original article collagen dressing versus heparin dressing in burn wound management rakesh rai1, sunil h. sudarshan2, reshmina dsouza3, elr

ORIGINAL ARTICLE
COLLAGEN DRESSING VERSUS HEPARIN DRESSING IN BURN WOUND MANAGEMENT
Rakesh Rai1, Sunil H. Sudarshan2, Reshmina Dsouza3, Elroy Saldhana4,
P.S. Aithala5
HOW TO CITE THIS ARTICLE:
Rakesh Rai, Sunil H Sudarshan, Reshmina Dsouza, Elroy Saldhana, PS
Aithala. “Collagen dressing versus heparin dressing in burn wound
management”. Journal of Evolution of Medical and Dental Sciences 2013;
Vol2,
Issue 47, November 25; Page: 9124-9130.
BACKGROUND: One of the greatest discoveries of mankind is the double
edge sword “fire”. This has been both a boon and a bane to mankind, on
one side it helps in the survival and on the other it causes suffering
to those who succumb to its injuries. Burn injuries are known for
their complexity and their treatment requires a complete understanding
of patho-physiology and interaction of the major organ systems. In
India burn injuries account for most of the hospital admissions.
Various treatment options are available for burn wound management.
Heparin and collagen are the two dressings have been found to useful
in burn wound management, hence we decided to study their comparison
in burn wound management. AIMS: In view of the above said we
considered to study the effectiveness of collagen dressing in treating
burns with that of heparin dressing. METHODS AND MATERIAL: A
prospective study was done at between June 2010 to September 2012 in
which 100 patients who presented with second degree burns were chosen
by random sampling technique, and were grouped into 2 groups
consisting of 50 patients each after excluding patients who did not
meet the inclusion criteria and those who met the exclusion criteria.
STATISTICAL ANALYSIS: Chi square test, Fishers exact test used to
assess the statistically significant values. Values of p<0.05 or less
were considered to be statistically significant. RESULTS: In our study
it was observed that duration taken for wound healing is lesser in the
collagen group than heparin group, 17.36 days in case of collagen
dressing and 21.26 days in case of conventional dressings. It was also
observed that duration of hospital stay was less that is 10.02 days in
those treated with collagen dressing as compared to 15.32 days in
heparin group. It was also observed that there was less pain and
better patient compliance with collagen dressing. CONCLUSION: Collagen
sheet is very useful in second-degree burns when compared to heparin.
It, is well tolerated, provides multiple benefits and the overall
cost-benefit factor is very good when compared to the heparin
dressings in burn wound management.
KEYWORDS: heparin, collagen, burn
INTRODUCTION: One of the greatest discoveries of mankind is the double
edge sword “fire”. This has been both a boon and a bane to mankind, on
one side it helps in the survival and on the other it causes suffering
to those who succumb to its injuries. Burn injuries are known for
their complexity and their treatment requires a complete understanding
of patho-physiology and interaction of the major organ systems. In
India burn injuries account for most of the hospital admissions.
Various treatment options are available for burn wound management.
Heparin and collagen are the two dressings which have been compared
with conventional dressings and have been found to useful in burn
wound management, but no study available has heparin and collagen,
hence we decided to study the comparison between the two modalities in
burn wound management.
METHODS: A prospective study was done at between June 2010 to
September 2012 in which 100 patients who presented with second degree
burns were chosen by random sampling technique, and were grouped into
2 groups consisting of 50 patients each after excluding patients who
did not meet the inclusion criteria and those who met the exclusion
criteria.
Inclusion criteria:
*
Patients who present with partial thickness and deep dermal burns.
*
Patient presenting within 2 days of burns.
*
Patient below 60 years of age.
Exclusion criteria:
*
Patient with full thickness burns.
*
Patient with allergy to collagen dressing.
*
Patient with wound having extensive necrosis.
*
Patient with infected burns.
