Clinical Application of MEBT in the Regenerative Repair of Large Area Burn

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1 Clinical Application of MEBT in the Regenerative Repair of Large Area Burn Wei Dahe Affiliated Hospital of Tibet Nationalities Institute, Shanxi Xianyang Abstract Objective: To conclude and elaborate the effect of moist burn therapy (MEBT/MEBO) in skin regeneration and repairing of large area burn, especially in deep burn wounds. Method: Standard MEBT/MEBO therapy was adopted in 46 cases of large area burn patients treated by this hospital in recently years in the whole process and initial skin tension releasing, ploughing and blading therapy was adopted for deep burn wounds. Results: All of the patients in 46 cases were healed with the shortest healing time of 21 days, the longest healing time of 58 days and the average healing time of 38 days without skin grafting. Physiological healing, no deformity and no dysfunction were achieved for all of the wounds. Conclusion: The efficacy of moist therapy for large area burn is obvious. Physiological healing was realized for deep burn wounds. The purpose of allowing burn wound to heal in situ was achieved. Key words Large area burn; Moist therapy; Skin regeneration and repairing CLC (Chinese Library Classification) No. R644 Document Identification Code A Article No (2003) In mid 1980s, an fundamental revolution occurred in the burn treatment field of China. Professor Xu Rongxiang of Beijing Guangming Chinese Medicine Institute for Burns, Wounds and Ulcers established moist burn therapy system. The technical core of the system is to keep wound moist, which is completely different from traditional dry therapy. The creation of moist therapy successfully released the pains of many burn patients. Since 1989, this hospital adopted moist exposed burn ointment (MEBO) in treating 2040 cases of various kinds of burn patients and gained certain experience in using MEBO. Especially in recent years, along with the gradually matured moist burn therapy and the success of human tissue organs skin in situ regeneration and copy therapy, this hospital has treated and healed 46 cases of large area burn patients with MEBT/MEBO comprehensive treatment and obtained satisfactory effect. 1. Clinical data 1.1 General information This group comprised 48 cases of hospitalized patients from 1995 to 2002, including 34 cases of male and 14 cases of female from 2 to 76 years old. There were 38 cases with 30-50% TBSA and 10 cases of above 50% TBSA. Causes included electricity injury, flame burn, hot liquid scald etc. The wounds were mainly deep second-degree accompanying with small area third-degree burn (5%~15%). Among, 46 cases were healed with 1 case of death and 1 cases being transferred to other hospital. The shortest wound healing time was 21 days; the longest healing time was 58 days and the average healing time was 38 days. Moist burn therapy - 1-1

2 MEBT/MEBO comprehensive treatment was adopted for all cases in the group. No cases had implemented skin grafting. As shown from follow-up visit of 15 cases for half a year and 4 cases for one year after they were discharged from hospital, no scar was observed on patients with deep second-degree wound, some dots or slight strip soft scar was found on patients with third-degree wound but without dysfunction. Physiological healing was realized for wounds. 1.2 Therapeutic methods and results MEBO moist exposed burn therapy was adopted for all cases in this group. Initial skin tension releasing, ploughing and blading therapy was applied for deep second-degree and third-degree burn wound. Small fluid-filled blisters were absorbed itself. For the large fluid-filled blister, fluid was discharged at the lower position and the blister skin were kept there. Anaesthetization was not required during the process of wound cleansing and no damage cleansing principle would be followed strictly. Moist exposed burn ointment was applied at once after treatment through above method. 1mm MEBO was applied every four to five hours and the original liquid and secretion were eliminated before drugs application to guarantee the smooth discharging of wound. According to the difference in seepage period, liquefying period and healing stage, the dosage and interval time of MEBO were regulated until the wounds were healed completely. For the treating results, superficial second-degree burns were healed in 10 days or so, deep second-degree wounds were healed in 25 days or so and third-degree wounds were healed in about 30 to 58 days. 2. Typical cases Case 1: Si XX, male, 21 years old, fell in boiled water when working in a workshop and was sent to this hospital within 16 hours after injury and hospitalized in May 10, Physical examination results: T39.5, P120 times/minutes, R26 times/minutes, Bpl2/8kpa, poor spirit, drowsiness, left upper limb, left side breast, belly, back and parts below xiphoid process were burned completely with the area reaching 72% including 20% of superficial second-degree burns, 45% of deep second-degree burn and 7% of third-degree burn. He was in shock status when hospitalized and anti-shock treatment was implemented at once with antibiotics applied routinely. At the same time, MEBO was applied at once for systemic wounds after treated with 1 Benzalkonium Bromide. The state of illness was stabilized two days later. Ploughing and blading therapy was implemented for deep second-degree and third-degree wounds. 1.0mm drugs were applied once every 4 to 6 hours. 6 days later, wounds began to be liquefied. 16 days later, liquefied necrotic tissue of wound was eliminated completely, Skin Island occurred on wound surface and skin regeneration and repairing was began. 26 days later, deep second-degree wounds were healed completely. 38 days later, third-degree wounds were healed. MEBT/ MEBO treatment was adopted during the whole process of treatment without skin grafting. No scar was found on wound surfaces in the one-year follow-up visit after leaving the hospital

