57.6 The exposure method for dressing a graft

This method is well suited to warm countries, especially if dressings are scarce. There is no pressure on the capillaries under the graft. It is cooler, has a lower metabolic demand, and so is more likely to live. You can also observe a graft and express fluid from underneath it more easily. If possible, apply the graft while a patient is conscious, because success depends absolutely on his cooperation. He is much more likely to cooperate if you use local anaesthesia, and carefully explain everything to him. He is least likely to cooperate as he thrashes about while he is recovering from a general anaesthetic or ketamine. This is an excellent method for the caring surgeon applying a critical graft, but it needs excellent nursing care: (1) To make sure the patient does not absent-mindedly scratch away the graft when he is drowsy or confused, and (2) to swab away the exudate from under the graft 2 hourly.

THE EXPOSURE METHOD FOR SKIN GRAFTS

INDICATIONS (1) A very cooperative patient. (2) Small areas that can be grafted under local anaesthesia. (3) Large flat areas such as those on a patient’s trunk. (4) Areas such as his perineum where applying a pressure dressing is difficult. (5) Chronic wounds such as varicose ulcers and leprosy ulcers where the underlying bed is poor. (6) Delayed primary grafting and secondary grafting.

CONDTRAINDICATIONS (1) An uncooperative patient. (2) Poor nursing.

METHOD Explain to the patient exactly what you are going to do. Take the graft as usual. If he is under general anaesthesia or ketamine, take the graft, store it and apply it in the ward later. If you are using local anaesthesia, apply the graft directly.

Try to control bleeding perfectly.

If bleeding is perfectly controlled, apply the graft immediately. The tissues underneath it will keep it moist. It may not need to be fixed. If it is thick, fix it with strips of adhesive paper.

If bleeding is not perfectly controlled, wait 24 to 48 hours before applying the graft to allow bleeding to stop completely. A nurse may be able to apply the stored graft.

Put a few sutures round its edges. Make sure there are no blood clots under it. You may be able to syringe out the under side of the graft until bleeding has stopped.

Keep the grafted part still and don’t allow the patient to touch it. If flies are a problem, put him under a mosquito net or in a gauze cage.

Look at the graft after 4 hours, and lightly express any blood or serum from under it with a piece of sterile gauze or forceps.

If necessary, repeat the syringing. Repeat this in the evening, and then daily until the graft has taken.

At 48 hours the graft should have stuck to its bed, so you can allow moderate movement. Leave it undisturbed for 7 days. If pus appears, dress it.

CAUTION! (1) Regular gentle swabbing is absolutely essential. (2) Don’t allow the graft to become dependent for at least 10 days.