The UK Consensus Statement for the Use of Enzymatic Debridement in Burn Care

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This manuscript presents the development of a UK National Consensus Statement on the use of enzymatic debridement in burn care, using a modified Delphi process. The topic is relevant, particularly in light of reported safety concerns in large burns and variability in practice across the UK.

The manuscript addresses an important gap in harmonisation of practice. However, in its current form, it presents significant methodological and structural weaknesses that must be addressed before publication. The reporting lacks sufficient methodological transparency for a consensus study, and several sections require clarification and editorial revision.

Intro :

This article echoes the European consensus published in Burns in 2017 on 500 patients, and subsequently in 2020 on more than 1,200 patients. However, the reference does not correspond to the article mentioned in the text (2017 vs 2020, line 47-49).

Methods :

The references for the Delphi approach is missing (REFs), line 100.

Please define more precisely what you consider as « large burns » (%TBSA)

Results :

The recruitment strategy raises concerns about selection bias and representativeness: Participation was voluntary via BBA mailing lists : How many eligible professionals were invited?Please provide response rate ( it cannot be calculated since no denominator is provided). It is unclear whether multiple respondents came from the same centre and how this was handled.

Allowing surveys to be completed “as a team” potentially biases results. What was the proportion of each specialty among the respondents (surgeons, anaesthe- tists, critical care specialists, nurses, physiotherapists, and psychological therapists)? How many burn centres are there in the UK, and how many responses were received from each centre? Was centre-weighting considered?

These issues need clarification, you could maybe provide a « flow chart ».

 

 

Please insert % in line 143.

 

Does the expert panel of 68 burn care professionals includes the 47 responders, the 22 initial volunteers or/and the 16 of June 22 ?

Or are they a new independant expert panel ?

 

 

Discussion :

The Discussion needs revisions and could be composed of :

A structured comparison with existing European and international guidelines and a reflection on whether the UK consensus diverges — and why.

A clearer statement of what is evidence-based versus expert-opinion-based.

 

Author Response

Intro :

This article echoes the European consensus published in Burns in 2017 on 500 patients, and subsequently in 2020 on more than 1,200 patients. However, the reference does not correspond to the article mentioned in the text (2017 vs 2020, line 47-49).

Completed and added pg 67

 

Methods :

The references for the Delphi approach is missing (REFs), line 100.   Added Page 117

Please define more precisely what you consider as « large burns » (%TBSA) unable to see reference to be able to correct?

 

Results :

The recruitment strategy raises concerns about selection bias and representativeness: Participation was voluntary via BBA mailing lists : How many eligible professionals were invited?Please provide response rate ( it cannot be calculated since no denominator is provided). It is unclear whether

added in results section line 154

multiple respondents came from the same centre and how this was handled.

One was removed due to duplication as stated in results section line 155

Allowing surveys to be completed “as a team” potentially biases results. What was the proportion of on 2 were team based answers each specialty among the respondents (surgeons, anaesthe- tists, critical care specialists, nurses, physiotherapists, and psychological therapists)? added line 161

How many burn centres are there in the UK  added line 157 - 158

how many responses were received from each centre? Was centre-weighting considered? as above

These issues need clarification, you could maybe provide a « flow chart ».

Please insert % in line 143. Done line 163

Does the expert panel of 68 burn care professionals includes the 47 responders, the 22 initial volunteers or/and the 16 of June 22 ?

mix of old and new 

Or are they a new independant expert panel ?   added line 166

 

Discussion :

The Discussion needs revisions and could be composed of :

A structured comparison with existing European and international guidelines and a reflection on whether the UK consensus diverges — and why. A clearer statement of what is evidence-based versus expert-opinion-based.

Completed and added in discussion section

Reviewer 2 Report

Comments and Suggestions for Authors

The most authoritative guidelines are evidence-based guidelines. Consensus guidelines developed when strong evidence is limited or absent, relying mainly on expert opinion and agreement. In these cases, this type of consensus of expert opinions is helpful until more evidence is obtained. The study conducted is valuable and useful, and only some questions arise for me:

1. As the authors mentioned in the introduction, a robust study was conducted by the European Burn Society with the same title and guidelines were written on it. Please explain further what was the necessity of writing this guideline in the UK? Are burn treatment differences in the UK much different than in other parts of Europe? Were there etiological differences in burns in the UK?
2. For which type of enzymatic agent was the study conducted? Is this guideline applicable to all enzymatic agents currently are on the market?
3. Did all the survey participants have sufficient experience using enzymatic debridement? What were the criteria for selecting participants?
4. The Delphi technique has been a good method for gathering expert opinions. The results of the study were presented at the Working Group in spring 2023 and the BBA Consensus Meeting. Were expert panel discussions held at these conferences? And did they affect the survey results? If the answer is yes, please explain in more detail.

 

Overall, I find the study useful and I would like to recommend acceptance with minor revision. I would be happy to review the revised manuscript.

Author Response

• As the authors mentioned in the introduction, a robust study was conducted by the European Burn Society with the same title and guidelines were written on it. Please explain further what was the necessity of writing this guideline in the UK? Are burn treatment differences in the UK much different than in other parts of Europe? Were there etiological differences in burns in the UK?

Added to introduction for clarification

• For which type of enzymatic agent was the study conducted? Is this guideline applicable to all enzymatic agents currently are on the market?

In the UK there is only one enzymatic debridement agent that is Nexobrid

• Did all the survey participants have sufficient experience using enzymatic debridement? What were the criteria for selecting participants?

Results added  128 - 129

• The Delphi technique has been a good method for gathering expert opinions. The results of the study were presented at the Working Group in spring 2023 and the BBA Consensus Meeting. Were expert panel discussions held at these conferences? And did they affect the survey results? If the answer is yes, please explain in more detail.  

All agreed with the survey results and clarification of the final wording of the consensuses paper was agreed only meeting outlined in paper were had around this consensus paper

Reviewer 3 Report

Comments and Suggestions for Authors

This manuscript very interesting but seems need to be completed.

Please consider the below. Manor remarks

Introduction:

- Please, add about what are enzymes?

- When and by whom were enzymes discovered

- add when are they used?

- Types of enzymes (proteolytic enzymes………..)

- What kind enzymes used in UK

 

Materials and Methods: Minor remarks

-Were there patients of concurrent acute injury, hepatic, neoplastic diseases and others?

-How burn depths determined?

- How about child, elderly

Results

Good.

 

References

- Please, add some references

Comments on the Quality of English Language

No

Author Response

• Introduction: - Please, add about what are enzymes? - When and by whom were enzymes discovered - add when are they used? - Types of enzymes (proteolytic enzymes………..) - What kind enzymes used in UK

added in introduction

• Materials and Methods: Minor remarks -Were there patients of concurrent acute injury, hepatic, neoplastic diseases and others? -How burn depths determined? - How about child, elderly  

added introduction

• References - Please, add some references

added

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Good  corrections 

Author Response

Thank you!

Reviewer 3 Report

Comments and Suggestions for Authors

The manuscript very interesting and completed

Comments on the Quality of English Language

No

Author Response

Thank you!