In the treatment of extensive burns, cultured epithelial autograph (CEA) became available commercially in Japan from 2009. Based on the 6 years multicenter surveillance data on using CEA for extensive burns, it is reported that using 6:1 split thickness skin graft together with CEA is successful after wound bed preparation for extensive deep dermal burn or patients with deep burn [1].
This paper reports a rare case where we can get successful outcome clinically and pathologically if the patient was treated strategically using artificial dermis together with CEA without split thickness skin graft after wound bed preparation for extensive deep dermal burn. This paper also reviews the literature and discusses the merits of this technique which may become part of strategy for the treatment of extensive burns. According to the above-mentioned evidence, using 6:1 split thickness skin autograft together with CEA is useful and recommended for deep dermal burn. However, we tried and succeeded another strategy for extensive burns implanting CEA without split thickness skin autograft, using artificial dermis for wound bed preparation. It suggests that this strategy may result in good epithelialization on the wound bed prepared with artificial dermis.
A 21-year-old man was driving his car on a mountain road at 600 m height above sea level at midnight. After finishing smoking, he threw the cigarette butt out through the car window, however, the wind blew the cigarette butt back into the car. The cigarette butt fell on the blanket in the back seat and caught fire. The fire spread so rapidly that he could hardly escape from the car. He suffered flame burns to his face, back, trunk and limbs. He was unable to call for emergency service and had to walk down the mountain on his own strength before he reached the fire station. He was immediately transferred to our hospital for treatment, ten hours after sustaining burn injury.
Initial physical findings: The patient was alert and oriented. His vital signs showed that the heart rate was 120 beats/min, blood pressure 140/100 mmHg, body temperature 36.6˚C, and respiratory rate 14 breaths/min. Contusion on the back of the head and physical injury. And his clothes were burned extensively. The burn wounds were found on his face, neck, back trunk, and limbs. Back trunk and left limb were assessed as deep dermal burn (DDB), and others as superficial dermal burn (SDB) (
The medical history of the patient was unremarkable. The laboratory blood data were as follows: WBC 25.28 × 103/μL, Hb14.7 g/dL, platelet 25.6 × 103/μL, total protein 6.0 g/dL, BUN 23 mg/dL, Creatinine 0.72 mg/dL, AST 132 IU/L, ALT 42 IU/L, Na 137 mEq/L, K 3.9 mEq/L, Prothrombin time 14.6 sec, APTT 28.6 sec, Antithrombin 97%. Arterial blood gas analysis (at room air) was as follows; pH 7.35, PaCO2 33.4 mmHg, PaO2 126.7 mmHg, Lactate 2.5 mmol/L (22.5 mg/dL). Chest X-ray and brain CT scan investigation did not show any abnormal findings. The characteristics of the patient’s laboratory data were summarized
in
During emergency treatment, lactate Ringer’s solution was infused for fluid resuscitation to maintain urinary output of 0.5 - 1.0 mL/kg/hr in the first 24 hours after admission. The volume of total fluid resuscitation reached 9020 mL during the first 24 hours after admission. The serum lactate level was maintained below 2.0 mmol/L (18 mg/dL) within the first day of admission. The patient had no complications such as hypovolemic shock or pulmonary edema. The treatment included the application of dimethyl isopropyl azulene ointment with puffing basic fibroblast growth factor (b-FGF; Fibrast Spray®; KAKEN Company, Japan)
Gender | male |
---|---|
Age | 21 years old |
Marital status | unmarried |
Employment | Full-time work |
Height | 170 cm |
Body Weight | 66.6 kg |
Vital signs on admission | |
Blood Pressure | 140/100 mmHg |
Heart Rate | 120/min |
Respiratory Rate (/min) | 12/min |
Body temperature | 36.6˚C |
Consciousness on admission | clear |
%TBSA | 37% |
WBC | 25,280/μL |
---|---|
Hb | 14.7 g/dl |
Plt | 25.6 ×103/μL |
Na | 137 mEq/L |
K | 3.9 mEq/L |
AST | 132 IU/L |
ALT | 42 IU/L |
TP | 6.6 g/dL |
BUN | 23 mg/dL |
Creatinin | 0.72 mg/dL |
PT | 14.6 sec |
APTT | 28.6 sec |
Arterial Blood Gas (room air) | |
pH | 7.35 |
PaO2 | 126.7 Torr |
PaCO2 | 33.4 Torr |
on the wounds after washing, every day. The use of CEA was considered and decided with the patient on the day of admission. JACE® (Japan tissue engineering company Aichi Japan; J-TEC) is only certified as CEA by health insurance in Japan. We harvested full thickness healthy skin from unburned areas (right lower abdomen) which measured 2 cm × 4 cm in size under local anesthesia on the first day of admission and ordered to prepare JACE®. In clinical course, the wounds on his hands, back and left upper extremity were epithelized well. However, the wound on his back trunk, which had been diagnosed as DDB, deteriorated into full thickness burn with necrotic tissue on the 9th day of admission (
