Hello, I'm Dr. John Lantis, I'm a vascular surgeon who practices in New York City, I'm actually the chief of surgery at Mount Sinai West Hospital and have been working clinically in wound care and vascular surgery for 23 years.

How can clinicians prepare a wound site for debridement?

I think preparing a wound site for debris management is very interesting and when you're a surgeon, you realize that in the operating room, you always prepare the wound bed. And both Dr. Kim and myself have some data that we previously published about this. But actually, when you're taking care of a patient in the office, which is what we're really talking about here, in the outpatient setting, here are a couple of things you have to think about. One is how much pain is the patient going to have and pain modulation. Number 2 is going to be wound bed preparation prior to cutting away tissue.

If you are planning that, those 2 things are really paramount. You also want to be set up with all of your correct materials available to you, whether it's a nurse, a medical office assistant, a resident, or someone who will make sure you have everything available to you when you are doing the procedure. So you don't want to be reaching around for things.

So fundamentally, you want to establish a pain control situation with the patient. And this may require a conversation prior to debridement. Obviously, in things like diabetic foot, there is a lot of neuropathy and you can usually do debride the diabetic foot without lots of consideration about causing the patient pain. A venous stasis ulcer, a pressure injury, or a typical ulcer, certainly a post -operative wound, all may have much higher levels of pain. So number one is getting the right environment and addressing the patient's level of pain so that they're aware of what you're going to do.

A lot of times, a topical, 4% lidocaine gel applied to the wound directly for up to 10 minutes can have a beneficial effect, both psychological and in reality. You put that on, you put an occlusive cover such as saran wrap or a transparent dressing over that, and you can do that. If you're going to do something deeper or possibly a more painful wound, you may want to discuss providing an injectable local anesthetic such as 1% lidocaine usually without epinephrine because you do not want to have a basal constrictive event occurring.

Then immediately prior to debridement, you should probably prepare the wound bed and what Dr. Kim and I have both shown in trials have been that if you prepare the wound in the office setting, you're going to reduce the bacterial burden by 2-3 folds. That's, you know, 90 % or 99%. And so this really has to do with reducing bio burden prior to debridement. Again, we'll just use topical betadine on the wound, allow it to dry. Because again, we're debriding the wound. A lot of us think, well, betadine is caustic, inhibits wound healing, but in this case you're going to be removing all of that material during your sharp surgical debris. So again, pain control first, followed by wound bed preparation, betadine in general is going to dry over the course of 1-3 minutes, so you need a little bit of time to prep it. Obviously, these wounds are not sterile. In different countries, sometimes the debriding is required to be done in a quote -unquote sterile environment.

Quite frankly, that doesn't make good scientific sense. A clean environment with all the stuff around you that you need is appropriate, but in most cases, unless you have a severely immunocompromised patient, the wound you're in a class 4 wound, you're probably dealing with a dirty wound, or certainly a contaminated wound, class 3 wound, and therefore further sterility is not necessary.

The things you would like to have, probably a sharp curette available to you. You can certainly have a 15 blade available to you. I prefer a sharp curette in most settings. And a ring curette seem to be the nicest.

And then a suture removal kit, where you're going to have a pair of forceps and a pair of scissors. I would also recommend having some silver nitrate and gauze all available to you. Now this is different than if you're pairing a callus.

And that's not what we're discussing at this point. At times, there can be a chronic wound that has a lot of callus associated, but we're talking about the actual wound bed here. At that point in time, you want to use the best material going forward for your technique, but that's really the wound bed preparation.

What are the most important aspects, in your experience, of sharp debridement technique?

The most important aspect of sharp debris technique are two -fold, really. One is you want to take away the senescent cells, the cells that are old, that don't want to turn on and are not actively moving in a particular direction from the edges of the wound. So, you want to get rid of those hyperkeratotic keratinocytes and get the edges back.

I always joke and tell my residents that just like most humans, although maybe fun for humans at times, but cells don't really like to jump off a cliff. They want to run down a beach. So you want to get those edges back to a nice 45 degree, slightly bloody angle, honestly. But then just cutting back the edges of the wound is not enough.

What you also want to do is to debride the fibro-exudative material off the base of the wound. In general, I will do a sharp, excisional, circumferential debridement on the appropriately prepared wound. So that wound that has good anesthesia and a topic antimicrobial, such as betadine on it, I'll cut the edges back down to a bleeding edge. Now if it gets too bloody there, I'll pat that dry, hold some pressure with gauze and potentially use a little silver nitrate, which will allow for cautery, plus it will allow for killing bacteria.

Then I will take the dull edge of my curette and move from the edge to the base of the wound and take off the fibro-purulent exudate, which is going to reduce your bioburden. So you don't want to do one or the other. In the one place, you may not do this is possibly if you have been using a cellular tissue-based therapy or a CTP, as we change the nomenclature, but a skin substitute of some sort, extracellular matrix, etc, and that's on the wound bed. At times, you may opt to leave that behind, especially if you're pretty sure you're actually looking at the matrix that you left behind or the skin substitute you left behind. And you don't want to excise that or to debride that from the actual wound bed.

