Biobrane in the treatment of burn and scald injuries in children

Evaluation of EpiProtect® microbial cellulose burns dressings in young children

INTRODUCTION

EpiProtect® is a biosynthetic cellulose dressing indicated for the treatment of superficial burns and the dressing of deep burns. Prior to this study the youngest reported patient treated with EpiProtect® was aged 13 years.

METHOD

Data were collected prospectively for patients aged < 5 years, presenting to the Children's Burns Unit with ⩾ 2% total body surface area (TBSA) burns sustained by any mechanism.

RESULTS

Thirty children were treated (median age = 17 months, age range = 1-61 months). Thirty-six burn depths were documented: superficial partial thickness (SPT) in 53% (n=19); mid-partial thickness (MPT) in 33% (n=12); deep partial thickness (DPT) in 11% (n=4); and full thickness (FT) in 3% (n=1). Median burn size was 4.5% TBSA (range = 2%-12%). EpiProtect® was applied under general anaesthesia in all cases. The median length of stay (LOS) was two days (range = 0-6 days). EpiProtect® was tolerated well and provided effective analgesia for subsequent dressing changes. Median healing time was 13 days (SPT burns), 14 days (MPT) and 24 days (DPT burns). Three patients required split skin grafting. Hypertrophic scarring arose in one patient.

DISCUSSION

This case series represents the youngest published patient group to have been treated with EpiProtect®. Authors conclude that EpiProtect® provides a safe, reliable and well-tolerated dressing option for all burn depths in young children. Importantly, EpiProtect® is culturally neutral and may be used in situations which, for cultural reasons, may preclude the use of animal-derived products. Further studies are warranted to evaluate pain scores, burn depth, size and LOS correlation, and comparative analysis between dressing types.

LAY SUMMARY

Burn injuries in the paediatric population are common and often require multiple dressing changes. Dressing changes can be painful and distressing to both children and their care givers. This article describes the experience of using a synthetically derived burns dressing, called EpiProtect®, in children aged ⩽ 5 years. Thirty patients were recruited with varying depths of scald burns and all underwent application of EpiProtect® dressing. The results suggested that EpiProtect® was a user-friendly dressing that can be used to treat partial-thickness burns and to dress full-thickness (FT) burns. It was well-tolerated and provided effective analgesia at the time of dressing changes. There was no incidence of increased burn wound infection rates and all wounds healed. In addition, as EpiProtect® is a synthetic product, it has the benefit of being culturally neutral, which is advantageous in a culturally diverse population. Further studies are warranted to evaluate the effectiveness of this dressing and to compare it to similar dressings that are available.

Wound Coverage Technologies in Burn Care: Established Techniques

Major advances in burn care have reduced post-burn morbidity and mortality. The development and incorporation of new wound healing modalities into the clinical arena have contributed to this improvement by allowing standard-of-care regimens to be established. These regimens range from early excision to the use of cultured epithelial autograft. Here, we review the wound care options that are now well established and used by many burn surgeons.

Delayed Healing Associated with Silver Sulfadiazine Use for Partial Thickness Scald Burns in Children

Burns are a leading cause of injury in children. Management principles vary widely, with no consensus about the best treatment. The purpose of this study was to compare outcomes of three different dressings for pediatric partial-thickness scald burns. A retrospective, single-center study was conducted for patients 0–16 years old with a diagnosis of acute partial-thickness scald burn between July 2007 and December 2012. Data regarding prehospital, inpatient, and outpatient course were collected. Cohort was stratified into topical antimicrobial (TA) ointment, silver sulfadiazine (SS), and biosynthetic dressing (BD) groups for analysis. The primary outcome of interest was time to full healing. One hundred and seventy-seven patients met all study criteria. Overall, mean total body surface area burned was 8.3 per cent. TAwas used in 24 per cent cases, SS in 32 per cent, and BD in 44 per cent. The groups were comparable in terms of presenting burn characteristics and hospital course with the exception of the BD group being associated with greater extent of injury. Patients treated with SS had a significantly longer time to full healing and increased requirement of compression garments for scar therapy. Based on these data, the authors have amended their practice and presently use BD or TA dressings to improve healing.

