ment of surgery. Incorporating this into the WHO patient safety checklist should minimize complications of blood loss [36].

Blood loss during surgery can also be minimized by the use of sterile limb tourniquets, infiltration of the eschar and donor sites with 1/106 solution of adrenaline (1 mg in 1,000 ml N saline) and warm topical phenylephrine (2% solution) soaked dressings. It is possible to debride and excise significant wounds (>30%) without the need for blood transfusion.

Antibiotics

The reported incidence of nosocomial infections varies at 63–240 per 100 patients and 53–93 per 1000 patient days. Infections precede multiple organ failure and are independently associated with adverse outcomes and increased mortality.

The wound plays a major role as the site of infection with rapid contamination and colonization with Gram positive bacteria, mainly staphylococci. The moist burn wound is a perfect site for proliferation of bacteria. Gram negative bacterial infections are thought to result from bacterial translocation from the gut. Burn patients are known to be immunecompromised and often require intensive care support making them prone to ventilator associated pneumonia and catheter related infections.. In general the consensus view in the current literature that prophylaxis with systemic antibiotics should not be given to patients with severe burns based on the lack of evidence, no obvious benefit and risk of adverse effects. However a recent meta-analysis of antibiotic prophylaxis indicated a reduction in the mortality risk in burn patients although the methodological quality of the data analysed was weak [37].

It is our practice to give antibiotic prophylaxis to patients undergoing surgical procedures. The antibiotic given and duration of therapy depend on the time since the injury, the surgical procedure being undertaken and microbiological surveillance and advice.

Anatomical considerations

The sequence of areas to be autografted is variable depending on the surgeon’s individual preference.

In general the authors try to cover the posterior trunk, anterior trunk, lower limbs, upper limbs, and head and neck in order. This sequence maximizes the area covered with autograft early in the course and allows for earlier ambulation. Areas not covered with autograft have allograft placed, which is removed when autograft is available at subsequent operations.

In general sheet grafts should be used whenever possible, however this not possible in burns over 30% TBSA. Care must be taken when mesh grafts are used as contracture can occur in the line of the interstices.

Mesh graft interstices on the trunk and breast should be placed horizontally. Care should be taken to preserve the breast or breast bud, especially in females, and to place enough skin with minimal mesh expansion into the infra mammary folds and the sternal area to try and reduce subsequent breast deformity. The umbilicus should be preserved if possible.

The buttocks are difficult to manage and skin graft take is poor. They are prone to faecal soiling and shearing and can be the site of repeated bouts of invasive wound sepsis. It is often worth autografting them in the first operation, but graft take can be disappointing. If the grafts fail it is then best to leave the area for a time when the patient can be nursed prone while the grafts take. This is usually done after all other areas are healed. It is not usually necessary to perform a colostomy to prevent fecal soiling as the faecal stream can be diverted with a rectal tube. The perineum and genitalia are usually managed conservatively with grafting of any unhealed areas later on in the course of surgical treatment.

Mesh graft interstices on the limbs should run longitudinally along the line of the limb except at the joints. At the knee, ankle, axilla, elbow and wrist joints graft expansion should be minimized if possible and the direction of the interstices should be the same as the axis of rotation of the joint i. e. perpendicular to the longitudinal axis of the limb.

The skin on the sole of the foot is glabrous skin and is very thick and specialized. It will commonly re-epithelialize despite what initially seems a full thickness injury. The sole of the foot is best treated conservatively until it is apparent that spontaneous re-epithelialization will not occur. In contrast the skin on the dorsal aspect of the foot is very thin and