Correlation of Hypernatremia to Success Rate of Skin Graft in Burn Patients Dr. Soetomo Hospital Burn Centre from 2014- 2018

Background : From collective data from 2014 – 2018 from Burn Centre in Dr. Soetomo Hospital, the rate of failed skin graft was 26%. This high number became a concerned because skin graft was the main procedure to close large burn wound. This event is affected by many problems, one of them is electrolyte imbalance. Hypernatremia was seen in major burn patients that causes the disruption of wound healing process of skin graft. Methods: A cross sectional study of patients with burns admitted to the Burn Centre of Dr. Soetomo Hospital between January 2014 and December 2018 were evaluated. Results : 143 subjects were involved in this study. 44 subjects are female (31%) and 99 subjects are male (69%). 66% of the burn injuries are caused by fire (93 subjects), 14% caused by electricity (20 subjects), 8% caused by scald (12 subjects), 6% caused by boiled oil (8 subjects), 4% caused by chemical agent (6 subjects) and 2% caused by blast injury (1 subject). 77% of all subjects (110 subjects) underwent split thickness skin graft less than 10% while 23% (33 subjects) underwent the procedure 10% or more than it. Hypernatremia is found in 16% of all subjects (23 subjects), 19% with hyponatremia (28 subjects) and majority of it, 65%, with normonatremia (92 subjects). From the study, it was found that the risk of failed skin graft was higher on hypernatremia subjects than normonatremia subjects, the relative risk was 6,06 to fail. This number was higher if the skin graft procedure took more than 10%. But, it was found the risk was higher on hyponatremia subjects than the rest of subjects, with the relative risk was 7,75 to fail. Conclusions: Hypernatremia caused high risk of failed skin graft on major burn patients

kin graft remains as main choice to close burn wound especially large burn wound on severe burn patients. This is a routine procedure but there are various risks than can cause the failure. From data from 2014-2018, failure rate of skin graft in RS dr. Soetomo Surabaya reached 26%. This is such a high number that shows the dynamic of clinical conditions of burn makes it hard to assure the successful of skin graft.
Electrolyte imbalance is one of risk that affects the success rate of skin graft. Hypernatremia is increasing the risk of apoptosis thus can deepen the burn. With that, it is believed that hypernatremia can also influence skin graft healing process.

Hypothesis
Hypernatremia is one of risk factor that can decrease success rate of skin graft to less than 90% on burn patients.

Study Design
This study used cross-sectional analytic descriptive design with retrospective secondary data.

Variables
Independent variable of this research sodium serum in blood of burn patients. Independent variables are take skin graft (take <90%, dan take >=90%).

Research samples
Samples of this research are all of burn patients that underwent skin graft procedure in RS dr. Soetomo Surabaya on period of time January 2014 to December 2018, which were 143 patients. The inclusion criterias of the sample are : • Burn patient that underwent skin graft with hypernatremia • Skin graft procedure was done by third year of recidency or above The skin graft procedure mainly did for less than 10%, which were 110 cases. The rest were more than 10% or 33 cases.

Chart 3. Skin Graft Procedure
Total patients with hypernatremia were 23 patients, mostly were normonatremia, which were 92 patients Chart 4. Natrium Rate From research, there were 23 burn patients with hypernatremia; those 4 patients underwent skin graft procedure for more than 10%, the rest, 19 patients, underwent the procedure for less than 10%.
From analytic, hypernatremia patients have bigger chance to failed skin graft, which is 6.06 times than normonatremia patients. From more than 10% skin graft procedure, hypernatremia patients have bigger chance to failed skin graft, which is 16.5 times than normonatremia patients. From less than 10% skin graft procedure, hypernatremia patients have bigger chance to failed skin graft, which is 6.06 times than normonatremia patients.

Discussion
From this research, it showed that hypernatremia can be one of the risk that decreasing success rate of skin graft on burn patients.
Hypernatremia showed the large movement of fluid through membrane that caused systemic dehydration; this caused decreasing of tissue perfusion. Also because there was a systemic activation of Na-K pumps that used a large amount of energy, this lead to decreasing number of energy for healing process. All of them caused cell apoptosis.
The cell apoptosis also caused by protein that is produced by the heat of burn. Hypernatremia condition is signed of osmotic injury that can accelerate the apoptosis process of cell.
Without sufficient perfusion of recipient bed, revascularization is not achieved thus caused disrupt of healing process of skin graft.

Conclusion
Hypernatremia increased the risk of failed skin graft than normonatremia. The bigger precentage of skin graft, the bigger risk to fail