Biobrane dressing for paediatric burns in Singapore: a retrospective review

INTRODUCTION

The ideal burn dressing for children should aim to alleviate pain, decrease length of hospital stay and minimise complications such as conversion and infection. The current literature is still inconclusive with regard to the gold standard burn dressing for the paediatric population.

METHODS

We retrospectively reviewed children with superficial partial thickness burns admitted to our paediatric burns unit from January 2014 to April 2015. A total of 30 patients were included in our study, of whom 13 had Biobrane^® dressing. The remaining 17 patients were treated with conventional silver foam dressing (i.e. Biatain^® Ag) and served as matched controls. Long-term follow-up scar evaluation was carried out at an average interval of two years after injury.

RESULTS

In the Biobrane group, the length of hospital stay was significantly shorter (Biobrane vs. silver foam: 4.76 ± 2.64 days vs. 8.88 ± 5.09 days; p = 0.01) and the infection rate was significantly lower (Biobrane vs. silver foam: 0% vs. 35.3%; p = 0.02). The Biobrane group had no hypergranulation or wound infection and did not require skin grafting. Long-term follow-up scar evaluation did not reveal any statistical difference between the patient groups at the two-year interval.

CONCLUSION

Paediatric patients with partial thickness burns treated with Biobrane dressing had shorter hospital stay and lower incidence of infection compared to those treated with conventional silver foam dressing. Biobrane and silver foam dressings did not demonstrate any significant difference in terms of long-term scar outcomes over an average follow-up duration of two years.

Lack of a standardised UK care pathway resulting in national variations in management and outcomes of paediatric small area scalds

INTRODUCTION

There is a paucity of evidence guiding management of small area partial thickness paediatric scalds. This has prevented the development of national management guidelines for these injuries. This research aimed to investigate whether a lack of evidence for national guidelines has resulted in variations in both management and outcomes of paediatric small area scalds across England and Wales (E&W).

METHODS

A national survey of initial management of paediatric scalds ≤5% Total Body Surface Area (%TBSA) was sent to 14 burns services in E&W. Skin graft rates of anonymised burns services over seven years were collected from the international Burns Injury Database (iBID). Average skin grafting rates across services were compared. Length of stay and proportion of patients receiving general anaesthesia for dressing application at each service were also compared.

RESULTS

All 14 burns services responded to the survey. Only 50% of services had a protocol in place for the management of small area burns. All protocols varied in how partial thickness paediatrics scalds ≤5% TBSA should be managed. There was no consensus as to which scalds should be treated using biosynthetic dressings. Data from iBID for 11,917 patients showed that the average reported skin grafting rate across all burns services was 2.3% (95% CI 2.1, 2.6) but varied from 0.3% to 7.1% (P<0.001). Service provider remained associated with likelihood of skin grafting when variations in the %TBSA case mix seen by each service were controlled for (χ(2)=87.3, P<0.001). The use of general anaesthetics across services varied between 0.6 and 35.5% (P<0.001). The median length of stay across services varied from 1 to 3 days (P<0.001).

DISCUSSION

A lack of evidence guiding management of small-area paediatric scalds has resulted in variation in management of these injuries across E&W. There is also significant variation in outcomes for these injuries. Further research is indicated to determine if care pathways and outcomes are linked. An evidence-based national policy for the management of small area paediatric scalds would ensure that high quality, standardised care is delivered throughout E&W and variations in outcome are reduced.

