Skip to main content
NCBI home page
Annals of Surgery logoLink to Annals of Surgery
. 1974 Oct;180(4):670–703. doi: 10.1097/00000658-197410000-00032

Chemical Debridement of Burns

Stanley M Levenson, Dorinne Kan, Charles Gruber, Leo V Crowley, Richard Lent, Alvin Watford, Eli Seifter
PMCID: PMC1344165  PMID: 4606330

Abstract

The development of effective, non-toxic (local and systemic) methods for the rapid chemical (enzymatic and non-enzymatic) debridement of third degree burns would dramatically reduce the morbidity and mortality of severely burned patients. Sepsis is still the major cause of death of patients with extensive deep burns. The removal of the devitalized tissue, without damage to unburned skin or skin only partially injured by burning, and in ways which would permit immediate (or very prompt) skin grafting, would lessen substantially the problems of sepsis, speed convalescence and the return of these individuals to society as effective human beings, and would decrease deaths. The usefulness and limitations of surgical excision for patients with extensive third degree burns are discussed. Chemical debridement lends itself to complementary use with surgical excision and has the potential advantage over surgical excision in not requiring anesthesia or a formal surgical operation. The authors' work with the chemical debridement of burns, in particular the use of Bromelain, indicates that this approach will likely achieve clinical usefulness. The experimental studies indicate that rapid controlled debridement, with minimal local and systemic toxicity, is possible, and that effective chemotherapeutic agents may be combined with the Bromelain without either interfering with the actions of the other. The authors believe that rapid (hours) debridement accomplished by the combined use of chemical debriding and chemotherapeutic agents will obviate the possibility of any increase in infection, caused by the use of chemical agents for debridement, as reported for Paraenzyme21 and Travase.39,48 It is possible that the short term use of systemic antibiotics begun just before and continued during, and for a short time after, the rapid chemical debridement may prove useful for the prevention of infection, as appears to be the case for abdominal operations of the clean-contaminated and contaminated types.

Full text

PDF
670

Images in this article

674Figs. 1a-c.
on p.674
674Fig. 1b.
on p.674
675Fig. 1c.
on p.675
676Fig. 2.
on p.676
677Fig. 3.
on p.677
677Fig. 4.
on p.677
678Fig. 5.
on p.678
679Fig. 6.
on p.679
680Fig. 7.
on p.680
680Fig. 8.
on p.680
681Fig. 9a.
on p.681
682Fig. 9B.
on p.682
682Fig. 10.
on p.682
683Fig. 11.
on p.683
683Figs. 12a-c.
on p.683
684Fig. 12b.
on p.684
685Fig. 12c.
on p.685
689Figs. 14a-c.
on p.689
690Fig. 14b.
on p.690
691Fig. 14c.
on p.691
691Figs. 15a-c.
on p.691
692Fig. 15b.
on p.692
693Fig. 15c.
on p.693

