Objective Enzymatic debridement (ED) of burn eschar became an accepted and widely used technique for acute burn wound treatment over the last years. However, it is not exempted from failure and recent experimental studies indicated that it may not be as efficient in scalds as in flame burns. This matched case-control study aimed to evaluate the efficacy of ED defined as the absence of additional surgical debridement in scald and flame burns representing the two most common mechanisms of burn. Methods Patients that were admitted to the burn intensive care unit between June 2017 and February 2021 and received ED within the first 72 hours after scald and flame burn were included. Patients with scald burns were matched regarding age, sex and per cent total body surface area (%TBSA) burned in a 1:2 ratio with patients presenting with flame burns. Results Eighteen patients with scald burns were matched to 36 patients with flame burns. After matching, both groups were similar in terms of age (flame burns 44.5±21.1 years vs. scald 41.8±22.6 years, p=0.666), and %TBSA burned (11.0±8.2% vs. 10.6±9.6%, p=0.851). Patients with scald burns significantly more often needed further surgical debridement compared to controls (scald 16 (88.9%) vs. flame 19 (52.8%), p=0.016). Length of stay per %TBSA was significantly longer in scald burns (scald 7.8±9.2 days vs. flame 3.7±3.8, p=0.013). Conclusion This study is the first to compare the clinical efficacy of ED in different burn mechanisms. It indicates that ED may not be as effective in scalds as in flame burns. It was shown that patients with scalds and subsequent ED more frequently needed additional surgical intervention and that the size of the transplanted area was larger compared to control. Moreover, those patients had a longer length of stay at the hospital per %TBSA burned. We believe that larger, multicenter studies would be beneficial to further evaluate the efficacy of ED in different mechanisms of burn.

P.029 Enzymatic debridement in scalds is not as effective as in flame burns regarding necessity of additional surgical debridement: a retrospective matched-control study

P.098 Use of xenograft compared with synthetic cellulose dermal substitute (EPICITE) in patients with second degree burns

P.060 Combination of “Sandwitch” Grafts and Autologous PRP in the treatment of Severe Burns

P.113 Bromelain Based Enzymatic Debridement in the treatment of Burns: a standardized post-treatment dressing proposal

Objectives
Pain associated with surgical or enzymatic burn wound debridement prevents many burn centres from working outside an operating theatre, creating a burden. Alternatives for general anesthesia to manage pain in burn patients treated with enzymatic debridements, such as regional anesthesia, have not been studied in detail. This study explores the different possibilities for pain management during a bedside NexoBrid™ procedure.
Methods
We performed a single-centre retrospective study that included 82 paediatric, adolescent, and adult patients with deep dermal and full-thickness burns treated bedside with NexoBrid™ under regional or general anesthesia. Outcome measures were pain during the NexoBrid™ procedure, the safety of the anaesthesia and the NexoBrid™ procedure, logistics of the bedside NexoBrid™ procedure, and time to wound closure.
Results
Forty-three patients in the adult group (43/67, 64%) only presented with burn wounds on one upper or the one or two lower extremities. In 29 of them (29/43, 67%), a NexoBrid™ procedure was performed under regional anesthesia, which resulted in low pain levels without any adverse events. All seven patients in the pediatric group, where only one upper or one or two lower limbs were involved (7/15, 47%), underwent a NexoBrid™ procedure performed under regional anesthesia where no adverse events were reported. In these children, the use of regional anesthesia was associated with a significant decrease in time to wound closure (average treatment effect on the treated = -22.5 days, p=0.021).
Conclusions
This study highlights that regional anesthesia administered at the bedside should be the method of choice for pain management during NexoBrid™ procedures because often, it can be adequately and safely performed in all age groups. This approach will reduce the burden on operating theatres. A flow chart has been developed to guide pain management during a NexoBrid™ procedure (Figure 1).

P.003 Pain management during a bromelain-based selective enzymatic debridement in paediatric and adult burn patients.

The polylactic acid is one of the most reliable skin substitutes in the management of burn injuries, preserving dermal tissue thus allowing for primary healing with a single treatment In our experience, the polylactic acid has shown remarkable effectiveness for patient comfort and management of acute burn injury pain, which allow undisturbed dressing changes while improving healing time and need for hospitalization We observed that the use of  the polylactic acid may further improve healing times, particularly in burns with full or even partial dermal sparing

P.156 The use of Polylactic acid in acute burns

P.155 Simplified easy-to-use hydro active dressing for burns on hard-to-dress areas relieves pain, increases healing, prevents complications and saves resources in terms of time and cost.