Rapid expansion and auto-grafting efficiency of porcine full skin expanded by a skin bioreactor ex vivo

Full skin auto-grafts are required for reconstruction of skin burns and trauma scars. However, currently available clinical approaches such as sheet skin graft, mesh skin grafts, artificial skin graft, and in vivo skin expansion have limitations due to their potential danger for secondary damage and scar formation at the donor site, and discomfort during skin expansion. We developed an advanced bioreactor system and evaluated its function in skin expansion using porcine full skin. The reactor was designed as a pneumatic cylinder type, was programmed to adjust the pressure and the operating time. The system was composed of culture chamber unit, environmental control unit, and monitoring unit. Skins were expanded at 200 kPa pneumatic force and the expanded skins were analyzed by immunohistochemistry and histology. Furthermore we carried out auto-grafting experiment of the expanded skins in vivo using Yucatan pigs and skins were harvested and histologically analyzed after 8 weeks. The results showed that the bioreactor expanded skins to 160% in 4 hours. Histological analysis of the expanded skins revealed that epidermal cells and dermal fibroblasts were viable and remained integrity. The results of auto-grafting experiment indicated that fibrosis and scars were not detected in the grafted skins. This study demonstrates that the newly developed skin bioreactor enabled to obtain large sized full skin rapidly and successful grating.

Gallium-Loaded Dissolvable Microfilm Constructs that Provide Sustained Release of Ga(3+) for Management of Biofilms

The persistence of bacterial biofilms in chronic wounds delays wound healing. Although Ga(3+) can inhibit or kill biofilms, precipitation as Ga(OH)3 has prevented its use as a topical wound treatment. The design of a microfilm construct comprising a polyelectrolyte film that releases noncytotoxic concentrations of Ga(3+) over 20 d and a dissolvable micrometer-thick film of polyvinylalcohol that enables facile transfer onto biomedically important surfaces is reported. By using infrared spectroscopy, it is shown that the density of free carboxylate/carboxylic acid and amine groups within the polyelectrolyte film regulates the capacity of the construct to be loaded with Ga(3+) and that the density of covalent cross-links introduced into the polyelectrolyte film (amide-bonds) controls the release rate of Ga(3+) . Following transfer onto the wound-contact surface of a biologic wound dressing, an optimized construct is demonstrated to release ≈0.7 μg cm(-2) d(-1) of Ga(3+) over 3 weeks, thus continuously replacing Ga(3+) lost to precipitation. The optimized construct inhibits formation of P. aeruginosa (two strains; ATCC 27853 and PA01) biofilms for up to 4 d and causes pre-existing biofilms to disperse. Overall, this study provides designs of polymeric constructs that permit facile modification of the wound-contacting surfaces of dressings and biomaterials to manage biofilms.

The safety of general anaesthesia in paediatric patients undergoing the application of Biobrane® for small scalds

BACKGROUND

Each year more than 5000 children present to English and Welsh hospitals for the management of scalds; 60% of these are small scalds of less than 10% body surface area. There are no agreed UK care pathways for this injury. One method of management is to use a biosynthetic wound dressing after thorough wound cleaning. In children, this usually utilises general anaesthesia. This study investigates the incidence of adverse events during anaesthesia for the application of biosynthetic dressings in children with small-area scalds.

METHODS

The medical records of 500 consecutive admissions to a tertiary care paediatric burn centre between July 1st 2007 and June 30th 2012 were analysed. The primary outcome was any patient-related adverse event incurred as a result of the general anaesthesia. Secondary outcomes included delays in discharge and any recovery sequelae to the adverse events.

RESULTS

There were 21 (4.2%) documented adverse events associated with 500 episodes of anaesthesia. Of these, the majority (52%) were documented as self-resolving laryngospasm. All episodes were temporary with no recovery sequelae and did not delay discharge from the post-anaesthetic recovery area.

CONCLUSIONS

The use of general anaesthesia in this setting for the application of biosynthetic dressings in children with small-area scalds has a low incidence of anaesthesia-related complications with no associated long-term sequelae. This incidence is similar to that quoted for adverse events related to anaesthesia for other procedures and is lower than that reported for procedures using sedation.