So there's a little bit of a nuance to what you do in general, and if you did the base of the wound and then did the circumference of the wound, there's no data to say that one or the other is right, but I find it easier to freshen up the entire circumference of the wound and then proceed to the base of the wound.

What should clinicians consider when it comes to debridement aftercare?

The question in regards to, you know, aftercare, right? Why do you want to make sure that you have to, after you've debrided a wound effectively, you would really like to do something to make sure that you don't have any ongoing hemorrhage or bleeding?

Because that is disconcerting to the patient. It may not be bad for you as a clinician. You may not be unhappy with it, but it will just, you know, the patient, if they put on a shoe and a gauze and they put on their sock and they get home and the sock's bloody, that is never going to be something that they find beneficial. It just isn't. So the reality and perception here is a little bit different.

We will usually use, you know, manual pressure to obtain hemostasis. Then, of course, there's debridement there prior to placing a skin substitute, quote unquote, again, using that sort of vernacular, but a cellular tissue-based therapy. In that case, you're going to put on a biologic dressing right after the debridement, possibly, where you are going to put on a non-stick layer and you're going to put on some form of secondary dressing, such as an adhesive foam and a wrap. But in general, depending on your goals is really going to depend on your aftercare of that wound. You're going to want to give pretty specific instructions about what dressing you put on, how long that dressing is going to stay, and what your goals are. And it's worth communicating with the patient and certainly the patient's caregiver, that's family, friend, nurse, etc, what your expectations are.

And if you think it's going to be a little bloody when they take down the dressing, in a day or two, you may say, “the wound might look a little bloody, but that's okay. That was our goal. We wanted to clean this up,” and you may want to use in that case hydrogen peroxide. Get rid of some of that blood clot, just to clean the wound up and that can be used to dilute hydrogen peroxide. And really, your contact dressing is going to be based upon your long-term goals and your underlying pathophysiology. I would say that if your goal has been to reduce the bacterial burden, you might be putting on a long acting iodine type product with a cadexomer starch, which you can put on every 3 days. If your goal in a diabetic foot wound is small, might be just to apply a pro-generative therapy. You may use recombinant platelet-derived growth therapy, which is associated with better outcomes with weekly debridement.

If it's a venous stasis ulcer, you may be using the debriding and then putting on atopical antimicrobial therapy such as sustained release silver product and the multi-layer compression.

The one thing to remember is the debridement goes hand in hand with correct therapy. So for diabetic foot wound, you're definitely going to want to make sure that you've offloaded that patient appropriately. Manage their hemoglobin A1C, make sure that you're not debriding an arterial compromised wound. In a setting of venostasis disease, you're obviously going to want to debride the wound there with very nice outcomes, you're going to want to compress and treat the underlying venous disease, and ideally get a venous anatomy diagnosis. Is this something that needs to be referred to a venous specialist who could do something?

In atypical wounds, you want to be debriding potentially and treating the underlying pathophysiology, whether that's rheumatoid arthritis, ulcerative colitis, lupus, etc. Post -surgical wounds, you're going to want to deal with the pain control and the expectations of the patient.

And then, pressure ulcers obviously focusing on offloading, non-contact layers, and also nutritional support. but I would say that if I debride 30 wounds in an office day, there's probably going to be you know 18 different types of post-op, post procedural treatment based on the underlying etiology and the overall goals of therapy.

What else would you like to add?

I think there are some things that we should keep in consideration. One has to do with the area of the wound. Almost all our wound agreements that are under 10 square centimeters, so 3 ½ by 3 ½ , etc, are definitely done in the office. If we have a wound that's greater than a 100 square centimeters. We really do think about doing it only in the operating room. For people who don't have that access, they may want to think about partnering with someone who has access to an operating room because of pain control, hemostasis, and adequacy of debridement.

We do tend to like to do even debridement that's greater than 40 square centimeters in the operating room. But, of course, this is the opinion of a surgeon who has access to the OR. Between 10 and 40 square centimeters, there is certainly a gray area, and we're very comfortable doing wounds up to 40 square centimeters in the office, so that has to do a little bit with how to triage where you're doing your debridement.

Now the etiology of that wound matters as well, so a diabetic foot ulcer lends itself to office debridement whereas a venous stasis ulcer may require, especially a large one, may require better pain control.

We do triage our debridements by wound size and etiology of the wound. And then finally, besides pain control, the other thing you obviously have to be very aware of is anticoagulation. And in this day and age, more and more patients are on anticoagulation. So you have to specifically ask about anti-platelet therapy, and also standard anticoagulants, whether that's Coumadin or some of the other brand name anticoagulants that are available, but you want to make sure you get a good history before embarking on debridement. Because the last thing you want to do is be in the office doing a sharp debridement with all the best intentions in a patient who may be likely to bleed and be more of a problem for you than you need.

So those will be the last caveats I would say you really have to consider, pain control and anticoagulation. These can all be managed with appropriate thought process prior. But sometimes that might mean that you see the patient and you put off their debridement for 4-7 days depending on what's going on with the rest of their plan.