Hirche Christoph, Citterio Antonella, Hoeksema Henk, Koller Ján, Lehner Martina, Martinez José Ramón, Monstrey Stan, Murray Alexandra, Plock Jan A, Sander Frank, Schulz Alexandra, Ziegler Benjamin, Kneser Ulrich
BG Trauma Center, Hand-, Plastic and Reconstructive Surgery, Burn Center, University of Heidelberg, Ludwigshafen, Germany.
Anestesiology, Plastic and Reconstructive Surgery, Burn Unit, Ospedale Niguarda, Milano, Italy.
Burns. 2017 Dec;43(8):1640-1653. doi: 10.1016/j.burns.2017.07.025. Epub 2017 Oct 13.
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.
早期清创和/或焦痂清除被视为深度部分厚度和全层烧伤治疗中的重要步骤。其目的是控制伤口生物负荷，并通过保守治疗或皮肤移植实现早期伤口闭合。保留有活力的真皮并实现早期伤口闭合，被视为减少瘢痕相关并发症（如功能受限和/或不美观瘢痕形成）的必要步骤。除了手术切除（如用于焦痂清除的削痂术）等经典技术外，水刀清创术、蛆虫疗法、激光、酶促清创术也已被描述为烧伤外科医生的可用技术。人们普遍认为，72小时内早期清除焦痂可通过减少伤口细菌定植、感染和住院时间来改善烧伤创面治疗效果。相比之下，正确的焦痂清除技术仍存在争议。越来越多的证据表明，酶促清创术是清除烧伤创面焦痂的有力工具，可减少失血、自体皮肤移植需求以及需要手术切除的伤口数量。为了评估富含菠萝蛋白酶（Nexobrid）的蛋白水解酶混合物进行酶促清创术的作用和临床优势，超出文献范围并结合用户经验，安排了一次欧洲共识会议。目的是根据共识小组成员在500多名成人和儿童患者中应用酶促清创术的共同经验，提供应用声明。需要解决的问题包括：适应症、疼痛管理与麻醉、应用时机、应用技术、干预后护理、酶促清创术后的皮肤移植、失血、培训策略与学习曲线以及未来研究需求领域。针对酶促清创术的使用提供了68条共识声明。共识程度非常高，88.2%的声明达成了一致共识，只有3条声明的最低共识程度为70%。在有进一步证据和系统指南之前，这份共识文件可作为酶促清创术使用的初步指南，并提供以用户为导向的建议。
