A m n i o t i c M e m b r a n e is an Effect ive B u r n Dress ing Mater ia l

Subhash C h a n d r a SHARMA, M a d a n Mojan BAGREE, Ami Lal BHAT, Brij Bhushan BANGA and M a h e n d r a P ra t ap SINGH

A B S T R A C T : H u m a n amnio t ic m e m b r a n e is a readi ly avai lable biological dressing mate r i a l used to t rea t burns. It not only prevents oozing of p lasma from burn wounds bu t also relieves pa in and controls sepsis. We used h u m a n amniot ic m e m b r a n e to t rea t fifteen burn pat ients , and this ma te r i a l was effec- tive. T h e app l i ca t ion of this cost-free dressing ma te r i a l warrants fur ther s tudy as it can be m a d e use of in areas where expensive and special ized equ ipmen t is not avai lable .

KEY WORDS: amnion , burns , wound dressing

INTRODUCTION

Thermal burns are ma jo r surgical and socio- economic problems. F lu id loss, electrolyte im- ba lance , pain , toxemia and sept icaemia are pos t -bu rn sequalae.

Bacter ia l invasion, passive evapora t ive water and heat loss, inhib i t wound heal ing. T h e ra te of water and hea t loss is p ropor - t ional to the surface area and dep th of the burns. 1 Prevent ion of the occurrence of these factors will a id in the hea l ing process and can be achieved immedia te ly , covering the bu rn wound with an a l lograf t or xenograf t . 2 H u m a n amniot ic m e m b r a n e is sui ted for this purpose and has many advantages .

MATERIALS AND METHODS

Fif teen pat ients with second degree burns were separa ted into three ma jo r groups of

Department of Surgery, S.P. Medical College, Bikaner, India

Reprint requests to: Subhash Candra Sharma, Department of Surgery, S.P. Medical College, Bikaner, India, Madan Bagree, 9; Kalawati Bhawan, Bikaner-334001, India

five. Group I - - T h e entire b u r n e d area was covered by amnio t ic m e m b r a n e . Group I I - - Ha l f of the total b u r n e d area was covered with amnio t ic m e m b r a n e and the r ema in ing ha l f was left uncovered. Group I I I This group was t r ea ted by convent ional methods and served as the controls.

Af ter t r ea tmen t with in t ravenous fluid and o ther convent ional methods, the pat ients in groups I & II were br0flght to the opera t ing theatre , where blisters were sn ipped off and the loose skin was cut, unde r condi t ions of l ight sedat ion . T h e raw a rea was cleansed with weak savlon solution and was dr ied be- fore the amn ion appl ica t ion . H u m a n am- niotic m e m b r a n e s were separa ted , cleansed s and s tored at room t empera tu r e for one hour pr ior to app l ica t ion . They were then spread out over the wounds. All the air and fluid blebs were smoothened out to ensure un i fo rm and firm contac t between the m e m b r a n e and the wound surface. Excess m e m b r a n e s were cut. No dressings were app l i ed except in case of c i rcumferen t ia l burns.

P a r a m e t e r s - - T h e cases were assessed on the fol lowing cr i ter ia .

(a) Oozing: Ni l Bed sheets below the b u r n e d area were dry. M i l d - - S l i g h t s ta ining

JAPANESE JOURNAL OF SURGERY, VOL. 15, No. 2 pp. 140-143, 1985

Volume 15 Amniot ic membrane as burn dressing material 141 Number 2

of the bed sheets. M o d e r a t e - - E x u d a t i o n re- q u i r e d superdress ings and c h a n g e o f bed

sheets. (b) Pa in : A b s e n t - - A n a l g e s i c s no t re-

qu i r ed . M i l d - - P a i n re l ieved wi th n o n - n a r -

cotics. M o d e r a t e - - N a r c o t i c s r e q u i r e d for a

pa in - f r ee s tate .

(c) Su r face Cu l tu re : C u l t u r e swabs were

t aken f r o m the b u r n e d sur face be fo re and

af te r the a p p l i c a t i o n of the a m n i o t i c m e m -

b r a n e . In t he con t ro l g roup , c u l t u r e swabs

were t aken .

(d) Ev idence o f T o x e m i a : i) Vi ta l signs, viz. pulse ra te , r esp i ra t ion r a t e a n d t e m p e r a -

tu re were r e c o r d e d every fou r to six hours , ii)

Sur face cul tures .

RESULTS

T h e age a n d sex o f the pa t i en t s a re shown

in T a b l e 1. I n g roups I & II for w h o m am-

n io t ic m e m b r a n e was used, the pulse , respi ra-

t ion a n d t e m p e r a t u r e were closer to n o r m a l

a n d the re was no s igni f icant c h a n g e in these

p a r a m e t e r s in the cont ro ls ( T a b l e 2). O o z i n g

was c o m p l e t e l y checked a f te r the m e m b r a n e

a p p l i c a t i o n in g r o u p I. T h e cove red wounds

r e m a i n e d dry, e x c e p t in one p a t i e n t where

s l ight ooz ing o c c u r r e d on 9th p o s t - m e m b r a n e

a p p l i c a t i o n day. T h e m e m b r a n e p e e l e d off

a u t o m a t i c a l l y l eav ing b e h i n d a b lu i sh p ink

e p i t h e l i u m cove r ing the a rea o f t he b u r n t

surface, wi th in an ave rage p e r i o d o f 16 days.

O o z i n g c o n t i n u e d f r o m the b u r n e d a rea

wh ich was lef t u n c o v e r e d in g r o u p I I a n d in

pa t i en t s in t he con t ro l g r o u p .

