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. 2020 Mar 31;33(1):33–37.

Optimizing the use of Aquacel Ag® for pediatric burns - When to start?

d Kruchevsky 1,∗, y Pikkel 1, s Mattar 1, y Ramon 1, y Ullmann 1
PMCID: PMC7263723  PMID: 32523493

Summary

Most pediatric burns are 2nd degree partial thickness, and most will heal spontaneously by providing a good healing environment, though there is no standardized treatment protocol. Aquacel Ag® has shown good clinical results in reducing the need for frequent dressing changes in the pediatric population. This study’s goal was to review our experience using this dressing for pediatric partial thickness burns in order to optimize and customize its use. A retrospective study included all pediatric patients suffering from burns, admitted to our institution between July 2013 and May 2018. We investigated a total of 705 dressing changes in our cohort of 276 patients. The most prevalent dressing material was Aquacel Ag®, used in 48% of cases. We examined the pattern of using Aquacel Ag® dressings. The average time until dressing change was required proved to be much longer when applied on the 1st day after burn and onward in comparison to the day of injury (4.85 vs. 2.21 days, p<0.001). Moreover, when it was applied on the 1st day after burn, a dressing used on a superficial 2nd degree burn needed to be changed less often than when it was applied on a deep 2nd degree burn (4.95 vs. 2.29 days, p=0.024). To optimize its use and cost effectiveness, dressing with Aquacel Ag® should be initiated on the 1st day after burn, or on the 2nd day when a deep 2nd degree burn is suspected; until then a standard topical preparation should be used.

Keywords: pediatric burns, aquacel AG, burn dressing, hydrofiber dressing

Introduction

Children are disproportionately affected by burn injuries, most of which are 2nd degree partial thickness, caused by scalding as the leading mechanism.1-4 Most partial degree burns will heal spontaneously just by avoiding infection and deepening of the burn. Various treatment options have been proposed, but there is no standardized treatment protocol.5,6

An ideal dressing should provide a good healing environment, a moisturized environment with antibacterial properties, without interference to tissue healing, be cost effective, and be easy to use without the need for frequent changes, which is especially important for the pediatric population.

Aquacel Ag® (ConvaTec, Princeton, NJ, USA) is a nonwoven sodium carboxymethylcellulose impregnated with 1.2% ionic silver, which has been shown in vitro and in clinical studies to possess most of the above qualities.7-14 Among children suffering from partial thickness burns, this dressing has been shown to be effective by reducing painful dressing changes, nursing time and length of hospitalization, thus reducing the cost of treatment despite the higher cost per dressing unit.15-20

This study’s goal was to review our experience using this dressing for pediatric partial thickness burns in order to optimize and customize its use.

Patients and methods

This study was approved by the institutional Ethics Committee. It is a retrospective study including all pediatric patients up to the age of 16 admitted to our institution, which serves as a referral center for pediatric burns in the north of Israel. This study included children admitted between July 2013 and May 2018, all suffering from partial degree burns. Those suffering from full thickness burns and patients who presented to our institution more than 48 hours after burn injury were excluded.

Medical records were reviewed regarding demographic information (i.e. age, gender, place of residence), burn characteristics (e.g. mechanism, surface area injured, suspected degree, body parts injured etc.), hospitalization details (e.g. length of stay, sepsis episodes, treatment, dressings used and frequency of replacement, etc.) and follow up (time to closure and scarring).

Student’s T-test was applied for continuous variables. Chi-square test was used for categorical variables analysis. Pearson correlations were applied for examining correlations between continuous variables. P-value of 5% or less was considered statistically significant. The data were analyzed using the SPSS version 23 (SPSS Inc. Chicago, IL, USA).

Results

Our search yielded 276 admissions of children in the years 2013-2018. Of those, 34 patients suffered from 3rd degree burns, thus were excluded. Eight patients were transferred from other hospitals, admitted to our institution more than 48 hours post injury with an in-complete clinical data, therefore were also excluded from the study. Our final study group included 234 patients.

Fifty-nine percent of the cohort were male. Sixteen percent were less than one year old, 60% were 1-3 years old, 12% were 4-6 years old, and 12% were older than 6. The majority had scald injuries (85%), while 9% were injured by contact burn, 5% by direct fire and 1% by another mechanism. The injured TBSA (total body surface area) was on average 8.48% and length of hospitalization was 5.97 days (Table I).

Table I. Characteristics of the cohort.

