May - June 2022
Debridement: A Concise Guide Introduction
D
ebridement is the process of removing any devitalised tissue and bioburden from wounds. This includes necrotic material, eschar, infected tissue, slough, pus, haematoma, and debris. Caution should be exercised when debriding the wound in the community. Many patients are taking anticoagulants, and even the minimal amount of debridement can cause significant bleeding and blood loss1.
We have been taught that, in general, you should not undertake a procedure independently unless you are equipped to deal with the worst possible complication, forming the foundation for our clinical practice. However, it is vital to ensure that wound care practitioners are knowledgeable in the most recent advancements in debridement tools and techniques so patient care and clinical outcomes are improved2.
It is important to maintain meticulous documentation at each wound care visit to assess progress and standardised medical photography should also be utilised at each visit. The main features to document are: •
Location of the wound
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Site
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Size: considering all dimensions; length, width and depth
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Stage: what stage of wound healing is the wound currently in
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Vascular status of the wound
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Exudate level
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Wound bed
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Periwound
Ascertain the tissue type in the wound1 It is important that the method of debridement selected is the most effective for the patient and not limited by the skills of the practitioner. If the practitioner lacks the required skills they should seek support from within their own team, or consider further training if the situation is likely to occur frequently. Debridement is dependent on the clinical status of the wound, the general health of the patient and the skill and qualification of the healthcare personnel.
General Principles
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Viable tissue: this appears with a light pink to red hue and may be moist
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Epithelial tissue: this tissue is pale pink and may appear white, this normally signifies a healing wound
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Granulation tissue: often appears red and dotted in appearance. It is vital to identify overgranulation, as this requires early treatment
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Infected tissue: may be inflamed, red, swollen and have a border of erythema or cellulitis surrounding the periwound
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Necrotic tissue: is a result of cell death and may occur when there is concomitant bacteria, viruses, fungi or parasites present. It can also occur if there is a hypoxic wound environment present. Standard treatment generally involves surgical debridement, and antibiotics as per local protocol
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Eschar or slough: may be yellow, gray, black or brown in appearance. It may be soft or hard with a leathery appearance. Generally, dry, stable eschar should stay in place
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Exposed tendon, ligament or bone: this may appear yellow or off-white and is shiny unless dehydrated. Bone is hard and white unless it is
Assessment of the Wound
Miss Negin Shamsian Consultant Plastic & Reconstructive Surgeon (Locum) Chief Editor of Wound Masterclass London, United Kingdom
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Pick a suitable clinical area that has good lighting, access to all dressings and a sterile field to operate in. Ensure the patient is comfortable and provide an explanation to the patient. Assessment includes a full history of the patient, including duration of wound, exploring comorbidities and any other contributing factors that may highlight the potential aetiology to you.
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Debridement: A Concise Guide
in a necrotic phase. This often requires surgical reconstruction but in some instances may be temporised with dermal matrices and Negative Pressure Wound Therapy (NPWT).
Assessing Your Own Level of Expertise and the Debridement Ladder Most debridement should only be carried out by a trained professional as it carries a considerable risk with it. Debridement, carried out safely, minimizes tissue loss to avoid deep tissue exposure such as bone, joint, cartilage and tendons1. Some gentle debridement devices are licensed and recommended for use of all health care professionals regardless of experience level. Recent evidence suggests that wound healing is stalled by chronic infection, which consists of the presence of bacteria in a biofilm state. Guidelines recommend adequate wound bed preparation to physically remove the biofilm, with topical products assisting in this process.
