Clinical evaluation of sutilains (Travase) in the enzymatic debridement of burn eschar
Creators: name: Kester, David Anderson
Publisher: name: University of British Columbia
Year: 2010

description: The early enzymatic debridement of burn eschar and subsequent skin grafting can greatly reduce patient morbidity, mortality, and also decrease total hospitalization. Since the 1940's, a succession of enzymes from various sources have been carefully evaluated and reviewed both in vitro and in vivo, and been rejected because of inadequate effect or excessive complications. Bacillus subtilis protease, the most recent agent to be developed, has been extensively studied in vitro and recently been released for clinical use in the United States and Canada. To date, in vitro investigation has established it as an effective proteolytic agent, and early in vivo investigation results, primarily under the auspices of the developing laboratory (Flint), are remarkable for their lack of complications and effectiveness of debridement. Preliminary use of this agent at the Vancouver General Hospital Burn Unit indicated a higher complication rate than those previously reported. The purpose of the study was then to clinically evaluate the debridement of burn eschar by Travase and to evaluate the complications encountered. Travase therapy was begun on selected cases as soon as possible after initial resuscitation and stabilization of the burn patient had been completed. Areas selected were less than 15% Body Surface Area (BSA) and generally of functional importance such as the hand. The Travase was applied three times daily in ointment form over the eschar and covered with moist saline mesh dressings as recommended by the manufacturer. In selected control cases, areas of clinical mirror image burns or adjacent burns of similar depth, were treated identically except for the application of the enzyme. Photographic records were maintained of the progression of debridement and the Travase was continued until debridement was complete, judged ineffective, or complications necessitated discontinuance of therapy. A total of 25 cases were evaluated, 5 of which had areas of similar burn treated identically, except for the use of Travase, serving as areas of comparison. Adequate debridement judged as completion of debridement within two weeks of initiation of therapy occurred in 65% of overall cases. Treatment begun within 48 hours of burn injury debrided faster clinically than older, more leathery eschar. The incidence of complications and discontinuation noted was higher than previous studies, namely 28% of 25 cases were discontinued, and all but 3 cases of 25 had some complication. Pain on application was more common than previously reported and a major source of patient dissatisfaction. Concurrent burn wound sepsis with Travase application occurred in 25% of cases, but may be controlled in some cases by concurrent use of a topical antimicrobial, although this was not controlled. Overall, clinical results were judged satisfactory in limited clinical situations, specifically, small local areas of full thickness burn in otherwise healthy patients, or functional areas such as the hand in larger, otherwise stable burns. The results of this study reveal the need for caution in clinical use of Travase not sufficiently emphasized in the previous literature and emphasize its adjunctive role to conservative management.