volume off the anterior surface. By now, some of that lung trouble that we get from inhalation injury has been brewing.

And in spite of best pulmonary toilet practices. There are still challenges with being supine and swollen. I would likely try to take the patient prone for the next case. So they spend a little bit of time face down. We'll get after the back, which is functionally a less vital part of the body, but a large surface area.

Dr. Fidler:

It's technically fairly straightforward. Less challenging certainly than a hand to excise. It's a big space, but it's fairly flat, right?

So removing that unhealthy real estate is something that I feel is helpful. Getting whatever your skin substitute is going to be on there at that time is worth considering. And then having had the patient prone for a while, I feel like you interrupt a little bit of that chance for the real bad posterior or atelectasis that is famously occurs.

And then the patient can be back, supine, to do any more procedure or to go back to the intensive care unit. And now you've got a couple of days where you don't have to worry so much about what's going on posteriorly and often find that a good suctioning of the airway after that, or even bronchoscopy may be a very rewarding having had them prone for a while in the operating room was a way to take advantage of two circumstances.

Dr. Crombie:

What are the things as you’re in the operating room are you thinking about that would make you say, “Well, we need to stop.”

Dr. Fidler:

I think you need to set the environment up for success. So environmentally, the thing you probably have most control over is hypothermia, right? Hypothermic patient causes cardiovascular collapse, it promotes bleeding, as we know, these are two things you don't want to be battling in the operating room. So I would start with everything your individual facility can do to mitigate hypothermia. Heating the room is an unpleasant thing for everybody working in the operating room, but it is the simplest.

If there's more sophisticated warming blankets, certainly resuscitated fluids. And in conjunction with your anesthesia colleagues, warming those fluids, I highly recommend. You can avoid hypothermia, I think you could probably spend more time. A lot of the time restriction is recommended for burn surgery or any surgery for that matter or in some ways are surrogates for hypothermia.

Because it's not so much how much time you've been in the operating room as much it is if you haven't kept that environment warm, patient's starting to get really cold at that point. So if you're avoiding hypothermia, I think you could certainly be one reason to persist. If you cannot be one reason to start to get out of there, it's probably easier to warm up the patient's room and their local environment than it is in operating room.

That would certainly be. I've been in the circumstance where the warming device actually malfunctioned and cooled the patient. Now that was a very unpleasant thing to come across.

In terms of blood loss, if you are excising, carefully and moving along and in particular about mitigating blood loss, if you're using pro coagulants, things in the fibrin family, things in the thrombin family.

Those, I think have helped us accomplish more in the days without those readily available interventions. The patient's cold with too much blood loss? It's time to get out of the operating room. Don't think by definition, the operating room should be thought of as a dangerous place. Because you should be able to accomplish everything you can in the regular ICU. But for generally not operating in the ICU, although we've all felt compelling reasons to do that. Those are exceptions. Move with a sense of urgency, a patient's under general anesthesia. They're not asleep. Sleep is a therapeutic condition that's good for people. It's restorative. General anesthesia is measured poison that we accept. So move along. Get your stuff ready. 

Start sharing with your circulator and your nurse about dressings in advance, all that time. Keep the patient dry. 

Dr. Fidler:

If you’re irrigating with a lot of things, have your circulator and your scrub aware and empower them to say, "Hey, if you see any fluid collecting over here while working, I want you to want you to dry it up." It's incredibly helpful. To have those extra set of eyes and hands.

And if you're missing any blood loss, usually the anesthesiologist will...Will trigger them to speak up. But you want to encourage that because you can get very focused sometimes on something technically small. And miss the forest for the trees.

Dr. Crombie:

How do you make a decision about when to skin graft versus using a dermal substitute? And then when do you make a decision to use one or the other? Because they're very different.

Dr. Fidler:

If you feel that there's going to be a challenge in obtaining adequate donor skin, the patient's overall condition would be definitely one of them, the elderly patient, what have you. Those are times where I feel a skin substitute is going to be likely necessary because it's a safer test to use a skin substitute.

And see what kind of adherence you get, what kind of perfusion, what kind of wound recovery, rather than go straight to split thickness skin graft, say, and hazard the chance that it doesn't work out as well. Now you've got two wounds, right?

You've got the donor to pay the price for, you've got the recipient side. So there's some measure about that. I can't tell you a formula with numbers, but if you showed me the patient, I could say in that case. Areas of high function, particularly hands, I think, which are costly in terms of donor.

I think we forget sometimes that the hand is three dimensional. So when you are covering the dorsum, the radio, and the ulnar sides, a hand is actually three hands in size. We try not to widely mesh skin grafts as my practice to try to use it as a sheet, as much as possible, maybe pie crust. If we're really stuck on a large burn, one to one match is as much as I dare to go. Obviously very badly burn patient, any closure is worth it. But in those ideas, try to get those done earlier for a few reasons. From a functional standpoint, getting those hands and positions of safety, MCP is down, properly splinted, and allow some of that donor to potentially recover is valuable. So I'm a believer in trying to get those hands covered safely early, then you just got to cover the land mass. Of course, face is a huge priority too. From a day to day recovery standpoint, I think the hands are even more important get heal the patient, thinking down the road, getting the patient independent, helping themselves, right? Those hands are important, to get closed as soon as safe

Dr. Crombie:

Say you know you're ready to either autograft or put some dermal substitute. What are you specifically looking at in the wound bed to know that timing? 

Dr. Fidler:

I think it's a good idea, in theory, to have essentially the same concept behind excision, whether it's a skin substitute or a split thickness skin graft. There's no good reason to leave, obviously devitalized tissue. So very careful about removing all devitalized tissue. That questionable tissue, right? Where you think it might be in the balance where the benefit of having some level of dermis recover on that patient versus right down to fat. That's a big difference in terms of functionality and overall appearance. The test is better done with a skin substitute.

And if those deeper tissues do in fact recover by virtue of a healthy skin substitute and there it's ready for grafting. Great. And if not, then be prepared to excise that skin substitute till you get healthy, viable looking tissue. Pearly white dermis, pale yellow fat. And/or punctate bleeding if that's how you need to see that. And only until then put the skin graft on it.