Page 30 - Read Online

Ziegler et al. Plast Aesthet Res 2018;5:33 I http://dx.doi.org/10.20517/2347-9264.2018.46 Page 3 of 7

regional anesthesia (e.g., plexus anesthesia) has been used successfully and is favorable due to its little side
[7]
effects . To perform treatment of large surfaces including the trunk or the head, general anesthesia in an in-
tensive care setting is recommended.

Because the enzymes can only process moist tissue, a wound condition have to be prepared by pre-soaking
with crystalloid or anti-infective fluids for at least 2 h, and even longer in burns with delayed application of
[10]
ED . Some users report better outcomes of ED after prolonged pre-soaking for up to 12 h, but there is yet
no evidence to support this approach - nevertheless it might help overcome logistical deficiencies at the burn
center if being more flexible in the time of post-soaking. On the other hand, when a patient is presented im-
mediately after burn trauma, the burn wounds should be still moist enough to skip pre-soaking phase and
start with ED immediately - which is mandatory for emergency ED to prevent surgical escharotomy in cir-
cumferential burns

APPLICATION
For ED procedure itself, the prepared enzyme gel is calculated with 2 g of enzyme powder per treated % BSA,
which is applied on the wound after rehydration. Unburned skin, mucosa and especially cornea and tym-
panic membrane must be protected thoroughly from contact with the gel by stoma paste or vaseline gauze.
The active gel for ED is fixed with an occlusive dressing in order to increase the contact surface. To ensure
removal of entire eschar, the gel should be placed on the wound for at least 4 h. In the absence of adverse ef-
fects of longer contact time, the enzyme can be safely left on the wound beyond the 4 h recommended by the
[10]
producer .

After removal of the enzyme gel including debris and mechanical cleaning, wound bed evaluation is neces-
sary with regard to the bleeding pattern, followed by a post-soaking phase to remove further remnants of
debris and enzyme gel. Post-soaking again can be performed with saline or anti-infective solutions while a
superiority could not be shown by now for any agent. Duration of post-soaking should be at least 2 h, but
some users report superior results with a prolonged post-soaking of up to 12 h.

WOUND BED ASSESSMENT
One key point in treating burn wounds with ED is the postprocedural wound bed assessment. It should be
performed prior to the post-soaking phase and after mechanical removal of gel remnants and debris. Pho-
tography of the wound is recommended to archive the results and as basis for further professional decision in
case of late-night application. At this time, depth of the burn injury and the need for further surgical proce-
dures should be estimated by assessment of wound bed color and bleeding patterns. A uniform pink wound
bed or a uniform white wound bed with pin-point, small and dense, punctate bleeding pattern represent a
high chance for spontaneous healing of the debrided burn wound putting the patient on a track for healing
in-between 21 days. On the other hand, a wound bed with large diameter red circles or oval patterns, distant
from each other, indicates a prolonged healing time with increased risk for necessary grafting. Exposure of
[10]
subdermal tissue like fat or blood vessels indicate a full thickness burn injury and requires grafting .

Figure 1 shows an exemplary case of a deep partial thickness burn wound treated with ED that healed with-
out split-thickness skin grafting.

POST TREATMENT
After ED, the burn wound is vulnerable and needs to be protected against wound infection and desiccation
by a suitable dressing. Some authors report the use of epidermal substitutes like Suprathel or even allografts
to cover the wound bed after ED in order to promote spontaneous reepithelization without instable scar-