Dressings in the control group: Heparin treatment was started as soon
as the patient was received in the Burns Ward after the initial
assessment and resuscitation was complete and was continued till seven
post burn day and stopped if the patient was taken up for any form of
surgical intervention. The affected area was thoroughly cleaned for
removal of any external contamination. If the wound was infected, the
wound was debrided properly before dressing. The side effects of
heparin and/or alteration of the bleeding profile were monitored and
if present were a definitive indication for stopping heparin,and the
effects reversed with protamine sulphate 1 ml diluted with 9 ml of
distilled water over ten minutes.Dressings were changed daily.
Dressings in the test group: Before applying collagen dressing, the
affected area was thoroughly cleaned for removal of any external
contamination. If the wound was infected, the wound was debrided
properly following that collagen sheets as required for the raw
surface area were used of appropriate size are selected. Collagen
sheets were rinsed thoroughly in normal saline before application to
remove all traces of the preservation fluid. Sheets were applied
firmly so as to cover the whole raw area. Care was taken to remove any
air bubble between the burn surface and the collagen which was
facilitated by using the back of the thumb-forceps.
Data collection: During the period of study, the data collected from
the patients’ files regarding the following characteristics
*
Age of the patient,
*
The cause of burns
*
Type of burns
*
Degree and percentage of burns,
*
Treatment given
*
The time taken for wound healing
*
Duration of hospitalization
Statistic analysis: Statistic analysis was done using the Mann whitney
test, chi square test, fishers exact test and Mann whitney test , and
the analysis was interpreted by the p value and z value. p value of
less than 0.05 was considered as statistically significant.
RESULTS: Subject characteristics are shown in [Fig-1]. There was no
statistically significant difference with a X2 value of 6.619 and p
value 157, NS in the age distribution among the test and control
groups hence the data is comparable between the test and control
groups. The age of the participants ranged from 26-80 years with the
mean age 38.8 years. Out of total 100 patients 18 were males while 82
of them were females.

In our study it was observed that duration taken for the wound healing
is much lesser in the collagen group compared to the heparin
dressings, 17.36 days in case of collagen dressing and 21.26 days in
case of conventional dressings.
It was also observed that duration of hospital stay was less that is
10.02 days in those treated with collagen dressing as compared to
15.32 days in heparin group.
It was also observed that there was less pain and better patient
compliance with collagen dressing.
DISCUSSION: Burn injuries produce coagulative necrosis of the skin and
underlying tissues which is very painful and is associated with
complex local and systemic pathology and a high mortality.
Superficial burns i.e. First degree burns heal in 5-7 days time
without any scarring. While superficial dermal or deep dermal burns
i.e. 2nd degree burns take anytime between 2 to 4 weeks to heal and
are extremely painful. Second degrees burns if not treated promptly
and properly, may get infected & get converted into third degree i.e.
Deep burns resulting in scarring & contracture formation.
Inspite of rapid strides made in treatment of burns and better
understanding of patho-physiology of burns and advent of good spectrum
of antibiotics to prevent infection in burns, the 2nd to 3rd degree
burns are still an enigma and challenge to the surgeons. The morbidity
& mortality in burns is still high. In burn wound management the
efforts to prevent the progression of depth of burns, the relief of
pain, the requirement of high quantities of intra-venous fluid for
resuscitation & use of multiple antibiotic is still a daunting tasks
for the surgeons.
The age of the participants ranged from 26-80 years with the mean age
38.8 years In study of the sex distribution our data was comparable to
most of the studies in which females succumbed more to the burn
injuries.43 patients had flame burns and 57 patients had scald burns.
In our study 87 patients had accidental burns, 13 were suicidal burns.
Heparin is an antagonist to histamine, bradykinin, and prostaglandin
E1 combined with platelets inhibited complement C1 esterase;
protective against toxic oxygen metabolites and it also bound to
tumor-necrosis-factor 1. Heparin is a naturally-occurring
anticoagulant produced by basophils and mast cells.2 In 1916, McLean,
a second-year medical student at Johns Hopkins University, while
working under the guidance of Howell investigating pro-coagulant
preparations, isolated a fat-soluble phosphatide anti-coagulant in
canine liver tissue3, Various studies4,5
The work of Ramakrishna6 showed that heparin when used in the
management of burns, had anti-inflammatory properties.
The work of Saliba7proved that when heparin was added in the
management of burns, not only did it reduce pain, but, also limited
the inflammation, caused revascularization of ischemic tissue and
enhanced tissue granulation.
