Therapy for patients with burns - an integrating review

SUMMARY

OBJECTIVE:

to identify, through an integrative review, national studies published over the last ten years highlighting products and therapies used in burns.

METHODS:

integrative research with studies published in the last ten years. Including clinical studies describing the use of the already established or innovative therapies in burns and the results obtained, published in national journals in the last ten years. Excluding articles published before 2007 and those that did not present results regarding the use of products in burns.

RESULTS:

ten articles that met the inclusion criteria were selected. Collagenase, 1% silver sulfadiazine, and porous cellulose membrane were some of the therapies cited.

CONCLUSION:

the casuistry was low; however, the good results obtained with porous cellulose membrane and silver nanocrystalline dressing are highlighted, since they were used in a larger number of patients in the studies evaluated.

KEYWORDS:
Burns; Burn units; Wound Healing; Debridement; Bandages

RESUMO

OBJETIVO:

Identificar, por meio de revisão integrativa, estudos nacionais publicados nos últimos dez anos que destaquem produtos e terapêuticas utilizados nas queimaduras.

MÉTODOS:

Pesquisa integrativa com estudos publicados nos últimos dez anos. Incluídos os estudos clínicos que descreveram a utilização de terapias já consagradas ou inovadoras em queimaduras e os resultados obtidos e publicados em periódicos nacionais nos últimos dez anos. Excluídos os artigos publicados antes de 2007 e os que não apresentaram resultados quanto ao uso de produtos nas queimaduras.

RESULTADOS:

Selecionados dez artigos que atenderam aos critérios de inclusão, sendo colagenase, sulfadiazina de prata 1% e membrana celulósica porosa algumas das terapias descritas.

CONCLUSÕES:

A casuística foi baixa, porém, ressaltam-se os bons resultados obtidos com a membrana celulósica porosa e o curativo com prata nanocristalina, em virtude de terem sido utilizados em um maior número de pacientes nos estudos avaliados.

DESCRITORES:
Queimaduras; Unidades de queimados; Cicatrização; Desbridamento; Bandagens

INTRODUCTION

Burns are secondary injuries from accidents involving thermal, chemical, or electrical energy capable of producing excessive heat, damaging the skin and/or other tissues, leading to cell death. They are classified according to the depth of the site affected, as first, second, or third grade. First degree burns (Figure 1A) affect the epidermis and do not form blisters; they cause pain, hyperemia, and edema. Second-degree burns (Figure 1B) affect the epidermis and the dermis, forming blisters; they can be superficial, with the basis of the blister pink, wet and painful, or deep, with the basis of the blister white, dry and less painful¹. Third-degree burns (Figure 1C) affect even deeper structures; there is no pain due to the destruction of the nerve endings; there is no capillary return, and blood vessels are compromised due to coagulation; there is no spontaneous regeneration, grafting is indicated and, when there is healing, there is retraction of edges^2–4.

FIGURE 1
ILLUSTRATIVE IMAGES OF DIFFERENT DEGREES OF BURNS. A: FIRST-DEGREE BURN; B: SECOND-DEGREE BURNS; C: THIRD-DEGREE BURNS;

The therapy of burned patients has always been a global challenge, both due to the complexity of lesions and to the need for intensive and multidisciplinary care involving several health professionals, such as clinicians, intensivists, psychologists, nutritionists, physical therapists, and nurses with expertise in this area⁵. A complex wound raises the rates of morbidity and mortality, increases the overall costs of treatment (inputs and human resources), and leads to longer hospital stays⁶. The systemic treatment of burn patients focuses on reducing edema, maintaining hemodynamics and renal function, preventing or combating infections, preserving the viable tissues, protecting the microcirculation, strengthening innate defenses, and providing essential substrates to support viable tissues and recovery⁷.

The topical therapy appropriate to an injury due to burns considers the use of products that control bacterial growth, remove the devitalized tissue, and promote healing⁸. Several studies mention the products used in the treatment of burns. One of them mentions that the first option of health institutions for the treatment of burns from the second degree is silver sulfadiazine 1%⁹, a topical antimicrobial drug of the sulfanilamide class found in the presentation of a white, odorless, and soluble cream¹⁰. Another report mentions silver sulfadiazine at 1%, cream or solution, and its combination with cerium nitrate, besides other preparations with silver¹¹. Hyperbaric oxygen therapy for burns was also highlighted in a study⁷, as well as the use of hyaluronic acid (HA)¹². HA is involved in several cellular functions, including cell proliferation, cell locomotion, and interactions with leukocytes. It is used clinically to treat articular disease and in ophthalmic surgical devices; some studies suggest benefits from using it in wound healing¹³.

