1. Investigating the role an Enzyme Alginogel can play in the management of burns.
Mr Peter Campbell, Dr John Vandervord, Ms Diane Van Der Saag
Royal North Shore Hospital, Sydney, Australia
Introduction
Traditionally Silver based products have formed a primary strategy in the management of Partial Thickness burns. The introduction of an Enzymatic Alginogel has provided a potential alternative for the management of partial thickness burns. Enzymatic Alginogels combine the benefit of an alginate with an enzymatic delivery system to debride and hydrate the wound.
The aim of the study was to ascertain if an Enzymatic Alginogel was of benefit in the management of partial thickness burns. To achieve this, a comparative analysis was undertaken to investigate the benefits compared to Silver foams and Nano-crystalline silver.
Conclusion
An Enzyme Alginogel has demonstrated superior action when insitu to relieve pain from the burn wound when compared to Nano-Crystalline Silver.
An Enzyme Alginogel is effective in creating a moist wound healing environment where debridement of bio-burden and wound re-epithelialisation can occur.
Wound healing times in partial thickness burns are not affect by the use of an Alginogel.
Wound interventions are more labour intensive when using a Enzymatic Alginogel but wound healing times are slightly less than when using a Silver Foam if the patient has Gram + colonisation.
Enzymatic Alginogels are as effective as Nano-Crystalline Silver in managing Gram + Staphylococcal infections.
Despite a more labour intensive approach to using Enzymatic Alginogels, potential cost savings are considerable when compared with Silver based interventions to achieve wound healing.
Enzymatic Alginogels are a valuable wound management tool for the management of partial thickness burns regardless of burn surface area.
Flame burn to arm showing Enzyme Alginogel use after confirmation of depth by LDI and outcome at day 14.
Methods
Comparative data was obtained from 29 cases where silver was used 16 (silver foam) 13 (Nano-crystalline silver) and compared against 25 patients where Enzymatic Alginogel was used. All patients had the depth of burn confirmed using LDI (Laser Doppler Imaging).
Measuring tools included; time to re-epithelialisation, pain on application and insitu, and to a smaller extent, management of gram positive staphylococcal infections.
Burns percentage ranged from 5 to 20% TBSA and pain was assessed using the Numerical Pain Rating Scale.
Time to wound healing was assessed from time of injury to the wound no longer requiring dressing interventions.
Pain was assessed by asking the patient to rate their pain before during and after the dressing procedure.
Wound colonisation was assessed by Micro Culture & Sensitivity swabs being conducted on presentation, at day 3 and day 7.
Discussion
From the data obtained, it became obvious that an Enzyme Alginogel was a viable alternative for treating Partial thickness burns. The difference in Pain scores when compared to Nano-crystalline silver were significant with little significant difference in burn wound healing times. When compared with a Silver foam there was a reduction in pain (10%) but not to the extent experienced by the Alginogel group (55%).
Patients rating of pain before, during and post-dressing, demonstrated significant decreases for Enzyme Alginogel upon application. Whilst pain is considered an individual response by every patient, all stated there was initial tingling on application with Enzyme Alginogel, but all patients in the test group did not associate the tingling with pain and found the tingling subsided within 5 minutes of application and had had no ongoing significant pain until the next wound review.
The time to apply the Enzyme Alginogel and frequency of dressing changes (2nd Daily), proved more labour intensive when compared to Nano-crystalline Silver and Silver Foam. But the cost of care from a wound management perspective was significantly less to achieve wound healing.
The ability of the Enzyme Alginogel to combat Gram + infections was significant and more effective when compared with a Silver Foam. Whilst more cases are required to confirm this outcome the combination with pain reduction was significant when compared to Nano-Crystalline silver when dealing with gram + burn wound colonisation.
Re-epithelialisation rates whilst there was no significant difference, Enzyme Alginogel did not delay wound healing when compared to both silver products used and enabled partial thickness wound healing with the 14 day period. At wound review, there was no trauma involved in the removal of the product, this was comparable to Silver foam, whilst the Nano-Crystalline silver caused trauma on removal if the product had not been kept moist.
Future Research
The studies undertaken have demonstrated Enzymatic Alginogels have the potential to significantly reduce pain whilst promoting wound re-epithelialisation in partial thickness burn injuries. The reason for this phenomenon requires further investigation to ascertain if it is due to the Enzymatic action, or the effect the Alginogel has on exposed nerve endings through moisture and protection.
To confirm the findings that Enzymatic Alginogels are effective in managing Gram + organisms, a larger population study will be required. This should include patients colonised with a variety of microorganisms.
Cost implications and the impact this has on patient treatment modalities requires further investigation. Preliminary findings demonstrated significant cost savings when compared to Silver based products, but formal research into the potential in this area requires further analysis as whilst Silver products are more expensive, Enzymatic Alginogels require increased clinician interaction to apply.
Results
Time to re-epithelialisation between the 2 silver products and the Enzyme Alginogel proved insignificant. Silver foam Range (mean 8.8), Nano-crystalline Silver Range 7-15 (Mean 9.1) and Enzyme Alginogels (Mean 8.6).
Pain experienced by the patient demonstrated a significant difference between Nano-Crystalline Silver (7.7 mean) and Enzymatic Alginogels (Mean 2.4). Silver Foam had a mean of 3.2. Whilst Nano Crystalline Silver had an increased pain level post procedure, Silver foam had a minor decrease in pain, less than 10% whilst Enzyme Alginogel patients reported a decrease in pain by up to 55%.
Management of wound colonisation (Staph Aureus) was measured on 6 patients, 2 in each group. Enzyme Alginogel proved to be as effective at reducing wound colonisation as Nano-crystalline Silver (significant reduction by day 7) but was significantly more effective than a Silver Foam (16 days).
Terminology
The following products were used to conduct the clinical studies;
Enzyme Alginogel – Flaminal Forte – Flen Pharma.
Nano-Crystalline Silver – Acticoat – Smith & Nephew.
Silver Foam – Mepilex Ag – Molnlycke.
Acknowledgements
All patients enrolled in the clinical study consented for the use of Enzyme Alginogel as an alternative to Silver Based therapies.
Flen Pharma and Aspen Australia for their technical advice and support during the trial.
All products were purchased and used independently of any pharmaceutical company.
The patients enrolled for their enthusiasm and openness in providing feedback for the clinical trial.
3 y.o. child partial thickness burn right flank on presentation
Left – Partial thickness burn colonised treated with Enzymatic Alginogel at Initial presentation, day 4, day 7, day 10.
Right – Partial thickness burn treated with Enzyme Alginogel at Presentation, day 5, discharge day 12.
Both patients had Staphylococcus Aureus infection on presentation
Re-epithelializing 5 days after commencing Enzyme Alginogel