The production and application of CEAs across borders
Tantula, S., Gigante-Bounid, M., Lindford, A. and Vuola, J.
Introduction In Europe there are only a few institutions that can produce cultured epithelial autografts (CEAs). We herein describe the process in which CEAs were produced in one European country and then transported to another country for wound coverage in patients with major burn in a well-planned time schedule. The purpose of this poster is to describe this process and the preparation of the patient for the procedure.
Methods
During 2016-2021 three severely burned patients received treatment with CEAs in the Helsinki Burn Centre. Skin biopsies were sent to Switzerland where they were cultured in the Centre de production cellulairé, CHUV, Lausanne. After 3-4 weeks the cells attached to polyamide sheets were delivered by personal courier in a time window of 8 hours straight to the operation theatre and applied to the patients successfully. Prior to this, the patients had undergone several debridements and allograft treatments and the wounds were confirmed as not having any infection or necrosis.
Results
Three patients with TBSA burn % ranging from 78 % to 92 % each received 3000cm2 of CEAs. Unfortunately, the first two patients eventually died but the third patient with TBSA 78 %, survived. The CEAs were applied on top of widely meshed autografts to enhance the epithelialization. The exact benefit of the accelerated healing was difficult to measure. Histological staining confirmed that the cells were alive on arrival. The total costs were less than 10€/cm2.
Conclusions
Cultured epidermal autografts have not (yet) achieved large popularity. The high price and strict regulations are clear hindrances to their production and delivery. With good co-operation autologous cells can be cultured in one non-EU country and delivered to another EU country located far away, by careful planning and a strict time schedule with acceptable costs.

P.105 The production and application of CEAs across borders

Introduction: Today, there is a wide variety of wound care dressings available commercially. and providers have a choice when it comes to what dressing may be best suited for a specific wound etiology.  Clinicians strive to achieve fast wound closure; minimize trauma at the wound site; provide an optimal environment for wound healing that   results in minimal scaring. Wound contact layers should also be durable for prolonged wound contact and be available at a cost-effective price.  Silicone wound dressings are often the choice of the medical professional because they tend to not integrate into the healing wound bed and allow for atraumatic removal from the fragile peri-wound margins. We present a patented technology platform that includes two primary wound contact layers and one secondary wound contact layer.
Methods: These wounds dressings represent a unique line of patented products based on a technology that combines silicone and Teflon to create a strong, reusable, long lasting products.   A temporary skin replacement dressing is indicated for post-operative laser resurfacing, dermabrasion wounds and an excellent alternative for any toxic epidermal necrolysis diagnoses. A new non-adherent wound contact layer can be used as a primary dressing over partial thickness wounds and skin grafts or as a secondary wound dressing over biosynthetic skin substitutes as well as other biologic options to provide protection until wound closure is achieved. A third dressing is used as a secondary dressing option that combines a foam which can absorb copious exudate without expanding. The dressing’s outer silicone lining is used as a reinforcing mechanism prevents contamination of the wound can be used as a bolster to prevent shearing of fresh grafts and provide the necessary pressure to contribute to optimal graft take
Results: The benefits of the primary wound dressings are a) transparency for easy visualization of the wound; b) the ability to gently cling to the wound surface and surrounding skin, without incorporation into the wound and c) painless, atraumatic removal when desired. These dressings can remain intact for up to 7 days. Additionally, when used over biosynthetic skin substitutes, these dressings can remain intact for up to 14 days providing minimal to no replacement of the dressing until full closure is achieved. The foam lined silicone dressing prevents shearing of fresh grafted sites and provides some pressure to promote graft take.  All three of these materials utilize a unique chemistry to provide a dressing to fit the demands of the wound environment.
Conclusions:  These dressing options provide the clinician with a myriad of options to address the demands of the wounds in which they are utilized. Each dressing is designed to meet the needs of the clinician to assist them in their dressing choice pathway and they also help to ensure that the impact to the patient is minimized via a amenable contact layer. These silicone wound dressings  d

P.145 Silicone dressings for effective wound care – a review of a versatile product line based on a unique design platform    