Heparin therapy consistently relieved pain, reduced inflammation,
limited cellular-destruction, was neoangiogenic, regulated tissue
restoration, shortened and facilitated healing and resulted in smooth
healing. Patients were more alert, physically active, cooperative,
able to eat and help in their care. There was a significant reduction
in need for escharotomies and fasciotomies and skin grafting8-12.
Collagen dressing is a type of wound dressing that is made with a form
of collagen to aid in body’s healing processes13.
A study done by SINGH O, GUPTA14 and colleagues has shown that use of
collagen dressings hastens the wound healing in burns, reduces scar
contracture and reduces need for skin grafting.
In a study by Gupta RL, 15 et al collagen sheet cover was used in 32
cases of fresh burns and 26 cases of post burn contractures. In
majority of cases of burns, the collagen sheet remained dry and there
was no infection. It safeguards against exogenous infection, prevented
exudation from the raw areas and provided rapid epithelialization and
healing.
Gerding RL 16et al concluded that when used on properly selected
wounds Biobrane therapy can significantly decrease pain and total
healing time. Improved patient compliance may be added benefit.
Demling RH17, Desanti L,et al. in their study concluded that a
bioengineered skin substitute significantly improves the management
and healing rate of partial thickness facial burns, compared to the
standard open topical ointment technique.
Barret, Jaun P.M.D 18et, al in their study noted the Length of
hospital stay and wound healing time were also significantly shorter
in the Biobrane.
A prospective comparative study by Mukund.et.al14 comprising of 50
patients majority of the patients had less than 10% burns in both the
groups in comparison to our study which had 21% TBSA as the mean when
the Percentage of burns was analyzed.
Marilyn and his colleagues19 studied 43 patients aged 1 to 57 years of
either sex with deep second- degree burn injury ranging 8% to 40% of
the body surface area, randomized to receive the type-1 collagen
dressing or 1% silver sulphadiazine. In their study 23 patients were
randomly allocated to receive collagen dressings and 22 to silver
sulphadiazine.2 patients in silver sulphadiazine group lost follow up,
thus a total of 43 patients were evaluated.
A prospective comparative study by Mukund.et.al14 comprising of 50
patients majority of the patients had less than 10% burns in both the
groups in comparison to our study which had 35% as most cases of burns
, this change in the percentage is probably because our hospital is a
tertiary care and referral centre. There were 4 mortalities, 2 in each
group, all 4 had above 95% burns.
]
CONCLUSION: Collagen sheet is very useful in second-degree burns when
compared to heparin. It, is well tolerated, provides multiple benefits
and the overall cost-benefit factor is very good when compared to the
heparin dressings in burn wound management.
ACKNOWLEDGMENTS:
1.
To Dr. Leo Theobald. Menezes Plastic Surgeon for supporting in
conducting the study.
2.
To the administration of the institution for allowing to conduct
the study.
3.
To the anaesthesia and general surgical residents for their prompt
services whenever required.
REFERENCES:
1.
Guyton, A. C.; Hall, J. E. (2006). Textbook of Medical Physiology.
Elsevier Saunders. p. 464.
2.
Marcum JA (January 2000). "The origin of the dispute over the
discovery of heparin". Journal of the History of Medicine and
Allied Sciences 55 (1): 37–66.
3.
J. Carr, The anti-inflammatory action of heparin: heparin as an
antagonist to histamine, bradykinin, and prostaglandin E1.
Thrombosis. Res. 16 (1979), pp. 507–516.
4.
Oremus M Hansen Mark D. Richard W. A systematic review of heparin
to treat burn injury. Journal of burn care and Research 2007; 26;
6: 794-804.
5.
Venkatachalapathy J.S, Mohan Kumar, Saliba Jr. A comparative study
of burns related with topical heparin and without heparin, Annals
of Burns and Disasters Dec 2007; vol XX; 44: 189-198.
6.
Ramakrishnan K, Jayaraman V. Efficacy of low molecular weight
heparin in wound healing. Buns Feb 2007, 33:1; 158-159.
7.
