Abstract
The purpose of this study is to investigate the effect of hydrocolloid dressing combined with low molecular weight heparin calcium on scar hyperplasia in burn patients with venous thromboembolism. A retrospective analysis was made on 98 patients with burns complicated with venous thromboembolism in Renmin Hospital, Hubei University of Medicine from January 2020 to April 2021. According to different treatment methods, they were divided into a control group (48 cases) and a research group (50 cases), who were given low molecular weight heparin calcium combined with routine treatment and hydrocolloid dressing on the basis of the control group. The wound healing time, dressing change times and infection symptom regression time in the study group were significantly lower than those in the control group (P < .05). After the intervention, the degree of wound pain in both groups was reduced, and the degree of wound pain in the study group was significantly lower than that in the control group, with statistical significance (P < .05). Fibrinogen, activated partial thromboplastin (APPT), D‐dimer, fibrinolytic degradation products, prothrombin time and activated partial prothrombin time of the two groups were all improved. The degree of scar hyperplasia in both groups was improved, and the degree of scar hyperplasia in the study group was significantly better than that in the control group, and the difference was statistically significant (P>.05). Complications in the study group were lower than those in the control group, and the difference was statistically significant (P < .05). The hydrocolloid dressing combined with low molecular weight heparin calcium can effectively shorten the wound healing time and infection symptom regression time of burn patients with venous thromboembolism, reduce the number of dressing changes, reduce the degree of pain, have no influence on coagulation function, reduce the degree of scar, and reduce the incidence of complications.
Keywords: burn complicated with venous thromboembolism, degree of scar hyperplasia, hydrocolloid dressing, low molecular weight heparin calcium
1. INTRODUCTION
Venous thromboembolism, including pulmonary embolism and deep venous thrombosis, is the manifestation of the same disease in different parts and stages. 1 According to relevant research, 2 the incidence of symptomatic venous thromboembolism is about 1.5 million cases in Europe and 600 000 cases per year in the United States. Venous thromboembolism not only has high mortality but also induces serious complications such as venous insufficiency and chronic pulmonary hypertension, which seriously affects the health of patients. Studies have pointed out 3 that venous thromboembolism is the most likely preventable fatal disease.
According to the relevant data, in 2020, the World Center for Disease Research reported that nearly 9 million people were burned every year. The burned patients were at high risk of venous thromboembolism because of a large amount of bleeding from the wound, severe pain, long‐term bed rest, repeated venipuncture and other reasons, and the existence of the hypercoagulable state, slow venous blood flow and vascular injury. 4 Different literatures indicate that the incidence of venous thromboembolism in burn patients is between 1% and 23.7%, and the highest incidence of venous thromboembolism is 3.3%. 2 , 3 , 5 After venous thromboembolism occurs in burn patients, mild cases will affect the prognosis of burn patients, and severe cases will lead to direct death of burn patients. 6 The treatment of clinical burn wounds runs through the whole treatment process. Hydrogel dressing is a kind of medical dressing prepared by mixing polymer hydrogel with synthetic rubber and adhesive with strong elasticity. It is widely used in chronic wounds such as pressure ulcers and venous ulcers, as well as acute wounds such as surgical wounds, superficial wounds and skin donation wounds. 7 , 8 , 9 Low molecular weight heparin calcium is a widely used anticoagulant in the clinic, which can effectively prevent venous thrombosis, and the occurrence of venous thrombosis can aggravate scar or hinder scar healing, and low molecular weight heparin calcium can effectively improve the burn with microcirculation of venous thromboembolism, accelerate local blood supply, so as to improve scar hyperplasia. 8 , 10 At present, there are few clinical reports about hydrocolloid dressing combined with low molecular weight heparin calcium in burn patients with venous thromboembolism. This study observed that hydrocolloid dressing combined with low molecular weight heparin calcium can effectively improve the scar hyperplasia degree of burn patients with venous thromboembolism, and the curative effect is remarkable. Based on this, this study will explore the effect of hydrocolloid dressing combined with low molecular weight heparin calcium on scar hyperplasia in burn patients with venous thromboembolism.
