How to use NexoBrid®

NexoBrid is an effective enzymatic agent indicated for eschar removal in adults and pediatric patients with deep partial thickness (DPT) and/or full thickness (FT) thermal burns.1

NexoBrid can be applied as a 4-hour application within hours of patient presentation for earlier and more informed medical planning for healing and care. NexoBrid must be removed after 4 hours.1-3

NexoBrid may be applied to up to 15% body surface area (BSA) in one application1

Nexobrid Dosing1 Unit Orders*
  • Up to 15% body surface area (BSA) in one application
  • A second application may be applied 24 hours later—total treatment area must not exceed 20% BSA
6 units =
~15% BSA

Nexobrid Dosing1 Unit Orders*
  • Up to 15% BSA in one application
  • A second application is not recommended
6 units =
~15% BSA

Nexobrid Dosing1 Unit Orders*
  • Up to 10% BSA in one application
  • A second application is not recommended
4 units =
~10% BSA
Age NexoBrid Dosing1 Unit
Orders*
Adults
  • Up to 15% body surface area (BSA) in one application
  • A second application may be applied 24 hours later—total treatment area must not exceed 20% BSA
6 units=
~15% BSA
Pediatric Patients
6–17 Years of Age
  • Up to 15% BSA in one application
  • A second application is not recommended
6 units=
~15% BSA
Pediatric Patients
under 6 Years of Age
  • Up to 10% BSA in one application
  • A second application is not recommended
4 units=
~10% BSA

*Please consider that adults and pediatric patients have different body proportions and this may affect how surface area is calculated across the body.


  • Use pain management as practiced for an extensive dressing change of burn wounds 15 minutes prior to all NexoBrid-related procedures

NexoBrid Preparation1

NEXOBRID is only to be administered by a healthcare provider. Take precautions to avoid exposure to NEXOBRID during preparation and handling (e.g., use gloves, surgical masks, other protective coverings, as needed)

 

  • Gather the following sterile supplies prior to NEXOBRID preparation and application:
    • Instrument for mixing (e.g., spatula or tongue depressor)
    • Tongue depressor for NexoBrid application
    • 0.9% Sodium Chloride Irrigation
    • Occlusive film dressing
    • Loose, thick fluffy dressing and bandage

Wound Preparation, Cleansing, and Soaking1

  • Thoroughly clean the wound to remove any charred tissue, blisters, and any topical products
    • Keratin isolates the eschar from direct contact with NexoBrid and prevents eschar removal4
    • Eschar saturated with topical medicinal products and their remains (e.g., silver-based products or povidone iodine) can interfere with the activity of NexoBrid and decrease its efficacy4
  • Apply a dressing soaked with an antibacterial solution to the treatment area for at least 2 hours
  • Ensure the wound bed is clear of any remnants of topical agents (e.g., silver sulfadiazine or povidone iodine)
NexoBrid powder and gel

Product illustration

Nexobrid Mixing1

  • Prepare NexoBrid at the patient’s bedside within 15 minutes of the intended application
  • Using aseptic technique, mix NexoBrid lyophilized powder and gel vehicle as follows:
    • Pour the NexoBrid lyophilized powder into the gel vehicle jar
    • Thoroughly mix the NexoBrid lyophilized powder and gel vehicle using a sterile instrument (e.g., tongue depressor or spatula) until the mixture is uniform
    • The mixed lyophilized powder and gel vehicle produce NexoBrid in a final concentration of 8.8%
  • Discard NexoBrid if not used within 15 minutes of preparation, as the enzymatic activity of NexoBrid decreases progressively following mixing

Wound Preparation1

  • Apply an ointment skin protectant (e.g., petrolatum) 2 to 3 cm outside of the treatment area to create an ointment barrier. Avoid applying the protectant ointment to the treatment area itself, as this would impede direct contact of NEXOBRID with the eschar
  • Protect any other open wounds (e.g., laceration, abraded skin, and escharotomy incision) with skin protectant ointments or ointment gauze to prevent possible exposure to NexoBrid

