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VNAA - Visiting Nurse Associations of America
VNAA The Voice of Home Healthcare
Past Topics
Growth Factors: Role and Function in Chronic Wound Care
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This Month Debridement
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Wound Healing and Cellular Communication
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Proteases and the Chronic Wound
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Bacterial Loads - Contamination, Colonization & Infection
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Friend or Foe? The Role of Inflammation in Wound Healing
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Perfusion - the Lifeline for Wound Healing
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Challenges with OASIS and Wound Assessment
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Assessment and Documentation Issues in Wound Care
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The Environment of the Patient and The Healing Process
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Examining the Environments of Wound Healing


Debridement



Debridement is the intentional removal of necrotic tissue, cellular debris or foreign material from a wound bed. It is indicated to promote healing, manage infection, and control odor. Debridement promotes migration of the neutrophils, macrophages and epithelium, encouraging healing. Debridement may be a one-time procedure or an on-going treatment, utilizing one or more of four methods. Methods of debridement vary, based on the wound type, pain level, situational urgency, and other issues.

Prior to debridement, determine wound etiology. Consider debridement for wound emergencies, such as rapidly spreading cellulitis or necrotizing faciitis. In chronic wounds evaluate for the need for debridement when necrosis impedes wound closure and adequate healing potential exists.

To improve healing potential, address many factors: off-load pressure wounds, contain incontinence, manage edema with venous insufficiency, optimize protein intake, promote blood glucose control, and manage bacterial load and moisture balance. Culture wounds that have the clinical appearance of infection: non-progression, change in granulation color or quality, increasing drainage or pain, as well as the classic signs of infection. Implement antimicrobial topical therapy when indicated. Manage moisture levels to promote healing without over hydration or desiccation of tissue.

Finally, determine arterial perfusion, which is a prerequisite for healing. Some tests to determine flow are pulsed volume recording (PVR), Doppler studies, duplex imaging, and arteriogram. In the home or clinic, consider using local tissue perfusion study (TcP02), ankle-brachial index (ABI), or toe-brachial index (TBI). One rule of thumb holds that hair growth on toes indicates minimally adequate arterial flow. Clinical assessment of skin quality, hair growth, color and other assessment factors is essential.

Contraindications

Debridement is contraindicated for untreated bleeding disorders, arterial insuffiency or when underlying conditions have not been managed. For example, without first treating the disease, pyoderma gangrenosum wounds actually enlarge with debridement. . Most practitioners do not debride heel wounds covered with intact eschar, particularly in the presence of poor perfusion. They let the wound slowly debride itself by autolysis. However, if the eschar softens or loosens, it should be evaluated.

Four types of debridement are used: surgical or sharp, mechanical, autolytic and enzymatic.

Surgical and Sharp Debridement

Surgical debridement is indicated for large, deep tissue damage, painful wounds, and urgent situations, utilizing scalpels, scissors, forceps, pickups and other instruments. Sharp debridement is usually a minor bedside procedure, with limited removal of nonviable tissue. Although both methods are selective and speedy, surgical and sharp debridement can be painful and require some form of pain control or anesthesia. Only those thoroughly trained, with an extensive understanding of the underlying anatomical structures, should undertake surgical or sharp debridement. Surgical debridement is usually prescribed together with one or more the other methods.

Mechanical Debridement

Mechanical debridement is indicated for wounds with adherent necrosis. Methods include whirlpool, pulsed lavage, use of syringe and catheter, or wet to dry dressings to remove devitalized tissue by force.

Pulsed lavage systems use a spray gun and piston to irrigate a wound. A 19 g catheter combined with a 30 cc syringe to irrigate can also be used. These methods work particularly well with deep, tunneling wounds. Both work with a fair amount of selectivity, hydrating and loosening nonviable tissue.

Finally, the wet-to-dry method uses moist dressings that are placed upon an open wound, allowed to dry, and then forcibly removed. This is painful and removes tissue in a nonselective manner. Wet-to-dry dressings should usually be avoided.

Autolytic Debridement

Autolytic debridement is indicated for the gradual softening and liquefying of necrotic tissue. Consider autolysis if a client cannot tolerate a more aggressive treatment, when speed is not essential, and when the wound is non-infected. Moisture retentive dressings bathe tissues in wound fluid to encourage phagocytic activity and local proteolytic enzymes. Transparent films, hydrocolloids, gel sheets, and amorphous gel preparations are commonly used. This method is gentle but may be slow. Sharp debridement can speed this method by removing stringy or loose tissue. Prevent over hydration of the wound and wound margins. Be very cautious when infection is present or threatened.

Enzymatic Debridement

Enzymatic debriding agents are indicated for necrotic wounds and burns. Consider this method for a slightly faster outcome than with autolytic debridement, for persons who cannot tolerate a more aggressive procedure, or when peri-wound skin will not tolerate an occlusive, adhesive dressing. Collagenase and papain-urea products are the most commonly available enzymes. Collagenase degrades wound bed collagen without affecting viable tissue. Papain-urea ointments break down protein more rapidly than Collagenase.

Crosshatch eschar prior to application of any enzymatic preparation. Be cautious in the presence of an infected wound. Refer to the package insert on each product for specific recommendations.

Biodebridement

Sterile fly maggots have also been used to debride wounds. They digest necrotic material without damaging healthy tissue. This method has not proved to be a popular usage in the medical community.

In conclusion, before proceeding with debridement, ensure a clinician has:

  1. reviewed debridement indications and contraindications
  2. determined wound etiology and treated or minimized the underlying condition
  3. assessed healing potential
  4. determined adequacy of arterial flow
  5. selected appropriate method(s)

Debridement is an important component of wound bed preparation, used to promote healing, restart the healing cascade, reduce infection, and manage odor. Four methods are used; surgical or sharp, mechanical, autolytic and enzymatic. Mechanical, autolytic and enzymatic methods are not a replacement for surgical or sharp debridement. These methods are not mutually exclusive, but are frequently used together. While necrotic tissue delays healing, not all necrotic wounds should be debrided. Trained clinicians can determine when and if debridement is necessary. Address causative factors and underlying issues prior to debridement. Debride necrotic tissue from wounds that exhibit good healing potential. For non-healable wounds, remove only nonviable tissue, avoid bleeding tissue, and avoid injury to underlying structures. Only those trained in wound care should determine if debridement is indicated. If debridement is advised, use the least invasive, most gentle method that can accomplish the task, with due consideration given to speed and efficacy.

This article was written by Ruth Tamulonis, RN MSN CWOCN


References

The Wound & Skin Care Center is possible thanks to the generous support of Johnson and Johnson Wound Management Worldwide.




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