State of the art in enzymatic debridement

Abstract

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.

Keywords

State of the art / enzymatic debridement / Nexobrid / eschar removal / burns

References

[1] Xiao-Wu W,Spies M,Wolf SE.Effects of delayed wound excision and grafting in severely burned children.Arch Surg2002;137:1049-54

[2] Janzekovic Z.A new concept in the early excision and immediate grafting of burns.J Trauma1970;10:1103-8

[3] Gravante G,Esposito G.Versajet hydrosurgery versus classic escharectomy for burn débridment: a prospective randomized trial.J Burn Care Res2007;28:720-4

[4] Rosenberg L,Bogdanov-Berezovsky A,Krieger Y,Sagi A,Singer AJ.Safety and efficacy of a proteolytic enzyme for enzymatic burn débridement: a preliminary report.Burns2004;30:843-50

[5] Rosenberg L,Bogdanov-Berezovski A,Shoham Y.A novel rapid and selective enzymatic debridement agent for burn wound management: a multi-center RCT.Burns2014;40:466-74

[6] Krieger Y,Gurfinkel R,Sagi A.Efficacy of enzymatic debridement of deeply burned hands.Burns2012;38:108-12

[7] Cordts T,Vogelpohl J,Kneser U.Enzymatic debridement for the treatment of severely burned upper extremities - early single center experiences.BMC Dermatol2016;16:8 PMCID:PMC4920996

[8] Schulz A,Rosenberg L,Perbix W,Lipensky A.Enzymatic versus traditional surgical debridement of severely burned hands: a comparison of selectivity, efficacy, healing time, and three-month scar quality.J Burn Care Res2017;38:e745-55

[9] Schulz A,Rothermundt I,Rosenberg L,Oberländer H.Enzymatic debridement of deeply burned faces: healing and early scarring based on tissue preservation compared to traditional surgical debridement.Burns2017;43:1233-43

[10] Hirche C,Hoeksema H,Lehner M,Monstrey S,Plock JA,Schulz A,Kneser U.Eschar removal by bromelain based enzymatic debridement (Nexobrid®) in burns: an european consensus.Burns2017;43:1640-53

[11] Krieger Y,Lapid O,Bogdanov-berezovsky A,Sagi A.Escharotomy using an enzymatic debridement agent for treating experimental burn-induced compartment syndrome in an animal model.J Trauma2005;58:1259-64

[12] Schulze SM,Choo J,Moore AL,Neumeister MW.Amputation following hand escharotomy in patients with burn injury.Eplasty2016;16:e13 PMCID:PMC4780278

[13] Kern MA,Schackert C,Hirche CR.Enzymatic burn wound debridement with NexoBrid®: cost simulations and investigations on cost efficiency.Gesundheitsökonomie Qual2018;23:21-8

[14] Schulz A,Shoham Y,Charalampaki C,Schiefer J.Our initial learning curve in the enzymatic debridement of severely burned hands-management and pit falls of initial treatments and our development of a post debridement wound treatment algorithm.Burns2017;43:326-36

[15] Jaeger M,Kornhaber R,Zerach A.Treatment of hypergranulation tissue in burn wounds with topical steroid dressings: a case series.Int Med Case Rep J2016;9:241-5 PMCID:PMC4986970

[16] Loo YL,Jeffery S.An overview of the use of bromelain-based enzymatic debridement (Nexobrid®) in deep partial & full thickness burns: appraising the evidence.J Burn Care Res2018;

[17] Osinga R,Giovanoli P,Mannil L.Burn wound treatment through enzymatic debridement: first experience in Switzerland.Handchir Mikrochir Plast Chir2018;

[18] Edmondson SJ,Murray A.Is it time to start putting down the knife? a systematic review of burns debridement tools of randomised and non-randomised trials.Burns2018;

[19] Schulz A,Rothermundt I,Rosenberg L,Oberländer H.Enzymatic debridement of deeply burned faces: healing and early scarring based on tissue preservation compared to traditional surgical debridement.Burns2017;43:1233-43