2. DATA AND METHODS
2.1. General information
A retrospective analysis of 98 cases of burn complicated with venous thromboembolism treated in Renmin Hosptial, Hubei University of Medicine from January 2020 to April 2021 was made, and they were divided into a control group (48 cases) and a research group (50 cases) according to different treatment methods. Research group: aged 23–73 years, with an average age of (56.89 10.08) years. Control group: aged 23–72 years, with an average age of (56.91 10.12) years. There is no significant difference between the two groups in general data such as patients' ages (P > .05), which is comparable. This study was approved by the Ethics Committee of Renmin Hospital, Hubei University of Medicine.
2.2. Inclusion and exclusion criteria
Inclusive criteria: the burn of lower limbs; All of them are thermal burns, and they are deep second‐degree burns; Use of anhydrous gel dressing and low molecular weight heparin is contraindicated; No immune and blood system diseases; No venous valve insufficiency or deep venous thrombosis of both lower limbs was found in peripheral blood vessels examined by colour Doppler ultrasound before operation.
Exclusion criteria: there are contraindications to anticoagulant therapy; Those with thrombosis; Patients with platelet count <100× 109 L‐1 or heparin‐associated thrombocytopenia; Those with liver and kidney dysfunction; Pregnant or lactating women; Patients with active visceral haemorrhage and coagulation dysfunction; Combined with pulmonary hypertension; Patients with active bleeding; Wound purulent blood or vital organ failure; Uncontrolled hypertension diastolic blood pressure > 120 mmHg; Postoperative bleeding; A history of threatened abortion.
2.3. Methods
The control group was given low‐molecular‐weight heparin calcium injection combined with routine treatment, including disinfection of burn wounds with 0.5% iodophor, routine debridement, washing with normal saline, covering with an ordinary gauze dressing, and fixing with the custom‐made ultra‐thin breathable elastic sleeve on the outer layer. The residual wounds were changed once every 1–2 days until the wounds healed. Low molecular weight heparin calcium injection (batch number: 20130219; Manufacturer: GlaxoSmithKline [China] Investment Co., Ltd.), 0.3 mL/d‐1, continuous administration for 14 days.
The study group was treated with hydrocolloid dressing on the basis of the control group. Routine wound cleaning, and debridement, after the wound is dry, apply the hydrocolloid dressing to protect the local skin, cover the foam dressing on the hydrocolloid dressing, fix it properly, protect the local compressed skin, reduce the influence of shear force and friction force on the skin, and cut the dressing based on the skin to finish sticking. Every 2–3 days, instruct the patient to turn over and check the skin and dressing stick. When the hydrocolloid dressing turns pale yellow or white, change the dressing in time.
2.4. Observation indicators
The degree of wound pain and coagulation function at admission and after treatment were compared, and the wound healing time, times of dressing change, time of infection symptom regression and complications were counted. The degree of scar hyperplasia in two groups at different time periods was recorded. Wound healing time: record the time from seeing a doctor to healing.
Pain degree of the wound: Visual analogue scale 10 was used to assess the degree of pain on admission and after treatment, with a total score of 0–10. The higher the score, the more obvious the pain degree of the affected limb.
Coagulation function: 5 mL of elbow venous blood was taken from patients at admission and 1d after treatment, and then centrifuged (3000 r/min for 15 min) for inspection. Fibrinogen (Fbg), activated partial prothrombin time (aPTT), D‐dimer (D‐D), fibrinolytic degradation products (FDP), prothrombin time (PT) and thromboplastin time were measured.
Degree of scar hyperplasia: assessed by Vancouver Scar Scale. 11 The scale includes four indicators: colour, thickness, blood vessel distribution, and softness, with a total score of 15 points. The higher the score, the more serious the scar will be. Complications: including itching, redness, wound bleeding, wound infection, etc.
2.5. Statistical treatment
Used the SPSS software program (version 21.0; IBM, Chicago, Illinois, USA). The measurement data of normal distribution are expressed as mean standard deviation (SD), and the measurement data is compared between the two groups by T‐test. The data were expressed in percentage (%), and the χ 2 test was used for comparison between groups (all the counting data were tested by chi‐square test). 0.05 on both sides of the test level. P < .05 is considered to be statistically significant.
