Recent advances in burns management by Dr. Sunil Keswani, National Burns Centre, Airoli
Upcoming SlideShare
Loading in...5
×

Like this? Share it with your network

Share
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
No Downloads

Views

Total Views
887
On Slideshare
887
From Embeds
0
Number of Embeds
0

Actions

Shares
Downloads
28
Comments
0
Likes
1

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide

Transcript

  • 1. Recent Advances in Burns Management Dr. Sunil Keswani National Burns Centre Dr.Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 2. Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 3. Factors Affecting Wound Healing Systemic Local Age Mechanical injury Nutrition Infection Trauma Edema Metabolic diseases Ischemia/necrotic tissue Immunosuppression Topical agents Connective tissue disorders Ionizing radiation Smoking Low oxygen tension Foreign bodies Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 4. AGE •Aging produces intrinsic physiologic changes that result in delayed or impaired wound healing. •Dermal collagen content decreases with aging and aging collagen fibers show distorted architecture and organization. •The increased incidence of cardiovascular disease, metabolic diseases (diabetes mellitus, malnutrition, and vitamin deficiencies), cancer all contribute to the higher incidence of wound problems in the elderly •Non collagenous protein accumulation at wounded sites is decreased with aging, which may impair the mechanical properties of scarring in elderly patients Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 5. HYPOXIA, ANEMIA, AND HYPOPERFUSION •Low oxygen tension has a profoundly deleterious effect on all aspects of wound healing. •Fibroplasia, although stimulated initially by the hypoxic wound environment, is significantly impaired by local hypoxia. •Optimal collagen synthesis requires oxygen as a cofactor, for the hydroxylation steps. •Increasing subcutaneous oxygen tension levels for brief periods during and immediately after surgery results in enhanced collagen deposition and in decreased rates of wound infection after elective surgery. Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 6. STEROIDS •Large doses or chronic usage of glucocorticoids reduce collagen synthesis and wound strength. •Inhibit the inflammatory phase of wound healing (angiogenesis, neutrophil and macrophage migration, and fibroblast proliferation) and the release of lysosomal enzymes. •Steroids used after the first 3 to 4 days postinjury do not affect wound healing as severely as when they are used in the immediate postoperative period. •Steroid-delayed healing of cutaneous wounds can be stimulated to epithelialize by topical application of vitamin A Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 7. METABOLIC DISORDERS •Uncontrolled diabetes results in reduced inflammation, angiogenesis, and collagen synthesis. •Defects in granulocyte function, capillary ingrowth, and fibroblast proliferation all have been described in diabetes •Obesity, insulin resistance, hyperglycemia, and diabetic renal failure contribute significantly and independently to the impaired wound healing observed in diabetics. •Diabetic wound appears to be lacking in sufficient growth factor levels, which signal normal healing. Dr.Sunil Keswani, National •Uremia also hasBurns Centre, www.burnsbeen associated with disordered wound healing. india.com, nbcairoli@gmail.com
  • 8. NUTRITION •Not fully understood •Efforts are being made to develop wound-specific nutritional interventions and the pharmacologic use of individual nutrients as modulators of wound outcomes. •Malnourished patients have diminished hydroxyproline accumulation (an index of collagen deposition) •It reflects impaired healing response as well as reduced cell-mediated immunity, phagocytosis, and intracellular killing of bacteria by macrophages and neutrophils. Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 9. • The main effect of Arginine on wound healing is to enhance wound collagen deposition. • Arginine deficiency results in decreased wound-breaking strength and wound collagen accumulation. • Vitamins most closely involved with wound healing are vitamin C and vitamin A. • vitamin C deficiency, leads to a defect in wound healing, particularly via a failure in collagen synthesis and cross-linking. • Biochemically, vitamin C is required for the conversion of proline and lysine to hydroxyproline and hydroxylysine, respectively. • Vitamin C deficiency has also been associated with an increased incidence of wound infection Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 10. • Vitamin A deficiency impairs wound healing, whereas supplemental vitamin A benefits wound healing. • Vitamin A increases the inflammatory response in wound healing, probably by increasing the lability of lysosomal membranes. • Vitamin A directly increases collagen production and epidermal growth factor receptors when it is added in vitro to cultured fibroblasts. • Supplemental vitamin A can reverse the inhibitory effects of corticosteroids on wound healing. • Vitamin A also can restore wound healing that has been impaired by diabetes, tumor formation, cyclophosphamide, and radiation. • Dr.Sunil Keswani, National Doses rangingBurns Centre, www.burns- IU per day from 25,000 to 100,000 india.com, nbcairoli@gmail.com
