A Nursing Perspective on the ReCell Breakthrough in Burn Treatment

Severe burn treatment has always required a multifaceted approach to provide prophylactic, analgesic, and regenerative care. Severe burns, even if localized, have both expected and potential systemic impact. This paper will be focused on treatment of third- and fourth-degree burns using ReCell treatment although the principles discussed overlap across all burn treatment. A mental grasp of burn implications and effects when placed alongside the physiologic function and mechanism of the new ReCell treatment offers nurses the tools to make appropriate critical thinking connections and implications. Improved patient outcomes and care will be the result.

Implications of a Burn

Destruction of the papillary layer and reticular fibers of the dermis by a burn results in: impaired immune system barrier protection, damaged or impaired osmotic and hydrostatic forces in localized capillary exchange, fluid loss secondary to impaired localized capillary exchange, ion imbalance secondary to fluid loss and cell damage, risk for impaired cardiac output secondary to hyperkalemia, hyponatremia, and fluid loss, and risk for shock related to infection, fluid loss, and/or impaired cardiac output. All of these complications are directly caused by or directly related to the loss of dermal and epidermal tissue (Haberal, Abali & Karakayali, 2010).

ReCell Treatment

ReCell treatment requires removing a small amount of skin, maximum two centimeters by two centimeters, and placing it in a heated porcine enzyme solution that causes cellular disaggregation. The resulting disaggregated cells are filtered and then added to a growth promoting buffer solution. The solution containing melanocytes, fibroblasts, keratinocytes, and Langerhans cells is then sprayed onto the debrided and clean burn site. Rapid cellular regeneration and migration across the sprayed surface results in granular tissue and healing across the wound bed (Gravante et al., 2007). ReCell use was approved by the FDA in August of 2018 after two randomized control trials showed that the amount of donor skin needed to treat acute burn injuring with ReCell was significantly less than the amount required for a typical skin graft. ReCell allows donor skin to be spread over an area up to eighty times larger than the donor site making it possible for a donor site the size of a credit card to provide coverage for the entire back. A study published in May of 2018 showed that ReCell used 97.5% less donor skin than traditional methods and resulted in significantly decreased pain, scarring, and improved patient satisfaction (Holmes et al, 2018).

Advantages of ReCell

Advantages of ReCell treatment include homologous skin cells and a small donor site. The homologous nature of ReCell is essential because allogeneic skin transplants are acutely rejected and, unlike other organ transplants, immunosuppressive treatments have little efficacy in preventing rejection (Benichou et al., 2011). Multiple variations of donor skin are currently used in treatment including porcine derived and grafts grown from stem cells but the concerns with CD-8 positive cell-mediated tissue rejection and the length of time required to grow the graft contribute to decreased patient outcomes. Removing a donor skin graft from elsewhere on the patient eliminates immune rejection concerns but involves other complications. Burns covering over 25% of total body surface area make it extremely difficult to find a sufficiently large graft donor site and if the donor tissue needs to be meshed in order to increase surface area the meshing often scars for life resulting in a displeasing cosmetic appearance. The donor site also becomes an additional wound to monitor and graft removal is extremely painful. Thus, the small donor site size and homologous nature of ReCell can drastically improve patient outcome and experience (Echlin, Way & Jones, 2012).

Nursing Interventions to Ensure ReCell Success

Effective nursing interventions during the care of a burn patient being treated with ReCell can prevent serious systemic impact and ensure that the ReCell skin has the best possible chance to repair burn damage. The following are nursing areas of care that may present with unique indications during use of ReCell treatment.

Fluid Replacement

While ReCell treatment can increase the speed of skin renewal and diminish need for intravenous fluids, severe fluid loss is the greatest problem after a severe burn (Haberal, Abali & Karakayali, 2010). Hypovolemia secondary to fluid loss results in decreased perfusion and impaired cardiac output. Lack of perfusion will impair ReCell growth and should be prevented by giving intravenous fluid, usually Lactated Ringers, given in proportion to burn area as a percentage of total body surface area using the Parkland Formula. Use of two large bore intravenous catheters is indicated. Urine output should be monitored at the expected rate of 1ml/kg/hr along with strict intake and output to prevent fluid loss (The Royal Children’s Hospital Melbourne, 2015). The amount of intravenous fluid given may need adjustment along the clinical course.

Debridement or Cleaning

ReCell produces granular tissue best on a clean wound bed. If ischemic or necrotic tissue is not noted, sterile cleaning of the burn with saline, water, or another solution is indicated. It is of note that pressurized washing of the wound site, while resulting in improved cleaning, results in tissue damage and increased risk for infection and is, consequently, not indicated. Appropriate debridement techniques, if indicated to remove necrotic tissue, include all common methods including mechanical, enzymatic, and bio-debridement (Block, King & Gosain, 2015). After ReCell is applied, debridement and cleaning may not be indicated as it may damage ReCell granular tissue.

