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Efficiency of platelet-rich plasma in the management of burn wounds: A meta-analysis
Imam, M. S., Alotaibi, A. A. S., Alotaibi, N. O. M., Alosaimi, N. S., Alotaibi, S. G. M., Abdelrahim, M. E. A.
International wound journal. 2023
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Abstract
The meta-analysis aimed to assess the efficiency of platelet-rich plasma (PRP) in the management of burn wounds (BWs). Using dichotomous or contentious random- or fixed-effects models, the outcomes of this meta-analysis were examined and the odds ratio (OR) and the mean difference (MD) with 95% confidence intervals (CIs) were computed. Thirteen examinations from 2009 to 2023 were enrolled for the present meta-analysis, including 808 individuals with BWs. PRP had significantly shorter healing time (MD, -5.80; 95% CI, -7.73 to -3.88, p < 0.001), higher healing rate (OR, 3.14; 95% CI, 2.05-4.80, p < 0.001), higher healed area percent (MD, 12.67; 95% CI, 9.79-15.55, p < 0.001) and higher graft take area percent (MD, 4.39; 95% CI, 1.51-7.26, p = 0.003) compared with standard therapy in patients with BW. However, no significant difference was found between PRP and standard therapy in graft take ratio (OR, 1.70; 95% CI, 0.86-3.34, p = 0.13) and infection rate (OR, 0.55; 95% CI, 0.20-1.47, p = 0.23) in patients with BW. The examined data revealed that PRP had a significantly shorter healing time, a higher healing rate, a higher healed area percent and a higher graft take area percent; however, no significant difference was found in graft take ratio or infection rate compared with standard therapy in patients with BW. Yet, attention should be paid to its values since all of the selected examinations had a low sample size and some comparisons had a low number of selected studies.
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Effect of platelet-rich plasma in treating patients with burn wounds: A meta-analysis
Lin, C., Xin, L., Xie, S.
International wound journal. 2023
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A meta-analysis was conducted to investigate the effects of platelet-rich plasma (PRP) in the treatment of burn wounds and to provide a scientific basis for clinical drug therapy. We searched PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure and Wanfang databases to identify randomised controlled trials (RCTs) on PRP in treating burn wounds, with the control group being treated with conventional treatments and the intervention group being treated with PRP alone or combined with PRP on the basis of the control group. The search duration was each database's inception to September 2023. The literature was screened, data were extracted and quality was assessed by two independent researchers. Data analysis was performed using the Review Manager 5.4 software. Eighteen RCTs comprising 1463 patients were included in the analysis. The meta-analysis revealed that the application of PRP significantly improved the wound healing rate (standardised mean difference [SMD]: 1.11, 95% confidence interval [CI]: 0.54-1.67, p < 0.001), shortened wound healing time (SMD: -1.69, 95% CIs: -2.21 to -1.17, p < 0.001) and reduced the incidence of adverse events (7.03% vs. 18.93%, odds ratio [OR]: 0.32, 95% CI: 0.20-0.53, p < 0.001), and also significantly reduced patients' pain (SMD: -1.86, 95% CI: -2.47 to -1.25, p < 0.001) of burn patients when compared with the control group. This study showed that PRP is effective in repairing burn wounds, promoting wound healing, reducing the incidence of adverse events and reducing patient pain, making it worthy of clinical promotion and application.
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Bromelain-based enzymatic burn debridement: A systematic review of clinical studies on patient safety, efficacy and long-term outcomes
Shoham, Y., Gasteratos, K., Singer, A. J., Krieger, Y., Silberstein, E., Goverman, J.
International wound journal. 2023
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Abstract
In 2012 the European Medicines Agency approved a pineapple stem-derived Bromelain-based debridement concentrate of proteolytic enzymes (NexoBrid®, MediWound Ltd, Yavne, Israel) for adult deep burns. Over 10 000 patients have been successfully treated with NexoBrid® globally, including in the US. The aim of our study is to perform a systematic review of the current literature on Nexobrid® outcomes. We conducted a literature search in PubMed, Google Scholar, Embase, and other search engines (2013-2023). The online screening process was performed by two independent reviewers with the Covidence tool. The protocol was reported using the Preferred Reporting Items for Systematic Review and Meta-Analyses, and it was registered at the International Prospective Register of Systematic Reviews of the National Institute for Health Research. We identified 103 relevant studies of which 34 were found eligible. The included studies report the positive effects of Nexobrid® on burn debridement, functional and cosmetic outcomes, scarring, and quality of life. Also, they validate the high patient satisfaction thanks to enhanced protocols of analgosedation and/or locoregional anaesthesia during Bromelain-based debridement. Two studies investigate potential risks (coagulopathy, burn wound infection) which concluded there is no strong evidence of these adverse events. NexoBrid® is a safe, selective, non-surgical eschar removal treatment modality. The benefits of Bromelain-based debridement are faster debridement and healing times, reduced operations, length of stay, cases of sepsis, blood transfusions, and prevention of compartment syndrome. Existing evidence suggests that the indications and the role of Bromelain-based debridement are expanding to cover "off-label" cases with significant benefits to the global healthcare economy.
