Part 4: Debridement and the Role of EnzymesWound Bed PreparationIt’s About TIMEAn important aspect of the TIME principle is the need to address non-viable or deficient tissue and restore the wound base and extracellu-lar matrix proteins. In acute wounds, wound debridement is an effec-tive way to remove necrotic tissues and bacteria so the wound canheal with relative ease. This is not the case for chronic wounds,where much more than debridement needs to be addressed for opti-mal results. Chronic wounds, such as venous ulcers, have a “necroticburden” consisting of both necrotic tissue and exudate — as such,these wounds can be intensely inflammatory. They produce substan-tial amounts of exudate that interfere with healing and the effective-ness of therapeutic products such as growth factors and bioengi-neered skin. Therefore, in the context of wound bed preparation, clini-cians need to remove not only eschar and frankly nonviable tissue,but also wound exudate.Management of nonviable tissue (necrotic burden barrier) throughdebridement is one key aspect of the TIME principles though whichwe remove the barriers to closure and provide an optimal woundenvironment. Expert opinion advocates the removal of nonviable tis-sue as essential to promoting healing and reducing the risk of localinfection, provided adequate blood supply to the wound is present.This is part 4 of a 12-part series of articles on Wound Bed Preparationand TIME.83 General Warren Boulevard, Suite 100 This publication is provided by Smith & Nephew, Inc., as aMalvern, PA 19355 continuous professional service. For additional reprints or informationPhone (800) 237-7285 FAX (610) 560-0502 on Smith & Nephew products, contact your local Smith & Nephewwww.hmpcommunications.com representative or call (800) 876-1261.
The Problem — What is Nonviable or System enable surgeons to remove damaged tissue and con-Deficient Tissue? taminants precisely without the collateral trauma often associat- ed with current surgical modalities. Debridement of traumaticNonviable or deficient tissue is collectively termed necrotic tis- wounds, chronic wounds, and other soft-tissue lesions issue or slough. Necrotic tissue may appear black or brown — achieved in a single step while sparing healthy tissue and per-slough is yellow and fibrinous. When the tissue dries out and mitting the healing process to progress naturally.develops a thick, deficient, leathery texture, it is called eschar. Enzymatic debridement. Enzymatic debridement uses manufac-Necrotic burden is used to describe necrotic material, nonviable tured proteolytic enzymes to remove necrotic tissue and celltissue, exudates, and high levels of bacteria. Necrotic burden debris from the wound. When these exogenous enzymes aretends to accumulate continually in chronic wounds because applied directly to the wound surface, they work with naturallysuch wounds generally result from underlying and uncorrected occurring enzymes to degrade necrotic tissue. One of the old-pathogenic abnormalities such as diabetes mellitus or venous est types of enzymatic debriding agents, used for more thaninsufficiency. Fully resolving these systemic problems often is half a century, comprises a combination of papain and urea.impossible; in such cases, wound bed preparation is even more Papain-urea products such as GLADASE Ointment providecrucial to help facilitate wound closure. debridement by first degrading the surface necrotic tissue and then debriding the surface of the wound.The Solution — Debridement Papain-urea chlorophyllin products such as GLADASE-CWhat is debridement and why is it important? Debridement Ointment offer a combination of papain urea and sodium cop-is the removal of dead (necrotic), devitalized, or contaminated per chlorophyllin that can be applied continuously throughouttissue and foreign material from a wound — a key initial step in the treatment period to remove necrotic tissue and liquefywound bed preparation. slough; thereby, preparing the wound bed for healthy tissue granulation and healing. Sodium copper chlorophyllin, aThe removal of necrotic tissue by debridement is important for a chlorophyll derivative, is an anti-agglutinin that may reducenumber of reasons. First, devitalized tissue in the wound bed will inflammation in the wound. Chlorophyll is known for its abilityreduce the clinicians ability to adequately assess the depth of to reduce odors.the wound or the condition of the surrounding tissue. Concealeddead spaces can harbor bacteria and increase the risk of local Autolytic debridement. Autolytic debridement occurs