Enzymatic debridement for circumferential deep burns: the role of surgical escharotomy.

INTRODUCTION: Circumferential deep burns carry a high risk for a burn induced compartment syndrome. It was recently shown that an enzymatic bromelain-based debridement with Nexobrid® is a safe and efficient procedure to release pressure in deep circumferential extremity burns reducing the need for surgical escharotomy. We therefore herein aimed to analyze the conceptual relation between Nexobrid® and surgical escharotomy. PATIENTS AND METHODS: We conducted a retrospective study on all patients with circumferential deep partial-thickness or full-thickness burns requiring immediate escharotomy that was either performed by surgical incision or Nexobrid®. Medical records of 792 patients that were treated at the burn center of the University Hospital Zurich between 2016 and 2021 were analyzed. RESULTS: Overall, 62 patients with circumferential deep partial-thickness or full-thickness burns who received preventive decompression either by Nexobrid® (N = 29) or surgical escharotomy (N = 33), were included. Whilst distribution of age, sex, BMI and type of injury showed no difference between the groups, the ABSI score, TBSA, percentage of third degree burns and mortality were significantly higher in patients who received a surgical escharotomy. CONCLUSION: While the use of Nexobrid® to prevent burn induced compartment syndrome has steadily increased, surgical escharotomies were predominantly performed in severely burned patients with a high degree of full-thickness burns. Thus, higher mortality in this patient group needs to be considered with caution and is mainly attributed to the higher TBSA. Although evidence is lacking for the use of Nexobrid® for larger body areas exceeding 15%, escharotomy is also the more reliable and faster approach in such critically burned patients.

Safety of enzymatic debridement in extensive burns larger than 15% total body surface area.

OBJECTIVES: Bromelain-based enzymatic debridement has emerged as an alternative to surgical eschar removal. Indications include partial thickness, mixed pattern, and full-thickness burns. Enzymatic debridement has been approved by the European Medicines Agency for treating burn wounds affecting <15% total body surface area (TBSA). Data and evidence for the treatment of areas >15% TBSA in one session is scarce. The aim of this retrospective study was to retrospectively analyze off-label use of enzymatic debridement in a single burn center for large TBSA burns. METHODS: Between 01/2017 and 12/2018, 59 patients with partial- to full-thickness burns underwent enzymatic debridement in a single center study. Patients were categorized into two groups: the regular use group with a treated area less than 15% TBSA and the off-label group (OG) with larger TBSA debrided in one session. Treatment was evaluated for systemic inflammatory reaction, bleeding, hemodynamic instability and electrolyte shifts. RESULTS: In total, 49 patients were treated in the regular use group with a median application area of 6% (IQR 2.5-9.5) and 10 patients were treated in the off-label group with a median application area of 18% (IQR 15-19) TBSA. We found no significant differences regarding blood pressure, body temperature or hemodynamic stability during and after enzymatic debridement. No treatment-related serious adverse events were observed in either group. Catecholamine use was similar in both groups. No differences in leukocyte counts, CRP, PCT and lactate prior to application and during the following three days were observed. Sodium, potassium, chloride and phosphate levels did not differ. We found no evidence of an electrolyte shift. Survival was 49 of 49 patients (100%) in the RG and 7 of 10 patients (70%) in the OG (p = 0.004). CONCLUSION: Enzymatic debridement did not result in any expected or unexpected side effects in the patient groups investigated. These preliminary results indicate the potential safety of bromelain-based enzymatic debridementin the treatment of burns greater than 15% TBSA.

[Burn wound treatment through enzymatic debridement: First experience in Switzerland]. / Enzymatisches Débridement zur Behandlung von Brandverletzungen: Erste Erfahrungen in der Schweiz.

INTRODUCTION: Thermal injuries are frequent and can be associated with relevant morbidity and mortality in severe cases. Excisional debridement followed by autografting is the standard of care for deep burns, but is associated with serious potential complications. Clinical results of a novel enzymatic debridement based on Bromelain raw material extracted from the pineapple plant (Nexobrid™) were published in 2014. At the Center for Burns at the University Hospital Zürich enzymatic debridement was introduced in 2016. Our experience and interpretation of the first 12 cases are reported. PATIENTS AND METHODS: Patients of at least 18 years of age with second and third degree burns were included in this study. Pregnant or breast feeding women were excluded. After so-called "pre-soaking" with saline solution, the Nexobrid™ gel was applied for 4 hours with occlusive sealing. After abrasion of the debris, "post-soaking" with Prontosan® followed and definite wound dressings were applied. RESULTS: The mean age of the patients was 51 (19-78) years, the length of hospital stay was 38 (1-92) days. The amount of burns was 25 (1-67) % of the total body surface area (TBSA). On average, 11 (1-18) % of the TBSA was debrided with Nexobrid™ after 7 (1-19) days. In 8 patients, the defects completely healed without scarring after Nexobrid™ treatment. In 4 patients additional surgical measures were necessary to complete the debridement as well as to cover the defect. The treatment with Nexobrid™ was efficient in difficult treatment areas such as back, hands and feet, where preservation of the demis prevented joint contracture through scarring. CONCLUSION: Treatment with Nexobrid™ extends the armamentarium to treat partial second-degree thermal injuries with good long-term results. It can be applied in analgosedation in an intensive care setting and reduces the need for surgical treatment.