Application of NexoBrid1

  • Apply NexoBrid within 15 minutes of preparation as follows:
    • Moisten the treatment area by sprinkling sterile 0.9% Sodium Chloride Irrigation onto the burn wound
    • Using a sterile tongue depressor, completely cover the moistened burn wound treatment area with the mixed NEXOBRID in a 3 mm thick layer (approximate thickness of a tongue depressor). Ensure NEXOBRID covers the burn wound entire target treatment area
    • Cover the treated wound with a sterile occlusive film dressing
    • Gently press the occlusive film dressing at the area of contact with the ointment barrier
    • Ensure adherence between the occlusive film dressing and the ointment barrier
    • Achieve complete containment of NexoBrid on the treatment area
    • There should be no visible air under the occlusive film dressing
  • Position patient to minimize movement and avoid pressure on the treatment area during treatment time5
    • NexoBrid will liquify as enzymatic process begins
    • Care should be taken to keep gel vehicle in place
    • Monitor throughout application for continuous coverage
  • Cover the occlusive film dressing with a sterile loose, thick, fluffy dressing and secure with a sterile bandage
  • Discard any unused portions of NexoBrid

Monitoring1

  • Monitor patients for signs of local or systemic allergic reactions. If a hypersensitivity reaction occurs, remove NexoBrid (if applicable) from the treatment area and initiate appropriate therapy

  • Remove NexoBrid after 4 hours
  • Gather the following sterile supplies prior to NexoBrid removal:
    • Blunt-edged instruments (e.g., tongue depressor)
    • Large dry gauze
    • Gauze soaked with 0.9% Sodium Chloride Irrigation
    • Dressing soaked with an antibacterial solution
  • Remove the occlusive film dressing using aseptic technique
  • Remove the ointment barrier using a sterile blunt-edged instrument
  • Remove the dissolved eschar from the wound by scraping it away with a sterile blunt-edged instrument
  • Wipe the wound thoroughly with a large sterile dry gauze
    • Then wipe with a sterile gauze that has been soaked with sterile 0.9% Sodium Chloride Irrigation
    • Rub the treated area until the appearance of a clean dermis or subcutaneous tissues with pinpoint bleeding
  • To remove remnants of dissolved eschar, apply a dressing soaked with an antibacterial solution for at least 2 hours

NexoBrid may lead to more precise wound depth determination.2,6

The post-NexoBrid wound bed may reveal a shiny, healthy white dermis with pinpoint bleeding, similar to the appearance of a freshly harvested donor site.7

  • Burns originally deemed as “mixed” or “deep” may be reassessed as only superficial or partial thickness with viable dermal layers capable of re-epithelialization8
    • The distribution of any full thickness defects within the burn may be clearly diagnosed, as well as the other levels of injury with the exposure of underlying structures6,9
  • Selective eschar removal with NexoBrid may reveal a clear view of the extent of the original injury6,9
    • Optimal wound management begins with accurate determination of wound depth10,11
    • After NexoBrid, these assessments can be made according to the vascular patterns and colors which may coincide with relevant structures of the dermis and subcutaneous layer6,9
Before NexoBrid
Wound before NexoBrid

Post Burn Day 2: Wound appearance evaluated as containing a full thickness component by treating surgeon.

After NexoBrid
Wound after NexoBrid

Post Burn Day 3: After eschar removal with NexoBrid, a shiny, white dermis was revealed with superficial, deep dermal and full thickness components.

Images are from a real NexoBrid patient. Individual results may vary.

The Visual Diagnosis Scale6,11–13

After NexoBrid, wound depth may be determined according to vascular patterns and colors. The vascular patterns and colors coincide with relevant structures of the dermis and subcutaneous layers, including the blood vessels and hair follicles throughout various dermis depths.

Wound visual diagnosis

This Visual Diagnosis Scale is being provided for information purposes only. It is not used as part of the standard of care or as a validated scale. It was used to initiate a burn center into the DETECT and NEXT Clinical Trials, as well as for education during wound bed diagnosis after treatment with NexoBrid.

Burn Depth Diagnosis6,11

The post-NexoBrid wound bed is different in appearance from wounds that have been surgically excised. The following clinical examples detail what has been seen after eschar removal with NexoBrid.6,11

Papillary Dermis6,11

Papillary dermis depth
Papillary dermis depth
Papillary dermis depth
Papillary dermis depth
Papillary dermis color scale

Papillary Dermis6,11

A uniform red color (with no visible circles) remains as a result of an abundance of capillaries.

High chance for spontaneous re-epithelialization

Images are from real NexoBrid patients. Individual results may vary.