naturally, toinfection. Second, necrotic tissue also may mask signs of local some extent, in all wounds. A highly selective process, itwound infection. Finally, the presence of necrotic tissue is a phys- involves macrophages and endogenous protelytic enzymes thatical barrier to healing and it supports bacterial growth. Bacterial liquefy and spontaneously separate necrotic tissue and escharcolonies can produce damaging proteases that can break down from healthy tissue. Wound dressings that maintain a moistimportant constituents of the extra-cellular matrix and inhibit the wound bed can provide an optimal environment for autolyticformation of granulation tissue and re-epithelialization. Therefore, debridement because they allow the phagocytic cells to liquefyin addition to removing cell debris, debridement reduces wound necrotic tissue; thereby, promoting granulation tissue. Smallercontamination and tissue destruction. areas of slough or necrotic tissue can be quickly and safely removed using interactive dressing products that enhance theTypes of debridement. There are five methods of debridement: bodys ability to debride devitalized tissue by the process ofsurgical (or sharp), enzymatic, autolytic, mechanical, and biologic. autolysis. Maintaining a moist wound surface helps promoteSeveral factors can influence the choice of debridement method rehydration of slough and necrotic tissue while allowing leuko-used,1,2 including the size, position, and type of wound; moisture cytes and enzymes present in exudates to break down avascu-level; pain management; time available for debridement; and the lar tissue. The speed of this process depends on a number oftype of healthcare setting. It is also important to consider the factors, including the size of the wound and the general physi-patients overall condition when choosing the debridement cal condition of the patient. In many instances, significantmethod. In some cases, the use of more than one debridement improvement can be observed with 3 to 4 days. For drymethod may be appropriate (see Table 1 and Table 2). wounds, autolytic debridement can be facilitated through the use of hydrogel, transparent film, or hydrocolloid dressings. ForSurgical (or sharp) debridement. Surgical, or sharp, debridement exudating wounds, absorptive dressings, such as a foam dress-is the fastest way to remove debris and necrotic tissue from the ing like Allevyn, or alginate dressings can be used.wound bed. Surgical debridement is sometimes performedwhen an extensive amount of necrotic tissue is present, which Autolytic debridement requires limited technical skill, is easy tois often the case when the depth of the wound cannot be perform, and does not damage healthy tissue surrounding thejudged or when widespread infection requires the removal of wound. Furthermore, the patient experiences minimal pain withbone and infected material.3 In addition to its efficiency, surgical this method. However, it is a slower method of debridementdebridement causes minimal damage to surrounding tissues and may be contraindicated if a high bacterial burden is presentand the minor bleeding that follows the procedure can release in the wound.inflammatory mediators, such as cytokines, that can assist thewound repair process. Mechanical debridement. Mechanical debridement is a non- selective method that physically removes debris from wounds.However, surgical debridement has limitations. It cannot be Examples of mechanical debridement include wound irrigation,used for patients with bleeding disorders or who are immuno- whirlpool therapy, and wet-to-dry dressings.compromised. The procedure may be painful and may causetransient bacteremia and damage to nerves and tendons.4 Wet-to-dry dressings are the simplest form of mechanicalNewer technologies such as the VERSAJET Hydrosurgery debridement.5 These dressings cause mechanical separation of
Part 4: Debridement and the Role of Enzymes Table 1. Comparison of Debridement Methods Type Mechanisms Precautions Comments Surgical/Sharp Removal of devitalized tissue using Make sure there is potential for healing and Fastest and most effective way to remove curved scissors curette. scalpel, laser, enough blood supply to support healing. debris and necrotic tissue that can serve hydro-surgical In lower extremity ulcers: as a nidus for infection. Local anesthetic Ankle-brachial index >0.5m: — topical Toe pressure >50 mm Hg, Transcutneous oxygen saturation >30 mm Hg Enzymatic Exogenous topically applied chemical A transient burning sensation may be experi- Enzymatic debridement can be facilitated by