Reduction in wound bioburden using a silver-loaded dissolvable microfilm construct

Silver is a widely used antimicrobial agent, yet, when impregnated in macroscopic dressings, it stains wounds, can lead to tissue toxicity, and can inhibit healing. Recently, polymeric nanofilms containing silver nanoparticles were reported to exhibit antimicrobial activity at loadings and release rates of silver that are 100× lower than conventional dressings. Here, fabrication of composite microfilm constructs that provide a facile way to transfer the silver-loaded polymeric nanofilms onto wounds in vivo is reported. The construct is fabricated from a silver nanoparticle-loaded polymeric nanofilm that is laminated with a micrometer-thick-soluble film of polyvinylalcohol (PVA). When placed on a moist wound, the PVA dissolves, leaving the silver-loaded nanofilm immobilized on the wound-bed. In vitro, the immobilized nanofilms release <1 μg cm(-2) d(-1) of silver over 30 d from skin dermis and they kill 5 log10 CFUs of Staphylococcus aureus in 24 h. In mice, wounds inoculated with 10(5) CFU S. aureus presented up to 3 log10 less bacterial burden when treated with silver/nanofilms for 3 d, as compared to unmodified wounds. In uncontaminated wounds, silver/nanofilms allow normal and complete wound closure by re-epithelialization. Dissolvable microfilm constructs may overcome key limitations associated with current uses of silver in wound healing.

Biological therapies for the treatment of cutaneous wounds: phase III and launched therapies

INTRODUCTION

Normal wound healing mechanisms can be overwhelmed in the setting of complex acute and chronic tissue injury. Biological therapies are designed to augment and/or restore the body's natural wound healing abilities. There are a variety of available and emerging technologies utilizing this approach that have demonstrated the ability to augment wound healing.

AREAS COVERED

In this review, the clinical data on launched and emerging biological therapies for wound healing applications are summarized. The methodologies discussed include biological skin equivalents, growth factors/small molecules and stem cell-based therapies.

EXPERT OPINION

While many products possess convincing clinical data demonstrating their efficacy in comparison to standard treatment options, more robust, controlled studies are needed to determine the relative value among established and emerging biological therapies. Future bioengineering and stem cell-based approaches are of particular interest due to the simultaneous correction of multiple deficiencies present in the nonhealing wound.

Antibacterial efficacy of silver-impregnated polyelectrolyte multilayers immobilized on a biological dressing in a murine wound infection model

OBJECTIVE

To investigate the antibacterial effect of augmenting a biological dressing with polymer films containing silver nanoparticles.

BACKGROUND

Biological dressings, such as Biobrane, are commonly used for treating partial-thickness wounds and burn injuries. Biological dressings have several advantages over traditional wound dressings. However, as many as 19% of wounds treated with Biobrane become infected, and, once infected, the Biobrane must be removed and a traditional dressing approach should be employed. Silver is a commonly used antimicrobial in wound care products, but current technology uses cytotoxic concentrations of silver in these dressings. We have developed a novel and facile technology that allows immobilization of bioactive molecules on the surfaces of soft materials, demonstrated here by augmentation of Biobrane with nanoparticulate silver. Surfaces modified with nanometer-thick polyelectrolyte multilayers (PEMs) impregnated with silver nanoparticles have been shown previously to result in in vitro antibacterial activity against Staphylococcus epidermidis at loadings of silver that are noncytotoxic.

METHODS

We demonstrated that silver-impregnated PEMs can be nondestructively immobilized onto the surface of Biobrane (Biobrane-Ag) and determined the in vitro antibacterial activity of Biobrane-Ag with Staphylococcus aureus. In this study, we used an in vivo wound infection model in mice induced by topical inoculation of S aureus onto full-thickness 6-mm diameter wounds. After 72 hours, bacterial quantification was performed.

RESULTS

Wounds treated with Biobrane-Ag had significantly (P < 0.001) fewer colony-forming units than wounds treated with unmodified Biobrane (more than 4 log10 difference).

CONCLUSIONS

The results of our study indicate that immobilizing silver-impregnated PEMs on the wound-contact surface of Biobrane significantly reduces bacterial bioburden in full-thickness murine skin wounds. Further research will investigate whether this construct can be considered for human use.

