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Eschar removal by bromelain based enzymatic debridement (Nexobrid®) in burns: An European consensus.
Burns 2017; 43(8):1640-1653B

Abstract

Early debridement and/or eschar removal is regarded as a significant step in the treatment of deep partial and full thickness burns. It aims to control wound bioburden and allows early wound closure by conservative treatment or skin grafting. Preservation of viable dermis accompanied by early wound closure, is regarded as a necessary step to reduce scar related complication, e.g. functional limitations and/or unaesthetic scar formation. Aside from the classical techniques of surgical excision as tangential excision for eschar removal, hydro-surgery, maggot therapy, laser, enzymatic debridement have been described as additional techniques in the burn surgeon's armamentarium. It is widely accepted that early eschar removal within 72h improves the outcome of burn wound treatment by reducing bacterial wound colonization, infection and length of hospital stay. In contrast, the right technique for eschar removal is still a matter of debate. There is increasing evidence that enzymatic debridement is a powerful tool to remove eschar in burn wounds, reducing blood loss, the need for autologous skin grafting and the number of wounds requiring surgical excision. In order to assess the role and clinical advantages of enzymatic debridement by a mixture of proteolytic enzymes enriched in Bromelain (Nexobrid®) beyond the scope of the literature and in view of users' experience, a European Consensus Meeting was scheduled. The aim was to provide statements for application, based on the mutual experience of applying enzymatic debridement in more than 500 adult and pediatric patients by the consensus panelists. Issues to be addressed were: indications, pain management and anesthesia, timing of application, technique of application, after-intervention care, skin grafting after enzymatic debridement, blood loss, training strategies and learning curve and areas of future research needs. Sixty-eight (68) consensus statements were provided for the use of enzymatic debridement. The degree of consensus was remarkably high, with a unanimous consensus in 88.2% of statements, and lowest degree of consensus of 70% in only 3 statements. This consensus document may serve as preliminary guideline for the use of enzymatic debridement with user-oriented recommendations until further evidence and systematic guidelines are available.

Authors+Show Affiliations

BG Trauma Center, Hand-, Plastic and Reconstructive Surgery, Burn Center, University of Heidelberg, Ludwigshafen, Germany. Electronic address: christoph.hirche@bgu-ludwigshafen.de.Anestesiology, Plastic and Reconstructive Surgery, Burn Unit, Ospedale Niguarda, Milano, Italy.Burn Unit, Department of Plastic Surgery, Ghent University Hospital, Gent, Belgium.Burn Department, University Hospital Bratislava, Ruzinov Hospital Univerzitná nemocnica Bratislava, nemocnica Ružinov, Bratislava, Slovak Republic.Department for Plastic, Aesthetic and Reconstructive Surgery, University Hospital St. Pölten, St. Pölten, Austria.Burn Unit, Hospital Universitario La Paz, Madrid, Spain.Burn Unit, Department of Plastic Surgery, Ghent University Hospital, Gent, Belgium.Burn Unit, Stoke Mandeville Hospital, Aylesbury, Buckinghamshire, United Kingdom.Division of Plastic Surgery and Hand Surgery, Burn Center, University Hospital Zurich, Zurich, Switzerland.Burn Center with Plastic Surgery, Unfallkrankenhaus Berlin, Berlin, Germany.Department of Plastic Surgery, Hand Surgery, Burn Center, University of Witten/Herdecke, Cologne-Merheim Medical Center (CMMC), Cologne, Germany.BG Trauma Center, Hand-, Plastic and Reconstructive Surgery, Burn Center, University of Heidelberg, Ludwigshafen, Germany.BG Trauma Center, Hand-, Plastic and Reconstructive Surgery, Burn Center, University of Heidelberg, Ludwigshafen, Germany.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