No analgesics were n e e d e d to keep t h e pa-

t ients p a i n free af ter a m n i o n a p p l i c a t i o n

whi le analgesics were r e q u i r e d r o u n d the

c lock for t he contro ls . T h e second degree

bu rns were c o n v e r t e d in to th i rd d e g r e e ones

d u e to in fec t ion caused most ly by t h e Pseu-

d o m o n a s , S taphy lococc i , S t r ep tococc i and Klebsie l la g r o u p of bac t e r i a in the con t ro l

g r o u p , whi le even previous ly i n f ec t ed b u r n

wounds were f o u n d to be sterile a f t e r 14 days

o f a m n i o n a p p l i c a t i o n (Fig. 1).

O u t o f t he f i f teen pa t ien ts , fou r in t he con-

t rol g r o u p and one in g r o u p II r e q u i r e d skin

g ra f t ing , whereas no pa t i en t in g r o u p I re-

q u i r e d this t r e a t m e n t .

Tab le 1. Cl inicalData on Burned Patients

Percentage of surface area of burns Age in Less than 20% 20% to 40% Over 40% years

Male Female Male Female Male Female

0 - 5 . . . . .

6-10 2 -- 1 -- -- -- 11 20 . . . . . 21 30 -- -- -- 8 -- -- 31 40 -- -- 2 -- -- -- 41-50 -- -- -- 1 -- 1

Total 2 -- 3 9 -- 1

Tab le 2, Clinical Data on Burned Patients with Amnion Application

Pulse rate Temperature Respiration per minute in F per minute

Groups Before After Before After Before After Amnion graft ing Amnion grafting Amnion grafting

I 130 98 99.8 98.4 32 26 II 116 96 99.8 98.6 30 24

III 138 130 99.8 99.6 30 28

142 Sharma et al.

20-

15-

< 10-

5

0

-F

i

I

GROUPS

II III

INDEX

~ STERILE STREPTO. BETA. HAEMOL. STAPHYLO. AUREUS. PSEUDOMONAS. E . C O L I . K L E B S E I L L A STAPHYLO. ALBUS.

Fig. 1. Incidence of bacterial infection in burned patients. Note that after 14 days of amnion application the burn wounds were sterile.

Jpn. J. Surg. March 1985

D i s c u s s i o N

Miller et al. 4 demonstrated that partial thickness burn wounds healed faster than controls when protected by immediate allo- grafting. But the routine use of allograft is limited to special centres as it requires a well c;rganised skin bank. On the other hand, Xenograf t (porcine skin) is inferior to allo- graft, is more expensive and is not readily available in many countries. 2,5 Clinical trials and animal experiments showed that amnion is superior to both allograft and xenograft, s

Oozing of plasma f rom the burnt surface was minimal in our patients with amnion ap- plication while it cont inued in significant amounts in the controls. Other workers reported similar findings. 7.s

Pain was markedly relieved after amnion application while it cont inued in the controls. This finding corresponds to the data of Sukla, 9 who found that pain was completely relieved in second degree corneal burns, after amnion application. He considered that the nerve endings were exposed to irritation due to atmospheric exposure, but that the contact was abolished when the amnion was applied. Robson et al. 2 noted that the membrane in- hibited infection. This antibacterial property

is said to be due to lysozyme and progesterone content of the amniotic fluid. The progeste- rone is bacteriostatic to various g ram positive organisms. Burleson and Eiseman 7 confirmed that biological dressings which adhere to the wound surface and prevent the accumulat ion of pus on the granulat ion surface aid in the sterilization of the wound.

As h u m a n amniotic membrane is embryo- logically derived f rom trio fetal ectoderm, it is considered to be analogous to fetal skin allo- graft. 7 Therefore, it can fulfill some of the functions of the destroyed skin, but unlike skin allograft, vascularization and rejection of the m e m b r a n e does not occur when the amnion is directly placed over the wound sur- face. 6 The m e m b r a n e promotes healing by accelerating the migrat ion of fibroblasts and development of collagen dur ing the first 6-8 days of repair.

We conclude that h u m a n amniotic mem- brane is effective for thermal burns as it checks oozing of plasma, aids in the manage- ment of hypovolaemia, pain is markedly reduced so that smaller doses of narcotics are required at less frequent intervals, it prevents sepsis and as infection is inhibited, toxemia and shock are reduced.

(Received for publication on Sept. 27, 1984)

Volume 15 Amniot ic membrane as burn dressing material 143 Number 2

R e f e r e n c e s

1. Moncrief JA. Unlocking the mysteres of the burn wound. Bulletin of the American College of Sur- geons 1977; 62: 11: 11-19.

2. Robson MC, Krizek TJ, Koss N, Samburg JL. Human amniotic membrane as a temporary wound dressing. Surg Gynecol Obstet 1973; 136:904 906.

3. Bose B. Burn wound dressing with h u m a n amniotic membrane . Ann Royal Coll Surg 1979; 61: 444 447.

4. Miller TA, Switzer WG, Foley FD, Moncrief JA. Early homograft ing of second degree burns. Plast Reconstr Surg 1967; 40:117 125.

5. Llyoid JR. Management of burns. Surg Clin North Am 1977; 57: 121-137.

6. Colocho G, Grahm WP, Gren AE, Mateson DW, Lynch D. H u m a n amniotic membrane as a physio- logical wound dressing. Arch Surg 1974; 190: 370-373.

7. Burleson R, Eisernan B. Mechanism of anti-bacte- rial effects of biological dressings. Ann Surg 1973; 177:181 186.

8. Rao TV, Chandrasekharan V. H u m a n amnion as dressing material in burns. Ind J Surg 1981; 8: 561-565.

9. Sukla IM. Amniotic membrane graft in corneal ulcers. Journal of All India Ophthalmologic Society 1962; 10: 55-60.