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Vasoactive and/or inotropic drugs in initial resuscitation of burn injuries: A systematic review
Knappskog K, Andersen NG, Guttormsen AB, Onarheim H, Almeland SK, Beitland S
Acta anaesthesiologica Scandinavica. 2022
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BACKGROUND According to current guidelines initial burn resuscitation should be performed with fluids alone. The aims of the study were to review the frequency of use of vasoactive and/or inotropic drugs in initial burn resuscitation, and assess benefits and harms of adding such drugs to fluids. METHODS A systematic literature search was conducted in PubMed, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, UpToDate, and SveMed+ through 3 December 2021. The search included studies on critically ill burn patients receiving vasoactive and/or inotropic drugs in addition to fluids within 48 hours after burn injury. RESULTS The literature search identified 1058 unique publications that were screened for inclusion. After assessing 115 publications in full text, only two retrospective cohort studies were included. One study found that 16 out of 52 (31%) patients received vasopressor(s). Factors associated with vasopressor use were increasing age, burn depth and % total body surface area (TBSA) burnt. Another study observed that 20 out of 111 (18%) patients received vasopressor(s). Vasopressor use was associated with increasing age, Baux score and %TBSA burnt in addition to more frequent dialysis treatment and increased mortality. Study quality assessed by the Newcastle-Ottawa quality assessment scale was considered good in one study, but uncertain due to limited description of methods in the other. CONCLUSION This systematic review revealed that there is lack of evidence regarding benefits and harms of using vasoactive and/or inotropic drugs in addition to fluids during early resuscitation of patients with major burns.
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Examining 1:1 Versus 4:1 Packed Red Blood Cell to Fresh Frozen Plasma Ratio Transfusion During Pediatric Burn Excision
Tejiram S, Sen S, Romanowski KS, Greenhalgh DG, Palmieri TL
Journal of burn care & research : official publication of the American Burn Association. 2020
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Blood transfusions following major burn injury are common due to operative losses, blood sampling, and burn physiology. While massive transfusion improves outcomes in adult trauma patients, literature examining its effect in critically ill children is limited. The study purpose was to prospectively compare outcomes of major pediatric burns receiving a 1:1 vs 4:1 packed red blood cell (PRBC) to fresh frozen plasma (FFP) transfusion strategy during massive burn excision. Children with >20% total body surface area (TBSA) burns were randomized to a 1:1 or 4:1 PRBC/FFP transfusion ratio during burn excision. Parameters examined include patient demographics, burn size, Pediatric Risk of Mortality (PRISM) scores, Pediatric Logistic Organ Dysfunction (PELOD) scores, laboratory values, total blood products transfused, and the presence of blood stream infections or pneumonia. A total of 68 children who met inclusion criteria were randomized into two groups (n=34). Mean age, PRISM scores, estimated blood loss (600 mL (400 - 1175 mL) v 600 mL (300 - 1150 mL), p = 0.68), ventilator days (5 v 9, p = 0.47), and length of stay (57 v 60 days, p = 0.24) had no difference. No differences in frequency of blood stream infection (20 v 18, p = 0.46) or pneumonia events (68 v 116, p = 0.08) were noted. On multivariate analysis, only TBSA burn size, inhalation injury, and PRISM scores (p < 0.05) were significantly associated with infections.
