Enzymatic debridement of deeply burned faces: Healing and early scarring based on tissue preservation compared to traditional surgical debridement

Schulz, Alexandra; Fuchs, Paul Christian; Rothermundt, Irene; Hoffmann, Alexandra; Rosenberg, Lior; Shoham, Yaron; Oberlander, H; Schiefer, Jennifer Lynn

doi:10.1016/j.burns.2017.02.016

Cited by 65 publications

(45 citation statements)

References 35 publications

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“…No significant difference could be shown in time to wound closure and scar quality. While these results could be confirmed by other authors [6,7] one group even reported a reduced time to wound closure and an improved scar quality in comparison to historical control groups [8,9] . Further encouraging results could be shown by Osinga et al [17] who presented a series of 12 cases.…”

Section: Discussionsupporting

confidence: 65%

“…The advantages in preserving more viable dermis compared to conventional excision is most important in delicate regions with high function and relatively thin subcutaneous tissue, like on the hands, feet, genitals, perineum, axilla or in the face. Application in these regions revealed good results and can be further encouraged [6][7][8][9] .…”

Section: Indicationsmentioning

confidence: 99%

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State of the art in enzymatic debridement

Ziegler¹,

Hundeshagen²,

Cordts³

et al. 2018

PAR

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Surgical treatment of deep partial thickness to full thickness burn wounds by knife has been the undisputed standard of care and was one key point in surgical burn medicine for decades. Recently, it gets more and more challenged by Bromelain-based enzymatic burn wound debridement (ED) as technique for non-surgical, selective eschar removal. Although the literature on ED is increasing constantly it cannot comprise the rapid progress that is made in clinical application of ED. To outline the current state of art in ED, recent literature as well as clinical experience is summarized and the main steps in clinical application including indications, wound preparation, application of the enzyme, wound bed assessment and further treatment after ED are discussed. Initial indications and limitations in application of ED could be gradually extended to increase versatility of ED as tool in burn surgery. Several randomized controlled trials compared ED to standard of care (SOC). They could show significant shorter time to complete burn wound debridement and wound closure, reduced need for surgery, reduced blood loss, reduced area of burns that needed surgical excision and need for autograft as well as an improved scar quality. Further research is necessary to justify an extensive use of ED as tool for burn eschar removal. Especially a robust comparison to surgical burn wound excision by knife as SOC is required to facilitate evidence-based burn surgery.

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Section: Discussionsupporting

confidence: 65%

Section: Indicationsmentioning

confidence: 99%

State of the art in enzymatic debridement

Ziegler¹,

Hundeshagen²,

Cordts³

et al. 2018

PAR

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“…When applying NexoBrid ® the number and area of donor sites may decrease resulting in a reduced scarring. This is of considerable importanceinviewoflifequality [6,7,9].Anapplicationadvantage is seen in the treatment of extremities burns, e. g. hand and feet burns and in the face because NexoBrid ® simplifiesdebridement andhasthepowertopreservemoreviabledermis [13,15,16].At least conservation of dermal structures using NexoBrid ® favours reepithelialisation and thereby ensures higher quality of life to burn patients. Moreover NexoBrid ® improves propaedeutic diagnostics of post-debridement procedures at an early time point of therapy.…”

Section: Discussionmentioning

confidence: 99%

Enzymatic burn wound debridement with NexoBrid®: Cost simulations and investigations on cost efficiency