  • 11. ZINC •In deficiency states there is decreased fibroblast proliferation, decreased collagen synthesis, impaired overall wound strength, and delayed epithelialization. Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 12. INFECTION •If the wound is contaminated with >105 microorganisms, the risk of wound infection is markedly increased, but this threshold may be much lower in the presence of foreign materials. •The most common organisms responsible for wound infections, in order of frequency, are Staphylococcus species, coagulase-negative Streptococcus, enterococci, and Pseudomonas. •Bacteria prolong the inflammatory phase and interfere with epithelialization, contraction, and collagen deposition. •Bacteria may accelerate expression or increase concentrations of MMPs, growth factors, and cytokines in chronic-type wounds Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 13. DRESSING •The main purpose of wound dressings is to provide the ideal environment for wound healing. •Ideal dressing – not a clinical reality. DESIRED CHARACTERISTICS OF WOUND DRESSINGS Promote wound healing (maintain moist environment) Conformability Pain control Odor control Nonallergenic and nonirritating Permeability to gas Safety Nontraumatic removal Cost-effectiveness Dr.Sunil Keswani, National Burns Centre, www.burnsConvenience india.com, nbcairoli@gmail.com
  • 14. • Occlusion also helps in dermal collagen synthesis and epithelial cell migration and limits tissue desiccation. • As it may enhance bacterial growth, occlusion is contraindicated in infected and highly exudative wounds. • Dressings can be classified as primary or secondary. • A primary dressing is placed directly on the wound and may provide absorption of fluids and prevent desiccation, infection, and adhesion of a secondary dressing. • A secondary dressing is one that is placed on the primary dressing for further protection, absorption, compression, and occlusion. Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 15. Absorbent Dressings •Absorb without getting soaked through, as this would permit bacteria from the outside to enter the wound. • sponge. Non adherent Dressings •Dressings impregnated with paraffin, petroleum jelly, or water-soluble jelly for use as non adherent coverage. •A secondary dressing must be placed on top to Dr.Sunil Keswani, National seal the edges and prevent desiccation and infection. Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 16. Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 17. Occlusive and Semiocclusive Dressings •Good environment for clean & minimally exudative wounds. •Waterproof and impervious to microbes, •Permeable to water vapour and oxygen. Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 18. Alginates •Brown algae and contain long chains of polysaccharides containing mannuronic and glucuronic acid. •Processed as the calcium form, alginates turn into soluble sodium alginate through ion exchange in the presence of wound exudates. •The polymers gel, swell, and absorb a great deal of fluid. •Used when there is skin loss, in open surgical wounds with medium exudation, and on full-thickness chronic wounds. Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 19. Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 20. • Type of dressing to be used depends on the amount of wound drainage • Nondraining Wound - with a semiocclusive dressing. • Mild Drainage (1 to 2 mL/d) - semiocclusive or absorbent nonadherent dressing. • Moderately draining wounds (3 to 5 mL/d) - dressed with a nonadherent primary layer plus an absorbent secondary layer plus an occlusive dressing to protect normal tissue. • Heavily draining wounds (>5 mL/d) require a similar dressing to moderately draining wounds, but with the addition of a highly absorbent secondary layer. Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 21. • Vacuum-assisted closure system assists in wound closure by applying localized negative pressure to the surface and margins of the wound. • Found to be effective for chronic open wounds (diabetic ulcers and stages 3 and 4 pressure ulcers), acute and traumatic wounds, flaps and grafts, dehisced incisions. Mechanism of action Problems – Pain, fluid loss, especially in large wounds, and risk of bleeding. It is contraindicated in patients with frail, thin or easily bruised skin, and in those Dr.Sunil Keswani, National with neoplasms forming part of the wound floor. Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 22. Hyperbaric oxygen •As adjunct in the management of nonhealing wounds. •Most non-healing tissues are hypoxic Mechanism of action of hyperbaric oxygen •Hyperoxygenation causes 1. Immune stimulation by restoring WBC function and enhancing their phagocytic capabilities and 2. Neo-vascularization in hypoxic areas by augmenting fibroblastic activity and capillary growth. •Vasoconstriction reduces edema and tissue swelling while ensuring adequate Oxygen delivery. •Bactericidal for anaerobic organisms & inhibits growth of aerobic bacteria. It Inhibits production of alpha-toxin by C Welchii and is synergistic with Dr.Sunil Keswani, National Aminoglycosides and Quinolones. Thus it is life saving in gas gangrene and Burns Centre, www.burnssevere necrotising infections. india.com, nbcairoli@gmail.com