Introduction 
The hands represent one of the most highly affected areas of the body because  of a burn injury. In addition to this, it is difficult to use dressings to cover the  area, due to the normal irregular anatomy of the hand skin. Dressing with  cultured human keratinocytes, stimulates migration of cells and promote  growth factors, playing an important role in the proliferative phase for  faster restoration of tissue structure and function.  Objective To evaluate pain, infection rates, re-epithelialization time, and long-term  scarring using cultured human keratinocytes treatment for superficial and  partial thickness hand burns.
Material and methods 
Records of patients attended for hand burns treated with cultured human  keratinocytes, 6 months prior to this study, analyzing age, sex, cause of burn,  depth, and total body surface area affected (TBSA). Measures of pain scale  (Verbal Rating Scale 1-10), time of re-epithelialization and complications  recorded. VSS (Vancouver Scar Scale) and POSAS (Patient and Observer Scar  Scale) applied at 6 months, recording data. Exclusion criteria: infection prior to application and full thickness burns. 
Results 
50 patients with hand burns treated with cultured human keratinocytes were  collected. 86% male (43), 14% female (7), mean age 29 years (range 1 to 87  years), average total body surface area affected (TBSA) of 15% (range 1% to  50%), 94% superficial and partial thickness burn (47 cases), 6% full thickness  burns (3 cases that were excluded). Cause of burns 88% fire, 12% scald, 6%  chemical and 4% contact with hot material. The pain scale mean was 2 (range  1-5) and re-epithelialization was 8 days (range 5 -14 days). No complications  were registered including infections or allergies. VSS and POSAS <1 /6.5.
Conclusions
Dressing with cultured human keratinocytes demonstrates its effectiveness in reducing pain and prevent infections. It also reduced the re-epithelialization time and prevented hypertrophic scarring. It can be safely used on skin surfaces where the epithelium is missing, helping improve quality of life by functional and aesthetic outcomes being a great option for hand burn treatment.

P.150 Treatment of superficial and partial thickness hand burns using cultured human keratinocytes 

Objective Healthcare professionals represent the link between the population and the health environment. Corporate training course on prevention and health promotion are mandatory to raise their awareness. The course presented, identifies the major risks of burns present in the home environment, promoting change in their behavior and then in general population. Method As Burn Center nurses we decided to set up a course about the most frequent causes of domestic accidents that lead individuals to access our operating unit, according to the priority training objectives identified by the Regional Health System. The course has been activated since November 2017 thanks to the Continuing Education Plan staff. The course, over the years, has been enriched including the experience of pediatric nurse colleagues from the Regina Margherita Children's Hospital of Turin. Reporting the subjective perceptions of a burn patient, hospitalized at the burn center, in his own words there is a fundamental part of the course to sensitize healthcare professionals on the changing identity of burn patients. Results From 2017 we have trained 108 caregivers and 350 healthcare professionals (nurses, physical therapists, lab technicians, radiology technicians and physicians). During end-of-course interviews, it was found that participants had poor behaviors in handling flammable materials and heat sources present at home. Therefore, it appears that there is a lack of attention to the prevention of domestic accidents due to old habits. The course is still ongoing. Conclusions We can affirm that this course leads each individual to analyze his personal experience, avoiding to underestimate the risks that surround them, especially in the place they consider safest, their own home. It also stimulates each professional to take responsibility for themselves and others and to create new habits of behavior. The experience told by a witness who wear the burn marks on her skin and on her soul, emotionally involves health professionals who claim to have a greater incentive to do prevention. Let's Keep Our Skin Dear!

P.088 Home burns: prevention and treatment. Corporate Training Course. The experience of the Burn Center in Turin

Heat burn injury in a neonate: a clinical and surgical challenge
Objectives: neonatal burn injuries are rare and challenging. Immature immune system and fragility of thin skin, paucity of donor sites for wound coverage and long-term complications make clinical management and surgical treatment of burned newborns extremely difficult.
Methods. Case report: a 23-day-old female neonate presented abdominal colic. His father decided to utilize the white noise of a hairdryer to control pain and reduce crying time. Accidentally the baby remained in contact with the heat of the hairdryer for several minutes and she sustained a full thickness burn to the face, left forearm and hand. She was admitted on the same day to our Center, Regina Margherita Children’s Hospital in Turin, in December 2021.
Results: due to the deep circumferential wrist burn, an escharotomy was performed at the arrival to the Emergency Department. In the acute phase, the baby was promptly managed by fluid resuscitation, analgesics, antibiotics and initial conservative wound care. First surgical procedures, escharectomy to the forearm and hand and debridement to the face, were performed at day 5. At day 10, the face and upper extremity were, respectively, covered with amniotic membranes and autologous skin grafts. Due to the depth of burn, a second application of amniotic membranes to the face was performed at day 22. Complete healing was achieved after thirty-five days from burn injury.
Physical therapy and splinting were started promptly. After wound healing, physical therapy was intensified and at day 42, first dye-laser therapy to control hypertrophic scars, was performed. The baby was discharged after forty-eight days. Dye-laser therapy to the face is still performed every 30 days. Despite timely scar management, an important scar contracture of the wrist and hand is present. First surgical intervention for scar release is planned. Psychological support to the parents and their involvement during physical therapy are mandatory throughout the hospitalization and are still ongoing.
Conclusion: this case report presents a challenging situation with a female neonate, with a deep burn to the face and upper limb. A multidisciplinary healthcare team of physicians and therapist is imperative to optimize functional, cosmetic and psychosocial outcomes. A multistep approach consisting in neonatal intensive care, timely surgical indication and prompt post-operative re-habilitation constitute a key points for the successful treatment in neonatal severe burns.