3. RESULTS
3.1. Comparison of clinical data between the two groups
There was no significant difference in age, sex, duration of disease, cause of injury, wound site, wound site and complications between the two groups (P > .05), as shown in Table 1.
TABLE 1.
Comparison of clinical data between the two groups (points, ).
| Index | Research group (50) | Control group (48) | t/χ 2 | P |
|---|---|---|---|---|
| Age | 56.89 ± 10.08 | 56.91 ± 10.12 | −0.011 | .992 a |
| Gender | 29/21 | 28/20 | 0.001 | .973 b |
| Course time (h) | 23.09 ± 1.03 | 23.04 ± 1.12 | 0.231 | .819 a |
| Cause of injury (n) | 0.431 | .934 | ||
| Fire burn | 34 | 31 | ||
| Scald from steam | 8 | 9 | ||
| Electric arc burn | 5 | 6 | ||
| Chemical burn | 3 | 4 | ||
| Wound site (n) | 0.897 | .826 b | ||
| Shank | 26 | 24 | ||
| Knee joint | 13 | 11 | ||
| Popliteal space | 7 | 9 | ||
| Back of foot | 4 | 6 | ||
| Combined diseases (n) | ||||
| Hypertension | 3 | 4 | 0.201 | .654 b |
| Diabetes | 4 | 2 | 0.626 | .429 b |
| History of drinking (n) | 6 | 4 | 0.359 | .549 b |
| History of drinking (n) | 8 | 6 | 0.245 | .621 b |
Compared by Student's‐t test.
Compared by Chi‐square test.
3.2. Comparison of wound healing time, times of dressing change, and time of infection symptom regression between the two groups
The wound healing time, dressing change times and infection symptom regression time of the study group were significantly lower than those of the control group (P < .05), as shown in Table 2.
TABLE 2.
Comparison of wound healing time, dressing change times and infection symptom regression time between the two groups ().
| Index | Research group (50) | Control group (48) | t | P |
|---|---|---|---|---|
| Wound healing time (d) | 10.28 ± 2.39 | 11.29 ± 2.02 | −2.255 | .026 |
| Number of dressing changes (times) | 5.39 ± 1.02 | 7.34 ± 1.04 | −9.371 | <.001 |
| Time for symptoms to subside (d) | 6.67 ± 1.13 | 9.38 ± 1.23 | −11.365 | <.001 |
3.3. Comparison of wound pain degree between the two groups
At admission, there was no significant difference in the degree of wound pain between the two groups (P > .05). After the intervention, the degree of wound pain in both groups was reduced, and the degree of wound pain in the study group was significantly lower than that in the control group, with statistical significance (P < .05), as shown in Table 3.
TABLE 3.
Comparison of wound pain degree between the two groups ().
| Time | Research group (50) | Control group (48) | t | P |
|---|---|---|---|---|
| When admitted to hospital | 5.39 ± 0.31 | 5.32 ± 0.29 | 1.153 | .252 |
| Seven days after treatment | 2.87 ± 0.23 | 3.14 ± 0.27 | −5.336 | <.001 |
| Fourteen days after treatment | 0.23 ± 0.06 | 0.76 ± 0.07 | −40.296 | <.001 |
3.4. Comparison of coagulation function between the two groups
On admission, there was no significant difference in Fbg, activated partial thromboplastin (APPT), D‐D, FDP, PT, and aPTT between the two groups (P > .05). After the intervention, Fbg, APPT, D‐D, FDP, PT, and aPTT of the two groups were all improved. There was no significant difference in the levels of Fbg, D‐D, PT, APPT, FDP, and aPTT between the two groups (P > .05), as shown in Table 4.
TABLE 4.
