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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 26  |  Issue : 1  |  Page : 103-105

Therapeutic management of the enzymatic debriding agent Nexobrid® in the burn patient


Department of Plastic Surgery and Burns, University and Polytechnic Hospital La Fe, Valencia, Spain

Date of Web Publication11-Mar-2019

Correspondence Address:
Dr. Enrique Salmeron-Gonzalez
25 Francia Avenue, Stairs 2, Appt #25, 9th Floor, Valencia, Comunidad Valenciana 46013
Spain
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijb.ijb_32_17

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  Abstract 


Enzymatic debridement with Nexobrid® is a recently appeared resource, which allows a selective elimination of burned tissues with one single application, becoming a new resource in the therapeutic arsenal of the burn surgeon. In this article, we expose our experience with this product, and through a representative case, we explain the management of these patients performed in our burns unit, in consonance with national and international consensus.

Keywords: Burns, burns units, debridement, enzymatic debridement


How to cite this article:
Salmeron-Gonzalez E, García-Vilariño E, Sánchez-García A, Llinás-Porte A, Pérez-Del-Caz M D. Therapeutic management of the enzymatic debriding agent Nexobrid® in the burn patient. Indian J Burns 2018;26:103-5

How to cite this URL:
Salmeron-Gonzalez E, García-Vilariño E, Sánchez-García A, Llinás-Porte A, Pérez-Del-Caz M D. Therapeutic management of the enzymatic debriding agent Nexobrid® in the burn patient. Indian J Burns [serial online] 2018 [cited 2019 Jul 19];26:103-5. Available from: http://www.ijburns.com/text.asp?2018/26/1/103/253854




  Introduction Top


Nexobrid ® is a new resource for debridement which has emerged in recent years and is gaining relevance in the treatment of all kinds of thermal injuries.[1] Nexobrid ® is directly applied over the burn, performing a burned tissue-specific debridement in <4 h, leaving a vital and completely debrided wound bed.[1] This resource allows for the performance of an early debridement, at the very first evaluation of the patient, without the need of the logistics of an operating room, requiring only an adequate pain control and a nursing team for burn cleaning and applying the ointment. This debriding method achieves higher specificity in the process, preserving a higher amount of healthy dermis than traditional excisional debridement.[2],[3] Therefore, secondary intention healing of some mid-deep depth burns that otherwise would have been grafted can be achieved.[1],[2],[3],[4],[5],[6],[7],[8]

In this article, we expose the case of a patient suffering from deep second-degree burns in both hands, treated with enzymatic debridement with Nexobrid ® and secondary intention healing. The chronological sequence and evolution of the case are also exposed. Furthermore, the protocol utilized in our service for the application and management of Nexobrid ® is described.


  Case Report Top


We present the case of a 43-year-old male who suffered from circular second deep burns in both hands caused by electric flash and flame, in the context of a labor accident, with a total body surface affected of 2.5% [Figure 1].
Figure 1: Forty-three-year-old male suffering a deep second-degree burn in both hands caused by electric flash burn, before (a) and immediately after (b) thorough cleaning of the burn bed

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After the initial evaluation, a cure with liquid Prontosan ® was performed, and the Nexobrid ® application protocol was scheduled for the next day. At 7:00 am, a new wet-to-dry cure with liquid Prontosan ® was applied, and 2 h later (11 h after the burn), a layer of 2–3 mm of Nexobrid ® was applied over the burned surface. To prevent Nexobrid ® from spreading out, a thin line of Vaseline was applied around the burn, to isolate the area with Nexobrid ®. It must be highlighted that Nexobrid ® does not have any harmful effect over the intact skin. After 4 h, the liquefacted eschar was removed with tongue depressors and gauzes, thoroughly cleaning the wound bed and reapplying a wet-to-dry dressing with Prontosan ® and gauzes. Dressings were removed the following day [Figure 2], showing a wound bed with enough dermic remnants for spontaneous epithelization; thus, it was covered with Suprathel ®. Secondary dressings were changed every 2–3 days, performing serial cures until the 28th day, in which complete epithelization was achieved. After 102 days of follow-up, no scar anomalies were observed, with complete preservation of the range of movement of affected articulations [Figure 3].
Figures 2: (a) Application of Nexobrid® with sterile tongue depressor. (b) Burn recently covered with Nexobrid®; eschar degradation starts to be seen. (c) Aspect of burn bed after application of Nexobrid® for 4 h. (d) Aspect of burn bed after product and eschar remains removal

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Figure 3: Aspect of burned surface 102 days after the accident, with completely preserved functionality, without scar anomalies

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  Discussion Top


This case shows the representative evolution and management of a burned patient treated with Nexobrid ®. The results of this case regarding time until epithelization, avoidance of skin grafting, and time until complete debridement are similar to the ones exposed by other authors,[1],[4],[5],[6] notwithstanding, no case report article has been published till date focusing on the explanation of the management algorithm. Despite the existence of many emerging protocols and guidelines,[2],[3] no consensus has been reached regarding management of the debrided burn bed. This part of our protocol has been modified many times, adapting the dressings utilized according to our experience and the actualizations of national and international consensus.[2],[3] At present, and according to these guidelines and our experience with 52 patients treated with Nexobrid ®, the protocol we apply is as follows:

First, deepness of debrided burn beds is assessed, following the guidelines provided in the work of Krieger et al.[4]

In cases of third-degree and deep second-degree burns without enough dermic remnants for a spontaneous epithelization in 21–28 days, cures with hydrocolloids are performed every 48 h. These patients are scheduled for grafting after 4–5 days, to achieve wound bed stabilization and disappearance of product remains, which could interfere with graft take.[2],[3],[6],[7],[8] A decrease in graft taking has been described when early grafting is performed over burns debrided with Nexobrid ®.[4]

In cases of second-degree burns with the possibility of spontaneous epithelization, coverage with Suprathel ® is performed, replacing secondary dressings every 2–3 days. It has been observed that healing by secondary intention after Nexobrid ® application allows for longer waiting times than regular cases, without an increased incidence of scar anomalies.[1],[2],[3],[4]

Indications are yet still to be clearly defined through more extensive and specific studies, as it is to be expected that not every burn will benefit from treatment with Nexobrid ®. Habitual indications in our great burns unit are as follows:

  1. Deeply burned hands, when there exists the possibility of preserving unburned dermis. Many comparative studies have been published reporting better results in burned hands treated with enzymatic debridement rather than burned hands treated traditionally [4],[5],[6]
  2. Circular burns affecting limbs, deep enough to cause a compartment syndrome. An experimental study described a reduction in intercompartmental pressure below 30 mmHg after 90 min of Nexobrid ® application.[8] Another study by Rosenberg et al. showed a reduction in the number of escharotomies performed in the Nexobrid ® group compared to the traditional treatment [1]
  3. Great burns, with extensive body surface affection. In this sort of patient, Nexobrid ® allows for the removal of a great amount of eschar, without supposing such an aggressive intervention as surgery, with less blood loss than the traditional treatment.[1]


As regards complications of the enzymatic debridement with Nexobrid ®, a recently published meta-analysis, including 622 patients of seven different clinical trials, did not report any significative differences among adverse event incidence between the traditional treatment group and patients treated with Nexobrid ®.[4] Furthermore, various studies have reported a reduction in the amount of body surface requiring skin grafting in patients treated with Nexobrid,® and therefore, a reduction of the amount and size of donor sites.[1],[4],[6]


  Conclusion Top


Despite adequate debridement is achieved with the application of Nexobrid ®, more studies are still required to improve the management of the debrided wound bed, and to establish the optimal timing for grafting. Furthermore, indications must be reevaluated and clearly defined, without assuming that every burn would benefit from treatment with NexoBrid ® unless this statement is reinforced with enough scientific evidence.

Informed consent

Informed consent was obtained from all patients included in this study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rosenberg L, Krieger Y, Bogdanov-Berezovski A, Silberstein E, Shoham Y, Singer AJ, et al. A novel rapid and selective enzymatic debridement agent for burn wound management: A multi-center RCT. Burns 2014;40:466-74.  Back to cited text no. 1
    
2.
Martínez-Méndez JR, Serracanta-Domènech J, Monclús-Fuertes E, Pérez-del-Caz D, López-Suso E, García-Contreras JD, et al. Guía clínica de consenso en el uso de desbridamiento enzimático en quemaduras con NexoBrid®. Cir Plast Iber 2017;43:193-202.  Back to cited text no. 2
    
3.
Hirche C, Citterio A, Hoeksema H, Koller J, Lehner M, Martinez JR, et al. Eschar removal by bromelain based enzymatic debridement (Nexobrid®) in burns: An European consensus. Burns 2017;43:1640-53.  Back to cited text no. 3
    
4.
Krieger Y, Bogdanov-Berezovsky A, Gurfinkel R, Silberstein E, Sagi A, Rosenberg L, et al. Efficacy of enzymatic debridement of deeply burned hands. Burns 2012;38:108-12.  Back to cited text no. 4
    
5.
Schulz A, Shoham Y, Rosenberg L, Rothermund I, Perbix W, Christian Fuchs P, et al. Enzymatic versus traditional surgical debridement of severely burned hands: A Comparison of selectivity, efficacy, healing time, and three-month scar quality. J Burn Care Res 2017;38:e745-55.  Back to cited text no. 5
    
6.
Rosenberg L, Shoham Y, Krieger Y, Rubin G, Sander F, Koller J, et al. Minimally invasive burn care: A review of seven clinical studies of rapid and selective debridement using a bromelain-based debriding enzyme (Nexobrid®). Ann Burns Fire Disasters 2015;28:264-74.  Back to cited text no. 6
    
7.
Schulz A, Perbix W, Shoham Y, Daali S, Charalampaki C, Fuchs PC, et al. 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. Burns 2017;43:326-36.  Back to cited text no. 7
    
8.
Krieger Y, Rosenberg L, Lapid O, Glesinger R, Bogdanov-Berezovsky A, Silberstein E, et al. Escharotomy using an enzymatic debridement agent for treating experimental burn-induced compartment syndrome in an animal model. J Trauma 2005;58:1259-64.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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