The use of cultured epithelial autograft in the treatment of major burn injuries: A critical review of the literature☆
Introduction
The need to achieve rapid wound closure in patients with massive burns and limited skin donor sites led to the discovery that in vitro cellular expansion of keratinocytes could be achieved [1].
Reproduction and cell expansion techniques made it possible to explore the clinical potential of these techniques [2], [3], [4], [5]. O’Connor et al. first reported the use of cultured epithelial autografts in the treatment of major burns in 1981 [6]. Since that time, support for the use of CEA has varied, ranging from ‘a useful agent’ [7] to ‘no demonstrable effect on the outcome of extensively burned patients’ [8].
Evidence based medicine uses the best proof available to answer questions and develop optimal clinical practice. In answering the question, ‘Is there an evidence based practice for burns?’ Childs [9] clearly identified the difficulties in sourcing solid evidence for clinical practice. Cox [10] indicates that clinical practice is ‘too complex, ill defined, multi-faceted and situational to be handled by applying scientific method to its activities of diagnosis and management’, and further that, ‘value judgements pervade the balancing of trade-offs in every clinical decision but science has no calculus for handling meaning, purpose and choice of actions’.
The review aims to critically appraise the published literature on the use of CEA in major burns.
Section snippets
Methods
Electronic databases were searched using Medline and the key words ‘cultured epithelial autografts in burn wound care’. Publications were limited only by English language. Personal communications were included where appropriate.
In this critical review, the Australian National Health and Medical Research Council (NH&MRC) Guidelines on systematic identification and review of the scientific literature provided the framework to appraise the literature. Only the findings from rigorous studies with
Findings
The literature relating to the use of CEA in burn care was predominantly case studies and case series. The main issues consistently apparent included:
- 1.
time taken to culture cells for clinical use;
- 2.
preparation and provision of an appropriate wound bed;
- 3.
vulnerability to infection;
- 4.
difficulty in assessing ‘take’;
- 5.
long-term fragility;
- 6.
cost of treatment;
- 7.
quality of outcome (Table 2).
Discussion
The literature review presents benefits and limitations of using CEA in major burns. Despite these issues, there is a solid theoretical base for its use [3], [4], [5].
This critical review of the literature examines issues associated with the use of CEA and the introduction of the technology. The main limiting factors are the time necessary to culture CEA sheets, the reliability of ‘take’, vulnerability of grafts, long-term durability and the cost implications of such treatment.
The management of
Acknowledgments
We wish to thank Max Bulsara Director, Biostatistical Consulting Group School of Population Health, University of Western Australia; Susan Stanley Administrative Assistant Clinical Cell Culture; Mark Duncan-Smith Plastic and Reconstructive Surgeon; Burn Unit Royal Perth Hospital Multidisciplinary Burn Care Teams Royal Perth Hospital and Princess Margaret Hospital Perth, Western Australia Bess Fowler, Epidemiologist, Burns Unit Royal Perth Hospital.
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