operation was very good and there were no complications. On 28th day of admission, we decided to implant only CEA (JACE®) without using split thickness skin autograft on his back trunk (
We followed up the patients for 200 days after admission (146 days after discharge at the department of outpatient). The wound on his back was reassessed at out-patient clinic 90 days after discharge and evaluated as point 10 in the Vancouver Scar Scale (VSS) and point 13 in the Manchester Scar Scale (MSS). Two hundred days after discharge, the wound on his back was assessed as point 4 and in VSS and point 7 in MSS respectively (
Since early 1980s, CEA has been used clinically for patients with extensive burns. CEA “JACE®” has been recognized as a treatment for extensive burns. JACE® has been certified by the public health insurance since 2009 in Japan. Prior to the certification, we employed the procedure using JACE® combined with 6:1 split thickness skin graft, for the first time in Japan in 2006. It was very hard to make treatment plans for extensive burns using CEA, because we had few clinical evidences on the merits of using CEA. During this time, the treatment methodology for wounds of full thickness burn, was to implant with artificial dermis to reconstruct the dermis like normal tissue after debridement, followed by CEA implant combined with 6:1 split thickness skin graft. Matsumura [
In our case, we used artificial dermis to reconstruct dermis and implanted CEA onto the mixed full thickness burn (deep burn; DB) and DDB wounds. Since the patient was very young in age, the wound bed preparation with artificial dermis appears to have grown like normal tissue. This prevented the complications of graft donor sites and avoided the combination of split-thickness skin graft with CEA implantation [
We implanted Integra® artificial dermis onto the wound after debridement which is composed of bi-layered dermal substitute. The first layer is a matrix of bovine collagen and shark chondroitin 6-sulfate, cross linked with glutaraldehyde. The second layer is silicone membrane made of thin polysiloxane, which control fluid and heat loss and acts as a temporary epidermis. Integra® contains 70 - 200 µm pores, water and wound leachate can easily discharge from it. The cross-link structure of collagen layer makes horizontal cell movement easier and prompt soaking of dermis cell smoothly and quickly to form dermis tissue [
Based on this report, implanting independent CEA on the well reconstructed dermis would be effective for successful epithelization. Pathological studies on the use of Integra®, was originally targeted for damaged foot skin due to ulcer and was not about treatment of burn injury. This study showed vascularization and syncytial fibroblast movement into wound that replaced Integra® hence contributing to the formation of epidermis in microscopic examination [
Immunohistochemical analysis for our case is shown in
Basement membrane (basal cell layer) consist of collagen IV and laminin produced from basal cell. Basal cell is the stem cell of keratinocytes that forms basal cell, and basement membrane support the development of epidermal cells. This implies that implanting independent CEA can progress to epithelization of mixed DB and DDB wounds after reconstruction with artificial dermis. Therefore, good wound bed preparation with artificial dermis will produce successful healing process. The independent CEA applied on the burned wound can
promote the surviving dermis to epithelize. Further, it reduces the complication of hypertrophic scar since there is no need for harvesting dermis from normal skin.
In cases of patients with extensive skin burns with very limited donor sites, our strategy using CEA without autograft appears to be successful way to treat skin burns and could be considered as an alternative option. We would like to investigate further. Based on this experience, we propose the present strategy instead of split skin graft for clinical treatment of skin burned patients.
We report and suggest an additional strategy for deep dermal burns; the independent CEA (only) implantation can result in good epithelization after wound bed preparation with artificial dermis.
The authors declare no conflicts of interest regarding the publication of this paper.
Ueda, T., Matsushima, T., Ichinohashi, K. and Kitazawa, Y. (2018) Use of Artificial Dermis and Cultured Epithelial Autograft for Extensive Deep Dermal Burns―A Case Report. Open Journal of Emergency Medicine, 6, 73-81. https://doi.org/10.4236/ojem.2018.64009