Saliba Jr. M. Burn treatment with heparin added. Burns Feb 2007,
33: 1 S35.
8.
M.J. Saliba, Jr, Heparin in the treatment of burns. J. Am. Med.
Assoc. 200 (1967), p. 650.
9.
J. Saliba, Jr, Heparin efficacy in burns. II. Human thermal burn
treatment with large doses of topical and parenteral heparin.
Aerosp. Med. 41 (1970), p. 1302.
10.
M.J. Saliba, Jr, W.C. Dempsey and J.L. Kruggel, Large burns in
humans, treatment with heparin. J. Am. Med. Assoc. 225 (1973), p.
261.
11.
M.J. Saliba, Jr, Heparin, nature's own burn remedy?. Emergency.
Med. 106 (1973), p. 111.
12.
M.J. Saliba, Jr, W.J. Kuzman and M. Miller, Effect of heparin in
anticoagulant doses on the ECG and cardiac enzymes in patients
with acute myocardial infarction. Am. J. Cardiol. 37 (1976), pp.
604–607.
13.
Bishara S. Atiyeha, Shady N. Hayeka and S. William Gunnb. New
technologies for burn wound closure and healing—Review of the
literature. Burns 2005; 31(8): 944-956.
14.
Singh O, Gupta SS, Soni M, Moses S, Shukla S, Mathur RK. Collagen
dressing versus conventional dressings in burn and chronic wounds:
A retrospective study. J Cutan Aesthet Surg 2011; 4: 12-16.
15.
Gupta R L et al. Role of collagen sheet cover in burns- a clinical
study. Indian Journal Of Surgery1978;40(12):646.
16.
Gerding RL, Emerman CL and Effron D,et al. Outpatient management
of partial thickness burns: biobrane versus 1% silver
sulphadiazine. Annals of Emergency Medicine 1990;19:121.
17.
Demling RH. Desanti L, Management of partial thickness facial
burns (Comparison of topical antibiotics and bioengineered skin
substitutes). Journal of Burn Care and Rehabilitation1999;25:256.
18.
Juan P Barret, et al. Biobrane versus 1% silver sulphadiazine in
second degree pediatric burns. Plastic and Reconstructive Surgery
1999;105(1):62-65.
19.
Marily Kwolek, Dhanikachalam, R P Narayan et al. A comparative
second-degree burn treatment trial of collagen dressing versus
silver sulphadiazine alone at 31st annual meeting of society for
biomaterials.

D
C
B
A
A.
DAY ONE APPLICATION OF COLLAGEN
B.
RESULT ON DAY 5 FOLLOWING COLLAGEN DRESSING
C.
RESULT ON DAY 10 FOLLOWING COLLAGEN DRESSING
D.
FINAL HEALED AREA COLLAGEN DRESSING

F
E
E. HEPARIN APPICATION DAY 1
F. HEPARIN APPLICATION DAY 10

G. COLLAGEN BRAND USED
H. CLENSING OF COLLAGEN SHEET FROM PRESERVATIVE
I. SPREADING OF COLLAGEN SHEET
G
H
I
AUTHORS:
1.
Rakesh Rai
2.
Sunil H. Sudarshan
3.
Reshmina Dsouza
4.
Elroy Saldhana
5.
P.S. Aithala
PARTICULARS OF CONTRIBUTORS:
1.
Associate Professor, Department of General Surgery, Father Muller
Medical College.
2.
Assistant Professor, Department of General Surgery, Father Muller
Medical College.
3.
Assistant Professor, Department of General Surgery, Father Muller
Medical College.
4.
Senior Resident, Department of General Surgery, Father Muller
Medical College.
5.
Professor, Department of General Surgery, Father Muller Medical
College.
NAME ADRRESS EMAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Rakesh Rai,
Associate Professor,
Father Muller Medical College,
Kankanady, Mangalore – 575002.
Email – [email protected]
Date of Submission: 05/11/2013.
Date of Peer Review: 06/11/2013.
Date of Acceptance: 14/11/2013.
Date of Publishing: 20/11/2013
Journal of Evolution of Medical and Dental Sciences/ Volume 2/ Issue
47/ November 25, 2013 Page 9130

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