Wound Debridement

Debridement is an important component of the wound bed preparation (WBP) management Model.

Cause of the wound and patient-centered concerns, debridement is a necessary step in local wound care.

Debridement is the removal of necrotic tissue, exudate, bacteria, and metabolic waste from a wound in order to improve or facilitate the healing process

1. Wound Debridement

2. state the purpose of debriding a wound • list criteria for not debriding a necrotic wound describe types of debridement, including sharp/surgical, mechanical, maggot, enzymatic, and autolytic compare the advantages and disadvantages of type of debridement expertise , and healthcare system resources. 2 Lecture objectives

3. Debridement is an important component of the wound bed preparation (WBP) management Model. Cause of the wound and patient-centered concerns, debridement is a necessary step in local wound care. Debridement is the removal of necrotic tissue , exudate, bacteria, and metabolic waste from a wound in order to improve or facilitate the healing process 3 SPEEDING THE HEALING PROCESS

4. Accumulation of necrotic tissue usually results from poor blood supply, a prolonged inflammatory process, bacterial damage , or an untreated cause of the wound If host resistance is impaired by poor nutrition, continued pressure damage, or other comorbidities is required to facilitate wound healing 4

5. The removal of dead and necrotic tissue is necessary to reduce the biological burden of the wound to control and prevent wound infection Necrotic tissue (can’t removed) impedes wound healing, result in spread of bacterial damage to deeper tissue, causing cellulitis, osteomyelitis, septicemia, limb amputation, or death 5

6. By removing necrotic tissue , debridement creates an acute wound within a chronic wound, restoring circulation and allowing adequate oxygen delivery to the wound site . Leukocytes are the primary cells of the inflammatory process of wound healing . They enter the wound and remove devitalized tissue and foreign material. 6

7. Collaboration of local enzymes ( proteolytic , fibrinolytic , or collagenolytic ) also helps to dissolve and remove devitalized tissue Remodeling is part of the healing process in which the wound restructures into its final functional image . An acute wound with a good blood supply and essential nutrients generally “heals” within 14 days 7

8. Remodeling , or maturation, takes another 4 weeks, making the total healing process about 6 weeks . Collagen breakdown and collagen buildup occur in equal degrees Excess collagen can form a keloid or hypertrophic scar . 8

9. Dead or necrotic tissue may be loose and moist, or dry and firm . Oxygen and nutrients can’t penetrate a wound that is impaired by necrotic tissue . Dead tissue is the breeding ground for bacteria, and the eschar may mask an underlying abscess 9 Identifying Necrotic Tissue

10. Necrotic tissue that is soft, moist, stringy, and yellow is referred to as slough (devitalized/avascular) tissue). It may be white, yellow, tan, or green and may be loose or firmly adherent Removing necrotic tissue restores the local vascular supply to the wound and improves healing .Caution is indicated, all necrotic heels should be debrided. 10

11. Pyoderma gangrenosum is one example of a wound that should not be debrided Septicemia is another condition that requires serious caution before initiating debridement. Chronic wound care begins with treating the cause and patient-centered concerns, including pain and activities of daily living. 11

12. Assess individual patients to determine whether the wound is healable, maintenance, or non-healable. To assess healability , an adequate blood supply is needed Palpable pulses in the foot indicate a pressure in excess of 80 mm Hg and enough blood supply for healing to occur. 12

13. A maintenance wound is one that has a sufficient blood supply unable to heal due to patient or health delivery system factors . Debridement and local wound care should then be conservative for maintenance wounds . A non-healable or palliative wound does not have enough blood supply to heal; therefore, debridement should be conservative and limited to soft slough with a local antimicrobial 13

14. Wound bed preparation (WBP) is the management of a wound to accelerate endogenous healing or to facilitate the effectiveness of other therapeutic measures Use the DIME acronym in preparing the wound bed for healing. • D ebridement • I nfection or inflammation • M oisture imbalance • E dge-non-healing 14

15. Patient-centered care should include teaching about the purpose and usual expectations of the debriding process . It is vital that the patient and family understand why the necrotic tissue is being removed . Epithelium needs a firm granulation base to migrate optimally toward the center of a wound. 15 Predebridement Teaching