Bandaging and Dressing

ReCell’s primary functionality and effectiveness is based on creating a spontaneous granular bed across the wound surface. Consequently, dressings should allow adequate moisture and must avoid damage to granular tissue surface. Dressings of foam or hydrocolloid fiber sheets with silver are preferred. Dressings should be loosely wrapped in order to prevent blood vessel occlusion during the osmotic edema following the burn. If dressing change is indicated, normal saline or a similar solution should be applied as need to the dressing to be removed in order to prevent accidental wet-dry debridement and granular tissue damage (Block, King & Gosain, 2015).

Analgesia

Burns can cause extreme pain, especially third degree burns as the nerves are still intact and may be exposed resulting in hyperalgesia, and management of pain is essential for patient comfort and improved healing. Treatment with ReCell does not directly alter or affect the use of analgesics. Because ReCell requires a smaller graft site, patients complain of less pain or less sites of pain (Holmes et al, 2018). NSAID’s, Opioids, and Benzodiazepines may all be indicated depending on patient condition (The Royal Children’s Hospital Melbourne, 2015). Reduction of pain results in decreased production of glucocorticoids resulting in a myriad of wound-healing effects (Bechert & Abraham, 2009). Cortisol, the main glucocorticoid, increases protein breakdown, increases blood glucose levels, blocks activity of phospholipase A2, decreases prostaglandin synthesis, affects proinflammatory cytokine levels, and inhibits intracellular signaling all of which can result in delayed wound healing.

Infection

Sepsis is the leading cause of death in burn patients. The skin acts as the primary protection against infection and, consequently, burn patients are at a drastically increased risk for sepsis. It is of nursing note that the prolonged exposure to pathogens in a burn patient will result in a hypermetabolic state, tachycardia, leukocytosis, tachypnea, and a reset of the normal temperature to 38 degrees Celsius. This state may last for several months after the wound has closed (Greenhalgh, 2017). As treatment with ReCell may increase burn wound coverage and may speed healing, ReCell may decrease risk for infection. Prophylactic antibiotic use is not affected by ReCell treatment but current research does not strongly support its use (Avni et al., 2010).

Summary

ReCell was approved for use in the United States on August 8th of 2018 and, consequently, will require additional time and study to fully determine effectiveness; however, the ReCell breakthrough shows promise in offering large wound graft coverage without the meshed scaring of a typical graft; it also offers a solution for patients with severe burns that lack donor sites for graft harvesting. An understanding of ReCell’s source, function, and mechanism will assist nurses to appropriately plan interventions related to wound maintenance and help ensure ReCell treatment effectiveness.

References

Avni, T., Levcovich, A., Ad-El, D., Leibovici, L., Paul, M. (2010). Prophylactic antibiotics for burn patients: systemic review and metanalysis. BMJ, 340: c241. Retrieved from: https://www.bmj.com/content/340/bmj.c241

Bechert K., Abraham, S. (2009). Pain management and wound care. J Am Col Certif Wound Spec, 1(2): 65–71. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3478916/

Benichou, G., Yamada, Y., Yun, S., Lin, C., Fray, M., Tocco, G. (2011). Immune recognition and rejection of allogeneic skin grafts. Immunotherapy, 3(6): 757-770. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3738014/

Block, L., King, T., Gosain, A. (2015). Debridement techniques in pediatric trauma and burn-related wounds. Advanced Wound Care, 4(10): 596–606. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4593934/

Echlin, K., Way, B. & Jones, I. (2012) Autologous non-cultured epidermal cell suspension to accelerate healing of split thickness donor sites. International Society for Burns Injuries Meeting.

Gravante, G., Difede, M., Araco, A., Grimaldi, M., Deangelis, B., Arpino, A., Montone, A. (2007). A randomized trial comparing ReCell system of epidermal cells delivery versus classic skin grafts for the treatment of deep partial thickness burns. Burns, 33(8): 966-972. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/17904748

Greenhalgh, D. (2017). Sepsis in the burn patient: a different problem than sepsis in the general population. Burns Trauma, 5: 23. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5547526/

Haberal, M., Abali, A., Karakayali, H. (2010). Fluid management in major burn injuries. Indian Journal of Plastic Surgery, 43: 29-36. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3038406/

Holmes, J., Molner, J., Carter, J., Hwang, J., Cairns, B., King, B., Smith, D., et al. (2018). A comparative study of the recell device and autologous split-thickness meshed skin graft in the treatment of acute burn injuries. Journal of Burn Care and Research, 5(17): 694-702. Retrieved from: https://academic.oup.com/jbcr/article/39/5/694/5002035

The Royal Children’s Hospital Melbourne. (2015). Nursing management of burn injuries. Retrieved from: https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Nursing_management_of_burn_injuries/