wound debridement

1. WOUND DEBRIDEMENT
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2. Debridement
• Debridement is the removal of necrotic tissue, exudate, bacteria, and
metabolic waste from a wound in order to improve or facilitate the
healing process. Accumulation of necrotic tissue usually results from
poor blood supply, a prolonged inflammatory process, bacterial damage,
or an untreated cause of the wound (for example, increased interstitial
pressure, or other mechanical, chemical, or traumatic injury).
• In otherwise healthy people, natural debridement takes place with the
accumulation of dying tissue in a wound. If the host resistance is
impaired by poor nutrition, continued pressure damage, or other
comorbidities such as diabetes, medical intervention is required to
facilitate wound healing
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3. PURPOSE OF DEBRIDEMENT
• The primary purpose of debridement is to reduce or
remove dead and necrotic tissue that serves as a pro
inflammatory stimulus and a culture medium for
bacterial growth. The removal of this tissue is necessary
to reduce the biological burden of the wound in order
to control and prevent wound infection, especially in
deteriorating wounds
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4. Identifying necrotic tissue
• Dead or necrotic tissue may be loose and moist, or dry and firm.
This tissue is identified by its moist, yellow, green, or gray
appearance, and may become thick and leathery with a dry
black eschar due to dehydration. Oxygen and nutrients can't
penetrate a wound impaired by necrotic tissue. Dead tissue is the
breeding ground for bacteria, and the eschar may mask an
underlying abscess.
• Necrotic tissue that's moist, stringy, and yellow is referred to as
slough
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5. PRE DEBRIDEMENT TEACHING
• Patient-centered care should include teaching about the purpose
and usual expectations of the debriding process. This process
needs to be explained and understood by the patient and family
prior to initiating treatment. Include in your teaching the
debridement method that will be used and the desired outcome.
• It is vital that the patient and family understand why the necrotic
tissue is being removed. Some laypersons mistakenly believe
that necrotic tissue is a “scab” (eschar) and is a sign of healing.
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6. New wound bed preparation (DIME)
model
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7. Debridement methods
a. Mechanical,
b. sharp/surgical,
c. enzymatic,
d. autolytic are the common methods of debridement
a. 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 health care provider should consider pre medicating
the patient for pain. Both whirlpool and pulsed lavage require special
equipment and skill.
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8. • All of the mechanical methods are nonselective; that is,
they don't always discriminate between viable ( capable
for growth ) and nonviable tissue.
• 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.
(i) Wet-to-dry dressings
• Despite the drawbacks, such as pain and the necessary
application of up to 3 times per day, the use of wet-to-dry
dressings to debride a wound unfortunately remains a
common treatment in all health care settings. This
method involves placing a moist saline gauze dressing on
the wound surface and removing it when it's dry
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9. • A wet-to-dry dressing can be used when a moderate to large amount
of necrotic tissue is present and surgical intervention is not an
immediate option
• Indications
• Wet/moist necrotic tissue (slough) >50% of wound bed
• Contraindications
• Dry eschar
• Necrotic tissue <50% of wound bed
• Pain
• Excessive bleeding
• Use wet-to-dry cautiously because it can traumatize new granulation
tissue and epithelial tissue
• Administer adequate analgesia when method is employed
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10. ii - Hydrotherapy
• Hydrotherapy (or whirlpool) debridement may be indicated for
patients with large wounds that need aggressive cleaning or
softening of necrotic tissue. It is contraindicated in granulating
wounds because it can injure the wound bed. Hydrotherapy
should be discontinued after necrotic tissue has been removed
from the wound bed.
• Hydrotherapy is performed by putting the patient's wound in a
whirlpool bath and letting the swirling waters soften and loosen
dead tissue. This procedure is usually performed in the physical
therapy department, with an average treatment duration of 10 to
20 minutes up to twice per day
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11. (iii) Pulsed lavage
• Pulsed lavage debridement is often indicated for patients with
large amounts of necrotic tissue and for those whom other
debridement methods are not an option.
• It is accomplished by using specialized equipment that combines
a pulsating irrigation fluid with suction
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12. b. Sharp/surgical debridement
• Sharp/surgical debridement includes the use of a scalpel, forceps,
scissors, hydrosurgery devices, or lasers to remove dead tissue.
• Sharp debridement is considered the ‘gold standard’ of
debridement by many clinicians.
• It can cause pain so a topical anesthetic, such as lidocaine cream or
gels, may be required.Patients may also need follow-up
appointments for serial debridement.
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13. • Indications
• Extensive devitalized tissue
• Advancing cellulitis
• Sepsis
• May be an adjunct to other debridement methods
• Callus
• Contraindications
• Arterial insufficiency until adequate circulation has been determined
• Dark hole - tunnel/sinus tract
• Unsure of tissue
• Unsure of your skill
• Excessive bleeding (or patient taking Coumadin, Heparin, or high doses of
aspirin)
• Pain
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14. c. Enzymatic debridement
• Enzymatic debridement is considered safe, effective, and easy to
use. 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.
• Enzymatic agents are an ideal option for patients who are not
candidates for surgery, and for patients receiving care in a long-
term care facility or at home where other debridement methods
may not be available.
• Enzymatic debridement is accomplished by applying topical
enzymatic agents to devitalized tissue
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15. • If infection has spread beyond the ulcer (as in advancing
cellulitis), immediate removal of necrotic tissue is usually
recommended. Surgical debridement and then non enzymatic
debridement should be considered
• Enzymes that act on necrotic tissue are categorized as
proteolytics, fibrinolytics, and collagenases, depending
on the tissue component they target. Because papain urea
enzymatic debriding agents target eschar, they are often used on
wounds with necrosis.
• Collagenases target nonviable collagen tissue while sparing
viable tissue thereby making them useful in necrotic wounds with
slough tissue at the wound base
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16. • Indications
• Necrotic tissue
• Infected wounds
• Contraindications
• Granulation tissue
• Eschar
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17. d. Autolytic debridement
• Autolytic debridement 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.
• Autolytic debridement can be facilitated with
appropriate dressings in the superficial wound that
contains little necrotic tissue, or a larger, deeper
pressure ulcer
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18. • Autolytic debridement is easy to perform and involves
applying a moisture-retentive topical dressing, such as
a semiocclusive or occlusive dressings; types include
transparent films, hydrocolloids, hydrogels, and calcium
alginate dressings.
• Wound fluid accumulates under the dressing, aiding in
the lysis of necrotic tissue. This method is pain-free in
patients with adequate tissue perfusion
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19. • Indications
• Non-infected wounds with minimal to moderate amount of
necrotic tissue
• Should see effective clinical outcomes within 3-4 days after
treatment is initiated (complete debridement will take a lot
longer
• Contraindications
• Infected wounds
• Cellulitis
• Dry gangrene
• Dry ischemic wounds that do not have blood supply to properly
heal
• Immunocompromised patient
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20. • Maggot therapy (biological or larval therapy)
• Maggot therapy was widely used in the early part of the 20th
century.
• In this type of debridement, several applications of sterilized
medicinal Lucilia sericata (greenbottle fly) maggots are placed in
the wound bed every 2 to 3 days. The specific application
technique for how the maggots are actually put in the wound
varies.
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21. How much debridement is enough?
• Saap and Falanga developed a method to assess adequacy of
wound debridement. Their Debridement Performance Index may
make more effective comparisons between different
debridement methods and facilitate more predictive prognostic
information.
• Falanga has proposed that chronic wounds need constant
debridement because maintenance debridement is an
important part of the wound-bed preparation in these wounds.
In the past, debridement was regarded as a singular event based
on the visible assessment of the wound.
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