P.081 Heat burn injury in a neonate: a clinical and surgical challenge

Purpose
Wound caused by high-tension electrical burns is difficult to manage because the wound is deep and complex. Coverage of the wound at the entry point and the exit point often requires flap coverage. In addition, metallic foreign body can also cause significant deep injury on and near its contacting sites. We present a case of peroneal artery perforator free flap on the palm and removal of back foreign body in high voltage electrical burn patient.
Materials & Methods
A 38 year old male patient was transferred due to high voltage electrical burn on postburnday 7. The entry point of the current was on the right palm and the exit point was on the left foot and left lower back. The palm wound was progressively necrotic and deepened, finally, deep tissues of the tendon and palmar digital vessels were exposed. After several times of debridement, peroneal artery perforator free flap was performed on the right hand. The left foot wound was covered by full thickness skin graft. A 1.5cm-long wound of the left lower back healed and recurred repeatedly. On postburn6 month, Radiologic studies showed a metal image within the left gluteus muscle. The wound was explored and the sinus was excised. Multi-braid fine wires, supposedly put in by trauma at patient’s childhood, were found in the gluteus muscle
Results
The flap was survived well without complications, and the range of motion of the hand was good. All the other wounds (back) healed well. During 36 months after the operation, wound problem was not observed
Conclusion
Peroneal artery perforator free flap can be a useful treatment for resurfacing of palms. Also, it is recommended that the patients putting metals on or within the body, including ornaments, metal plates in orthopedics, dental implants, pacemakers or stents in the vessels and ducts should be careful about electrical injury because they may cause serious thermal damage on the wearing sites and adjacent areas by electrical burn.

P.115 Peroneal Artery Perforator Free Flap on the Palm and Removal of Back Foreign Body in High Voltage Electrical Burn Patient: A Case Report

Objectives:
Burn induced compartment syndrome (BICS) of the extremities or abdominal region requires escharotomy to maintain tissue viability. Until now, surgical escharotomy was the main option for prevention and treatment of BICS. However, this carries a risk of damaging anatomical structures, bleeding and infection. Enzymatic debridement with NexoBrid® (EDNX) has emerged as a valuable alternative for early, selective burn eschar removal.

Methods:
This case series includes 4 patients where, due to clinical signs of BICS, EDNX was used at a very early stage post burn (<24 hours). Our standard protocol for NexoBrid® application consists of 2 hours pre-soaking, 4 hours NexoBrid® application, 2 hours post-soaking and finally application of allografts.

Results:
Patient one (32-year-old male) had a 8.4% TBSA, third degree, circumferential burn on his right lower leg resulting in BICS. In addition to clinical symptoms (paresthesia, delayed capillary refill, cold temperature and blue color of his foot and toes), pressure measurement revealed intra-compartment pressures of 60 mmHg (Figure 1a-b). Within the first hour after NexoBrid® application, refill, temperature and color normalized. Intra-compartment pressures dropped to 20 mmHg post-procedure (Figure 1c-d).
Patient two (60-year-old female) had third degree, circumferential burns on the trunk and abdomen. Because she was intubated, BICS was diagnosed based on increasing intra-abdominal and ventilation pressures. 30 minutes after EDNX application, intra-abdominal pressures lowered to normalize by the end of the procedure. Ventilation pressures remained high due to a ventilation acquired pneumonia.
Patient three (32-year-old male) had deep second degree circular burns on both wrists and the dorsum of the hands (Figure 2a-c). Increased swelling of his hands and fingers and delayed capillary refill urged the need for NexoBrid® treatment. Swelling progressively decreased and refill normalized within the first hours of Nexobrid® application (Figure 2d-f).
Patient four (21-year-old male) had deep second and third degree burns on both wrists (circumferential) and hands (circumferential) (Figure 3a-b). A consistent increase in swelling of both hands with reduced capillary refill (nail beds) urged us to perform urgent EDNX. No additional surgical escharotomies were necessary, swelling of both wrists and hands was significantly reduced at the end of the procedure (Figure 3c-d).

