CME 23/04/2022 Summary
Systemic enzyme therapy with Trypsin, Bromelain and Rutoside Combination in Burns MODERATOR SPEAKER
Dr. Suhas Abhyankar MBBS, MCPS, MS - General Surgery, MCh - Plastic Surgery, DNB - Plastic Surgery
Dr. Arvind Vartak MBBS, MS – Gen Surgery, MS- Plastic Surgery
• Burns – A major public health problem worldwide • Main target in burns management – preventing complications, assisting physiological recovery • Targeting unchecked inflammation – key in faster recovery Case – High voltage electric flash injury → Thermal 3rd degree burns on dorsal aspect of left hand • Best modality - Conservative management with anti-inflammatory enzymes, and autograft after good granulation • Less effective modalities – i) Management with NSAIDs, and autograft after good granulation; ii) Tangential excision and cover with cadaveric graft followed by autograft Most common causes of failed or compromised skin graft • Poor vascularity • Hematoma or seroma, i.e., collections of blood or fluid • Infection at graft site • Mechanical shearing rd
Case – flame burns on dorsal aspects of right hand - 3 degree burns • Autograft after conservative management with NSAIDs → lot of swelling with impaired graft uptake • NSAIDs not effective in reducing edema; compromises graft uptake Risks with use of NSAIDs • Gastro-intestinal irritation • Renal disturbances (burns patients have hypovolemia) • Cardiovascular events • Potential hepatotoxicity • Marked negative impact on wound healing; may increase scar formation rd
Case - flame burns on right hand - 3 degree burns • Good recovery with anti-inflammatory enzymes; potentially due to: • Reduced edema; promoting healing • Local epidermal growth factor activation • Enhanced perfusion; better healing • Reduced edema & fibroblastic activity → better functional results in case of small hand joints
Comparison of mechanisms of NSAIDs & Systemic enzyme therapy with Trypsin, Bromelain and Rutoside
CME 23/04/2022 Summary
Tissue injury Coagulation
Vascular response
Secondary vasodilation ↑vascular permeability (plasma leakage)
Platelet aggregation Coagulation cascade initiation
(mediated by histamine, bradykinin, FDPs, NO)
Cyclo-oxygenase enzyme
Leucocyte activation & migration T cells
M1 macrophage
Phagocytosis
Cytokines+GFs
Neutrophil
Fibrin clot
Thromboxanes
Prostaglandins
Growth factors, Inflammatory cytokines, polyphosphates
Platelet activation Polyphosphates
Initial vasoconstriction
Inflammatory infiltrate
Proteases
M2 macrophage ROS, RNS
Tissue repair
Inhibition
Arachidonic acid Lysis
FDP: Fibrin Degradation Products ROS: Reactive oxygen species RNS: Reactive nitrogen species GFs: Growth Factors NO: Nitric Oxide
Bradykinin
NSAIDs Kininogen
Plasmin
Plasminogen
(non steroidal anti inflammatory drugs)
Multi-pronged action of systemic enzyme combination Tissue injury Coagulation
Vascular response Initial vasoconstriction Secondary vasodilation ? vascular permeability (mediated by histamine, bradykinin, FDPs, NO)
Eicosanoids (PG, TX)
Inflammatory infiltrate Growth factors, Inflammatory cytokines, chemokines
Platelet activation factor
Leucocyte activation & migration
Platelet aggregation Coagulation cascade initiation
Neutrophil
Fibrin clot
Proteases
T cells
M1 macrophage
Phagocytosis
Cytokines+GFs
Inhibition1
Arachidonic acid
Inhibition5 Kininogen
Plasminogen Depletion
Activation
↓ levels 8
Inhibition6
Plasmin
Tissue repair
1– by alteration of adhesion molecules on the platelet surface
Lysis
Bradykinin
ROS, RNS
↓production7
↑activation threshold
Inhibition2
M2 macrophage
↑availability 3
Potentiation4
2– by alteration of cell surface molecules involved in leucocyte activation and adhesion 3 – by displacing “bound” plasmin from plasma proteins 4 – by the activation of PAR1 and PAR2 receptors on macrophages 5 – by decreased production of iNOS-mediated NO 6 – by inhibiting intracellular Ca2+ mobilization in platelets
Bromelain
Trypsin
Rutoside
7 – by inhibiting the transcription of genes encoding for pro-inflammatory cytokines 8 – by scavenging action & iNOS inhibition
Trypsin, Bromelain and Rutoside in Burns
Take-home message Systemic anti-inflammatory enzymes – multi-pronged action Advantages of anti-inflammatory enzymes (trypsin, bromelain, rutoside) over NSAIDs • Reduction of edema; putting extra-vascular fluid back in circulation • Enhanced/quicker mobility • Enhanced wound healing • No nephrotoxicity
Link to CME & full length article on Burns
To access the CME ‘Potential role of systemic enzyme therapy with trypsin, bromelain and rutoside combination in burns’ please click on the youtube link.https://youtu.be/xRdLoSOo_NM
To access the full length article of ‘Potential role of systemic enzyme therapy with trypsin, bromelain and rutoside combination in burns’ Abhyankar, Suhas & Vartak, Arvind & Daftary, Gautam. (2021). International Surgery Journal 2021 Jul;8(7):2254-2259
https://www.ijsurgery.com/index.php/isj/article/view/7601/4791
An Aksigen Initiative
In the management of
BURNS S
disperse away the worry of inflammation, oedema & pain
Only dispersible enzyme trio…. Ensures faster recovery
1
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DCGI APPROVED BRAND 1 Trypsin, Bromelain & Rutoside
DCGI – Drugs Controller General, India; 1. Approval based on CTRI/2017/12/010804