Introduction

Debridement is the process of removing nonviable tissue and foreign objects (such as glass or shrapnel) from a wound bed to help the wound heal.¹ Decaying tissue can trap bacteria and lead to a harmful infection such as gangrene, which is the death of body tissue resulting from a lack of appropriate blood flow or in response to a severe bacterial infection.² Debridement is thus critical to effective wound management.

Why is Debridement Important?

Debridement is a standard wound management practice, but it may not be necessary for all wounds. According to Ratini,³ debridement is vital in keeping a wound healthy and free from nonviable tissue and debris such as dressing or suture material. When a wound heals appropriately, there may be no need for debridement. However, when the injury is not properly healing because of a lack of effective wound management techniques or the presence of complicating factors such as infection or the presence of comorbidities, then debridement becomes essential.

Beginning Stages of Wound Healing

Leonard⁴ stated that every wound goes through four major stages of healing. The first stage is hemostasis. This occurs when the body stops bleeding from the wound site by forming blood clots. The second phase is inflammation, in which phagocytic cells cause inflammation for usually 48 to 72 hours, in normal wound healing. Nonhealing wounds or those experiencing complications or stalling factors may remain in the inflammatory phase for weeks, months, or even years, until the stalling factors are resolved. Proliferation is the third process and begins as inflammatory cells undergo apoptosis. This process causes granulation tissue and blood vessels to form. The final stage, remodeling, is the generation of new epithelium and scar tissue.⁴

Debridement is the best way to prevent infection in both chronic wounds and acute wounds.¹ Early in the wound healing process, debridement helps the wound heal more quickly and easily by removing tissues that could delay healing or harbor bacteria, thereby leading to infection. According to Ratini,³ a laceration typically heals within four to six weeks. For those wounds that do not heal in that time frame, however, debridement becomes essential to a healthy healing process. Without debridement, the wound can become infected and potentially fall into a state of chronicity, and this can lead to a loss of limb or possibly a fatal infection.²

Debridement Guidelines

Debridement should be performed only when dead tissue or debris is present within the wound, thus interrupting the healing process. There are multiple ways a provider can perform the procedure, depending on the specific lesion. The bigger the wound, the more likely it is that debridement will be necessary. There are several techniques for debridement: autolytic, biological, enzymatic, mechanical, and surgical techniques. Ratini³ has discussed the various strategies for debridement, including when those strategies may be most appropriate for severe cases.

Autolytic.

A provider can use the autolytic method, which uses the body’s natural fluids and enzymes, to liquefy devitalized tissue through moisture-retaining dressings. According to Ratini,³ this method is best for noninfected wounds and pressure injuries. The patient must have a functioning immune system for this method to be effective.³

Biological.

In this method, the provider applies sterile maggot larvae that release enzymes into the wound to prevent dangerous bacteria from developing in the wound bed while they break down necrotic tissue. This method is primarily used when wounds are too large or are infected by bacteria that are antibiotic resistant, such as methicillin-resistant Staphylococcus aureus (MRSA).⁵ The larvae consume only devitalized tissue, thus making it an effective selective debridement method. It is not often used, however, because patients or providers may not be able to tolerate the procedure.

Surgical.

The surgical method is generally the preferred method of debridement because it is the quickest and most effective method of selective debridement. In this method, a provider physically removes the tissue by using a scalpel or surgical scissors to cut away the dead or devitalized tissue.³ It is important to have a pain management plan for this procedure because patients may experience pain during and after tissue removal.

Enzymatic.

Providers may also utilize an enzyme prescription to dissolve the tissue. This prescription includes a variety of chemicals that dissolve nonviable wound tissue.⁵

Mechanical.

Finally, providers may use the mechanical method, which is the most common form of debridement. It can be performed with a variety of tools. According to Nunez,⁵ a physician may use hydrotherapy to wash old tissue away with water, a wet-to-dry dressing that will dry to the wound and remove dead tissue when the dressing is removed, and monofilament debridement pads to brush away dead tissue and debris from the wound with gentle palpation.