Papillary-Reticular Interface

Papillary-Reticular dermis depth
Papillary-Reticular dermis depth
Papillary-Reticular dermis depth
Papillary-Reticular dermis depth
Papillary-Reticular Interface color scale

Papillary-Reticular Interface

White layer of the wound bed that is differentiated from burn eschar based on moisture content. Remaining eschar will be dry and not blanch.

Medium chance for spontaneous re-epithelialization

Images are from real NexoBrid patients. Individual results may vary.


Reticular Dermis6,11

Reticular dermis depth
Reticular dermis depth
Reticular dermis depth
Reticular dermis depth
Reticular Dermis color scale

Reticular Dermis6,11

A white color remains due to an abundance of collagen with small-to-medium pinpoint bleeding circles and some potential for translucent and visible fat.

Medium-to-low chance for spontaneous re-epithelialization

Images are from real NexoBrid patients. Individual results may vary.


Subcutaneous Fat6,11

Subcutaneous Fat depth
Subcutaneous Fat depth
Subcutaneous Fat depth
Subcutaneous Fat depth
Subcutaneous Fat color scale

Subcutaneous Fat6,11

Large pinpoint bleeding circles, visible fat, and blood vessels remain.

No chance for spontaneous re-epithelialization

Images are from real NexoBrid patients. Individual results may vary.



  • Soak the wound to remove all remains of NexoBrid and dissolved eschar14
  • After soaking, immediately cover the wound with moist dressings to prevent desiccation14
  • Dress wound(s) sterilely according to burn center protocols

Wound care considerations

Wound care considerations

Deep partial thickness wound

Wound care considerations

Mixed depth wound
(spontaneous healing)

Wound care considerations

Mixed depth wound (autograft)

Wound care considerations

Full thickness wound

Wound care considerations

Clinical Efficacy target icon

Clinical Efficacy

Review the Data 

Nexobrid Safety shield Icon

NexoBrid Safety

Important Safety Information

Indication

NEXOBRID® (anacaulase-bcdb) is indicated for eschar removal in adults and pediatric patients with deep partial thickness (DPT) and/or full thickness (FT) thermal burns.

Limitations of Use

The safety and effectiveness of NEXOBRID have not been established for treatment of:

  • Chemical or electrical burns
  • Burns on the face, perineum, or genitalia
  • Burns on the feet of patients with diabetes mellitus or on the feet of patients with occlusive vascular disease
  • Circumferential burns
  • Burns in patients with significant cardiopulmonary disease, including inhalation injury

NEXOBRID is not recommended for:

  • Wounds contaminated with radioactive and other hazardous substances to avoid unforeseeable reactions with the product and an increased risk of spreading the noxious substance
  • Treatment of burn wounds where medical devices (e.g., implants, pacemakers, shunts) or vital structures (e.g., large vessels) could become exposed during eschar removal

Important Safety Information

Contraindications

NEXOBRID is contraindicated in patients with: known hypersensitivity to anacaulase-bcdb, bromelain, pineapples, or to any other components; known hypersensitivity to papayas or papain because of the risk of cross-sensitivity.

Important Safety Information

Indication

NEXOBRID® (anacaulase-bcdb) is indicated for eschar removal in adults and pediatric patients with deep partial thickness (DPT) and/or full thickness (FT) thermal burns.

Limitations of Use

The safety and effectiveness of NEXOBRID have not been established for treatment of:

  • Chemical or electrical burns
  • Burns on the face, perineum, or genitalia
  • Burns on the feet of patients with diabetes mellitus or on the feet of patients with occlusive vascular disease
  • Circumferential burns
  • Burns in patients with significant cardiopulmonary disease, including inhalation injury

NEXOBRID is not recommended for:

  • Wounds contaminated with radioactive and other hazardous substances to avoid unforeseeable reactions with the product and an increased risk of spreading the noxious substance
  • Treatment of burn wounds where medical devices (e.g., implants, pacemakers, shunts) or vital structures (e.g., large vessels) could become exposed during eschar removal

Important Safety Information

Contraindications

NEXOBRID is contraindicated in patients with: known hypersensitivity to anacaulase-bcdb, bromelain, pineapples, or to any other components; known hypersensitivity to papayas or papain because of the risk of cross-sensitivity.

Warnings and Precautions

Hypersensitivity Reactions

Serious hypersensitivity reactions, including anaphylaxis, have been reported with postmarketing use of anacaulase-bcdb. If a hypersensitivity reaction occurs, remove NEXOBRID (if applicable) and initiate appropriate therapy.

