Wound debridement is a critical strategy in treating hard-to-heal wounds. It is a process that expedites healing by removing necrotic tissue, non-viable tissue, and foreign material.¹ It can also be used to manage biofilm to prevent infection. Debriding a wound exposes the healthy underlying tissue to promote healing.² There are several methods of debridement. Determining the best option will depend on the health care setting as well as the characteristics of the wound being treated.

Benefits of Debridement and Disrupting Biofilm Formation

It has long been recognized that regular debridement followed by strategies to prevent biofilm re-formation, such as the use of topical antimicrobial dressings, is crucial in managing biofilm.³ Biofilm interrupts the natural healing process and presents an obstacle to healing, particularly when other factors that may impede healing are present. The risk of infection related to the presence of biofilm is increased by the number and complexity of microbes, particularly when there is increased microbial virulence or antibiotic or antimicrobial resistance or when immunological defenses are impaired by other comorbidities, such as obesity or diabetes.⁴

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Despite advances in dressing technology and best practices, the number of hard-to-heal wounds is increasing. Improving the management of these wounds often involves addressing the tenacious biofilm that is frequently present on them.⁴ The presence of this biofilm in hard-to-heal wounds with delayed healing is well documented, as are the beneficial effects of removing or disrupting the biofilm.⁴

Debridement Methods

Debridement is one method for removing excessive biofilm. There are various methods of debridement, and selecting the most appropriate method is crucial in treating complex wounds. One or more methods of debridement can be used in managing hard-to-heal wounds.

• Sharp debridement: Sharp debridement uses surgical instruments to remove devitalized tissue.⁵
• Biological debridement: Biological debridement applies live sterile bottle fly larvae to consume non-viable tissue without harming surrounding healthy tissue.⁵
• Enzymatic debridement: Enzymatic debridement uses proteolytic enzymes to break down and dissolve non-viable tissue.⁵
• Mechanical debridement: Mechanical debridement from gauze, wet-to-dry dressings, monofilament polyester pads, and pulsed lavage uses abrasive force to remove non-viable tissue.⁵
• Autolytic debridement: Autolytic debridement uses the body’s own endogenous enzymes to liquefy non-viable tissue.⁵

Each method of debridement has benefits and drawbacks, and selecting the appropriate method will depend on the unique characteristics of the wound being treated. Despite their differences, all methods of debridement disrupt or impede the proliferation of microorganisms on the wound. Debridement removes currently infected tissue and can reduce the risk of wound infection or re-infection.⁶ The efficacy of debridement is well-documented. Studies indicate that with regular debridement of susceptible wounds, these wounds can heal up to 83% of the time; this figure is only 25% with sporadic debridement.⁵ Proper cleansing before and after debridement is essential in maintaining proper wound hygiene.

The Role of Cleansing in the Debridement and Wound Hygiene Process

Cleansing of both the wound and the periwound skin (extending 10-20cm) before and after debriding the wound provides a systematic approach needed to prepare hard-to-heal wounds for management and healing.⁷ It is an integral part of wound bed preparation because it removes surface debris, reduces the bacterial load, and mitigates biofilm activity. Even if the wound does not look like it has biofilm, wound cleansing must be a priority.⁴ Proper wound hygiene techniques embrace several premises, including⁴:

• Wound hygiene is a fundamental aspect of care for all patients with open wounds.
• The majority of hard-to-heal wounds contain biofilm.
• Non-healing should be regarded as a disorder that can be successfully addressed with the right tools, provided the underlying etiology is managed with gold standard care.
• Wounds should be triaged by the level of risk, regardless of wound duration.
• Wound hygiene should be performed at every dressing change.

Conclusion

Biofilm-based management strategies begin with wound hygiene, particularly throughout the debridement process. Cleansing should include the periwound area, and maintenance hygiene with each dressing change is essential for optimal results.⁸ When the appropriate method of debridement is selected and performed following rigorous wound hygiene practices, debridement disrupts biofilm formation and can prevent infection from developing. Debridement can also be used as part of a comprehensive care strategy for addressing an active infection.

References

1. Frykberg RG, Banks J. Challenges in the treatment of chronic wounds. Adv Wound Care (New Rochelle). 2015;4(9):560-582.

2. Madhok BM, Vowden K, Vowden P. New techniques for wound debridement. Int Wound J. 2013;10:247-251.

3. Bjarnsholt T, Eberlein T, Malone M, et al. Management of biofilm. Wounds Int. 2017;8(2).

4. Centers for Disease Control and Prevention (CDC). The biggest antibiotic-resistant threats in the U.S. https://www.cdc.gov/drugresistance/biggest-threats.html. Accessed November 28, 2020.

5. Manna B, Morrison CA. Wound Debridement. Treasure Island, FL: StatPearls; 2020.. https://www.ncbi.nlm.nih.gov/books/NBK507882/. Accessed December 16, 2020.

6. Attinger C, Wolcott R. Clinically addressing biofilm in chronic wounds. Adv Wound Care (New Rochelle). 2012;1(3):127-132.

7. Percival SL, Mayer D, Kirsner RS, et al. Surfactants: role in biofilm management and cellular behaviour. Int Wound J. 2019;16:753-760.

8. Weir D. Wound hygiene protocol: when, why, and how to cleanse. Presented at Fall 2020 WoundCon Conference. WoundSource.com.