  • 23. Skin Replacements •All wounds require coverage in order to prevent evaporative losses and infection and to provide an environment that promotes healing. Conventional Skin Grafts •Split thickness grafts •Full-thickness grafts •Autologous grafts •Allogeneic grafts •Xenogeneic grafts (e.g., porcine). Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 24. Current Skin Engineering • Tissue-engineered skin exists as cells grown in vitro and subsequently seeded onto a scaffold or some porous material which is then placed in vivo at the site of injury. • Three categories of skin substitutes: – Epidermal Substitutes – Dermal Substitutes – Dermo-epidermal Substitutes Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 25. NEED FOR ARTIFICIAL SKIN  Drawbacks of conventional treatment  In severe burns like 3rd degree burns, normal wound healing is slow and larger area is involved  Natural skin has limited options to recover, hence need for synthetic skin  Use of patient’s own skin - costly, hospitalization, anesthesia, pain, immobilization etc.  Solution to skin grafting is artificial skin transplants Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 26. EVOLUTION OF BURN WOUND CARE Burn wounds were occluded with dressings Animal and reptile skin used as a "skin substitute" Pig skin became popularized in the 1960’s Human tissue used as a skin substitute (cadaver skin & human amnion) Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 27. Contn… First Cultivation of Human Epidermal Cells (1960’s) (autologous keratinocytes) Use of allogenic keratinocyte grafts Bilayered Artificial Skin Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 28. Process Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 29. COMMERCIALLY AVAILABLE SKIN SUBSTITUTES With advancing technology, a host of both permanent and temporary biologically active skin substitutes are available to replace allograft and xenografts.I. Naturally occurring tissues - Cutaneous allografts - Cutaneous xenografts - Amniotic membranes II. Skin substitutes - Synthetic bilaminate - Collagen based composites Biobrane TransCyte Integra Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 30. III. Collagen based dermal analogs - De-epithelized allograft - Alloderm IV. Cell Culture -derived - Keratinocyte Cells Sprays -Bilayer human tissue (Apligraf) - Cultured autologous keratinocytes - Fibroblast seeded dermal analogs - Collagen-glycosaminoglycan matrix - Polyglycolic or acid mesh (Dermagraft) - Epithelial seeded dermal analog Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 31. Application of cells spray along with autograft for extensive burns Case Study Queen Victoria hospital, UK- 90% TBSA FT Successful Treatment with meek micro graft+ cell spray Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 32. Preliminary Safety-Study on application of autologous keratinocytes cell spray Before Cell Spray During Cell Spray No sign of any adverse reaction on day 4 after surgery Control arm Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 33. GMP cell culture facility @ NBC GMP cell culture facility @ NBC Change Room Clean room 3 class 1000 HEPA Class 1lakh HEPA Clean room 2 Class 10 000 HEPA Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 34. Cell Spray making process Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 35. Primary cell culture Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 36. Secondary Culture of keratinocytes Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 37. PREPARATION OF SKIN COMPOSITE Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com FUNCTIONAL EPIDERMIS
  • 38. BIOBRANE  Biobrane is a bilayer synthetic skin substitute  Outer epidermal analog constructed of a thin silicone film with barrier functions  Small pores present in silicone to allow for exudates removal and permeability to topical antibiotics  Inner dermal analog composed of nylon filament weave upon which is bonded type I collagen peptides Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 39. BIOBRANE Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 40. BIOBRANE APPLIED TO WOUNDS Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 41. PROCESS OF HEALING A superficial partial thickness burn The zone of necrosis isDr.Sunil Keswani, the upper dermis & is usually confined to National separated by a layer ofBurns Centre, www.burnsedema from the viable wound surface india.com, nbcairoli@gmail.com
  • 42. Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com Viable wound bed showing fibrin and collagen
  • 43. Dr.Sunil Keswani, National Bilayer BIOBRANE placed on clean wound Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 44. Biobrane adhered to surface by nylon-collagen mesh. Dr.Sunil Keswani, National Preservation of thin Burns Centre, www.burnswater layer on surface to allow epithelial india.com, migration along innernbcairoli@gmail.com layer
  • 45. Dr.Sunil Keswani, National Biobrane peeled back from surface to demonstrate rapid Burns Centre, www.burnsmigration of new epithelium along nylon-collagen mesh india.com, nbcairoli@gmail.com
  • 46. Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com Biobrane removed with re-epithelialization
