Keywords
Burn Nursing
Nursing Clinical Pathway
Bromelain-based Debridement
Enzymatic Debridement
How to Cite
Abstract
Introduction. Deep partial-thickness and full-thickness burns frequently require early eschar removal to reduce complications and support wound healing. Conventional surgical debridement, although effective, may result in blood loss, removal of viable tissue, and substantial resource use. Bromelain-based enzymatic debridement offers a selective, minimally invasive alternative that may preserve viable dermal structures while reducing the need for surgical excision.
Procedure or Intervention. This Procedure Update describes the standardized multidisciplinary clinical pathway adopted in a Major Burns Intensive Care Unit for bromelain-based enzymatic debridement using NexoBrid®. The pathway integrates plastic surgeons, anesthesiologist-intensivists, and nursing staff and encompasses patient assessment, environmental and sterile field preparation, wound preparation, product preparation and application, continuous monitoring during treatment, product removal, post-treatment wound management, and clinical documentation.
Key Updates. The pathway defines the sequence of care, professional responsibilities, safety measures, and nursing competencies required throughout the procedure. Particular emphasis is placed on multiparametric monitoring, pain assessment and management, maintenance of aseptic technique, protection of perilesional skin, surveillance for bleeding, and accurate procedural traceability. Proposed nursing-sensitive quality indicators are also presented to support future evaluation of care processes and outcomes.
Clinical Implications. Standardizing the procedure may support consistency, safety, and multidisciplinary coordination in enzymatic burn wound debridement. Clearly defined nursing competencies and structured training are essential for appropriate implementation and ongoing quality improvement.
Conclusions. A structured multidisciplinary pathway provides a practical framework for the safe and standardized delivery of bromelain-based enzymatic debridement in major burn care. Prospective multicenter studies and formal quality audits are needed to evaluate its clinical, organizational, and nursing-sensitive outcomes.
References
Agenzia Italiana del Farmaco. (2020). NexoBrid: Riassunto delle caratteristiche del prodotto. AIFA.
Aguirrezabala, J. A., Aguilera-Sáez, J., Illa-Boixaderas, M., Serracanta, J., Monte-Soldado, A., Rivas-Nicolls, D., et al. (2022). Response of a single European burn center to Centelles mass casualty burn disaster: Enzymatic debridement utility. Int J Burns Trauma, 12(6), 224–231.
American Burn Association. (2012). National Burn Repository 2012 report. American Burn Association.
Cecere, L., Anastasi, G., Pota, V., Villani, R., Abagnale, M., Limonti, F., et al. (2026). Respiratory outcomes during the use of the high flow nasal cannula in severe burn patients with inhalation injury: A systematic review. Scenario, 43(1). https://doi.org/10.4081/scenario.2026.656
Dreyfus, S. E., & Dreyfus, H. L. (1980). A five-stage model of the mental activities involved in directed skill acquisition. California University Berkeley Operations Research Center. https://www.researchgate.net/publication/235125013_A_FiveStage_Model_of_the_Mental_Activities_Involved_in_Directed_Skill_Acquisition
Edmondson, S. J., Jumabhoy, I. A., & Murray, A. (2018). Time to start putting down the knife: A systematic review of burns excision tools of randomised and non-randomised trials. Burns, 44, 1721–1737. https://doi.org/10.1016/j.burns.2018.01.012
European Medicines Agency. (2020). NexoBrid: Summary of product characteristics. EMA.
Giudice, G., Filoni, A., Maggio, G., Bonamonte, D., & Vestita, M. (2017). Cost analysis of a novel enzymatic debriding agent for management of burn wounds. Biomed Res Int, 2017, 9567498. https://doi.org/10.1155/2017/9567498
Greenhalgh, D. G. (2019). Management of burns. N Engl J Med, 380(24), 2349–2359.
Hartsock, L. A., O’Farrell, D., Seaber, A. V., et al. (1998). Effect of increased compartment pressure on the microcirculation of skeletal muscle. Microsurgery, 18, 67–71.
Hirche, C., Almeland, S. K., Dheansa, B., Fuchs, P., Governa, M., Hoeksema, H., et al. (2020). Eschar removal by bromelain-based enzymatic debridement (NexoBrid) in burns: European consensus guidelines update. Burns, 46(4), 782–796.
Hussain, A., & Dunn, K. W. (2013). Predicting length of stay in thermal burns: A systematic review of prognostic factors. Burns, 39(7), 1331–1340.
Hyland, E. J., D’Cruz, R., Menon, S., Chan, Q., Harvey, J. G., Lawrence, T., et al. (2015). Prospective, randomised controlled trial comparing Versajet hydrosurgery and conventional debridement of partial thickness paediatric burns. Burns, 41, 700–707. https://doi.org/10.1016/j.burns.2015.02.001
Italia. (2008). Decreto Legislativo 9 aprile 2008, n. 81. Gazzetta Ufficiale della Repubblica Italiana.