Conclusions:
To the best of our knowledge, this is the first case series that aims to provide clinical evidence for safe and effective use of NexoBrid® in the prevention of BICS in upper extremities, lower extremities, thoracic and abdominal regions. Surgical escharotomy was prevented in all cases.
Ruyssinck L 1 ,  De Decker I 1 ,  Hoeksema H 1 ,  Monstrey S 1 ,  Verbelen J 1 ,  Claes K 1 ,  De Mey K 1
1 Ghent University Hospital, Ghent, Belgium

P.032 Enzymatic debridement for the prevention of burn induced compartment syndrome: utility or futility?


Objectives:
Swallowing disorders or dysphagia, following severe burns can lead to dehydration, malnutrition, aspiration pneumonia, prolonged hospitalization and associated deterioration in quality of life. Concomitant psychological factors and burn injuries add a layer of complexity to the rehabilitation program. This case report highlights and emphasizes the role of the speech therapist in the multidisciplinary team approach.
Methods:
A 77-year-old female, with history of two strokes, psychiatric problems including anxiety and depression over the last 30 years sustained 25 % full thickness head and neck and thorax burns with inhalation injury due to suicide attempt by pouring and igniting pure spirit on herself. She was admitted on the day of injury and had a tracheotomy on the 5th post-burn day. Initial positive Evan’s Blue Dye Test on the 40th post-admission day showed penetration. A fiberopticendoscopic evaluation of swallowing (FEES) revealed severe oropharyngeal phase dysphagia characterized by delayed swallow initiation, pharyngeal pooling with residuals and penetration with silent aspiration of puree and liquid. Based on these results, a percutaneous endoscopic gastrostomy tube was placed and she was referred to speech therapy for the rehabilitation of dysphagia.
Results:
Repeat FEES after 26 sessions of therapy (3 times weekly), showed improvement in swallow function. She was able to clear residuals with multiple swallows. Coordination and swallow initiation speed increased enough to initiate oral feeding with the speech therapist. The patient’s dysphagia improved after 26 sessions and continued to improve over the following month. After 39 sessions she started oral feeding and drinking. After that, a Video Fluoroscopic Swallow Study (VFSS) was performed and she had the removal of her gastrostomy tube and could be discharged. Although an SLT is not a standard member of our Burns Unit her contribution in the rehabilitation of this long hospitalized patient was immense.
Conclusions:
SLTs are involved in the assessment and treatment of dysphagia for patients with burn injury. This case report emphasizes that burn management takes a team effort, including an early diagnosis and management of swallowing impairment. SLT has become a valuable member in the burn care team, in order to facilitate through multidisciplinary collaboration burns patients rehabilitation.

P.094 Swallow rehabilitation of a 77-year-old female, with self-inflicted 25% burns and psychiatric premorbidity: A case report

P.002 Initial burn resuscitation guided by the Parkland formula leads to high fluid volumes, increasing mortality and the risk for kidney injury

P.046 European regulatory aspects of phage therapy: magistral phage preparations

Objectives
Burn injury causes significant morbidity, functional impairment and disfigurement. Reducing the impact of such injury has led to early surgical intervention and methods to preserve or replace dermis where possible to reduce scar contracture. Enzymatic burn wound debridement has been proposed to preserve dermis, reduce the amount of burn requiring skin grafts and reduce time to treatment.  The objective of this study is to present a systematic review of the role of enzymatic debridement in burn treatment compared to standard of care (debridement and skin grafting) in adult patients with burns.
Methods
A systematic review of randomized controlled and case-control studies reporting and comparing healing outcomes of enzymatic debridement with the standard of care, published on Embase, Medline, PubMed, Google Scholar and Cochrane databases in the period from 1946 until August 2021 was performed. Relevant studies were extracted and analysed with the help of Review Manager Version 5.4.1, The Cochrane Collaboration, 2020. The systematic review was registered with the International prospective register of systematic reviews (PROSPERO) with registration number CRD42021283286.
Results
The database search identified thirteen articles that met the inclusion criteria. Of these, four were systematic reviews, one a consensus document, one randomized controlled trial, five non-randomized prospective studies and two were retrospective reviews. A combined number of 441 patients were included. The average age of patients in the enzymatic debridement intervention group was 42 years and in standard of care group 48 years. Nexobrid application average time was one day. The combined mean total body treated mean surface was 6.5%. Studies investigating Nexobrid mention the combined average success of debridement of 82.8%. Overall, Nexobrid reduces time to treatment, need for surgery and shortens hospital stay.
Conclusion
This systematic review presents the current data supporting Nexobrid usage for enzymatic debridement of partial thickness to deep dermal burns. Moreover, it also discusses trends and directions for further research in this field. Further randomized controlled trials or feasibility studies are warranted. The rrelevant areas of future research with Nexobrid use include reduction of local inflammatory response, optimization of perfusion and drainage due to reduced posttraumatic oedema, its role in preventing compartment syndrome, dermal layer preservation, patient satisfaction perspective, role in mass casualties and systemic response after enzymatic debridement.