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Restrictive Transfusion Strategy Is More Effective in Massive Burns: Results of the TRIBE Multicenter Prospective Randomized Trial
Palmieri TL, Holmes JH, Arnoldo B, Peck M, Cochran A, King BT, Dominic W, Cartotto R, Bhavsar D, Tredget E, et al
Military Medicine. 2018
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Objectives: Studies suggest that a restrictive transfusion strategy is safe in burns, yet the efficacy of a restrictive transfusion policy in massive burn injury is uncertain. Our objective: compare outcomes between massive burn (≥60% total body surface area (TBSA) burn) and major (20-59% TBSA) burn using a restrictive or a liberal blood transfusion strategy. Methods: Patients with burns ≥20% were block randomized by age and TBSA to a restrictive (transfuse hemoglobin <7 g/dL) or liberal (transfuse hemoglobin <10 g/dL) strategy throughout hospitalization. Data collected included demographics, infections, transfusions, and outcomes. Results: Three hundred and forty-five patients received 7,054 units blood, 2,886 in massive and 4,168 in restrictive. Patients were similar in age, TBSA, and inhalation injury. The restrictive group received less blood (45.57 +/- 47.63 vs. 77.16 +/- 55.0, p < 0.03 massive; 11.0 +/- 16.70 vs. 16.78 +/- 17.39, p < 0.001) major). In massive burn, the restrictive group had fewer ventilator days (p < 0.05). Median ICU days and LOS were lower in the restrictive group; wound healing, mortality, and infection did not differ. No significant outcome differences occurred in the major (20-59%) group (p > 0.05). Conclusions: A restrictive transfusion strategy may be beneficial in massive burns in reducing ventilator days, ICU days and blood utilization, but does not decrease infection, mortality, hospital LOS or wound healing.
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The Effects of Storage Age of Blood in Massively Transfused Burn Patients: A Secondary Analysis of the Randomized Transfusion Requirement in Burn Care Evaluation Study
Cartotto R, Taylor SL, Holmes JH 4th, Peck M, Cochran A, King BT, Bhavsar D, Tredget EE, Mozingo D, Greenhalgh D, et al
Critical Care Medicine. 2018;46((12):):e1097-e1104.
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OBJECTIVES Major trials examining storage age of blood transfused to critically ill patients administered relatively few blood transfusions. We sought to determine if the storage age of blood affects outcomes when very large amounts of blood are transfused. DESIGN A secondary analysis of the multicenter randomized Transfusion Requirement in Burn Care Evaluation study which compared restrictive and liberal transfusion strategies. SETTING Eighteen tertiary-care burn centers. PATIENTS Transfusion Requirement in Burn Care Evaluation evaluated 345 adults with burns greater than or equal to 20% of the body surface area. We included only the 303 patients that received blood transfusions. INTERVENTIONS The storage ages of all transfused red cell units were collected during Transfusion Requirement in Burn Care Evaluation. A priori measures of storage age were the the mean storage age of all transfused blood and the proportion of all transfused blood considered very old (stored ≥ 35 d). MEASUREMENTS AND MAIN RESULTS The primary outcome was the severity of multiple organ dysfunction. Secondary outcomes included time to wound healing, the duration of mechanical ventilation, and in-hospital mortality. There were 6,786 red cell transfusions with a mean (+/- SD) storage age of 25.6 +/- 10.2 days. Participants received a mean of 23.4 +/- 31.2 blood transfusions (range, 1-219) and a mean of 5.3 +/- 10.7 units of very old blood. Neither mean storage age nor proportion of very old blood had any influence on multiple organ dysfunction severity, time to wound healing, or mortality. Duration of ventilation was significantly predicted by both mean blood storage age and the proportion of very old blood, but this was of questionable clinical relevance given extreme variability in duration of ventilation (adjusted r ≤ 0.01). CONCLUSIONS Despite massive blood transfusion, including very old blood, the duration of red cell storage did not influence outcome in burn patients. Provision of the oldest blood first by Blood Banks is rational, even for massive transfusion.
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Transfusion Requirement in Burn Care Evaluation (TRIBE): a multicenter randomized prospective trial of blood transfusion in major burn injury
Palmieri TL, Holmes JH 4th, Arnoldo B, Peck M, Potenza B, Cochran A, King BT, Dominic W, Cartotto R, Bhavsar D, et al
Annals of Surgery. 2017;266((4):):595-602
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OBJECTIVE Our objective was to compare outcomes of a restrictive to a liberal red cell transfusion strategy in 20% or more total body surface area (TBSA) burn patients. We hypothesized that the restrictive group would have less blood stream infection (BSI), organ dysfunction, and mortality. BACKGROUND Patients with major burns have major (>1 blood volume) transfusion requirements. Studies suggest that a restrictive blood transfusion strategy is equivalent to a liberal strategy. However, major burn injury is precluded from these studies. The optimal transfusion strategy in major burn injury is thus needed but remains unknown. METHODS This prospective randomized multicenter trial block randomized patients to a restrictive (hemoglobin 7-8 g/dL) or liberal (hemoglobin 10-11 g/dL) transfusion strategy throughout hospitalization. Data collected included demographics, infections, transfusions, and outcomes. RESULTS Eighteen burn centers enrolled 345 patients with 20% or more TBSA burn similar in age, TBSA burn, and inhalation injury. A total of 7054 units blood were transfused. The restrictive group received fewer blood transfusions: mean 20.3 +/- 32.7 units, median = 8 (interquartile range: 3, 24) versus mean 31.8 +/- 44.3 units, median = 16 (interquartile range: 7, 40) in the liberal group (P < 0.0001, Wilcoxon rank sum). BSI incidence, organ dysfunction, ventilator days, and time to wound healing (P > 0.05) were similar. In addition, there was no 30-day mortality difference: 9.5% restrictive versus 8.5% liberal (P = 0.892, chi test). CONCLUSIONS A restrictive transfusion strategy halved blood product utilization. Although the restrictive strategy did not decrease BSI, mortality, or organ dysfunction in major burn injury, these outcomes were no worse than the liberal strategy (Clinicaltrials.gov identifier NCT01079247).