An evaluation of five different dressing materials on split-thickness skin graft donor site and full-thickness cutaneous wounds: an experimental study

The objective of this study was to investigate the healing effect of five different products on split-thickness skin graft (STSG) donor sites and full-thickness cutaneous wounds (FTCWs) using an occlusive dressing model. Six groups were included: 1 control and 5 experimental groups, with a total of 24 rats, using an occlusive dressing model. STSG donor sites and FTCWs were established in two separate areas, to the right and left on the animals' backs. Wound sites were dressed with one of the following materials: fine mesh gauze, microporous polysaccharide hemosphere (MPH), clinoptilolite, alginate, hydrogel or biosynthetic wound dressing (Biobran(®) ). These materials were compared in terms of healing rate, healing quality and histopathological findings. Occlusive dressings were applied to each wound on days 0, 3, 5, 7, 10 and 14. Area measurements were taken using images of each dressing. The alginate and clinoptilolite groups gave the best healing rate results for both STSG donor sites (P = 0·003) and FTCWs (P = 0·003). MPH came third in each group. The alginate group produced better results in terms of healing quality criteria, followed by hydrogel, MPH, clinoptilolite and Biobran(®) , in that order. Statistically significant results were obtained in all groups compared to the control group (P < 0·0007). Rapid and good healing quality for both the STSG donor sites and FTCWs were obtained with alginate. Healing with clinoptilolite and MPH was rapid, but poor quality, while slower but good healing quality was obtained with hydrogel. Slower and worse quality healing was obtained with Biobran(®) .

Polymeric multilayers that localize the release of chlorhexidine from biologic wound dressings

Biologic wound dressings contain animal-derived components and are susceptible to high infection rates. To address this issue, we report an approach that permits incorporation of non-toxic levels of the small molecule antiseptic 'chlorhexidine' into biologic dressings. The approach relies on the fabrication of polyelectrolyte multilayer (PEMs) films containing poly(allylaminehydrochloride) (PAH), poly(acrylicacid) (PAA), and chlorhexidine acetate (CX) on elastomeric poly(dimethylsiloxane) (PDMS) sheets. The PEMs (20-100 nm thick) are subsequently stamped onto the wound-contact surface of a synthetic biologic dressing, Biobrane, which contains collagen peptides. Chlorhexidine loading in the PEMs was tailored by tuning the number of (CX/PAA) bilayers deposited, providing burst release of up to 0.98 ± 0.06 μg/cm(2) of CX over 24 h, followed by zero-order release of 0.35 ± 0.04 μg/cm(2)/day for another week. Although the CX concentrations released were below the reported in vitro cytotoxicity limit (5 μg/mL over 24 h) for human dermal fibroblasts, they killed 4 log(10) counts of pathogenic bacteria Staphylococcus aureus in solution. The CX/PEMs could be stamped onto Biobrane with high efficiency to provide CX release kinetics and in vitro antibacterial activity similar to that on PDMS stamps. In a full-thickness 'splinted' dermal wound-model in normal wild-type mice, the CX-functionalized Biobrane showed no decrease in either its adherence to the wound-bed or wound closure rate over 14 days. The murine wounds topically inoculated with ∼10(5) CFU/cm(2) of S. aureus and treated with CX-functionalized Biobrane demonstrated a 3 log(10) decrease in the wound's bacterial burden within 3 days, compared to persistent bacterial colonization found in wounds treated with unmodified Biobrane (n = 10 mice, p < 0.005). Overall, this study presents a promising approach to prevent bacterial colonization in wounds under biologic dressings.

Effectiveness of Biobrane for treatment of partial-thickness burns in children

PURPOSE

Wound care for partial-thickness burns should alleviate pain, decrease hospital length of stay, and be readily applied to a variety of wounds. The effectiveness of Biobrane (UDL Laboratories, Rockford, IL) is compared with that of Beta Glucan Collagen (BGC; Brennan Medical, St. Paul, MN) in a retrospective cohort study.

METHODS

A retrospective chart review of all children treated at a tertiary care pediatric hospital between 2003 and 2009 identified patients with partial-thickness burns treated with Biobrane. These patients were compared with historical controls treated with BGC.