Another paper highlighted silver sulfadiazine in the first 48-72 hours, topical chemical debridement until the necrotic tissue is removed, a topical product with a growth factor, surgery for removal of devitalized tissue, and bandage embedded in saline solution⁸. Other authors have cited as topical agents, mostly antimicrobials, the associations between neomycin sulfate and bacitracin; between clostebol acetate and 5 mg of neomycin sulfate and silver sulfadiazine 1%¹⁴.

Other researchers have pointed out that in cases in which the burned surface area (BSA) is extensive, because of the greater complexity of therapy, other substances and techniques that stimulate and encourage healing must be used, such as heparin, papain, lidocaine, surgical treatment of autologous graft of the skin and/or debridement¹⁵.

In folk medicine, plants are used for the treatment of burns: Aloe barbadensis Mill (aloe vera), and Symphytum officinale (comfrey), which have healing action and are used generally in natura, as a poultice or decoction¹⁶. Aloe vera and comfrey are funded by the Ministry of Health for availability in the public health network and are part of the Brazilian Pharmacopoeia Phytotherapics List^17,18.

Other authors mention the use of Silver Sulfadiazine 1%, calcium alginate, hydrocolloid, petrolatum, and hydrogel, depending on the condition of the wound, with there is necrosis, exudate and/or bleeding¹⁴.

Due to the several options available on the market, more studies are necessary to define those that allow lower repair time, less retraction, lower probability of infection, and better pain control. Choosing an appropriate therapy for burns and hypoalgesia or analgesia is the goal of professionals who treat patients with this type of injury. Therefore, it is important to have scientific evidence to base adequate clinical behavior.

OBJECTIVE

To identify, by means of an integrative review, national studies published over the past ten years that highlight products and therapies used in burns.

METHODS

To build this integrative review, six distinct stages were followed¹⁹:

1. Research question: What therapies that have been cited in the literature for the treatment of lesions secondary to burns, in the last ten years?

2. Inclusion criteria: We used all field studies that described the use of established or innovative therapies for burns and the results obtained and published in online Brazilian journals over the past ten years (2007 to 2017). Exclusion criteria: We excluded articles published before 2007, those who do not focus on the treatment of lesions secondary to burns, that did not present results regarding the use of products on burns, and those that described therapies used outside of Brasil.

3. Categorization of studies: Extraction of information, database formation. The keywords were selected in accordance with the Health Sciences Descriptors (DeCs): burns, burns Units, healing, debridement, dressings. The relationship established between these words obeyed the following criteria: the search should relate three of them and, in the event of a negative result, relate two of them. The databases consulted were: SciELO, Lilacs, Medline-Bireme, and PubMed. The abstracts were read, and those relevant to the topic were selected for later in-depth reading.

The search in SciELO retrieved 177 papers; of these, one was selected. The search in PubMed retrieved 39 papers, but none met the inclusion criteria. In Lilacs, the search retrieved 30 papers, and eight were selected. The papers that were not selected approached burns related to the quality of life, team, and work in Burns Units, development of products for skin lesions, analgesia, epidemiological aspects, and animal studies, and many were not used because they were published before 2007. Some papers were not selected because their full text was not available. The search on Medline-Bireme, linking the keywords, resulted in 26 papers, but none was used because they were about animal studies, or studies were before 2007, or studies that addressed matters not relevant to the subject, or studies without permission for full access. One paper was included from the references for another study. Thus, in total, ten papers were selected.

Four field studies were also discarded because, although they described the use of products in burn patients, they did not describe how these products influenced the repair of tissues. One mentioned the use of silver sulfadiazine 1% and papain²⁰; another approached, in a case report, a patient with burns in several regions of the body and treatment with collagenase, silver sulfadiazine, among others, as needed: exudate, slough, bleeding²¹; another that described the use of products such as silver sulfadiazine, adaptic and carboxymethylcellulose in burned patients,⁵ and a final one that designed a guideline which included silver sulfadiazine at 1%, silver sulfadiazine at 1% with cerium nitrate at 2.2% and essential fatty acid²². A study published in a national magazine reports the use of dermal regeneration matrix in burns and described the result, but it was developed in Lisbon, Portugal; therefore, it was not used in this study²³. Below, a flowchart describes the results of the study selection procedure (Figure 2).

FIGURE 2
FLOWCHART OF THE RESULTS OF THE STUDY SELECTION PROCEDURE ROSADÉLIA MALHEIROS CARBONI

RESULTS

Based on the results obtained, we designed a figure compiling all the information from the selected studies, such as the author, title of the study, objective, type of research, the therapy used, and results. The research was conducted from April to June 2017.

