Debridement

Wound debridement is the mainstay treatment to create a healing wound matrix. Debridement is the process  whereby  nonviable  tissue is removed via various methods to allow for the ingrowth of healthy viable tissue, a key part in the process of wound bed preparation.


Surgical Debridement is pictured above (performed by Skilled Wound Care Practitioners). Copyright Skilled Wound Care.

DEBRIDEMENT INDICATIONS:

  • Presence of Devitalized Tissue.
  • Slough or Necrosis
  • Unhealthy Granulation tissue.
  • Presence of  Bioburden, which is defined as the build up of  a bacterial film layer on the surface of the wound.
  • Pressure Ulcers/Injuries with devitalized tissue.
  • Diabetic Ulcers with devitalized tissue or infection.
  • Venous Ulcers with devitalized tissue.
  • Arterial Ulcers with devitalized tissue that is broken down.
  • Burn wounds.
  • Infected traumatic wounds.
  • Non-healing wounds.

CONTRAINDICATIONS:

  • Granulating Wounds
  • Dry stable eschars in the lower extremity
  • Deep Tissue Injuries with intact skin
  • Lower extremity blisters
  • Eschars over healing wounds.

Debridement can mean anyone of the following:
  • Autolytic  Debridement: All  wounds  undergo  the  process of autolysis. In healthy individuals, this process is short and occurs during the inflammatory phase. In chronic wounds, we use dressings to facilitate enzymes and moisture to re-hydrate, soften and finally liquefy hard eschar and slough. Autolytic debridement can be achieved with hydrocolloids, hydrogels and transparent films.
  • Biologic Debridement: Although rarely used, sterile maggots can be placed on a wound, as they eat away dead tissue.
  • Enzymatic Debridement: Currently there is only a single enzymatic debriding agent on the market, which is collagenase. These agents enzymatically cleave or destroy the dead tissue from the healthy tissue.
  • Mechanical Debridement: Wet to Dry Dressings, are the most common technique, which has been used for decades in wound care. Allowing a dressing to proceed from wet to dry, then manually removing the dressing causes a form of non-selective debridement. Unfortunately healthy tissue can be traumatized via this method.
  • Selective Sharp Debridement: Rtemoval of necrotic tissue only, sparing all healthy tissue. In this method, the practitioner only removes dead, devitalized, hanging tissue, but does not probe or cut into tissue to reach bleeding tissue.
  • Non-selective Debridement: Debridement  is  nonselective when the method doesn’t discriminate between removing devitalized tissue and healthy tissue. Surgical debridement and mechanical debridement are the two most well known methods of nonselective debridement.
  • Surgical Debridement: Is a type of non-selective debridement where an experienced practitioner or surgeon excise devitalized tissue to the base of bleeding tissue as well as the perimeter of the wound.

 

Surgical Debridement ADVANTAGES

  1. Rapid removal of necrotic tissue, yellow slough can be performed. Necrosis and slough impede wound healing.
  2. Debridement can also be used to remove bacteria from the surface of the wound, known as bacterial bioburden.
  3. The edges of  a chronic wound should be debrided to remove nonfunctional fibroblasts, and to make way for healthy cells.
  4. Debridement   is   used   to   remove   infection   by   removing contaminated tissue.
  5. The entirety of the nonhealing wound edge must be removed.
  6. In studies comparing debridement versus nondebridement, 16% of debrided ulcers heal in 20 weeks versus 4.3% for controls.

Wet to dry dressings are no longer recommended because of the following:

  1. Painful for the patient,
  2. May remove healthy granulation tissue,
  3. May damage healthy granulation tissue,
  4. Causes unnecessary bleeding,
  5. May cause the wound to dry out removing the moist wound environment.

DEBRIDEMENT RECOMMENDATIONS:

Diabetic Foot Ulcer

A clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine recommends sharp débridement of all devitalized tissue and surrounding callus material from diabetic foot ulcerations at 1- to 4-week intervals.

VENOUS FOOT ULCER

The Society for Vascular Surgery® and the American Venous Forum recommend that venous leg ulcers receive thorough débridement at their initial evaluation to remove obvious necrotic tissue, excessive bacterial burden, and cellular burden of dead and senescent cells.  The panel also suggest that additional maintenance débridement be performed to maintain the appearance and readiness of the wound bed for healing.

PRESSURE INJURY/ULCER

The National Pressure Ulcer Advisory Panel European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance recommend practitioners debride devitalized tissue within the wound bed or edge of pressure injury when appropriate to the individual’s condition and consistent with overall goals of care.  They also recommend debridement of the wound bed when the presence of biofilm is suspected or confirmed.

References

  1. Anvar, B. Mastery of Skin, Wound and Ostomy Care 2nd Edition. 2017 Published by Skilled Wound Care.
  2. Wolcott RD, et al. Regular debridement is the main tool for maintaining a healthy wound bed in most chronic wounds. J Wound Care 2009 Deb; 18 (2):54-6
  3. Steed DL, Donohoe D,Webster MW, et al: Effect of extensive debridement and treatment on the healing of diabetic foot ulcers. Diabetic Ulcer Study Group. J Am Coll Surg 1996; 183(1):61-4.
  4. Brem et al. Molecular Markers in Patients with Chronic Wounds to Guide Surgical Debridement. Molecular Medicine 13(1-2)30-39, January-February 2007.
  5. Ayello et al, Debridemment: Controlling the Necrotic/ Cellular Burden. Advances in Skin & Wound Care: March 2004 - Volume 17 - Issue 2 - pp 66-75
  6. Anil Hingorani, MD et al. The management of diabetic foot: A clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine. Journal of Vascular Surgery February 2016 Volume 63, Issue 2, Supplement, Pages 3S–21S.
  7. O’Donnell Jr. et al, Management of venous leg ulcers: Clinical practice guidelines of the Society for Vascular Surgery® and the American Venous Forum. Journal of Vascular Surgery August 2014 Volume 60, Issue 2, Supplement, Pages 3S–59S.
  8. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Australia; 2014.

 

Page Content Curated by Dr. Bardia Anvar M.D.