Kern¹,

Depka²,

Schackert³

et al. 2017

Gesundh ökon Qual manag

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Aim Removal of eschar (debridement) is an essential and early step in the treatment of deep burns. Enzymatic debridement by NexoBrid® is a relatively new non-surgical tool for early, individualized and selective debridement which adds some advantages compared to surgical standard techniques known as standard of care (SOC). Nevertheless, until now it is not represented and calculated in the pricing system for German hospitals (G-DRG system), and an own operative procedure key (OPS) is lacking. The objective of this empiric cost study was to compare treatment cost of enzymatic debridement by NexoBrid® and SOC based procedures and to analyse the impact of improved burn wound care using NexoBrid® on total treatment costs of burn patients. Method The analysis is based on two different cost simulation models, the Average Outcome Model and the Defined Patient Model. Based on the results of a randomized phase III trial and treatment costs specified in the pricing system for German hospitals (G-DRG system), total costs of NexoBrid® based treatments were compared to those of SOC to determine cost saving potentials (Average outcome model). In addition, distinct burn wound treatment pathways common in clinical practice were assigned to actual treatment costs to allow economic considerations (Defined Patient Model). Results Using NexoBrid® cost savings are inversely related to the treated total burned surface area (1–15% TBSA) and directly related to the savings in burn centre stay (up to 6.5 days) (Average Outcome Model). Based on quantitative and qualitative aspects, three quarter of all cases in the range of 5% to 15% TBSA burned are in favour of NexoBrid®. Main cost drivers are LOS and ICU stay (45–80% of total costs). NexoBrid® becomes a more powerful cost driver with increasing TBSA treated. If NexoBrid® completely substitutes for SOC, the total cost per patient can be reduced by nearly 30% (treatment of 5% TBSA) or are in the range of SOC costs (treatment of 15% TBSA) (Defined Patient Model). Highest costs are generated when enzymatic and surgical methods for debridement are combined and an increased LOS or ICU stay is indicated. Conclusion Cost advantages of enzymatic debridement by NexoBrid® may emerge in cases with low or medium burned and treated surface area when costs for enzymatic debridement remain below the costs for SOC (excision plus autografting). Even in more severe cases (15% TBSA burned) total costs of basic NexoBrid®-based treatment pathways do not exceed costs of comparable SOC pathways. In addition, enzymatic debridement by NexoBrid® can be successfully applied as a strategic tool in order to reduce surgical procedure time and OR room capacity and making use of the redundant capacity for further surgical cases reimbursement. Beside these quantitative aspects that may improve overall economic efficiency, qualitative improvements of burn wound care must be considered separately from this analysis.

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“…Globally the two most popular products are derived from bacterial collagenase and bromelain, an enzyme found in pineapple stems. Bromelain-based products have attained widespread use [1][2][3][4][5][6][7][8][9][10] and have demonstrated superiority over traditional wound care with silver-impregnated products 1 . A recent review 11 has recently examined the evidence behind bromelain-based products.…”

Section: Introductionmentioning

confidence: 99%

The role of collagenase ointment in acute burns: a systematic review and meta-analysis

et al. 2019

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Aims: Clostridial collagenase ointment (CCO) is the only FDA-approved product for enzymatic debridement in the United States. Its efficacy in the burn patient has not been extensively examined. A systematic review and meta-analysis was performed to summarize the state of the literature in regard to the efficacy and uses of CCO in the burn patient. Methods: A systematic review of articles available on PubMed, Scopus, and OvidSP Medline was performed. Keywords utilized in the search process included: burns; thermal injury; collagenase; enzymatic debridement; wound care. Excluded articles included reviews, case reports, independent abstracts, consensus and opinion papers. A meta-analysis was performed for articles fitting inclusion criteria. Results: Six relevant articles were identified for systematic review. Few studies, with limited sample sizes, argue that collagenase ointment may be an effective debriding agent. CCO may also accelerate wound healing and avoid the pain associated with mechanical debridement. CCO lacks anti-microbial activity but the risk of burn wound infection does not appear to be significantly different than when using silver-impregnated products. CCO is more expensive than traditional wound care products but may halt burn depth conversion and prevent the need for surgery. Conclusions: CCO may be a safe and effective debridement agent for burn wounds with respect to decreasing wound healing time and minimizing pain without increasing the risk of infection. It should be used on a case-by-case basis due to its financial cost. The financial cost of CCO may be offset by its ability to manage burns non-operatively.

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Enzymatic debridement of deeply burned faces: Healing and early scarring based on tissue preservation compared to traditional surgical debridement

Cited by 65 publications

References 35 publications

State of the art in enzymatic debridement

State of the art in enzymatic debridement

Enzymatic burn wound debridement with NexoBrid®: Cost simulations and investigations on cost efficiency

The role of collagenase ointment in acute burns: a systematic review and meta-analysis

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