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Page 2 of 7 Ziegler et al. Plast Aesthet Res 2018;5:33 I http://dx.doi.org/10.20517/2347-9264.2018.46

basis for optimal wound bed conditioning, and thus prevents devastating scarring. Especially in severely in-
jured patients with a high extent of burned surface, early eschar removal is as important as optimal intensive
[1]
care treatment to optimize outcomes and reduce complications .
[2]
To date the conventional method of tangential excision by knife as introduced 50 years ago is still the most
applied technique of eschar removal worldwide. Nevertheless, several further techniques have been devel-
oped and became popular in the past decades. Hydrosurgery as most established additional technique for
example enables the surgeon to achieve a more selective debridement of the burn wound by an adjustable
[3]
water jet .
[4]
In the last decade, most progress has been achieved in enzymatic burn wound debridement (ED) . This
technique promises the effective eschar removal and uses bromelain-based enzymes extracted from pine-
apple stems in the most frequently applied medication (Nexobrid®). After preparation of the burn wound by
pre-soaking the eschar, the product promotes selective eschar removal from burn wounds within 4 h even
in full thickness burns, while viable dermal tissue is preserved. Due to encouraging reports and growing
[5]
evidence in literature, including benefits like lower blood loss and fewer need for consecutive skin grafting ,
ED continues to increase in popularity. While the group of users is growing continuously, indications are
widened and the technique of application is constantly refined.

To catch up with these developments, this article tries to give an overview on the current state of art on indi-
cations, implementation and post-treatment in the use of ED with Bromelain-based Nexobrid®.

INDICATIONS
According to its approval, ED can be used on all burn wounds up to 15% total burned surface area (TBSA)
in adult patients per application. Effective and safe treatment of children has been reported and is practiced
[5]
in pediatric surgery , but has to be considered as off-label use until further approval studies are evaluated.
Likewise, the treatment of a TBSA up to 30% per session can be performed with reasonable risks although it
is also regarded as off-label. Treatment of more than 30% TBSA in one session of ED cannot be recommend-
ed due to risks of increasing blood loss and hemodynamic instability. In addition, further systemic effects of
ED in extra-large surfaces > 30% remain unknown.

The advantages in preserving more viable dermis compared to conventional excision is most important in
delicate regions with high function and relatively thin subcutaneous tissue, like on the hands, feet, genitals,
perineum, axilla or in the face. Application in these regions revealed good results and can be further encour-
[6-9]
aged .
In deep circumferential burns at the extremities, the early application of ED can release tissue pressure by
timely removing the constrictive eschar, reduce inflammation-associated edema and thus may prevent pa-
tients from the need for surgical escharotomy and its possible complications and invasiveness. Despite the
successful implementation in specialized burn centers, it is mandatory to re-evaluate the wound frequently
and verify entire tissue release thoroughly and be prepared to perform additional surgical escharotomy or
even fasciotomy if necessary in case of burn induced compartment syndrome [10-12] .

As a bedside procedure, ED has the potential to shift early eschar removal to the patient ward and thus can
spare valuable resources in the operating room. In that way ED can be especially advantageous in mass casu-
[13]
alty incidents where a higher patient count can benefit from optimal and timely treatment .

PREPARATION
Prior to the application of ED, a sufficient analgesia must be ensured. For treatment of single extremities,