Comparison of coagulation function between two groups ().
| Group | Time | Research group (50) | Control group (48) | t | P |
|---|---|---|---|---|---|
| Fbg (g/L) | When admitted to hospital | 3.32 ± 0.14 | 3.30 ± 0.16 | 0.659 | .511 |
| After treatment | 2.86 ± 0.46 | 2.71 ± 0.39 | 1.738 | .085 | |
| APPT (mg/L) | When admitted to hospital | 28.19 ± 3.23 | 28.16 ± 3.25 | 0.046 | .963 |
| After treatment | 31.34 ± 4.26 | 32.09 ± 4.29 | −0.868 | .388 | |
| D‐D (mg/L) | When admitted to hospital | 62.19 ± 5.12 | 61.12 ± 5.09 | 1.037 | .302 |
| After treatment | 35.29 ± 5.01 | 36.81 ± 5.03 | −1.498 | .137 | |
| FDP (g/L) | When admitted to hospital | 2.12 ± 0.31 | 2.14 ± 0.33 | −0.309 | .758 |
| After treatment | 3.97 ± 0.49 | 4.11 ± 0.44 | −1.486 | .141 | |
| PT (s) | When admitted to hospital | 11.09 ± 1.21 | 11.12 ± 1.23 | −0.122 | .903 |
| After treatment | 14.29 ± 2.09 | 14.42 ± 2.19 | −0.131 | .764 | |
| aPTT (s) | When admitted to hospital | 28.38 ± 3.29 | 28.41 ± 3.32 | −0.045 | .964 |
| After treatment | 32.29 ± 4.11 | 33.92 ± 4.79 | −0.697 | .488 |
3.5. Comparison of scar hyperplasia degree between the two groups
At admission, there was no significant difference in the degree of scar hyperplasia between the two groups (P > .05). After the intervention, the degree of scar hyperplasia in both groups was improved, among which the degree of scar hyperplasia in the study group was significantly better than that in the control group, and the difference was statistically significant(P < .05), as shown in Table 5.
TABLE 5.
Comparison of scar hyperplasia degree between two groups ().
| Time | Research group (50) | Control group (48) | t | P |
|---|---|---|---|---|
| 4 weeks after treatment | 9.87 ± 1.34 | 9.71 ± 1.42 | 0.574 | .567 |
| 12 weeks after treatment | 5.09 ± 1.23 | 7.41 ± 1.27 | −9.187 | <.001 |
3.6. Comparison of complications between the two groups
Complications in the study group were lower than those in the control group, and the difference was statistically significant (P < .05). See Table 6 for details.
TABLE 6.
Comparison of complications between the two groups ().
| Index | Research group (50) | Control group (48) | χ 2 | P |
|---|---|---|---|---|
| Red and swollen | 1 | 2 | ||
| Itch | 0 | 3 | ||
| Wound bleeding | 0 | 1 | ||
| Wound infection | 0 | 1 | ||
| Insufficient blood volume | 0 | 0 | ||
| Total incidence rate | 1 | 7 | 5.172 | .023 |
4. DISCUSSION
Thromboembolism refers to the inability of blood to coagulate normally in the vein, blocking some or all blood vessels, which is a venous reflux disorder. Venous thromboembolism includes deep venous thrombosis and pulmonary embolism, among which deep venous thrombosis is the third most common vascular disease after coronary syndrome and stroke, which has the characteristics of high incidence, high misdiagnosis rate, high mortality rate, and high missed diagnosis rate, and is one of the main causes of death of hospitalised patients. 12 Burn patients complicated with venous thromboembolism will cause fatal embolism in severe cases, which seriously threatens the quality of life and health of patients. 13 At present, clinical research on burn complicated with venous thromboembolism mostly focuses on its high incidence, and there is little research on how to effectively prevent and treat burn complicated with venous thromboembolism, and there is no research on the degree of scar hyperplasia after burn complicated with venous thromboembolism.
