Sequential Bromelain-Based Enzymatic Debridement in a Near-Total (97%) TBSA Burn: A Case Report

Introduction: Early debridement of burn eschar is a cornerstone of care for patients with extensive burns, yet early large-area surgical excision may be limited by blood loss, physiological instability, and substantial logistical demands. Evidence on bromelain-based enzymatic debridement involving treatment areas greater than 15% total body surface area (TBSA) remains scarce. Case Report: A 38-year-old man sustained partial- and full-thickness burns involving 97% TBSA, together with inhalation injury. Sequential enzymatic debridement with NexoBrid was performed at the bedside in five 4-h sessions under intensive care conditions, with 14-27% TBSA treated per session. Complete eschar removal was achieved within 64 h of admission without transfer to the operating room, major procedure-related bleeding, or transfusion during the debridement period. The subsequent course was complicated by sepsis and severe respiratory failure requiring veno-venous extracorporeal membrane oxygenation. Following intensive care treatment, the patient stabilized markedly, ECMO support was discontinued, and near-complete wound coverage was achieved. He died on hospital day 87 following acute intrapulmonary and endotracheal hemorrhage of unclear etiology. Conclusions: This case illustrates the technical feasibility of early, sequential bedside enzymatic debridement in a near-total burn and may inform its carefully selected off-label use in highly specialized burn centers.