Table I

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We investigated a total of 705 dressing changes in our cohort. The most prevalent dressing material was Aquacel Ag®, a hydrofiber dressing impregnated with silver ions, for a total of 48% of our patients. Silver sulfadiazine was used for 24% of cases, Granuflex ® membrane for 11%, Flaminal® for 9% and hypochlorite solution (Eusol) was used for 2% of cases. Nine percent of the patients were treated with vaseline ointment only, since the burn was confined to the face area.

Observing the pattern of using Aquacel Ag® dressings, the average time until a change was needed due to excessive secretion was much longer when applied on the 1st day after burn and onward in comparison to when it was applied on the day of injury, 4.85 and 2.21 days respectively, p<0.001 (Fig. 1).

Fig. 1. Days to redressing with Aquacel Ag® by days after burn.

Fig. 1

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The characteristics of the patients who were treated with Aquacel Ag® dressings on the day of burn or after were comparable (Table II). Furthermore, when examining the variables that could affect the effectiveness of the hydrofiber dressings, we observed that when applying the dressing on the 1st day after burn, a dressing used on a deep 2nd degree burn needed to be changed more often than when it was applied on a superficial 2nd degree burn on 2.29 and 4.95 days respectively, p=0.024 (Fig. 2). Characteristics of the patients who were treated with hydrofiber dressings on the 1st day after burn divided by the assessed degree of burn are reported in Table III. On the 2nd day after burn and afterwards, no significant difference was noticed as regards time until a change of dressing was needed (Fig. 2).

Table II. Dressing with Aquacel Ag® on the day of burn vs. the day after burn.

Table II

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Fig. 2. Days to redressing by days after burn and by degree of burn.

Fig. 2

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Table III. Characteristics of patients dressed with Aquacel Ag® on the day after burn divided by assessed degree of burn.

Table III

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Discussion

Partial thickness burns are expected to heal spontaneously when provided with an optimal healing environment and by preventing infection.

Aquacel Ag® dressing combines the properties of hydrofiber material, which absorbs wound exudates to form a gel, allowing a good healing environment and reducing the need for repeated dressing changes13 with the gradual and prolonged release of silver ions, known for their antibacterial effect against a wide range of bacteria, yeast and fungi with low resistance.21-23

The advantages of this dressing include: good adherence to the wound surface, reduced need for dressing changes, and decreased nursing time and hospital stay. All this makes the dressing particularly suitable for pediatric patients in whom these advantages are even more beneficial.15-20

In this study, Aquacel Ag® has been the most used dressing for pediatric burns in our institution. The average dressing change frequency was every 4.02 days, comparable with previous studies. 9,10,15-20 However, the dressing was less effective when used on the day of burn and the 1st day afterwards for those suffering from deeper partial thickness burn, in terms of redressing: 2.21 and 2.29 days, respectively.

The cost of using Aquacel Ag® is higher than the topical preparations, but when calculating and comparing to total treatment cost, Aquacel Ag® was shown to be more cost effective due to a reduction in redressing procedures, nursing time and hospital length of stay.16,19,20 Our lesson from this study is that using hydrofiber dressing such as Aquacel Ag® is beneficial when not applied on the same day of injury, because the need for dressing change is significantly shorter. It is always better to begin with a cheaper preparation, and only after a day or two to start using it, when we are certain about injury depth. When the injury is diagnosed as deep 2nd degree, using Aquacel Ag® should be postponed until two days post injury because if used any earlier, a higher frequency of redressing is needed. Nevertheless, when 3rd degree burn is suspected, the more advanced dressing material is unnecessary, though surgical intervention should be performed early on. Our proposed algorithm for when to start dressing with hydrofiber dressing is shown in Fig. 3.

Fig. 3. Algorithm for starting treatment with Aquacel Ag® for partial thickness burn.

Fig. 3

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Our explanation for more frequent redressing when using the dressing on the injury day may be attributed to more secretion noticed on the first days post injury or to less adherence to the blisters and burnt epidermis that still covers some of the burnt area upon first dressing procedure. To conclude, according to our experience and previous studies,15-20 Aquacel Ag® is the favorable dressing material for the pediatric population suffering from partial thickness burns. It is cost-effective, reduces the need for painful dressing changes and anesthesia, and saves staff working hours while reducing the length of hospitalization. The proper use of this dressing is for it to be initiated on the 1st day after burn, or on the 2nd day when a deep 2nd degree burn is suspected. Until then a standard topical preparation should be used.

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