Low‐molecular‐weight heparin is an activator of antithrombin III, which can play an anticoagulant role by enhancing antithrombin III activity, and is the first choice for preventing or treating thrombosis. At present, clinical pressure is often used to treat burn patients. When the pressure is >3.3 kPa (> 25 mmHg), it will lead to relative ischemia of local tissues. Long‐term compression will reduce the blood supply of scar tissue, leading to tissue ischemia and limiting scar hyperplasia. 14 Stress will affect collagen formation and soften scars. However, after conventional germ pressure dressing, sterile gauze is used to cover the outer layer and bandage it under pressure. This kind of method will cause iodophor to dry in a short time, which will cause the dressing to adhere to the wound surface, causing secondary injury and increasing the pain of patients. Secondary injury can also easily cause blisters or wound ulceration, forming residual wounds, and affecting the scar prevention effect. 15 Hydrogel dressing is a new type of wound dressing derived from the principle of wet healing. It has been widely used in the treatment of various wounds and has achieved remarkable curative effect in the treatment of chronic refractory wounds. 16 Although hydrocolloid dressing has been widely used in clinic, and it has been proved that it can promote wound healing and improve clinical curative effect, the current research is limited to the treatment of pressure sore, and the research on burn complicated with venous thromboembolism is less. The research of Tenenhaus 17 pointed out that hydrocolloid dressing can effectively relieve the degree of wound pain, reduce infection, shorten wound healing time, and reduce the occurrence of adverse reactions in patients with superficial second‐degree burn of face and neck. The results of this study show that after the intervention, the wound healing time, the times of dressing change and the time of infection symptom regression in the study group are significantly lower than those in the control group (P < .05), suggesting that hydrocolloid dressing combined with low molecular weight heparin calcium can effectively shorten the wound healing time and infection symptom regression time of burn patients with venous thromboembolism, and reduce the times of dressing change. This may be because of the fact that hydrocolloid is a new type of wound dressing, which is a mixture composed of glue, water‐absorbent polymer, pectin coagulant and hydroxymethyl cellulose. It can absorb little to moderate amount of exudate, keep the wound moist, create a low‐oxygen and slightly acidic environment, promote the proliferation of capillaries and accelerate wound healing.
Burn can cause severe operational pain, which seriously affects patients' treatment compliance and physical and mental health. Previous studies have pointed out 18 that hydrocolloids can accelerate the dissolution of necrotic tissue, reduce the number of dressing changes and the pain of the wound, and keep the wound moist. The results of this study showed that after the intervention, the pain degree of the wound in the study group was significantly lower than that in the control group (P < .05), suggesting that hydrocolloid dressing combined with low molecular weight heparin calcium can effectively relieve the pain degree of burn patients complicated with venous thromboembolism. The hydrocolloid dressing has the advantages of a self‐adhesive edge, no need for adhesive tape, convenient use, etc., which can be well attached to the wound surface, and it is not easy to shift when used in conjunction with the pressure suit. Compared with traditional dressing, hydrocolloid dressing can effectively relieve the degree of pain, and it is not easy to leave traces when torn off, thus reducing the secondary injury of dressing changing parts. At the same time, the sleeping body dressing attached to the wound can create a slightly cool feeling for the patient, accelerate the loss of heat at the wound to suppress the pain, and make the body feel more comfortable.