P.034 The impact of Nexobrid in the treatment course in adults with partial thickness burns compared to standard of care – a systematic review

Objectives
Increased plasma levels of cell free DNA (cf-DNA) are observed in patients after severe thermal and traumatic injuries. The majority of cf-DNA is generated from neutrophil extracellular traps (NETs) and not only implicated in the pathophysiology of multiple organ failure (MOF) but may provide an early biomarker for sepsis (Hampson et al, Annals of Surgery, 2017). DNAse degrades NETs into nucleosomes with ~150 base pairs (bp) of DNA wrapped around a histone core. Recently, large circulating chromatin fibres have also been observed in burns (Otawara et al, Scientific Reports, 2018). Here, we measured the size of c-fDNA in burns and trauma patients to understand the post-injury dynamics of NET-cf-DNA generation and breakdown.
Methods
Cf-DNA concentrations were measured in plasma samples obtained from severe burns (>15% TBSA) and traumatically-injured (injury severity score >8) patients across a timescale of days 1-28 and ≤1-72 hours respectively. Concentrations were compared to those measured in plasma samples from healthy controls. DNA was also extracted from plasma and analysed by the high sensitivity Agilent 2100 Bioanalyzer to determine DNA size (bp). As an in vitro control, DNA was also measured from purified NETs generated from neutrophils stimulated with 50 nM PMA for 4 hours and digested with DNase, MNase or DNase 1L3.
Results
Unresolved high molecular weight DNA was detected in the acute post-burn phase (days 1-4), which was digested down to nucleosome bands at ~150 (bp) at later time-points (days 6-14) that persisted up to 28 days. The density of nucleosomes correlated with cf-DNA levels. Healthy donor plasma, with low cf-DNA levels contains no nucleosome bands. A ~150 bp nucleosome band was detected in trauma patient plasma at all sampling time-points. In samples acquired 1-hour post-injury, higher molecular weight nucleosome oligomers (i.e., ~ 300 and 450 bp) were also detected. DNase 1L3 and MNase digestion of NETs generated nucleosome bands in vitro,, although DNAse-1 completely digests away remnant nucleosomes.
Conclusions
This study demonstrates the nature of circulating NET derived DNA fragments in post-injury burn and trauma samples with a predominant ~150 (bp) nucleosome band apparent at most time points which correlates with cf-DNA levels. Ultra-early trauma samples (<1h after injury) also contain nucleosome oligomers. In vitro digestion of NETs confirms the role of DNases in breaking down NET derived chromatin into nucleosomes. These studies will help elucidate the role of NET derived chromatin and nucleosomes in the pathophysiology of DIC, MODS and sepsis.

P.012 Characterisation of Neutrophil-derived Cell Free DNA (cf-DNA) In Burns and Trauma

Purpose
High-voltage electrical burn injuries on the scalp often result in scalp and cranial bone necrosis, which can result in chronic osteomyelitis (OM) of cranial bones despite successful flap coverage of soft tissue. The aim of this study is to understand treatment of chronic OM of the skull caused by high-voltage electrical burn injury.
Materials & Methods
A 37 year-old male patient was transferred due to a 22,000-voltage electrical burn on scalp. At first, a 4 × 3-cm-sized discolored scalp wound was noted. After repetitive debridementsof necrotic tissues, the scalp wound had enlarged to 12 × 12 cm with cranial bone exposure at postburnday (PBD) 45. On PBD 50, under general anesthesia, complete debridement of necrotic cortical bone and latissimus dorsimusculocutaneous (LD MC) free flap was performed, and the flap was survived well. After discharge, at PBD 4 month (postoperative day 2 month), a small opening was noted on the posterior site of the scalp wound accompanied by a small amount of discharge. The brain MRI and skull CT and whole body bone scan showed signs of cranial bone OM at the previous burn injury site. The wound healed and recurred repetitively with administration of IV antibiotics. At PBD 19 months (postoperative day 17.5 months), surgical exploration of the scalp wound was performed by both plastic surgeons and neurosurgeons. Debridement and craniectomy(necrotic outer table) were performed without flap loss. The inner cortical bone was viable and preserved.
Results
At 14 months after the craniectomy, the radiological findings of chronic OM almost subsided. No further antibiotics or other treatments were performed. The scalp and flap were good without wound recurrence for 30 months after craniectomy(debridement of the outer table).
Conclusion
The treatment of chronic OM by electrical burn is surgical debridement and well vascularized flap re-coverage. The LD muscle free flap is suitable not only for coverage of the skull, but also for the treatment of chronic OM of the skull.