Kagan, R. J., Arenholtz, D. H., Hickerson, W. L., Holmes, J. H., Korentager, R. A., Kraatz, J. J., et al. (2009). Surgical management of the burn wound and use of skin substitutes: An American Burn Association white paper.
Kagan, R. J., Peck, M. D., Ahrenholz, D. H., Hickerson, W. L., Holmes, J. H., Korentager, R., et al. (2013). Surgical management of the burn wound and use of skin substitutes: An expert panel white paper. J Burn Care Res, 34, e60–e79. https://doi.org/10.1097/BCR.0b013e31827039a6
Kern, M. A., Depka, N., Schackert, C., Henkel, W., & Hirche, C. R. (2018). Enzymatic burn wound debridement with NexoBrid: Cost simulations and investigations on cost efficiency. Gesundheitsökonomie Qualitätsmanagement, 23, 21–28. https://doi.org/10.1055/s-0043-109520
Napolitano, G., Gravante, F., Gravante, A., De Rosa, F., Coletta, F., Tomasello, A., et al. (2024). Confronto tra cannule nasali ad alto flusso e ventilazione non invasiva nei pazienti critici gravemente ustionati affetti da insufficienza respiratoria acuta: Un protocollo di revisione della letteratura. Scenario, 41(3), 600. https://doi.org/10.4081/scenario.2024.600
Orgill, D. P. (2009). Excision and skin grafting of thermal burns. N Engl J Med, 360(9), 893–901.
Pertea, M., Poroch, V., Ciobanu, P., Filip, A., Velenciuc, N., Lunca, S., et al. (2021). Efficiency of bromelain-enriched enzyme mixture (NexoBrid) in the treatment of burn wounds. Appl Sci, 11, 8134. https://doi.org/10.3390/app11178134
Porter, C., Tompkins, R. G., Finnerty, C. C., Sidossis, L. S., Suman, O. E., & Herndon, D. N. (2016). The metabolic stress response to burn trauma: Current understanding and therapies. Lancet, 388, 1417–1426.
Rosenberg, L., Krieger, Y., Bogdanov-Berezovski, A., Silberstein, E., Shoham, Y., & Singer, A. J. (2014). A novel rapid and selective enzymatic debridement agent for burn wound management: A multicenter randomized controlled trial. Burns, 40, 466–474. https://doi.org/10.1016/j.burns.2013.08.013
Rosenberg, L., Shoham, Y., Krieger, Y., Rubin, G., Sander, F., Koller, J., et al. (2015). Minimally invasive burn care: A review of seven clinical studies of rapid and selective debridement using a bromelain-based debriding enzyme (NexoBrid). Ann Burns Fire Disasters, 28, 264–274.
Schulz, A., Perbix, W., Shoham, Y., Daali, S., Charalampaki, C., Fuchs, P. C., et al. (2017). Our initial learning curve in the enzymatic debridement of severely burned hands: Management and pitfalls of initial treatments and development of a post-debridement wound treatment algorithm. Burns, 43, 326–336. https://doi.org/10.1016/j.burns.2016.08.009
Schulz, A., Fuchs, P. C., Rothermund, I., Hoffmann, A., Rosenberg, L., Shoham, Y., et al. (2017). Enzymatic debridement of deeply burned faces: Healing and early scarring based on tissue preservation compared to traditional surgical debridement. Burns, 43, 1233–1243. https://doi.org/10.1016/j.burns.2017.02.016
Schulz, A., Shoham, Y., Rosenberg, L., Rothermund, I., Perbix, W., Fuchs, P. C., et al. (2017). Enzymatic versus traditional surgical debridement of severely burned hands: A comparison of selectivity, efficacy, healing time, and three-month scar quality. J Burn Care Res, 38, e745–e755. https://doi.org/10.1097/BCR.0000000000000478
Sheridan, R. L. (2001). Comprehensive treatment of burns. Curr Probl Surg, 38(9), 657–756.
Silver, G. M., Klein, M. B., Herndon, D. N., Gamelli, R. L., Gibran, N. S., Altstein, L., et al. (2007). Standard operating procedures for the clinical management of patients enrolled in a prospective study of inflammation and the host response to thermal injury. J Burn Care Res, 28(2), 222–230.
Snyder, R. J., Hoffmeister, T., Ead, J. K., Nass, A., Klinger, E., David-Zarbiv, K., et al. (2024). Bromelain-based enzymatic debridement: Mechanism of action in the wound environment. Wounds, 36(12), 429–436. https://doi.org/10.25270/wnds/24100
World Health Organization. (2018). Burn prevention and management. WHO Press.
This work is licensed under a Creative Commons Attribution 4.0 International License.
Copyright (c) 2026 Luciano Cecere, Tonia De Crescenzo, Antonella Falanga, Marzia Della Sala, Francesco Limonti, Marco Abagnale, Francesco Gravante, Vincenzo Pota, Romolo Villani