3 Case 2: Wang XX, male, 76 years oil, a retiree of this hospital (school). He was burned due to fire of gas at home and was emergently sent to this hospital within half an hour after injury and hospitalized on October 8, Physical examination results: T38,P110 times/minutes, R24 times/minutes, Bpll/8kpa, low spirit, head and face, hands, forearms, breast, belly, back and lower limbs were burned with the area reaching 60%, including 15% of superficial second-degree burns, 33% of deep second-degree burn and 12% of third-degree burn, among which, third-degree burn wounds appeared on hands, forearms, breast and belly. Admission diagnosis: (1) flame burn; (2) low blood volume shock. Active anti-shock treatment was implemented after hospitalized in combined with antibiotics. The state of illness was stabilized three days later. Initial ploughing and blading therapy treatment was implemented for deep second-degree and third-degree wounds. MEBO was applied routinely. One week later, wounds began to be liquefied and necrotic tissue was eliminated timely. Once incomplete necrotic tissue loosed, it was cut off immediately so as to guarantee smooth discharging. The principle of no pain, no bleeding and no tissue damage was followed in wound cleansing. 18 days later, necrotic tissue was liquefied and discharged completely and standard MEBT/MEBO treatment was adopted continuously. 30 days later, deep second-degree wounds were healed completely. 45 days later, third-degree wounds were healed without skin grafting. Few small soft strip scars were found on third-degree wound surface in the one-year follow-up visit after leaving the hospital. No dysfunction occurred in hands and forearms. 3. Discussions 3.1 Moist provides favorable physiological environment for regeneration of burn skin The regeneration speed of damaged cell depends mainly on the cell itself, while the external environment also plays a critical role. The adopted MEBT/MEBO treatment can not only prevent the evaporation of moisture from wounds, but also maintain effective blood volume, reduce the pain of wound and prevent the shock from further aggravation. At the same time, it can let wound in a physiological moist environment, create a wound insulation condition possessing skin aspiration function so as to prevent the wound from being damaged again and establish a favorable foundation for follow-up treatment of large area burn [1]. Traditional burn treatment is to keep the wound dry and make the wound form scabs as early as possible in order to protect the wound from being damaged and contaminated again, but the result is not good, or even worse. Scabs formed on wounds seem to have the function of protecting wound apparently and prevent the exterior from being further damaged and contaminated. But dry scabs do not meet the physiological requirements of wound tissue for regeneration and repairing; on the contrary, it can impel the wound tissue being dry and dehydrated and make the active tissue continue to be dry and necrotic so as to aggravate damage. Secondly, the dry scabs are not good for discharging of wound surface, so infection and empyema are easy to occur under the scab. The presence of scab shell arrest the discharge of empyema under the scab, which shall often cause infection that is diffused to deep tissues and cause systemic - 3-3