Healthcare personnel should take appropriate precautions to avoid exposure when preparing and handling NEXOBRID (e.g., gloves, surgical masks, other protective coverings, as needed).

Coagulopathy

Avoid use of NEXOBRID in patients with uncontrolled disorders of coagulation. Use with caution in patients on anticoagulant therapy or other drugs affecting coagulation, and in patients with low platelet counts and increased risk of bleeding from other causes. Monitor patients for possible signs of coagulation abnormalities and signs of bleeding.

Adverse Reactions

The most common adverse reactions (>5%) in adults were pruritus, pyrexia, wound complication, anemia, vomiting and insomnia. The most common adverse reactions (>5%) in pediatric patients were pruritus, pyrexia and vomiting.

Use in Special Populations
Geriatric Use

Clinical studies of NEXOBRID did not include sufficient numbers of subjects 65 years of age and older to determine whether they respond differently from younger adult subjects.

To report negative side effects contact Vericel Corporation at 888-454-BURN (888-454-2876) or FDA at 1-800-FDA-1088 (1-800-332-1088) or www.fda.gov/medwatch.

Please see Full Prescribing Information.

References: 1. NexoBrid Prescribing Information. Cambridge, MA. Vericel Corporation; 2024. 2. Krieger Y, Bogdanov-Berezovsky A, Gurfinkel R, et al. Efficacy of enzymatic debridement of deeply burned hands. Burns. 2012;38:108-112. 3. Singer AJ, Taira BR, Anderson R, et al. The effects of rapid enzymatic debridement of deep partial-thickness burns with Debrase on wound repithelialization in swine. J Burn Care Res. 2010;31(5):795-802. doi: 10.1097/BCR.0b013e3181eed48e 4. Hirche C, Almeland SK, Dheansa B, et al. Eschar removal by bromelain based enzymatic debridement (NexoBrid®) in burns: European consensus guidelines update. Burns. 2020; https://doi.org/10.1016/j.burns.2020.03.002 5. Rosenberg L, Krieger Y, Bogdanov-Berezovski A, et al. A novel rapid and selective enzymatic debridement agent for burn wound management: A multi-center RCT. Burns. 2014;40:466-474. 6. Palao R, Aguilera-Saez J, Collado JM, et al. Use of a selective enzymatic debridement agent (Nexobrid) for wound management: Learning curve. World J Dermatol. 2017;2;6(2):32-41. 7. Rosenberg L, Lapid O, Bogdanov-Berezovsky A, et al. Safety and efficacy of a proteolytic enzyme for enzymatic burn debridement: a preliminary report. Burns. 2004;30:843-850. 8. Schulz A, Perbix W, Shoham Y, et al. Our initial learning curve in the enzymatic debridement of severely burned hands-management and pit falls of the initial treatments and our development of a post debridement wound treatment algorithm. Burns. 2017;42:326-336. 9. Korzeniowski T, Struzyna J, Torres K. Evaluation of bromelain-based enzymatic debridement combined with laser doppler imaging and healing of burn wounds. Med Sci Monit. 2022;28:e936713. 10. Singer A, Boyce S. Burn wound healing and tissue engineering. J Burn Care Res. 2017;38(3):e605-e613. doi:10.1097/BCR.0000000000000538 11. Claes KEY, De Decker I, Monstrey S, et al. Helpful hints in deciding what and when to operate after enzymatic debridement. Burns. 2023;49(1):80-90. 12. Hamm RL, eds. Text and Atlas of Wound Diagnosis and Treatment, 2e. Figure 9-6. McGraw Hill; 2019. Accessed April 10, 2023. https://accessmedicine.mhmedical.com/content.aspx?bookid=2594&sectionid=21675325713. Zenn, M, Jones, G. Reconstructive Surgery: Anatomy, Technique, and Clinical Applications. Figure 15.1. Thieme; 2012. Accessed September 26, 2021. https://www.perlego.com/book/916981/reconstructive-surgery-pdf. 14. Hirche C, Citterio A, Hoeksema H, et al. Eschar removal by bromelain based enzymatic debridement (NexoBrid®) in burns: an European consensus. Burns. 2017;43(8):1640-1653. 15. Monstrey S, Shoham Y, Krieger Y, et al. Healing of the wound bed after selective enzymatic debridement. Presented at: 48th Annual ABA Meeting; May 2016; Las Vegas, NV. Abstract #433.