Previous studies have pointed out that, 19 , 20 the blood of burn patients is hypercoagulable in different degrees, which shows that the levels of APPT, FDP and PT are decreased and D‐D is increased. Six coagulation items are sensitive indexes to judge whether patients have hemorrhagic diseases, among which PT can effectively reflect the levels of exogenous coagulation factors i, ii, v, vii and X; APTT is a sensitive index to reflect the levels of endogenous coagulation factors vii, IX, XI, etc. Its shortening often appears in a prethrombotic state and in thrombotic diseases. The time required for Fbg to transform into fibrinogen can effectively reflect the abnormality of Fbg in plasma, the occurrence of fibrinolysis and the existence of anticoagulants. FDP can reflect the content of X, Y, D, and E fragments produced by Fbg in blood circulation under the action of a fibrinolytic enzyme, and its reaction is the activation of the fibrinolytic system and the generation of FDP. When the primary and secondary fibrinolytic activities increase, the content of FDP in blood will increase, and its level is also an important indicator that the body is in a hypercoagulable state. D‐D is one of the degradation products of cross‐linked fibrin, and it is also a part of fibrin and FDP with high specificity, so it can reflect the hypercoagulable state in the body and is one of the main markers of secondary fibrosis. Fbg is the main substrate of blood coagulation, and the increase in its index indicates a prethrombotic state. The results showed that after the intervention, the levels of Fbg, D‐D, PT, APPT, FDP, and aPTT in the two groups were compared (P > .05), suggesting that hydrocolloid dressing combined with low molecular weight heparin calcium would not affect the coagulation function of burn patients with venous thromboembolism. This may be because the main mechanism of low‐molecular‐weight heparin calcium is to prevent thrombin function of coagulation factor Xa, which can stimulate whether vascular endothelial growth factor (VEGF) is plasminogen activator and tissue factor inhibitor of coagulation pathway. At the same time, it is not neutralised by platelet factor IV, does not affect the aggregation function of platelets, has a synergistic effect of indirectly dissolving the formed thrombus, and has little effect on the new system of coagulation and fibrinolysis. It has the advantages of small molecular weight and high absorption rate, and has been recommended as a preventive anticoagulant by American Thoracic Physicians Association. The hydrocolloid dressing will not affect the anticoagulant effect of low molecular weight heparin calcium.
Karyakin 18 and other studies have pointed out that hydrocolloid dressing combined with pressure therapy can effectively reduce the degree of scar after limb burns. Wasiak 21 and other studies have pointed out that hydrocolloid dressing can relieve the pain of patients with superficial skin injuries, reduce the times of dressing changes, reduce the risk of wound infection, promote the healing of skin injuries and reduce scar formation, which has important application value. The results showed that the degree of scar hyperplasia in the study group was significantly better than that in the control group (P < .05), suggesting that hydrocolloid dressing combined with low molecular weight heparin calcium can effectively improve the degree of scar hyperplasia in burn patients with venous thromboembolism. This may be because of the fact that hydrocolloid dressing can firmly adhere to the tissues around the wound to form a closed wound that isolates the invasion of pathogenic microorganisms in the air, and that the neovascularization speed of the wound is faster in the micro‐oxygen state, which is more conducive to the crawling growth of granulation tissue, thus forming new epidermal tissue; At the same time, the hydrocolloid dressing contains a large number of hydrophilic molecules, which can form a semi‐fixed protective layer after being combined with the water seeping from the wound, so that the wound is always in a dry state, creating a good internal environment for the growth of new tissues; In addition, hydrocolloid dressing is rich in endogenous enzymes, which can improve the dissolution rate of fibrin. At the same time, a closed environment can stimulate macrophages and accelerate the removal of necrotic tissue on the wound surface, thus effectively improving the scar condition. Other studies also believe that hydrocolloid dressing can promote wound repair time and reduce the incidence of related complications after the application of the wound after a breast fibroma operation. The results of this study show that the incidence of complications in the study group is lower than that in the control group (P < .05), suggesting that hydrocolloid dressing combined with low molecular weight heparin calcium can effectively reduce the incidence of complications in burn patients with venous thromboembolism.
To sum up, hydrocolloid dressing combined with low molecular weight heparin calcium can effectively shorten the wound healing time and infection symptom regression time of burn patients with venous thromboembolism, reduce the number of dressing changes, relieve the degree of pain, have no influence on coagulation function, reduce the degree of scar, and reduce the incidence of complications. It can be widely used in the clinic. However, there are some shortcomings in this study, such as redness, itching, and pain, which are judged by the subjective feelings of patients, which have great subjective influence and are easy to cause errors. In addition, this study is a retrospective analysis, and a multicenter, prospective, large‐sample, randomised controlled study should be adopted to further confirm the results of this study.
Li C, Wang Y, Hu F, Gong H. Effect of hydrocolloid dressing combined with low molecular weight heparin and calcium on scar hyperplasia in burn patients with venous thromboembolism. Int Wound J. 2023;20(8):2981‐2988. doi: 10.1111/iwj.14165
Chengzhi Li, Yuanyuan Wang and Fan Hu contributed equally to this paper.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.