  • 47. APPLICATION OF BIOBRANE BIOBRANE REMOVAL Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 48. TRANSCYTE  Trancyte is a bilayer skin substitute  Outer epidermal analog is a thin nonporous silicone film with barrier functions  Inner dermal analog is layered with human fibroblast products mainly collagen type 1, fibronectin and Glycosaminoglycan  Subsequent cryo-preservation destroys fibroblasts but preserves activity of fibroblast-derived products  Thin water layer at surface is maintained for epidermal cell migration  It is removed after re-epithelialization Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 49. TRANSCYTE Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 50. TRANCYTE IN PLACE Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 51. TRANSCYTE Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 52. ALLODERM  AlloDerm is an acellular dermal matrix designed to serve as a biologic scaffold for normal tissue remodeling  It is a donated human tissue processed to remove all epidermal and dermal cells while preserving the remaining biological dermal matrix  It directs normal revascularization and cell repopulation as blood vessels, collagens, proteoglycans and elastin are preserved  This extracelullar matrix contains the blood vessel channels which serve as conduits for revascularization  Collagens, proteoglycans and elastin provide structure and information for cell repopulation  The preserved proteoglycans and proteins direct the patient's own cells to initiate revascularization andNational cell repopulation Dr.Sunil Keswani, Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 53. NORMAL DERMIS Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com ALLODERM
  • 54. Day 1: Biologic Scaffold Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 55. Day 7-10 • Host fibroblast cells and blood vessels respond to the transplantation of the AlloDerm matrix • Initiation of the revascularization and normal tissue remodeling process Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 56. Day 45 Replacement and revascularization of the transplant continues as normal connective tissue Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 57. Day 90 AlloDerm repopulated with the patient's own cells Fibroblasts continue to lay down autologous collagen Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 58. INTEGRA  INTEGRA is a bilayer membrane system for skin replacement  The dermal replacement layer - porous matrix of fibers of cross-linked bovine tendon collagen and a glycosaminoglycan (chondroitin-6-sulfate)  The temporary epidermal substitute layer - synthetic polysiloxane polymer (silicone) and functions to control moisture loss from the wound  The collagen dermal replacement layer serves as a matrix for the infiltration of fibroblasts, macrophages, lymphocytes, and capillaries derived from the wound bed  As healing progresses an endogenous collagen matrix is deposited by fibroblasts Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 59. Contn…  Upon adequate vascularization of the dermal layer and availability of donor autograft tissue, the temporary silicone layer is removed  A thin, meshed layer of epidermal autograft is placed over the "neodermis"(usually 14-21 days after application)  Cells from the epidermal autograft grow and form a confluent stratum corneum, thereby closing the wound reconstituting a functional dermis and epidermis  After final healing of the wound, the neodermis tissue histologically and functionally is similar to normal dermis  used for child limb injuries (Violas et al., 2005) Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 60. HEALING WITH INTEGRA Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 61. Integra Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 62. Acticoat Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 63. Fascial Excision Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 64. Integra applied Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 65. Covered with Acticoat Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 66. MATERIALS & METHODS Surplus cutting Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 67. MATERIALS & METHODS Positioning on plate. Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 68. MATERIALS & METHODS Dermatome cut through Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 69. MATERIALS & METHODS Adhesive Spraying Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 70. MATERIALS & METHODS Cork removing. Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 71. MATERIALS & METHODS Gauze expansion Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 72. MATERIALS & METHODS Gauze expanded. Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 73. MATERIALS & METHODS Micrograft positioning Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 74. MATERIALS & METHODS After gauze removal. 7th day. Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 75. MATERIALS & METHODS 10th day wound care. Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 76. MATERIALS & METHODS Long term control. POST-PHYSICAL REHABILITATION OUTCOME Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 77. Case 1- day of admission Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 78. Day 3-Preop Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 79. Day 3-Early excison and homografting-postop Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 80. Day 5 Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 81. Day 7 Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 82. Day 9 Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 83. Day 15 Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 84. Case 2- day of admission Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 85. Day 3 Postop Preop Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 86. Day 7 Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 87. Day 12 Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 88. Day 21 Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 89. Admission Discharge Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 90. Case 3- day of admission Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 91. Early excison and grafting Pre-Op wound Application of Homograft Day 3 Complete healing Day 21 Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 92. Case 4- day of admission Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 93. Pre-Op Wound Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 94. Progressive healing of Wound Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 95. On Discharge Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 96. On Discharge Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 97. Case 5- day of Admission Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 98. Before and After Homografting Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 99. Progressive healing Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 100. Progressive Healing Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 101. Case 6- day of admission Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 102. Progressive healing of RIGHT HAND Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 103. Progressive Healing of LEFT HAND Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 104. Day 15 Homograft Application Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com post op
  • 105. Case 7-Chemical Burns on admission Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 106. Progressive healing-Autografting Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 107. End Result-Autografting Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 108. DERMAGRAFT  is an example of a synthetic matrix combined with allogenic fibroblasts and has good resistance to tearing (Bello et al., 2001)  Dermal fibroblasts are seeded onto biocompatible Vicryl scaffold to form a living tissue  The scaffold Vicryl is a blend of polylactic and polyglycolic acids (synthetic absorbable surgical sutures)  Vicryl is inert, non-antigenic, non-pyrogenic and elicit only a mild tissue reaction during absorption  Dermagraft is a total skin replacement for • full thickness burns and • chronic wounds like diabetic foot ulcers Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 109. DERMAGRAFT Dermagraft cassettes ready for patient use Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 110. APLIGRAF  is supplied as a living, bi-layered skin substitute  The lower dermal layer combines bovine type 1 collagen and human fibroblasts (dermal cells), which produce additional matrix proteins  The upper epidermal layer is formed by promoting human keratinocytes (epidermal cells) first to multiply and then to differentiate to replicate the architecture of the human epidermis  APLIGRAF does not contain melanocytes, Langerhans' cells, macrophages, and lymphocytes, or other structures such as blood vessels, hair follicles or sweat glands  approved by the FDA to treat patients exhibiting venous leg ulcers & for diabetic foot ulcer treatment Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 111. Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 112. SOME CASE STUDIES FOR APLIGRAF APPLICATION 1 2 3 4 Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 113. Traditional Skin Graft Artificial skin • Skin graft from the patient • Two-layer template composed of a porous matrix inner layer applied to wound and a silicone outer layer applied to the wound • Grafted dermis does not • Dermis is regenerated and regenerate, resulting in grows scars that contract Regenerated dermis maintains • Larger donor sites are shape and strength needed to compensate for graft shrinkage • Harvested donor sites are Thin epidermal graft does not painful, itchy and red create lasting donor site wound Dr.Sunil Keswani, National • Stiffness of graft area Burns Centre, www.burns- skin • Pliable india.com, nbcairoli@gmail.com
  • 114. Current Research and Challenges    • Role of Stem cells in wound healing (e.g- MSCs) Role of Gene Therapy to stimulate wound healing Development of autologous cell based skin substitutes Methods to evaluate safety and efficacy of the products in vivo. • Challenges: Cost related concerns • Variable clinical study data Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 115. Future Directions  More effective cell preservation techniques could enhance shelf life and minimize issues related to storage  Simplified thawing and rinsing of cryopreserved products would make such products more user-friendly  A more complete understanding of the mechanism of therapeutic action of bioengineered skin could lead to even more efficacious products eg) genetic modification of the cells to overproduce specific cytokines like growth factors might be feasible and productive Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 116. Contn…  Efforts by manufacturers to further reduce the cost of cellular skin substitute wound therapy could change the role of this approach dramatically  Lower cost could also allow for multiple applications and possibly increase the efficacy of the course of treatment Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 117. Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  • 118. THANK YOU BURNS Helpline: 022 2779 3333 Dr.Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com www.burns-india.com