Strategic Planning of Primary Burn Wound Excision Volume in Severe Burn Trauma

Abstract

Radical excision with immediate autografting represents the standard of care for severe burn trauma, however, its application during the toxemia phase is frequently limited by hemodynamic instability and coagulopathy risks, particularly Disseminated Intravascular Coagulation (DIC). Currently, no objective method exists for determining the optimal extent of single-stage excision, leaving decisions reliant on subjective clinical judgment. This study aimed to optimize preoperative planning of primary tangential excision volume through a risk-stratified algorithm. We conducted a single-center cohort study combining retrospective (n=102) and prospective (n=25) designs. Patients were stratified into low, moderate, and high DIC risk categories using a predictive nomogram incorporating injury characteristics, age, heart rate, and D-dimer levels. The algorithm calculated the optimal excision area based on circulating blood volume and risk-specific blood loss coefficients (99, 132, and 171 mL per 1% TBSA). Predictive accuracy and clinical outcomes were compared between cohorts. The algorithm demonstrated high accuracy for intraoperative blood loss prediction: 91% for low/high-risk subgroups (weighted mean absolute percentage error 9%) and 86% for moderate-risk (14%). In the low-risk prospective subgroup, algorithm-guided planning enabled increased excision volume, reducing surgical interventions required to restore the skin (4 vs. 6, p=0.008) and shortening hospital stays (53 vs. 64 days, p=0.043). In the high-risk subgroup, reduced excision volume significantly lowered mortality during the toxemia phase (27.3% vs. 71.4%, p=0.013). No significant changes were observed in the moderate-risk group. This study has several limitations, including its single-center design and the relatively small size of the prospective validation cohort. The proposed algorithm objectively optimizes preoperative planning by integrating DIC risk stratification, circulating blood volume, and relative blood loss coefficients. It enhances clinical decision-making by enabling aggressive excision in low-risk patients while limiting invasiveness in high-risk patients, ultimately reducing mortality, surgical burden, and hospital length of stay