16. Mechanical Sharp/surgical Enzymatic Autolytic 16 Debridement Methods

17. Mechanical debridement Methods of mechanical debridement include wet-to-dry dressings, hydrotherapy (whirlpool ), and wound irrigation (pulsed lavage ). Mechanical debridement may be more painful than other debridement methods, and the healthcare provider should consider pre-medicating the patient for pain. 17

18. All of the mechanical methods are considered nonselective debridement . Mechanical methods may be harmful to healthy granulation tissue on the surface of the wound and lead to bleeding, trauma , and disruption of the collagen matrix along with the necrotic tissue. 18

19. Sharp/surgical debridement I ncludes the use of a scalpel, forceps, scissors, or lasers to remove dead tissue . Sharp debridement is considered by many clinician’s as gold standard , may cause pain Viable tissue may also be removed inadvertently with this method. 19

20. Clinicians need guidance in discerning the line of demarcation between viable and nonviable keratinocytes at the wound edge. The use of sharp debridement is based on expert opinion and clinical data . The removal of loose bright friable granulation tissue from the surface of an ulcer removes fibroblasts ,bacteria leading to damage the underlying tissue. 20

21. Surgical debridement is used for adherent eschar and devitalized or dead slough on the wound surface. This method can be used in infected wounds and should be the first choice for wounds demonstrating signs of advancing cellulitis or sepsis . Surgical/ sharp debridement must be performed with extreme caution in patients taking anticoagulant medications 21

22. Enzymatic debridement This is considered safe, effective , and easy to perform . Enzymes are effective wound surface cleaning agents that accelerate eschar degradation and debridement . The removal of debris helps a chronic wound move from the inflammatory stage to the proliferative stage , resulting in enhanced wound healing. 22

23. Enzymatic debridement is accomplished by applying topical enzymatic agents to devitalized tissue . If infection has spread beyond the ulcer, immediate removal of necrotic tissue is recommended. Enzymes often can be used alone, to break down the eschar before sharp debridement, or in conjunction with mechanical debridement 23

24. Enzymes that act on necrotic tissue are categorized as proteolytics , fibrinolytics , and collagenases , depending on the tissue component they target . Before reapplying any enzymatic agent, clean the wound with normal saline or a wound cleanser to remove any residual enzymatic ointment and loose wound debris. 24

25. Crosshatching without cutting deep enough to cause bleeding , is recommended prior to applying the enzyme to let the debriding agent penetrate into the eschar Apply a thin layer of enzymatic ointment onto the necrotic tissue, cover the wound with an appropriate dressing to keep it moist and let the debriding agent work. 25

26. Muller and colleagues found debridement with collagenase to be quicker and more cost-effective than autolytic debridement with a hydrocolloid dressing in pressure ulcers . Collagenase to reduce scarring in partial-thickness burn wounds 26

27. Autolytic debridement It uses the body’s endogenous enzymes to slowly remove necrotic tissue from the wound bed. In a moist wound, phagocytic cells and proteolytic enzymatic enzymes can soften and liquefy the necrotic tissue that is then digested by macrophages . 27

28. Autolytic debridement may take longer than other methods; it represents a less stressful method to the patient and wound than mechanical debridement. This method of debridement is contraindicated in infected wounds. Wound fluid accumulates under the dressing, aiding in the lysis of necrotic tissue. This method is pain-free in patients with adequate tissue perfusion. 28

29. Maggot therapy (biological or Larval therapy ) In this type of debridement, several applications of sterilized medicinal maggots are placed in the wound bed or directly into the wound so they can roam around Maggot therapy is believed to be by the enzymes the maggots secrete (proteinases - degrade the necrotic tissue)digest bacteria. 29

30. Contraindications life- or limb-threatening wound, psychological distress or the “ick factor,” bleeding abnormalities, and deep-tracking wounds ,osteomyelitis or critical ischemia associated with arterial insufficiency, Level of pain must be considered with maggot therapy. 30

31. “No one method of debridement has been proven optimal for pressure ulcers,” How Much Time Do You Have To Debride? What Are The Wound Characteristics? How Selective A Method Is Needed? What Methods Are Permitted? What’s The Care Setting? How Much Debridement Is Enough? 31 Choosing A Debridement Method

32. Wound care essentials, practice principles by Sharon Baranoski and Elizabeth A.Ayello : third edition 32 References

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