Debridement is the removal of devitalized tissue from a wound to promote healing. There are several methods of debridement including autolytic, biological using maggots, enzymatic using collagenase, surgical with sharp instruments, and mechanical. The key steps are to remove nonviable tissue through debridement, manage infection and inflammation, maintain a moist wound environment, and assess for reepithelialization. Debridement is essential for wound healing by removing barriers to healing like necrotic tissue but the method used depends on factors like wound severity, infection status, and patient factors.

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2. DEFINITION
The concept of preparing the wound bed to promote
reepithelialization of chronic wounds has been applied to
wound management for more than a decade.
The 4 general steps: DIME.
• D: Debridement of nonviable tissue within the
Wound.
• I: Management of Inflammation and Infection
• M: Moisture control
• E: Environmental and Epithelialization assessment
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Debrideement

3. SKIN: ANATOMY AND PHYSIOLOGY
Epidermis: composed up of closely packed keratinized,
stratified, squamous epithelial cells
Dermis: composed of dense, irregular connective tissue
where the blood vessels, hair follicles, sweat glands, and
other structures are housed.
Hypodermis: lies beneath the dermis. Its composition is
mostly loose connective and fatty tissues. Muscle, tendons,
ligaments, bone, and cartilage are all under the hypodermis.
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Skin

4. INDICATIONS
In general, the indication for debridement is the removal
of devitalized tissue such as necrotic tissue, slough,
bioburden, biofilm, and apoptotic cells for
reepithelialization.
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Debridement

5. INDICATIONS
Devitalized tissue, in general, and necrotic tissue, in particular,
serve as:
1. The source of nutrients for bacteria.
2. Acts as a physical barrier for reepithelialization,
3. Preventing applied topical compounds to make direct contact with
the wound bed to provide their beneficial properties.
4. Prevents angiogenesis, granulation tissue formation, epidermal
resurfacing, and normal extracellular matrix (ECM) formation.
5. Finally, the presence of necrotic tissue may prevent the clinician
from making an accurate assessment of the extent and severity of
the wound, even masking possible underlying infections.
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Debridement

6. INDICATIONS…
• Schiffman et al. include the following as common indications
for sharp surgical debridement:
1. Removal of the source of sepsis, mainly necrotic tissue
2. Removal of local infection to decrease bacterial burden, to
reduce the probability of resistance from antibiotic treatment,
and to obtain accurate cultures
3. Collection of deep cultures taken after debridement from the
tissue left behind to evaluate persistent infection and
requirements for systemic antibiotic treatment
4. Stimulation of the wound bed to support healing and to prepare
for a skin graft or flap
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Debridement

7. CONTRAINDICATIONS
• Contraindication of wound debridement, in general, may
be applied to dry and intact eschars with no clinical
evidence of underlying infection such as with an
unstageable pressure ulcer with an intact eschar at the
sacrum or buttock or heel.
• Other contraindications pertain to each particular method
of debridement.
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Debridement

8. TECHNIQUES
• Several types of the debridements can achieve removal of
devitalized tissue.
Autolytic Debridement
• This is the most conservative type of debridement. This type of
debridement is a natural process by which endogenous
phagocytic cells and proteolytic enzymes break down necrotic
tissue. It is a highly selective process whereby only necrotic
tissue will be affected in the debridement.
• It is indicated for noninfected wounds. It may also be used as
adjunctive therapy in infected wounds. It can be used with other
debridement techniques such as mechanical debridement in the
case of infected wounds.
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Debridement

9. TECHNIQUES…
• It requires a moist environment and a functional immune
system. The use of moisture retentive dressings can enhance it.
This type of debridement induces softening of the necrotic tissue
and eventual separation from the wound bed.
• The effectiveness of this type of debridement is mandated by the
amount of devitalized tissue to be removed as well as the actual
wound size.
• Autolytic debridement will take a few days. If a significant
decrease in necrotic tissue is not seen in 1 or 2 days, a different
method of debridement should be considered.
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Debridement

10. TECHNIQUES…
Biological Debridement
• Biological debridement, also known as larval therapy, uses
sterile larvae of the Lucilia sericata species of the green bottle
fly. It is an effective mode of debridement, particularly
appropriate in large wounds where a painless removal of
necrotic tissue is needed.
• The mechanism of action of mega therapy/debridement consists
mainly of the release of proteolytic enzymes containing
secretions and excretions that dissolve necrotic tissue from the
wound bed. Other modes of action contributing to the overall
result of larval therapy are:
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Debridement

11. TECHNIQUES…
1. Bacteriocidal, as the larvae ingest and digest bacteria
2. Inhibiting bacterial growth by producing in releasing
ammonia into the wound bed which increases the wound pH
3. Breakdown of existing biofilm at the wound bed and
inhibition of new biofilm growth
4. Direct ingestion of necrotic tissue
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Debridement

