14．手術療法—熱傷手術の特徴と術後管理の要点

Skin grafts

集中治療医は全身管理の知識に加えて，熱傷患者に対する手術についても精通しておく必要がある。熱傷の手術は，熱傷創の切除とその後の植皮術のことをいう。切除法には外科的に筋膜上切除と連続分層切除があり，さらに今後，酵素で熱傷創を除去する薬剤が導入され，外科的切除と組み合わせた戦略の展開が予想される。植皮術については自家皮膚，同種皮膚，異種皮膚，人工真皮を症例に応じて使い分ける。新しい選択肢として自家培養表皮，同種培養表皮，自家細胞懸濁液があり，それぞれに特徴を有している。そして術後管理では，熱傷創感染と凝固障害の合併による出血の可能性を念頭におくことが重要である。

Intensivists need to be familiar not only with systemic management but also surgical procedures for patients who suffered burn injuries. Burn surgery is performed as follows, first with excision of the burn wound followed by skin grafting. Surgical debridement includes sequential excision and fascial excision. Chemical debridement agents are expected to be introduced in the future, and it is anticipated that a combined strategy with surgical resection will be developed. For skin grafts, autologous skin, allogeneic skin, heterogeneous skin, and artificial dermis are used according to the individual situation, and new options include cultured epidermal autografts, cultured epidermal allografts, and autologous cell suspensions, each of which has its own characteristics. Postoperatively, it is important to keep in mind the possibility of burn wound infection and bleeding due to coagulopathy.