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MOIST
HEALING AND WOUND CARE INCLUDING BURNS
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(Advantages
and Current Approaches)
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Section
III. CURRENT USE OF ANTIBACTERIAL AGENTS IN BURNS
A)
Overview
The
burn eschar (non-viable tissue) is still considered to be not
only a high risk for infection, but also to contain toxins,
e.g. oxidants, cytokines which can produce systematic dysfunction.
The
major change in burn wound management over the past 40
years has been a more rapid removal of devitalized tissue (eschar)
and earlier wound closure. However, the perception of the
uninfected eschar as requiring an antibacterial cream
(solution) to control infection remains (at least until
excision can be initiated if needed). This concept includes
not only deep burns to be excised, but mid-deep dermal burns
which are managed with a topical cream until the eschar has
been removed and a re-epithelializing surface is
present.
Only
recently, in more superficial burns (and now deeper burns with
the availability of a sulfamylon solution) has "moist
wound healing" been used in the burn wound.
OVERVIEW:
Most Common Approach
Use
of Prophylactic Topical Antibiotic Cream
Use
of Topical Antibiotics to Treat Infection
B)
BURN MANAGEMENT
The
Superficial Burn
The
current approach is to use an occlusive dressing, e.g.
xeroform gauze and dressing or a skin substitute to maintain a
surface moisture layer. No antibacterial is needed.
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Click
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2)
THE MID TO DEEP DERMAL BURN
The
most common approach is to use a topical antibacterial cream
with fine mesh gauze covered with a dry occlusive dressing
once or twice daily. This approach does not produce the
optimum healing environment especially with the risk of
conversion with surface desiccation.
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Click
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Mid
to deep dermal burn
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3)
THE FULL THICKNESS BURN
The
most common approach to care is the use of a topical
antibiotic cream until excision and grafting. These would be
little advantages to a moist healing approach using an
antibacterial solution (unless the wound was over estimated as
to depth on initial assessment).
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Click
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C
) THE PROBLEM OF INFECTION IN SKIN GRAFT FOR BURNS
1
) Overview
As
the burn is a contaminated wound, some bacteria will be
present on the excised wound surface prior to skin graft
placement. Sheet grafts have a low infection risk as wound
closure will decrease bacterial count. Meshed grafts however
have the added risk of areas of wound surface exposure which
are prone to desiccation inflammation and infection. Cultured
cell autografts also have seams and open wound areas often
contiguous with epithelial cell graft and are very susceptible
to damage from bacteria.
Causes
of Infection after Skin Graft
Also
both local and systemic immune defenses are markedly impaired
in the major burn patient increasing wound infection risk. The
general consensus is that for meshed grafts some local
antibacterial coverage is needed.
2)
Use of moist wound healing methods
The
use of an occlusive dressing and an antibiotic solution
to maintain surface moisture is now a common approach to
management of the meshed skin graft (or excised wound)
The
Meshed Skin Graft
The
most common current approach is to use the moist wound healing
techniques using a topical antibiotic solution beneath an
occlusive dressing.
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Common
Antibiotic Solution |
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*5%
sulfamylon solution has been shown to a more effective
antibacterial solution and to also not retard healing |
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Use
of Antibacterial Cream
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ADVANTAGE |
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DISADVANTAGE |
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It
is likely that this depth of burn would heal faster
and be less likely to convert using a moist wound
healing approach, given the available research on this
approach. |
The
benefits of moist wound healing
could be obtained in this type of burn with the use of a
topical antibiotic solution which has the following
properties.
Properties
for Moist Healing |
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The
recent approved 5% sulfamylon solution in fact has
these properties, as will be described |
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Use
of Topical Antibiotic Cream for Mid to Deep Dermal Uninfected
Burns
(surface
pseudo eschar formation is not moist wound healing)
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Mid
to deep dermal burn not infected with use of
antibacterial cream |
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| Surface
dry with pseudo-eschar in place is a Typical
appearance with the cream and dry dressing approach |
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