4 infection and shall further aggravate the burn wounds. Zhao Junxiang, et al. [2] adopted MEBO therapy for 482 cases with burn area between 30%-50% and observed that only 14 cases occurred infection with the incidence rate being 0.95% only. The infection rate is 40% or so according to the statistics of traditional treatment data. Above results indicated that MEBO moist therapy not only could discharge the dirt, bacteria and necrotic tissue on the wound surface, but also can participate in the discharging process between burn tissues and promote the sphacelus and bacteria outflow from the wounds and damage the environment where bacteria grows and propagates to prevent the wounds from being infected and promote the repairing and regeneration of burn tissue. 3.2 The ploughing and blading therapy for deep burn wounds in initial stage is conducive to skin repairing and regeneration Leather-like scab will usually be formed on deep burn, especial third-degree burn wound. The presence of scab poses obvious impact on the repairing and regeneration of burn wounds. On the one hand, it does not allow MEBO to get in close contact with the substrate tissue, its normal biological action on the necrotic tissue of wounds cannot be exerted, so the process of enzymolysis, hydrolysis, spoilage and saponification of wounds will be delayed, the liquefying period be prolonged. On the other hand, the presence of scab will increase the tension of wound, together with obvious initial local swelling, the necrotic skin shall form oppression to the survival tissues under the skin, the local blood shall be squeezed, which shall result in blood supply obstruction and further affect the regeneration and repairing of wounds. Therefore, if the state of illness allows, skin tension releasing, ploughing and blading therapy shall be adopted in the initial stage for deep burn wounds so as to release the oppression of necrotic tissue to the survival tissue under the skin. MEBO shall be permeated into the stasis tissue under the necrotic layer, dredge the blood pipe and restore its physiological function. Then, in virtue of the effective ingredients in MEBO, the potential of regenerative cell of tissue shall be activated, the parabiosis tissue shall be revived so as to promote the skin regeneration and repairing of burn wound. 3.3 Appropriate environment temperature is conducive to the exertion of biological function of MEBO When the environmental temperature is relatively low, wound temperature required by the MEBO can not be reached so the status of upper ointment and lower liquid of MEBO cannot be formed, which will affect the exertion of the function of MEBO or even result in the soakage and infection of wounds. Someone discovered in the heating experiment that only when the temperature reaches 36, the status of upper ointment and lower liquid of MEBO will occur. Which is to say, only when the temperature of contact wound of MEBO reaches 36 or so, it can exert its due function and enter the tissue in the form of liquid and provide spatial moist environment so as to help MEBO to release its efficacy and save parabiosis tissue. Therefore, when using MEBO, the indoor temperature shall be higher than 25, then the surface temperature or wound temperature shall reach the level that is required - 4-4

