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Page 6 of 7 Ziegler et al. Plast Aesthet Res 2018;5:33 I http://dx.doi.org/10.20517/2347-9264.2018.46

To provide detailed user-orientated guidelines and recommendations based on available literature as well as
on the growing amount of experience with ED in Europe, a European Consensus Workshop was held in Jan-
uary 2017. As a result, 68 consensus statements based on the combined experience of > 500 patients treated
by the panelists from 10 European burn centers could be generated. Various aspects of ED were discussed in-
cluding indications, timing of application, preparations and application technique, pain management, blood
loss, post ED wound diagnosis and management including skin grafting, scar prevention, training strategies
and areas of future research. The degree of consensus was remarkably high, with a consentaneous agreement
on 60 of the 68 statements (88.2%). The consensus statements contain detailed recommendations aiming to
align current and future users and prevent unnecessary pitfalls. and may serve as preliminary user-orientated
[10]
recommendations for the use of ED until further evidence is available .

CONCLUSION
Although the number of patients in analogue with the experience increases in literature, further research
is necessary to prove further issues of superiority of ED in comparison with SOC, especially in the field of
cost-efficiency to justify the progressive use of the technique in large surfaces > 15% TBSA. In addition, for
large-surface areas, the potential systemic impact of ED in the severely burned patients should be addressed.
Nonetheless, Bromelain-based ED is a valuable tool, technique and concept in the armamentarium of burn
surgery.

DECLARATIONS
Authors’ contributions
Conception and design: Ziegler B, Kneser U, Hirche C
Data analysis and interpretation: Ziegler B, Hundeshagen G, Cordts T
Data acquisition: Hundeshagen G, Cordts T
Administration, technic, material, and revision: Kneser U, Hirche C

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
Ziegler B is a speaker for Mediwound, Germany. Hundeshagen G and Cordts T reports no disclosures. Kne-
ser U is a consultant and speaker for Mediwound, Germany. Hirche C is a consultant and speaker for Medi-
wound, Germany and member of the advisory board, KCI, Acelity, Wiesbaden, Germany.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.

Copyright
© The Author(s) 2018.

REFERENCES
1. Xiao-Wu W, Herndon DN, Spies M, Sanford AP, Wolf SE. Effects of delayed wound excision and grafting in severely burned children.
Arch Surg 2002;137:1049-54.