agents: papain-urea, papain-urea with enced by a small percentage of patients scoring the wound (cross-hatching of chlorophyllin eschar without causing bleeding) Autolytic The use of moist interactive dressings to Loose debris should be removed when chang- Occlusive dressings can relieve pain rehydrate eschar and help remove ing dressings to avoid infection. Dressing slough. Dressings include: transparent changes are usually required every 24 to 48 film dressings and hydrogels hours initially Mechanical The removal of necrotic tissue by means Excessive force will cause tissue damage. Use Whirlpool or saline wet-to-dry (painful if bleed- of force. Performed using: wet-to-dry an 18- to 20-gauge angiocath on a 30- to 60- ing induced with dressing change) are alter- dressings, hydrotherapy (whirlpool), cc syringe nate mechanical debriding methods pulsed lavage Table 2. Debridement Guidelines Description Debridement Decision Majority of wound is covered with necrotic tissue and suspect- Surgical debridement is the fastest method of wound debridement ed soft tissue or an especially large wound is covered with necrotic tissue Majority of wound is covered with necrotic tissue (slough or Apply a papain-urea ointment such as GLADASE or a papain-urea chlorophyllin oint- eschar) ment such as GLADASE-C to necrotic tissue. Majority of wound is clean and/or granulating. Necrotic tissue Apply a papain-urea chlorophyllin such as GLADASE-C Ointment to wound. Change dress- (slough or eschar) present. Wound is dry or has a small ing daily or as needed to avoid compromised healing amount of exudate Necrotic tissue on feet and/or toes. Arterial insufficiency Debridement not recommended. Refer to vascular specialistnecrotic tissue from the wound bed when the dressing is rather than a single intervention. An extended “maintenance”removed. However, this can cause the patient significant discom- phase of debridement, which will offer distinct advantages infort and damage newly formed tissue.6 wound management, has been proposed. Because autolytic and enzymatic debridement are more selective and generally lessWound irrigation utilizes a pressurized stream of normal saline. painful for the patient, these options are the recommendedHigh-pressure irrigation removes bacteria and necrotic debris methods of treatment when extended periods of debridementfrom wounds but also can drive bacteria into soft tissue.7 are required.Whirlpool therapy, another form of powered irrigation, loosensand removes necrotic tissue, debris, and exudates. Wound irri- Referencesgation is suitable for inflammatory wounds but not for wounds 1. Sibbald RG, Williamson D, Orsted HL, et al. Preparing the wound bed —that have fragile granulation tissue.8 debridement, bacterial balance and moisture balance. Ostomy Wound Manage. 2000;46:14–35.Biologic debridement. In some care settings, maggot larvae facili- 2. Falanga V. Classifications for wound bed preparation and stimulation oftate removal of necrotic tissue. chronic wounds. Wound Repair Regen. 2000:8:347–352. 3. Sieggreen MY, Makelbust J. Debridement choices and challenges. AdvMaintenance debridement: Why is an extended phase of Wound Care. 1997;10:32–37.debridement more appropriate than single-intervention 4. Baharenstani M. The clinical relevance of debridement. In: Baharenstanitherapy? Until recently, debridement — regardless of the M, Goltrup F, Holstein P, Vansceidt W, eds. The Clinical Relevance of Debridement. Berlin/Heidelberg, Germany: Springer-Verlag; 1999.method used — has been considered a single therapeutic stepwithin defined timelines. While a single episode of debridement 5. Jeffrey J. Metalloproteinases and tissue turnover. WOUNDS.may be appropriate for acute wounds, chronic wounds require 1995;7:13A–22A.more frequent debridement because of accumulating necrotic 6. Rodeheaver GT, Pressure ulcer debridement and cleansing: a review ofburden that results from underlying pathogenic conditions. Likely, current literature. Ostomy Wound Manage. 1999;45(suppl 1A):80S–85S.the accumulation of necrotic burden could, in itself, cause wound 7. Dow G, Browne A, Sibbald RG. Infection in chronic wounds: controver-repair failure; therefore, continuous removal of necrotic burden is sies in diagnosis and treatment. Ostomy Wound Manage. 1999;45:23–40.an important part of wound bed preparation. 8. Burke DT, HO CH, Saucier MA, Stewart G. Effects of hydrotherapy on pressure ulcer healing. Am J Phys Med Rehabil. 1998;77:394–398.For these reasons, when treating chronic wounds, debridementshould be viewed as an ongoing wound treatment process