Other Treatments.

Nonselective treatments can increase a person’s likelihood of bleeding, pain, and infection compared with other methods.⁶ In some cases, a physician may use a technique that could also destroy healthy tissue around the wound; however, the risks are higher for these methods, and a nonselective treatment should be used only when it is the best treatment method available. There are many forms of debridement that can be used based on the severity of the wound, and thus, a provider may use any one of these methods to ensure optimal healing and to prevent infection. It is vital to keep open communication with patients about debridement methods and recommendation based on specific patient conditions to communicate risks and achieve the best possible outcome. Patients may decline selected methods because of pain (such as with surgical debridement) or disapproval (such as with biologic debridement).

The Wound Bed

There are several principles medical professionals should follow to facilitate wound healing. One of clinicians’ top priorities is preventing infection or treating infected areas. The main goal of debridement is to remove dead tissue to optimize healing and prevent infection. If possible, providers should maintain healthy skin within and around the wound bed. According to Roddick,⁷ it is important that debridement procedures be specific to the wound etiology and patient needs to promote optimal healing, so it is critical to know when to use the specific methods listed earlier. Further, multiple debridement techniques can be used with the goals of preserving tissue and minimizing infection.

For example, a provider may choose to perform surgical debridement to remove the majority of devitalized tissue, then apply a dressing to promote autolytic debridement to liquefy remaining devitalized tissue along the wound edges. According to Roddick,⁷ all wounds are different and require subtle variations in treatment, and some wounds can be treated at home. Of course, it is essential that a provider evaluates any potentially serious injuries to determine the best course of action.

When to Use Debridement?

Debridement opens and enlarges a wound. However, clinicians trained in debridement should be careful when performing debridement and should remove only necrotic, nonviable tissue and debris while preserving as much healthy tissue as possible. The primary goal of debridement is to preserve healthy arteries, bone, and muscle tissue by disposing of necrotic of dead tissue within the wound. This is the highest priority and the first step toward creating an optimal healing environment; however, it can be a nuanced process.⁷

Conclusion

Debridement is an important part of wound healing, and it is essential for clinicians to be aware of the main methods of debridement, what tissues should be removed from the wound bed, and how to communicate these procedures to patients. Patients should always be involved in the treatment planning process, and they may object to the selected debridement method. In these cases, it is important to know what other methods will be effective to manage the wound.

References

1. Biagio M, Nahirniak P, Morrison CA. Wound Debridement. Stat Pearls; 2021. Accessed January 14, 2022. https://www.ncbi.nlm.nih.gov/books/NBK507882/
2. Gangrene. Mayo Clinic. 2021. Accessed January 15, 2022. https://www.mayoclinic.org/diseases-conditions/gangrene/symptoms-causes…
3. Ratini M. What is debridement? WebMD.com. 2021. Accessed January 14, 2022. https://www.webmd.com/skin-problems-and-treatments/what-is-debridement
4. Leonard C. The four stages of wound healing: an updated overview for clinicians. Vohra Wound Care. 2020. Accessed January 30, 2022. https://cert.vohrawoundcare.com/the-four-stages-of-wound-healing-an-upd…
5. Nunez K. What is wound debridement and when is it necessary? Healthline.com. 2019. Accessed January 15, 2022. https://www.healthline.com/health/debridement#when-its-done
6. Non-selective methods of debridement. Drugs.com. 2022. Accessed January 16, 2022. https://www.drugs.com/cg/non-selective-methods-of-debridement.html
7. Roddick J. Open wound. Healthline.com. 2018.. Accessed January 15, 2022. https://www.healthline.com/health/open-wound

Suggested Reading

Singhal H. Skin and soft tissue infections - incision, drainage, and debridement technique. Medscape. 2020. Accessed January 16, 2022. https://emedicine.medscape.com/article/1830144-technique