P.119 Chronic Osteomyelitis of Cranial Bones in a Patient with High-voltage Electrical Burn on the Scalp: A Case Report

Objectives: NexoBrid® (NXB) enzymatic debridement of deep burns is approved for use in adults in several regions worldwide. Clinical trial experience and off label reports point to NXB safety and efficacy in children as well. The objective of this study was to further assess the safety and efficacy of NXB in children, in efforts to support regulatory approval for its use in children.
Methods: 145 children ≤18 years old suffering from deep thermal burns between 1-30% TBSA were enrolled in a multicenter, multinational, open label, randomized, controlled phase III study. 72 children were randomized to debridement with NXB and 73 children to standard of care (SOC) surgical and/or non-surgical debridement methods, at the investigators' discretion. Patients who did not achieve complete debridement after NXB application were rescued with SOC debridement methods. Wound care after achieving complete debridement was according to routine methods, at the investigators' discretion. Patients then continued follow up for >3 years. This abstract reports the acute stage results of the study and the first year of follow-up.
Results: Baseline characteristics were similar between the arms. Median age was 3.4 years in the NXB arm and 3.9 years in the SOC arm. Average burn area was 7.0±4.9 %TBSA in the NXB arm and 6.2±4.8 %TBSA in the SOC arm. The study met all 3 primary endpoints: Median time to complete debridement was 1 day for NXB and 6 days for SOC (p<0.001), the percent wound area excised in order to complete debridement was 1.5% for NXB and 48% for SOC (p<0.0001), and MVSS scores at 12 months were 3.83 for NXB and 4.86 for SOC (non-inferiority endpoint). Secondary endpoints demonstrated 8.3% incidence of surgical excision to complete debridement for NXB and 64.4% for SOC (p<0.0001), mean debridement associated blood loss of 32±284ml for NXB and 202±409 for SOC (NS), a 25.9% incidence of autografting in DPT wounds for NXB and 37.7% for SOC (p=0.054), and a mean percent area of DPT wound autografting of 15.9±38.6 for NXB and 22.8±43.7 for SOC (NS). Safety endpoints demonstrated a non-inferior time to complete wound closure (median 32 days for NXB, 34 days for SOC) and the safety profile was consistent with the safety in adults.
Conclusions: NXB was shown to be a safe and effective debridement agent in pediatric burns.
*Funded by MediWound Ltd. and by US Federal funds from the Office of the Assistant Secretary for Preparedness and Response, BARDA, under Contract No. HHSO100201500035C

P.040 Safety and efficacy of NexoBrid enzymatic burn debridement in children: Results of the CIDS multicenter RCT