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Measuring coagulation in burns: an evidence-based systematic review
Marsden NJ, Van M, Dean S, Azzopardi EA, Hemington-Gorse S, EvansPA, Whitaker IS
Scars, Burns & Healing. 3:2059513117728201, 2017 Jan-Dec.. 2017;3:2059513117728201
Abstract
Introduction: Dynamic monitoring of coagulation is important to predict both haemorrhagic and thrombotic complications and to guide blood product administration. Reducing blood loss and tailoring blood product administration may improve patient outcome and reduce mortality associated with transfusion. The current literature lacks a systematic, critical appraisal of current best evidence on which clinical decisions may be based. Objectives: Establishing the role of different coagulation markers in burn patients, diagnosing coagulopathy, tailoring blood product administration and indicating prognosis. Methods: Literature during 2004-2017 from the Cochrane Library, PubMed, Scopus, Medline and Embase was reviewed. Eligibility criteria included randomised controlled trials, systematic reviews, multi-/single-centre study and meta-analyses. Keywords searched were 'burns', 'blood coagulation disorders', 'rotem', 'blood coagulation' and 'thromboelastography'. The PRISMA flow system was used for stratification and the CASP framework for appraisal of the studies retrieved. Results: In total, 13 articles were included after inclusion/exclusion criteria had been applied to the initial 79 studies retrieved. Hypercoagulation increases in proportion to the severity of thermal injury. Whole blood testing, using thrombelastography (TEG) and rotation thromboelastometry (ROTEM), was superior to standard plasma based tests, including prothrombin time (PT) and activated partial thromboplastin time (APTT) at detecting burn-related coagulopathies. Conclusions: Routine laboratory markers such as PT/APTT are poor indicators of coagulation status in burns patients. Viscoelastic tests, such as TEG and ROTEM, are efficient, fast and have a potential use in the management of burn patients; however, strong evidence is lacking. This review highlights the need for more randomised controlled trials, to guide future practice.
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Autologous keratinocyte suspension in platelet concentrate accelerates and enhances wound healing - a prospective randomized clinical trial on skin graft donor sites: platelet concentrate and keratinocytes on donor sites
Guerid S, Darwiche SE, Berger MM, Applegate LA, Benathan M, Raffoul W
Fibrogenesis & Tissue Repair. 2013;6((1):):8
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BACKGROUND Wound healing involves complex mechanisms, which, if properly chaperoned, can enhance patient recovery. The abilities of platelets and keratinocytes may be harnessed in order to stimulate wound healing through the formation of platelet clots, the release of several growth factors and cytokines, and cell proliferation. The aim of the study was to test whether autologous keratinocyte suspensions in platelet concentrate would improve wound healing. The study was conducted at the Lausanne University Hospital, Switzerland in 45 patients, randomized to three different topical treatment groups: standard treatment serving as control, autologous platelet concentrate (PC) and keratinocytes suspended in autologous platelet concentrate (PC+K). Split thickness skin graft donor sites were chosen on the anterolateral thighs of patients undergoing plastic surgery for a variety of defects. Wound healing was assessed by the duration and quality of the healing process. Pain intensity was evaluated at day five. RESULTS Healing time was reduced from 13.9+/-0.5 days (mean+/-SEM) in the control group to 7.2+/-0.2 days in the PC group (P<0.01). An addition of keratinocytes in suspension further reduced the healing time to 5.7+/-0.2 days. Pain was reduced in both the PC and PC+K groups. Data showed a statistically detectable advantage of using PC+K over PC alone (P<0.01). CONCLUSION The results demonstrate the positive contribution of autologous platelets combined with keratinocytes in stimulating wound healing and reducing pain. This strikingly simple approach could have a significant impact on patient care, especially critically burned victims for whom time is of the essence. CLINICAL TRIAL REGISTRY INFORMATION Protocol Record Identification Number: 132/03. Registry URL: http://www.clinicaltrials.gov.