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. ALTEMEIER W. A., COITH R., CULBERTSON W., TYTELL A. Enzymatic debridement of burns. Ann Surg. 1951 Oct;134(4):581–587. doi: 10.1097/00000658-195110000-00006. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Artz C. P. Burns in my lifetime. J Trauma. 1969 Oct;9(10):827–833. doi: 10.1097/00005373-196910000-00001. [DOI] [PubMed] [Google Scholar]
  3. BERMAN S., LOWENTHAL J. P., WEBSTER M. E., ALTIERI P. L., GOCHENOUR R. B. Factors affecting the elaboration by Clostridium histolyticum of proteinases capable of debriding third degree burn eschars on guinea pigs. J Bacteriol. 1961 Oct;82:582–588. doi: 10.1128/jb.82.4.582-588.1961. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. BURKE J. F., GOLDEN T. A clinical evaluation of enzymatic debridement with papain-urea-chlorophyllin ointment. Am J Surg. 1958 May;95(5):828–842. doi: 10.1016/0002-9610(58)90635-4. [DOI] [PubMed] [Google Scholar]
  5. Baliarsing S., Krishna G. Evaluation of chemicals and enzymes in the debridement of experimental burns. Indian J Med Res. 1968 Nov;56(11):1670–1674. [PubMed] [Google Scholar]
  6. CONKLIN D. A., WEBSTER M. E., ALTIERI P. L., BERMAN S., LOWENTHAL J. P., GOCHENOUR R. B. Large scale purification of proteinases from Clostridium histolyticum filtrates. J Bacteriol. 1961 Oct;82:589–594. doi: 10.1128/jb.82.4.589-594.1961. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. CONNELL J. F., Jr, DEL GUERCIO L. R., ROUSSELOT L. M. Debricin; clinical experiences with a new proteolytic enzyme in surgical wounds. Surg Gynecol Obstet. 1959 Jan;108(1):93–99. [PubMed] [Google Scholar]
  8. CONNELL J. F., Jr, ROUSSELOT L. M. Indications for and application of debricin ficus protease. Am J Surg. 1959 Nov;98:685–692. doi: 10.1016/0002-9610(59)90491-x. [DOI] [PubMed] [Google Scholar]
  9. CONNELL J. F., Jr, ROUSSELOT L. M. New concepts in the treatment of surgical wounds. Am J Surg. 1959 Apr;97(4):429–433. doi: 10.1016/0002-9610(59)90009-1. [DOI] [PubMed] [Google Scholar]
  10. CONNELL J. F., Jr, ROUSSELOT L. M. The use of enzymatic agents in the debridement of burn and wound sloughs. Surgery. 1951 Jul;30(1):43–55. [PubMed] [Google Scholar]
  11. Connor G. J., Harvey S. C. The Healing of Deep Thermal Burns: A Preliminary Report. Ann Surg. 1944 Sep;120(3):362–366. doi: 10.1097/00000658-194409000-00007. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Crawford B. S., Rozner L. A clinical trial of a desloughing agent in burns. A preliminary report. Br J Plast Surg. 1966 Apr;19(2):154–160. [PubMed] [Google Scholar]
  13. DEBELLIS R., MANDL I., MACLENNAN J. D., HOWES E. L. Separation of proteolytic enzymes of Clostridium histolyticum. Nature. 1954 Dec 25;174(4443):1191–1192. doi: 10.1038/1741191a0. [DOI] [PubMed] [Google Scholar]
  14. DOUGLAS J. F., FERRIDAY J. C., GAUGHRAN E. R. A new laboratory method for screening debriding agents. Am J Med Sci. 1958 Apr;235(4):420–425. [PubMed] [Google Scholar]
  15. DOUGLAS J. F., FERRIDAY J. C., GAUGHRAN E. R. Comparative laboratory study of the debriding effect of six enzymes. Am J Med Sci. 1958 Apr;235(4):426–430. [PubMed] [Google Scholar]
  16. Dimick A. R., Sullivan M. B., Jr Bacteremia due to tracheotomy or topical lytic enzymes in burn patients. Surgery. 1966 Dec;60(6):1154–1159. [PubMed] [Google Scholar]
  17. Forsgren L., Orell S. Aspiration cytology in carcinoma of the pancreas. Surgery. 1973 Jan;73(1):38–42. [PubMed] [Google Scholar]