MITOCHONDRIAL DYSFUNCTION IN EXTENSIVE BURNS
Magdaléna Švecová, Bohumil Bakalář, Tomáš Urban, Robert Zajíček
Introduction: Mitochondrial dysfunction is one of the main pathophysiological mechanisms of multiorgan dysfunction in critically ill patients. Mitochondria are cellular organelles in which the oxidation of macronutrients occurs and the formation of ATP takes place. Mitochondrial dysfunction is associated with the insulin resistance (IR) as well as increased production of reduced NADPH, and thus increased oxidative stress and the formation of reactive oxygen species (ROS) and nitrogen species (RNS). ROS and RNS directly damage DNA, structural proteins, and lipids; they act indirectly via intracellular stress-induced systems which leads to the production of proinflammatory cytokines.  Burns have been shown to reduce mitochondrial oxidative phosphorylation and significantly reduce ATP production. As found in 69 pediatric patients with burns, the respiratory capacity of mitochondria in skeletal muscle remains significantly reduced for 1 year following the injury; mitochondrial dysfunction in adult burned patients has been reported sporadically.
Objective: Determine the extent of mitochondrial dysfunction in adults with severe burn injury and the dynamics of this dysfunction during the treatment process. Severe injury being defined as an injury with at least 20% of total body surface area (TBSA) being 2nd and 3rd degree burns.
Methods: Prospective intervention non-randomized clinical study.  Inclusion criteria: age >18 years, both sexes, one signed informed consent, 2nd and 3rd degree burns on at least 20% TBSA.  Exclusion criteria: age <18 years, burns <20% TBSA, injury older than 3 days on admission to hospital, ongoing infections at the time of admission.  In enrolled patients, a muscle sample from the quadriceps femoris will be taken on days 10, 25, and 40 after the injury and examined on an Oxygraph O2K respirometer for high-resolution mitochondrial respirometry.  On the aforementioned days, the subjects will be insulin clamped to determine the degree of IR and indirect calorimetry will be measured to determine energy expenditure (Q-NRC +). These results will be related to appropriate clinical status indicators (SOFA score) and plasma markers of metabolism.
Results: 11 patients have been examined.  The metabolic results are presented and discussed during the presentation.
Conclusion: The dynamics of mitochondrial dysfunction are not yet known. The results of mitochondrial functions presented in skeletal muscle in 11 patients with severe burns on days 10, 25, and 40 after the injury document these changes.

P.011 Mitochondrial dysfunction in extensive burns

Objectives: Current advances in technology have made possible the modification in live tissues structures with the purpose of improving its intrinsic, innate abilities to support the healing of burns and wounds. This study examines how Kerecis Omega3 Burn Graft assists in the healing process and describes its changes over time after application.
Method: In this case series, multiple burn patients of varying age and ethnicity with a wide range of burn and wound sizes, received Kerecis Omega3 Burn Graft applied post debridement and/or excision. The fish skin graft effects on wound healing were evaluated regarding time to wound closure, restoration of barrier function, complications and pain severity.
Results: Overall the cohort of patients treated with Kerecis Omega3 Burn had an observed decrease in healing time, complications, and patient-reported pain. Clinical challenges encountered are outlined. Evidence of product assimilation is presented.
Conclusion: In this case study, the fish skin graft demonstrated similar or better results to our previous standard of care treatment. Certain characteristics observed during and after wound closure indicates relatively high speed of product assimilation compared to standard of care products.

P.159 The Use of Fish Skin Grafts for the Management of Burn Wounds

Objective: The aim of this work was to demonstrate the possibility of a local transposition of FC flaps to cover deep defects caused by a high voltage electrotrotrauma damage of the forearm soft tissues with a loss of many tendons, muscels and even main nerves.
Methods: We chose the method of covering the residual forearm tendons of flexors and extensors  without peritenonium. As the patient was in the critical condition, the treatment method had to be simple as much as possible. The radial artery was thrombotised.  Residual skin of the upper forearm was only available to cover wrist defects.
Result: Transposition flap from the forearm covered the dorsal wrist defect as well as volar wrist defect. The donor site was autotranplansplantated.
Conclusion: In the case of exposed deep structures such as nerves, tendons and bones, there is a need to protect these ones and to allow further reconstruction of tendons and nerves. Local random fasciocutaneous flaps could be the method of choice due to simplicity and possibility of other reconstructive surgery.

P.114 Severe electrotrauma treated by local fasciocutaneous flaps

Dear friends and colleagues,

We will be pleased to welcome you in Turin (Italy) for the 19th European Burns Association´s Congress in 2022. Italy is honored to hold the meeting of the European Burns Association for the second time, after Verona in 1995. Turin is easily reachable from everywhere in Europe, either travelling by car, train or choosing flight connections. During the meeting, held in the renewed industrial center of the main Italian historical automotive factory (i.e. Lingotto-FIAT), we will meet international burn specialists, focusing on standards of care, progresses in burn treatment, strategies to face disaster situations, with a special attention to education of younger colleagues. However, in your spare time, you might enjoy the sweet days of Italian late summer, simply wandering in the green parks and gardens along the two rivers which cross the city, or you might decide to discover the numerous art galleries, churches, palaces, libraries, walking across elegant squares and large boulevards, passing through centuries of art and history; finally, you may choose to immerse yourself in some of the most exciting museum experiences, such as the Cinema Museum and the Turin’s Egyptian museum.

Looking forward to seeing you all in Turin for the 19th European Association´s Congress in 2022!
Maurizio Stella, Congress President, Turin Burn Centre