29033046

Citation

Hirche, Christoph, et al. "Eschar Removal By Bromelain Based Enzymatic Debridement (Nexobrid®) in Burns: an European Consensus." Burns : Journal of the International Society for Burn Injuries, vol. 43, no. 8, 2017, pp. 1640-1653.
Hirche C, Citterio A, Hoeksema H, et al. Eschar removal by bromelain based enzymatic debridement (Nexobrid®) in burns: An European consensus. Burns. 2017;43(8):1640-1653.
Hirche, C., Citterio, A., Hoeksema, H., Koller, J., Lehner, M., Martinez, J. R., ... Kneser, U. (2017). Eschar removal by bromelain based enzymatic debridement (Nexobrid®) in burns: An European consensus. Burns : Journal of the International Society for Burn Injuries, 43(8), pp. 1640-1653. doi:10.1016/j.burns.2017.07.025.
Hirche C, et al. Eschar Removal By Bromelain Based Enzymatic Debridement (Nexobrid®) in Burns: an European Consensus. Burns. 2017;43(8):1640-1653. PubMed PMID: 29033046.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Eschar removal by bromelain based enzymatic debridement (Nexobrid®) in burns: An European consensus. AU - Hirche,Christoph, AU - Citterio,Antonella, AU - Hoeksema,Henk, AU - Koller,Ján, AU - Lehner,Martina, AU - Martinez,José Ramón, AU - Monstrey,Stan, AU - Murray,Alexandra, AU - Plock,Jan A, AU - Sander,Frank, AU - Schulz,Alexandra, AU - Ziegler,Benjamin, AU - Kneser,Ulrich, Y1 - 2017/10/13/ PY - 2017/05/09/received PY - 2017/07/22/revised PY - 2017/07/27/accepted PY - 2017/10/17/pubmed PY - 2018/7/14/medline PY - 2017/10/17/entrez KW - Burn KW - Consensus KW - Enzymatic debridement KW - Eschar removal KW - Nexobrid SP - 1640 EP - 1653 JF - Burns : journal of the International Society for Burn Injuries JO - Burns VL - 43 IS - 8 N2 - Early debridement and/or eschar removal is regarded as a significant step in the treatment of deep partial and full thickness burns. It aims to control wound bioburden and allows early wound closure by conservative treatment or skin grafting. Preservation of viable dermis accompanied by early wound closure, is regarded as a necessary step to reduce scar related complication, e.g. functional limitations and/or unaesthetic scar formation. Aside from the classical techniques of surgical excision as tangential excision for eschar removal, hydro-surgery, maggot therapy, laser, enzymatic debridement have been described as additional techniques in the burn surgeon's armamentarium. It is widely accepted that early eschar removal within 72h improves the outcome of burn wound treatment by reducing bacterial wound colonization, infection and length of hospital stay. In contrast, the right technique for eschar removal is still a matter of debate. There is increasing evidence that enzymatic debridement is a powerful tool to remove eschar in burn wounds, reducing blood loss, the need for autologous skin grafting and the number of wounds requiring surgical excision. In order to assess the role and clinical advantages of enzymatic debridement by a mixture of proteolytic enzymes enriched in Bromelain (Nexobrid®) beyond the scope of the literature and in view of users' experience, a European Consensus Meeting was scheduled. The aim was to provide statements for application, based on the mutual experience of applying enzymatic debridement in more than 500 adult and pediatric patients by the consensus panelists. Issues to be addressed were: indications, pain management and anesthesia, timing of application, technique of application, after-intervention care, skin grafting after enzymatic debridement, blood loss, training strategies and learning curve and areas of future research needs. Sixty-eight (68) consensus statements were provided for the use of enzymatic debridement. The degree of consensus was remarkably high, with a unanimous consensus in 88.2% of statements, and lowest degree of consensus of 70% in only 3 statements. This consensus document may serve as preliminary guideline for the use of enzymatic debridement with user-oriented recommendations until further evidence and systematic guidelines are available. SN - 1879-1409 UR - https://www.unboundmedicine.com/medline/citation/29033046/Eschar_removal_by_bromelain_based_enzymatic_debridement__Nexobrid®__in_burns:_An_European_consensus_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0305-4179(17)30419-9 DB - PRIME DP - Unbound Medicine ER -