Early non-excisional debridement of paediatric burns under general anaesthesia reduces time to re-epithelialisation and risk of skin graft

Abstract

Reported advantages of early excision for larger burn injuries include reduced morbidity, mortality, and hospital length of stay for adult burn patients. However, a paucity of evidence supports the best option for paediatric burns and the advantages of non-excisional (mechanical) debridement. Procedural sedation and analgesia in the emergency department is a popular alternative to debridement in operating theatres under general anaesthesia. This study aims to evaluate the association between early (< 24 h post-injury) non-excisional debridement under general anaesthesia with burn wound re-epithelialisation time and skin graft requirements. Cohort study of children younger than 17 years who presented with burns of five percent total body surface area or greater. Data from January 2013 to December 2019 were extracted from a prospectively collected state-wide paediatric burns’ registry. Time to re-epithelialisation was tested using survival analysis, and binary logistic regression for odds of skin graft requirementto analyse effects of early non-excisional debridement in the operating theatre. Overall, 292 children met eligibility (males 55.5%). Early non-excisional debridement under general anaesthesia in the operating theatre, significantly reduced the time to re-epithelialisation (14 days versus 21 days, p = 0.029)) and the odds of requiring a skin graft in comparison to paediatric patients debrided in the emergency department under Ketamine sedation (OR: 6.97 (2.14–22.67), p < 0.001. This study is the first to demonstrate that early non-excisional debridement under general anaesthesia in the operating theatre significantly reduces wound re-epithelialisation time and subsequent need for a skin graft in paediatric burn patients. Analysis suggests that ketamine procedural sedation and analgesia in the emergency department used for burn wound debridement is not an effective substitute for debridement in the operating theatre.

A Pilot Randomised Controlled Trial Evaluating a Regenerative Epithelial Suspension for Medium-Size Partial-Thickness Burns in Children: The BRACS Trial

“…The main challenge for these missed cases was that the burn surgeon declined participation as they did not agree that the initial burn wound debridement should be performed under general anaesthesia. In lieu of an initial non-excisional debridement under general anaesthesia, Ketamine-based procedural sedation and analgesia in the emergency department was a common alternative based on a retrospective cohort at the study centre [65]. Accessibility to the operating theatres, especially after hours, was not always guaranteed, and was thus viewed by the burn surgeons as disruptive to the intended wound management plan due to the potential delay of initial debridement and initial definitive wound cover while waiting for a theatre.…”

An Overview of Recent Developments in the Management of Burn Injuries

“…Moreover, it requires specialist care and intravenous analgesia [86]. Currently, other methods for removing dead epidermis are recommended, such as hydrosurgery, worm therapy, laser and special cauterization systems [87]. An interesting method for the non-surgical debridement of burns is using minimally invasive enzymatic debridement with proteolytic enzymes [88,89].…”

Preliminary Single-Center Experience of Bromelain-Based Eschar Removal in Children with Mixed Deep Dermal and Full Thickness Burns

“…The principal drawback of the fascia excision is that it may create a considerable contour deformity. The non-excisional eschar removal methods include abrasion technique, hydro-surgery and enzymatic debridement [ 7 ]. The latter, with the use of Nexobrid ® rich in bromelain-based enzyme agents, is growing in popularity.…”