RESULTS

A total of 235 children between the ages of 4 weeks and 18 years with an average of 6.0% body surface area partial-thickness burns were treated with Biobrane. In a multivariate statistical analysis, patients treated with Biobrane healed significantly faster than those treated with BGC (Biobrane vs BGC: median, 9 vs 13 days; P = .019; hazard ratio, 1.68). In addition, patients who required inpatient treatment trended toward having shorter length of hospital stay in the Biobrane group (2.6 vs 4.1 days, P = .079).

CONCLUSION

Partial-thickness burn care consists of early debridement and application of a burn wound dressing. Biobrane dressings result in faster healing compared with BGC and may decrease hospital length of stay for patients requiring inpatient admission.

Current scales for assessing human scarring: a review

Patients can have wide-ranging problems related to scars, in terms of cosmesis, function, symptoms, psychological problems and overall quality of life issues. A range of treatments have been recommended for problematic scarring, however it has been acknowledged that the evidence base for most of the recommendations for scar therapy is limited, with few studies using validated measures of scar assessment in generating data. This review critically evaluates the subjective scar assessment scales developed to date and provides an insight into developments required in this area for the future. The principles of psychometric theory are discussed as a means of developing reliable and valid outcome measures and these are also applicable for measuring outcomes in other fields of plastic surgery research.

Permanent scarring in a partial thickness scald burn dressed with Biobrane

Biobrane is a biosynthetic wound dressing which has shown to be effective in partial thickness burns by improving wound healing, reducing the pain in dressing changes, and the need to use skin grafts. In addition, it has been shown to reduce both in-patient and outpatient hospital costs and incur no increase in infection rates. Recently, the first reported case of punctate scarring from the use of Biobrane in a paediatric scald was published [Hassan Z, Shah M. Punctate scarring from use of porous Biobrane. Burns 2006;32:258-60]. We now report a second case of scarring with Biobrane, in which the Biobrane was left in place for a full 14 days, as recommended by the manufacturers.

Biomaterial scaffolds in pediatric tissue engineering

This article reviews recent developments and major issues in the use and design of biomaterials for use as scaffolds in pediatric tissue engineering. A brief history of tissue engineering and the limitations of current tissue-engineering research with respect to pediatric patients have been introduced. An overview of the characteristics of an ideal tissue-engineering scaffold for pediatric applications has been presented, including a description of the different types of scaffolds. Applications of scaffolds materials have been highlighted in the fields of drug delivery, bone, cardiovascular, and skin tissue engineering with respect to the pediatric population. This review highlights biomaterials as scaffolds as an alternative treatment method for pediatric surgeries due to the ability to create a functional cell-scaffold environment.

The use of Biobrane by burn units in the United Kingdom: a national study

Biobrane is a biosynthetic wound dressing, first used by Woodruff in 1979, which has many of the ideal properties of a dressing as outlined by Pruitt and Levine [Pruitt Jr BA, Levine NS. Characteristics and uses of biologic dressings and skin substitutes. Arch Surg 1984;119(3):312-22]. It is becoming increasingly popular in the management of superficial and moderate depth partial thickness burns and a range of other conditions. When used appropriately, it has been shown to reduce pain levels, healing time, inpatient stay and nursing requirements when compared to traditional dressings. We present the results of a national study concerning the use of Biobrane in the United Kingdom, highlight variations in practice, discuss the pertinent issues, make suitable recommendations and highlight the versatility of Biobrane as a wound dressing.

Paediatric partial-thickness scald burns--is Biobrane the best treatment available?

The article critically analyses the role of Biobrane, one of the widely used modern biosynthetic dressings, in paediatric partial-thickness scald burns. Most of the studies, available in the literature, confirmed that Biobrane has significantly reduced the hospital stay, wound healing time and requirements of pain medications. However, very few studies with long-term follow up are available. Further randomised controlled trials are required to challenge the supremacy of Biobrane in paediatric partial-thickness burns.