bacteria. This is still a common debridement method, often followed by another method of debridement. Irrigation is a non-selective debridement technique that is quick and costeffective •
Ultrasonic debridement therapy can also remove non viable tissue painlessly, safely and effectively, as well as selectively5
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Mechanical debridement is the process of physically removing devitalised tissue from the wound bed. Innovative, evidence based products have been developed to assist with mechanical debridement. Contact debridement pads can be used for mechanical debridement and there are specialised, single-use, monofilament fibre debridement pads and debridement cloths available. The Debrisoft® (L&R) monofilament fibre debridement pad is recommended by the National Institute for Health and Care Excellence (NICE) for use in the community, based on the evidence of effectiveness and estimated cost savings6
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Debridement pads can offer a quick and effective method of debridement that requires no specialist training and can be used in acute and chronic wounds in adults and children7
Debridement Methods •
Bacterial biofilm is a significant barrier to healing wounds2
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Sharp debridement is the most common form of wound debridement. It is considered a quick and easy method for removing non viable tissue
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Larval Debridement Therapy uses Lucilia sericata (greenbottle fly) larvae to remove necrotic, sloughy and/ or infected tissue, suitable for use in a wide variety of wound types. It should be considered for wounds where rapid debridement is required3
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Autolytic debridement is performed by the application of a prescribed topical agent that chemically liquefies necrotic tissues with enzymes. These enzymes dissolve and engulf devitalized tissue within the wound matrix4
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Enzymatic debridement, also known as chemical debridement, this method is similar to autolytic debridement, but uses proteolytic enzymes instead of the body’s enzymes. These chemical agents break down necrotic tissue. Commonly the enzyme is combined with a dressing that is changed regularly, which softens the tissue and allows for the necrotic tissue to be removed when the dressing is removed. This works faster than autolytic debridement, with little risk to healthy tissue when properly applied
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Jet lavage. Irrigation debridement uses fluid to remove wound debris topical agents, and surface
The management of hard-to-heal wounds by a multidisciplinary team is the best way of improving patient outcomes. The patient’s wishes and comorbidities should also be considered when choosing the type of debridement. Some wounds have the added challenge of requiring many months to heal and may require multiple debridements and/ or several different debridement methods6. However, when debridement is performed correctly and patients adhere to additional treatment recommendations, this procedure can lead to enhanced wound healing, even in chronic or complex wounds8.
References 1. Shamsian N. Wound bed preparation: an overview. Br J Community Nurs. 2021 Sep 1;26(Sup9):S6-S11. doi: 10.12968/bjcn.2021.26.Sup9.S6. PMID: 34473537. 2. Wolcott RD, Rhoads DD, Dowd SE. Biofilms and chronic wound inflammation. J Wound Care 2008;17:333–41). 3. Kon K, Rai M. Microbiology for Surgical Infections, 2014. 4. Steed DL. Debridement .Am J Surg. 2004 5. Gray D, Acton C, Chadwick P et al. Consensus guidance for the use of debridement techniques in the UK. Wounds UK 2011; (7)1:77-84 6. Vallejo A, Wallis M, McMillan D, Horton E. Use of low-frequency contact ultrasonic debridement with and without polyhexamethylene biguanide in hard-to-heal leg ulcers: an RCT protocol. J Wound Care. 2021 May 2;30(5):372-379. doi: 10.12968/jowc.2021.30.5.372. PMID: 33979219. 7. National Institute for Health and Care Excellence. The Debrisoft monofilament debridement pad for use in acute or chronic wounds. NICE Medical technologies guidance 17. Last updated March 2019 [Internet]. 2014. www.nice.org.uk/guidance/mtg17 [accessed 05/03/2021]. 8. Morris, C. Presented at EWMA Conference, Krakow, Poland, 9-11 May 2018. Available from https://lohmann-rauscher.co.uk/downloads/clinical-evidence/EWMA-2018-Debrisoft-v-UCSMolecuLight.pdf. [Accessed 20/06/2022]. 9. Manna B, Nahirniak P, Morrison CA. Wound Debridement. 2022 Apr 30. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 29939659. 10. Swezey L. Types of wound debridement. 2018. WoundEducators.com. Accessed 19th June 2022 11. Fonder MA, Lazarus GS, Cowan DA, et al. Treating the chronic wound: a practical approach to the care of nonhealing wounds and wound care dressings. J Am Acad Dermatol 2008;58:185–206.
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