FIGURE 3
INFORMATION FROM THE ARTICLES INCLUDED IN THE INTEGRATIVE REVIEW. ROSADÉLIA MALHEIROS CARBONI

DISCUSSION

Of the studies mentioned, one of them stressed that hyaluronic acid had better results than the essential fatty acid, but this was observed in a single patient²². Another more recent study, from 2017, also highlighted the use of hyaluronic acid, but it was a single case report²⁹.

Essential fatty acid (EFA) has been used in clinical practice as a preventive and for wound treatment for many years, and some brands on the market are considered correlated³⁴. Linoleic acid and linolenic acid are the most important fatty acids for treating wounds, and EFA-based products may contain one or both and have, in addition, vitamins A and E and soy lecithin³⁵.

A systematic review highlighted that the topical action of the combination of hyaluronic acid and silver sulfadiazine showed significantly favorable response in the mean time for healing of partial and deep-partial thickness burns¹².

A study that analyzed 132 medical records of children aged zero to 14 years old, affected by burns, found that the results from nanocrystalline silver dressings and those associated with the non-traumatic interface of the wound and of absorbent foam were better than the silver sulfadiazine²⁵. Metallic silver in the form of nanoparticles is a potent antimicrobial agent³⁶, with a more powerful fast bactericidal capacity greater than sulfadiazine and silver nitrate-based dressings³⁷.

In another study, conducted with 20 patients, researchers reported that in those who used collagenase (10 patients), the healing time was shorter than in those who used topical heparin (ten patients)²⁶; sodium heparin, which is known for its anticoagulant action³⁸. Researchers have pointed out that the effect of parenteral sodium heparin has been studied on thermal injuries in animals and in humans, with favorable effects²⁶.

Other researchers, in a case study, revealed that the soft silicone and foam dressing is a good option for treating burns in joint areas, such as the hand, avoiding long immobilizations, retractions, and sequelae²⁷. In research on 29 patients, it was reported that second degree burns epithelialized using the porous cellulose membrane, without the need of changing dressings. The authors emphasized that the membrane provides ease of application, excellent adhesion to tissues, reduction of pain, adequate visualization of the lesion, spontaneous drainage, reduction or absence of dressing changes, and increased intervals of medical supervision²⁸.

These studies cited used several topical therapies, and the results consist of a number of 184 patients, i.e., the sample was low.

In relation to hyaluronic acid, there were two cases presented, and a soft silicone and foam dressing was used in one case. Even though the authors highlighted good results, this is insufficient to assert that they are beneficial for burns^27.29.

In relation to silver sulfadiazine 1%, in the 132 patients studied, this type of therapy had lower results than nanocrystalline silver dressings and those associated with the non-traumatic interface of the wound and of absorbent foam²⁵. In another study with 20 patients, sulfadiazine was also compared with silver hydro-alginate, which had the best results in the healing³³. Nanocrystalline silver was also used in a study with eight patients and proved effective in the healing of burns³². One study presented the use of a compress soaked in a solution of 2 liters of warm water at a temperature between 38 and 40 °C and 200 ml of alcohol on the burn; however, only two cases were reported³¹. Researchers used Omiderm®, a biosynthetic dressing that is a semibiological substitute of the skin in a study with patients and reported favorable results in the healing of burns. The product is transparent, adherent, and semipermeable therefore has the property to protect and maintain the moisture in the wound³⁰.

CONCLUSION

We highlight, in this study, the good results obtained with porous cellulose membrane and nanocrystalline silver dressings in virtue of having been used in a larger number of patients in the 10 studies evaluated.

Many Brazilians suffer burns; however, in the literature, there are few articles that present the topical therapy used and its results. This study presented only 10 papers that met the inclusion criteria. Considering what was found in the literature, it is necessary to disseminate other studies showing the effectiveness of topical therapies, since burned patients are extremely vulnerable, suffer from hyperalgesia and have the injuries heal, often, after a long time, with retractions and impaired self-esteem.

There are more modern burn dressings, such as the Mepitel^®(Mölnlycke), which has a double layer of silicone, with perforated aspect; Biatain Silicone® (Coloplast), an absorbent foam dressing with soft silicone; Mepilex ^®Ag (Mölnlycke), a foam dressing with antimicrobial, with a bioburden-reducing action; Urgotul® (Urgo Medical), with a layer of flexible contact with the TLC healing matrix (made of flexible polyester mesh impregnated with a layer of carboxymethylcellulose and lipophilic particles dispersed); the negative pressure therapy (NPT), which provides uniform subatmospheric pressure to the wound, whose mechanism of action involves biological and physical effects³⁹, among others, but no published studies were found on these dressings for the treatment of burns.

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Publication Dates

• Publication in this collection
  02 Dec 2019
• Date of issue
  Nov 2019

History

• Received
  04 Mar 2019
• Accepted
  31 Mar 2019