Safety of enzymatic debridement in extensive burns larger than 15% total body surface area.

OBJECTIVES: Bromelain-based enzymatic debridement has emerged as an alternative to surgical eschar removal. Indications include partial thickness, mixed pattern, and full-thickness burns. Enzymatic debridement has been approved by the European Medicines Agency for treating burn wounds affecting <15% total body surface area (TBSA). Data and evidence for the treatment of areas >15% TBSA in one session is scarce. The aim of this retrospective study was to retrospectively analyze off-label use of enzymatic debridement in a single burn center for large TBSA burns. METHODS: Between 01/2017 and 12/2018, 59 patients with partial- to full-thickness burns underwent enzymatic debridement in a single center study. Patients were categorized into two groups: the regular use group with a treated area less than 15% TBSA and the off-label group (OG) with larger TBSA debrided in one session. Treatment was evaluated for systemic inflammatory reaction, bleeding, hemodynamic instability and electrolyte shifts. RESULTS: In total, 49 patients were treated in the regular use group with a median application area of 6% (IQR 2.5-9.5) and 10 patients were treated in the off-label group with a median application area of 18% (IQR 15-19) TBSA. We found no significant differences regarding blood pressure, body temperature or hemodynamic stability during and after enzymatic debridement. No treatment-related serious adverse events were observed in either group. Catecholamine use was similar in both groups. No differences in leukocyte counts, CRP, PCT and lactate prior to application and during the following three days were observed. Sodium, potassium, chloride and phosphate levels did not differ. We found no evidence of an electrolyte shift. Survival was 49 of 49 patients (100%) in the RG and 7 of 10 patients (70%) in the OG (p = 0.004). CONCLUSION: Enzymatic debridement did not result in any expected or unexpected side effects in the patient groups investigated. These preliminary results indicate the potential safety of bromelain-based enzymatic debridementin the treatment of burns greater than 15% TBSA.

The doctor's point of view: eye-tracking as an investigative tool in the extubation process in intensive care units. A pilot study.

BACKGROUND: Patient safety is a top priority in healthcare. Little is known about the visual behavior of professionals during high-risk procedures. The aim of this study was to assess feasibility, usability and safety of eye-tracking to analyze gaze patterns during the extubation process in the intensive care unit. METHODS: Eye-tracking was used in this observational study to analyze the extubation process in 22 participants. Independent variables were average fixation time, dwell time, fixation count, hit ratio and revisit count for eighteen areas of interest. Primary outcome was dwell time for all areas of interest. Secondary outcomes were average fixation time, fixation count and revisits. In subgroup analyses, experienced and non-experienced physicians were compared. RESULTS: The most important area of interest was the patient, as analyzed by dwell time. Fixation of other areas of interest varied significantly among participants. Only 54% checked ventilator respiratory rate, despite declaring it as important in questionnaires. Other neglected areas of interest included tidal volume (59%), peak pressure (63.6%), CO2 (63.6%), temperature (18.2%), blood pressure (59%) and heart rate (68%). Experienced physicians gazed more frequently and longer at the patient while spending less time on monitor and ventilator parameters. CONCLUSIONS: Eye-tracking can demonstrate that there is a mismatch between physicians' subjective evaluations and corresponding objective real-life measurements. Structured and standardized extubation processes should be performed to improve patient safety. In the immediate postextubation phase, long dwell time on the patient shows that clinical observation remains the most important cornerstone beyond monitoring devices.