SLR - July 2023 - Nicole Lagstein, DPM
Title: Use of Fish Skin Graft in Management of Combat Injuries Following Military Drone Assaults in Field-Like Hospital ConditionsReference: Fouad Reda, MD, Hilmar Kjartansson, MD, FACEM, Steven L A Jeffery, MD, RAMC (V), Use of Fish Skin Graft in Management of Combat Injuries Following Military Drone Assaults in Field-Like Hospital Conditions, Military Medicine, 2023;, usad028, https://doi.org/10.1093/milmed/usad028
Reviewed By: Nicole Lagstein, DPM
Residency Program: SAVAHCS, AZ
Podiatric Relevance: The 2020 Nagorno-Karabakh War was an armed conflict between Azerbaijan and Armenia over an ethnically and historically significant region. This is a report on the forward deployment of acellular fish skin graft (FSG) from Kerecis™, a biologic, acellular matrix derived from the skin of wild-caught Atlantic cod that contains intact epidermis and dermis layers. The goal of treatment under adverse circumstances is to temporize wounds until better treatment can be attained, when rapid treatment is necessary to prevent loss of life or limb. The harsh environment of war presents logistical barriers for the treatment of wounded soldiers. This war was well known for the use of drones for targeted airstrikes, long range weapons, and the use of white phosphorus, which can cause fatal chemical burns.
Methods: The manuscript is a report on the forward deployment of acellular FSG from Kerecis™ (Kerecis Omega3, Kerecis, Isafjordur, Iceland), a biologic, acellular matrix derived from the skin of wild-caught Atlantic cod that contains intact epidermis and dermis layers. The matrix retains natural Omega3 fatty acids, has a 3-year shelf life, and is reconstituted using only saline. FSG comes in the form of a thick sheet which is easy to handle and requires minimal training. Its thickness protects the graft against environmental irritants, reducing infection risk in much the same way as dressings. Furthermore, FSG possesses intact Omega3 fatty acids which have demonstrated bacteriostatic and anti-inflammatory properties. The product is simple to use and adapts to irregular surfaces. The sheets are premeshed and up to 300 cm2 in size. After hydration, it can stretch to cover up to 540 cm2. Dressings were changed 3-5 days after surgery
Results: Several patients were managed with fish skin. Injuries included large-area full-thickness burn and blast injuries. The majority of the wounds were 3- to 5-days old and had undergone one initial debridement and simple wet-to-dry dressings before the first application of FSG. When necessary, the wounds received further debridement. FSG was applied followed by NPWT, and follow-up was performed 7 days later. At follow-up, it was assessed whether the patient was ready for skin grafting. Management with FSG induced wound granulation several days sooner in all cases and even weeks in some instances. This permitted earlier skin grafting procedures and reduced the number of flap surgery. No infections were reported in any of the cases where FSG was used.
Conclusions: This manuscript describes the successful use of FSGs under harsh circumstances. Under military conditions, FSG, has shown easy portability and use. Fish skin has shown faster granulation rates in burn wounds for skin grafting, which have improved patient outcomes with no documented infections. Utilizing fish skin in military medical facilities, such as field hospitals, should be further explored in controlled environments, where further analysis can be performed and secondary outcomes can be evaluated.