5 by MEBO to exert its treatment function. 3.4 Appropriate use of MEBO is conducive to the regeneration and repairing of burn skin Moist therapy can provide an approximately normal physiological environment for repairing and regeneration of burn wounds [3]. And life regenerating substance is contained in MEBO, which can activate potentially regenerative cells and then develop them into stem cell and epithelial cell and then finally repair the wounds [4]. These factors play a critical role in regeneration and repairing of skin tissues. But the clinical experience of many years also tells us that: the appropriate use of MEBO shall not be ignored too, as it is still an important content in the repairing and regeneration of burn skin. The so-called appropriate use of MEBO includes: (1) To supply drugs continuously and in constant concentration. In other words, it means that the thickness of dressing and the interval time of wound shall meet the needs of different wound in different stage. (2) Wounds shall be kept moist but not soaked, and the secretion of wounds shall be cleaned timely to ensure smooth drainage. (3) The principle of two decreases and one increase shall be comprehended and applied correctly. Two decreases refers to exudation stage and healing stage. The purpose of drugs application in the exudation stage is to promote the process of enzymolysis, hydrolysis, rancidity, saponification of necrotic tissue of wounds and enter into liquefying period as early as possible. decrease in exudation state means the decrease of the times of application and the interval period, usually five to six hours is preferred and lmm-2mm shall be appropriate as the thickness of drugs application. Healing stage means the wounds have been healed basically and the surface has been grown and the dermis has begun to regenerate. The purpose of drugs application during this period is to maintain the physiological environment of dermis tissue regeneration, to promote the growth of epithelial tissue and to limit the hyperplasia of fibrous tissue, so that no scar forming on the wounds. Therefore, the decrease of drugs application during the healing state refers to the dosage and times of application. Drugs application should be thin during this period and 1.0mm is preferred with intervals of 8 hours or so. Principle is to maintain the moist and smooth of wounds. One increase means the dosage and frequency of drugs application during the liquefying period shall be larger than that during the exudation stage and healing stage. Liquefying shall occur from superficies to interior of necrotic tissue of wounds during the liquefying period, which is also the period of regeneration of tissue of wounds with active metabolism of wounds and large quantity of white exudates out of the wounds. The liquefied tissues shall be cleaned timely and drugs shall be applied again, or wounds seepage and infection shall be easy to occur. Therefore, the dosage of MEBO during this period shall increase

6 hours period is preferred for the intervals of wounds cleansing and drugs application with thickness of 1.0mm until necrotic tissue is discharged completely. (4) The principle of no anaesthesia, no pain, no bleeding and no tissue damage shall be followed during the whole process of wound cleansing and drugs application. The basic method of burn skin repairing is the same as that of other wound tissue repairing, which is to connect or replace defective tissues with accretive cell or intercellular substances after injury. While ideal means of repairing is to repair the defective tissues completely with cells of the same original nature so as to recover the original structure and function and realize healing without scars. For deep burn wounds, the opinion of traditional surgery is: wound healing is very slow or even impossible. Scars formation or scar hyperplasia are easy to occur after healing of this kind of wound and might cause deformity and dysfunction [5]. However, according to the requirements of skin regeneration medicine, only physiological (without scar forming) healing of burn wound is the objective of burn treatment. Namely, it is very difficult to solve the deep burn skin regeneration problem with the traditional therapy. Therefore, traditional treatment mind must be broken through to a certain extent. It is no doubt that established moist therapy has solved this problem successfully. At present, thousands of clinical data have proved that: by adopting standard MEBT/MEBO therapy, completely physiological healing without scars formation and dysfunction can be achieved for deep wounds, which fully illuminated that MEBO developed by Professor Xu Rongxiang and the physiologic moist environment are the foundation of skin regeneration in situ, which shall play a more and more important role in the field of burn treatment in the future. References [1] Wang Shiyou, Clinical Experience in Treating 15 Extensive Burn Cases with MEBT. THE CHINESE JOURNAL OF BURNS WOUNDS & SURFACE ULCERS,1998.1(34): 26. [2] Zhao Junxiang, et al. Clinical Treatment & Observations on Regeneration and Repairing of Burn Skin [J] THE CHINESE JOURNAL OF BURNS WOUNDS & SURFACE ULCERS,2003,15 (1): 53. [3] Xu Rongxiang. Mechanism Outlines of Basic Theory Subject and Effect of MEBT/MEBO [ J ] THE CHINESE JOURNAL OF BURNS WOUNDS & SURFACE ULCERS,1997,9 (3): 40. [4] Xu Rongxiang, Xu Zenglu, regeneration medical study: Study on Effect of Moist Exposed Burn Therapy to Regeneration of Skin Stem Cell, [M].Chinese Medicine and Science and Technology Publication House, [5] Qiu Fazhu, Surgery[M].Version 4, 1997,209. Brief introduction to the author Wei Dahe(1959 ),Male (Han),Xinhua, Henan province, graduated from department - 6-6

7 of medicine, Tibet Nationalities Institute in Undertaking surgery specialty, attending doctor