12. TECHNIQUES…
• Maggots can be applied to the wound bed. They can be enclosed
in a biological bag or are free range.
• Studies have shown that free-range maggots can debride a
wound at least twice as fast as bag-pain maggots. Comparison
studies of either free-range maggots treatment versus bio bag
contained maggots versus hydrogel autolytic debridement shows
days to complete debridement to be 14 versus 28 versus 72 days
respectively.
• Contraindications to biological debridement are an abdominal
wound contiguous with the intraperitoneal cavity, pyoderma
gangrenosum in patients with immunosuppression therapy, and
wounds in proximity to areas afflicted by septic arthritis.
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Debridement

13. TECHNIQUES…
Enzymatic Debridement
• This is a selective method for debridement of necrotic
tissue using an exogenous proteolytic enzyme, collagenase,
to debride Clostridium bacteria. Collagenase digests the
collagen in the necrotic tissue allowing it to detach.
• Enzymatic debridement is a slow method of the
debridement as from hair to mechanical and sharp
debridement.
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Debridement

14. TECHNIQUES…
• Collagenase and moisture retentive dressings can work in
synergy enhancing the debridement.
• Enzymatic debridement is not recommended for an
advanced process, or in patients with known sensitivity to
the product's ingredients.
• A relative contraindication of enzymatic debridement is its
use in heavily infected wounds. Furthermore, collagenase
should not be used in conjunction with silver-based
products or with Dakin solution.
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Debridement

15. TECHNIQUES…
Surgical Debridement with Sharp Instruments
• This is a type of debridement where devitalized tissue (slough,
necrotic, or eschar) in the presence of underlying infection is
removed using sharp instruments such as a scalpel,
Metzenbaum, curettes, among others. This can be done bedside,
in the office or wound care center, or in the operating room
depending on the adequacy of anesthesia and the ability to
control perioperative complications like bleeding. The
healthcare professional should be skilled and trained and
qualified and licensed to provide surgical treatment.
• Sharp-instrument debridement can be combined with all the
other methods of debridement during the perioperative period.
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Debridement

16. TECHNIQUES…
• Disadvantages of surgical debridement include adverse events
from the debridement itself, for example, bleeding and possible
general complications from the anesthesia.
• Contraindications for surgical debridement in the operating
room would have to take into account the particular surgical risk
stratification of the patient. Sharp surgical debridement is
contraindicated in patients with an intact eschar and no clinical
evidence of an underlying infection because in these cases, the
intact eschar functions as a biological covering for the
underlying skin defect. This is usually seen in unstageable
pressure injuries at the sacrum or buttocks or heels with intact
and/or dry eschars.
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Debridement

17. TECHNIQUES…
Mechanical Debridement
• Mechanical debridement is a nonselective type of
debridement, meaning that it will remove both devitalized
tissue and debris as well as viable tissue. It is usually
carried using mechanical force: wet-to-dry, pulsatile
lavage, or wound irrigation.
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Debridement

18. TECHNIQUES…
• It is indicated for both acute and chronic wounds with
moderate to large amounts of necrotic tissue, regardless of
the presence of an active infection.
• The contraindications include, depending on the modality
of mechanical debridement used, the presence of
granulation tissue in a higher amount than the devitalized
tissue, inability to control pain, patients with poor
perfusion, and an intact eschar with no gross clinical
evidence of an underlying infection.
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Debridement

19. COMPLICATIONS
• Depending on the type of debridement chosen,
complications range from local irritation to major bleeding.
• Surgical debridement and mechanical debridement will
have a higher risk for bleeding, along with peri-procedural
pain.
• Surgical debridement done in the operating room must
account for morbidity and mortality due to the anesthesia
used. A study by J. Shiffman et al. has shown operative
mortality to be 2% with long-term mortality, and as high as
68% following debridement.
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20. CLINICAL SIGNIFICANCE
The clinical significance of wound debridement and ulcers with
necrotic tissue, regardless of the infection status, cannot be
overstated and should not be underestimated. Debridement for
most wounds is considered a standard in the approach to wound
management. It provides the benefits of removal of necrotic tissue
and bacteria and senescent cells, as well as the stimulating activity
of growth factors. Sharp surgical debridement has been shown to
reset the proper timing of the phases of wound reepithelialization
by providing the initial trauma seen in the hemostasis phase of
wound healing. Angiogenesis has also been shown to be
stimulated by sharp surgical debridement.
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21. CLINICAL SIGNIFICANCE
• Of course, not all forms of debridement will have the same
impact on the wound or the ulcer as the mode of action differs;
however, either sharp surgical debridement or nonsurgical
debridement is fundamental to wound reepithelialization.
• A critical concept of debridement is the dry eschar such as in
unstageable pressure ulcers with no overt signs of infection,
where debridement is not always indicated because the dry
eschar will act as a biological covering.
• The mode of debridement should be tailored to the particular
wound presentation taking into account factors such as
comorbidities, other lower-risk options, and the patient's comfort
and desires.
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22. REFERENCE
• https://www.ncbi.nlm.nih.gov/books/NBK507882/
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