  18. GIMBEL N. S., WEISSMAN F., SCHIRLE J., ORTEN A. U. Acid debridement of burned rats and men. Am J Surg. 1960 May;99:676–678. doi: 10.1016/0002-9610(60)90012-x. [DOI] [PubMed] [Google Scholar]
  19. GOCHENOUR R. B., LOWENTHAL J. P., WEBSTER M. E., BERMAN S. Debridement of burns on various animal species by Clostridium histolyticum proteinases. Am J Vet Res. 1962 Sep;23:1089–1096. [PubMed] [Google Scholar]
  20. HAMIT H. F., UPJOHN H. L. Debridement of experimental burns with Clostridium histolyticum H-4 enzymes. Ann Surg. 1960 Apr;151:589–593. doi: 10.1097/00000658-196004000-00021. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. HEINICKE R. M. Complementary enzyme actions in the clotting of milk. Science. 1953 Dec 18;118(3077):753–754. doi: 10.1126/science.118.3077.753. [DOI] [PubMed] [Google Scholar]
  22. HOWES E. L., MACLENNAN J. D., MANDL I., DEBELLIS R. Debridement of burn slough by peptidases recovered from Clostridium hystolyticus. Bull N Y Acad Med. 1955 May;31(5):413–414. [PubMed] [Google Scholar]
  23. HOWES E. L., MANDL I., ZAFFUTO S., ACKERMANN W. The use of Clostridium histolyticum enzymes in the treatment of experimental third degree burns. Surg Gynecol Obstet. 1959 Aug;109(2):177–188. [PubMed] [Google Scholar]
  24. HOWES E. L. Use of proteolytic enzymes as debriding agents. Surgery. 1957 Nov;42(5):948–952. [PubMed] [Google Scholar]
  25. Jackson D. M. Second thoughts on the burn wound. J Trauma. 1969 Oct;9(10):839–862. doi: 10.1097/00005373-196910000-00003. [DOI] [PubMed] [Google Scholar]
  26. KLEIN G. K. ENZYMATIC DEBRIDEMENT OF THIRD DEGREE BURNS IN ANIMALS WITH BROMELAINS. A PRELIMINARY REPORT. J Maine Med Assoc. 1964 Sep;55:169–171. [PubMed] [Google Scholar]
  27. LILJEDAHL S. O., BACKDAHL M. Enzymatic treatment of deep burns. Experience with a new preparation: ethizyme. Acta Chir Scand. 1960 Apr 14;118:372–378. [PubMed] [Google Scholar]
  28. Lam C. R., Puppendahl M. The Pyruvic Acid Method of Burn Slough Removal: An Experimental Investigation. Ann Surg. 1945 Jun;121(6):866–871. doi: 10.1097/00000658-194506000-00011. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Langohr J. L., Owen C. R., Cope O. Bacteriologic Study of Burn Wounds : A Comparison of the Bacterial Flora of Burn Wounds of Patients Treated with Sulfonamides or Penicillin. Ann Surg. 1947 Apr;125(4):452–504. [PMC free article] [PubMed] [Google Scholar]
  30. Levine N., Ger R., Stellar S., Levenson S. M. Use of a carbon dioxide laser for the debridement of third degree burns. Ann Surg. 1974 Feb;179(2):246–252. doi: 10.1097/00000658-197402000-00024. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Levine N., Ger R., Stellar S., Levenson S. M. Use of a carbon dioxide laser for the debridement of third degree burns. Ann Surg. 1974 Feb;179(2):246–252. doi: 10.1097/00000658-197402000-00024. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Levine N., Seifter E., Connerton C., Levenson S. M. Debridement of experimental skin burns of pigs with bromelain, a pineapple-stem enzyme. Plast Reconstr Surg. 1973 Oct;52(4):413–424. [PubMed] [Google Scholar]
  33. Levine N., Seifter E., Levenson S. M. Enzymatic debridement of burns. Surg Forum. 1971;22:57–58. [PubMed] [Google Scholar]
