Quick Guide Moist Exposed Burn Treatment (MEBT)

Moist Exposed Burn Therapy (MEBT) is a new technique for burn treatment that follows and complies with pathogenesis of burns and the law of life. 

This new therapy comprises a complete set of theories and techniques for the local and systemic treatment of burns.  The profile of this therapy is, by applying MEBO, liquefies and removes necrotic tissues, meanwhile, protects and promotes the regeneration of residual viable skin tissues
During the entire treatment period, burn wound is not kept in a dry condition as required in conventional surgical burn therapy, but in a physiologically moist condition which is suitable for wound healing.
Locally, MEBO relieves pain and promotes wound self-healing. 

Through introducing bacterial variation, reducing its pathogenicity, and promoting local resistance to infections, MEBO effectively prevents wounds from infections. 

By providing a physiologically moist environment and nutrition supply, MEBO promotes tissue regeneration. 
Systemically, daily fluid requirements are reduced due to the reduction of water evaporation from burn wounds.  According to the severity of burns, systemic broad-spectrum antibiotics are needed to control infections at the early stage.
Wound Healing Process in MEBT

Under MEBO treatment, wound healing process can be divided into four phases. 

a) Early phase (3-4 days postburn): this phase lasts from right after injury to the end of shock phase.  The treatment in this phase is mainly on protecting wound, relieving pain, and avoiding injury progression. 

b) Liquefying phase: the necrotic tissue liquefies in this phase and a yellowish layer emerges on wound surface composed liquefied necrotic tissue.  Do not mistreat this condition as infection.  The treatment in this phase is mainly focusing on wiping off the liquefied matter and carefully redressing MEBO every 4-6 hours.

c) Wound regenerative phase: in this phase, necrotic tissues have been liquefied and discharged.  The wound bed is exposed and the residual tissues begin to regenerate to repair the skin structure.  The treatment in this phase should be focus on reducing stimulation to the wound, maintaining moisture, avoiding pressure on the wound, and keeping wounds clean. 

d) Skin functions restoring phase: after the basic skin structures are repaired, functions of skin appendages may be fully restored in few months.
Basic Principles for Practicing MEBT

Wound Management

The earlier use of MEBO, the better outcome.  For the best result, applying MEBO within 4 hours after injury is desirable.  MEBO must not be applied more than 1 mm in thickness to ensure underlying tissue’s ‘breath’.  Timely (4-6 hrs) cleaning of exudates, liquefied necrotic tissues, and ointment residues and re-applying MEBO is critical. 

Avoid causing pain, bleeding, or any secondary injuries to the wound when cleaning or making any necessary debridement.

Do not make any aggressive surgical excisions.  Keep wounds covered by MEBO all the time avoiding desiccation and maceration.

MEBO shall be applied throughout the treatment period with no interruption from other treatments.  Water, desiccants, and any stimulative disinfectors should not be used for cleaning the wound site.  If the wound is second degree or deeper, ‘translucent membrane’ may be formed on the wound surface during MEBO treatment.  It should be protected when changing the dressing.

Systemic Treatment of Burns

Since the changes in topical treatment directly affect the systemic pathophysiological reactions, systemic treatments with MEBT/MEBO are accordingly modified from conventional protocols, especially in anti-shock and antibiotic treatments for extensive deep burns. 

(1) Fluid Resuscitation:

a) Compositions of Fluid Infusion: The ratio of crystalloid solution (normal saline or 5% GNS) to colloid solution shall be 1:1.  Ideally, colloid solution should be composed of 3/4 plasma and 1/4 whole blood; 1/2 of plasma and 1/2 of plasma substitutes can also be used. 
b) Amount of fluid: In shock phase of massive burn patients (during 48-72 hours after injury), the amount of fluid replacement is calculated by the following formula:  Total amount of fluid (ml) = [Physiological water needs (5% GS 2000 - 2500 ml) + 1 ml/kg x TBSA% of 2nd and 3rd degree x body weight (kg)] / hourly urine volume per body weight (kg)   
c) Speed of fluid infusion: half of total fluid amount is given within the first 12 hours following injury, and another half is given over the next 12 hours according to vital signs and cardiac and renal functions.  During the second 24 hours postburn, fluid will be given at a unified rate.  During the third 24 hours after injury, the amount and speed of fluid infusion must be determined strictly by monitoring the shock symptoms and the amount of urine output. 

Once the shock symptoms are remarkably improved or disappeared and the hourly urine output is over 1 ml/kg, the speed of fluid infusion should be decreased and the fluid amount should be reduced by 1/3.

(2) Cardiotonic: Extensive burn patient is intravenously given cedilanid in the early stage.  Continuous use will be determined according to the changes in heart rate and peripheral circulation.
(3) Diuretic: Routinely given diuretic mixture to improve renal circulation and relieve renoarteriolar spasm in renal parenchyma.
(4) Maintaining the integrity of gastrointestinal barrier: For preventing stress ulcers, enteral resuscitation, early oral feed, gastric mucous protectant, and anti-acids are recommended.
(5) Monitoring body temperature: Body temperature may be affected by various factors in burn patients.  Timely and etiological interventions are needed to keep patients in normal body metabolism.
(6) Organ-protective: Since the wound liquefaction phase, every body organ systems are also entering their recovery process.  In order to maintain a functional environment for facilitating wound healing and systemic recoveries, protecting organ systems from secondary injuries is essential during this period.  a) evaluate all treatment protocols for acute resuscitation and withdraw any agent that may be harmful to internal organs; b) withdraw any drug that is detrimental to protein synthesis; c) ensure adequate energy supply and reduce catabolism.
Antibiotic Therapy

(1) Principles of using antibiotics: 

a) as a prophylactic measurement, systemic use of antibiotics is not routinely applied to patients with <30% TBSA burns; all patients with >30% TBSA burns (>10% TBSA in children) will be routinely given systemic antibiotics. 
b) for systemic therapeutical use, all of the following three indications must be met simultaneously: body temperature >39.5 °C, or < 36.0 °C; heart rate > 140/min; toxic granules occur in neutrophilic granulocytes. 

(2) Protocol:

a) for prophylactic use, single or combined broad-spectrum antibiotics are given intravenously or intramuscularly as early as possible and last for 5 days in extensive deep 2nd degree burns and 7-10 days in extensive 3rd degree burns.  Prolonged use is not recommended. 
b) for systemic therapeutic use, a single dose of potent broad-spectrum, renal nontoxic antibiotic(s) shall be given. 

One repeated dose will be administrated if the neutrophilic toxic granules are not disappeared after the first dose.  If the toxic granules still last after initial treatment, thoroughly examinations on potential infection site and appropriate interventions must be done before subsequent use of antibiotics.
Nutritional Support

Prolonged and generous energy and protein supplies are recommended. 

a) during the 4th and 8th day after injury, sufficient energy must be supplied;

b) during the 8th day and the end of liquefying phase, balanced energy and protein supply must be maintained;

c) in the wound repairing phase, protein will be preponderantly supplied; d) enteral supply is desirable; e) daily caloric requirements (kcal) = (24 kcal/kg x kg of body weight + 40 kcal x %TBSA) x 6.8