  34. MANDL I., MACLENNAN J. D., HOWES E. L. Isolation and characterization of proteinase and collagenase from Cl. histolyticum. J Clin Invest. 1953 Dec;32(12):1323–1329. doi: 10.1172/JCI102861. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. MCCONN J. D., TSURU D., YASUNOBU K. T. BACILLUS SUBTILIS NEUTRAL PROTEINASE. I. A ZINC ENZYME OF HIGH SPECIFIC ACTIVITY. J Biol Chem. 1964 Nov;239:3706–3715. [PubMed] [Google Scholar]
  36. MILLER J. M. The digestion of collagen in burns. J Invest Dermatol. 1959 Mar;32(3):467–470. [PubMed] [Google Scholar]
  37. MURACHI T., YASUI M., YASUDA Y. PURIFICATION AND PHYSICAL CHARACTERIZATION OF STEM BROMELAIN. Biochemistry. 1964 Jan;3:48–55. doi: 10.1021/bi00889a009. [DOI] [PubMed] [Google Scholar]
  38. OTA S., MOORE S., STEIN W. H. PREPARATION AND CHEMICAL PROPERTIES OF PURIFIED STEM AND FRUIT BROMELAINS. Biochemistry. 1964 Feb;3:180–185. doi: 10.1021/bi00890a007. [DOI] [PubMed] [Google Scholar]
  39. Pennisi V. R., Capozzi A., Friedman G. Travase, an effective enzyme for burn debridement. Plast Reconstr Surg. 1973 Apr;51(4):371–376. doi: 10.1097/00006534-197304000-00003. [DOI] [PubMed] [Google Scholar]
  40. Perlstein S. H., Kézdy F. J. Isolation and characterization of a protease inhibitor from commercial stem bromelain acetone powder. J Supramol Struct. 1973;1(3):249–254. doi: 10.1002/jss.400010309. [DOI] [PubMed] [Google Scholar]
  41. Prytz B., Connell J. F., Jr, Rousselot L. M. Bacillus subtilis protease in the digestion of burn eschar. Clin Pharmacol Ther. 1966 May-Jun;7(3):347–351. doi: 10.1002/cpt196673347. [DOI] [PubMed] [Google Scholar]
  42. Prytz B., Connell J. F., Jr, Rousselot L. M. The digestion of human burn eschar by proteolytic enzymes. Enzymologia. 1965 Jun 30;28(6):367–376. [PubMed] [Google Scholar]
  43. SAUTTER R. D., BUCKWALTER J. A., ZIFFREN S. E. Chemicals and enzymes in debridement of thermal burns. AMA Arch Surg. 1958 May;76(5):744–748. doi: 10.1001/archsurg.1958.01280230084012. [DOI] [PubMed] [Google Scholar]
  44. SHELBY R. W., TAYLOR L. E., GARNES A. L., PRIGOT A. Enzymatic debridement with activated whole pancreas. Am J Surg. 1958 Oct;96(4):545–549. doi: 10.1016/0002-9610(58)90972-3. [DOI] [PubMed] [Google Scholar]
  45. Stellar S., Levine N., Ger R., Levenson S. M. Carbon-dioxide laser for excision of burn eschars. Lancet. 1971 May 8;1(7706):945–945. doi: 10.1016/s0140-6736(71)91446-2. [DOI] [PubMed] [Google Scholar]
  46. Stellar S., Levine N., Ger R., Levenson S. M. Laser excision of acute third-degree burns followed by immediate autograft replacement: an experimental study in the pig. J Trauma. 1973 Jan;13(1):45–53. doi: 10.1097/00005373-197301000-00008. [DOI] [PubMed] [Google Scholar]
  47. Sulzberger M. B., Kanof A., Baer R. L. Studies on the Acid DéBridement of Burns. Ann Surg. 1947 Apr;125(4):418–430. doi: 10.1097/00000658-194704000-00003. [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. WEBSTER M. E., ALTIERI P. L., CONKLIN D. A., BERMAN S., LOWENTHAL J. P., GOCHENOUR R. B. Enzymatic debridement of third-degree burns on guinea pigs by Clostridium histolyticum proteinases. J Bacteriol. 1962 Mar;83:602–608. doi: 10.1128/jb.83.3.602-608.1962. [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. WEBSTER M. E., CLARK W. R., CONKLIN D. A., ALTIERI P. L., BERMAN S., LOWENTHAL J. P., GOCHENOUR R. B. Biological assay of proteolytic enzymes capable of debriding third degree burn eschars. Proc Soc Exp Biol Med. 1961 May;107:79–83. doi: 10.3181/00379727-107-26541. [DOI] [PubMed] [Google Scholar]

Articles from Annals of Surgery are provided here courtesy of Lippincott, Williams, and Wilkins

RESOURCES