Overview of Debridement in Wound Care

Debridement is essential to promote healing and prevent infection. There are five main types of debridement methods. BEAMS is the common mnemonic to remember all types: biological, enzymatic, autolytic, mechanical, and surgical. In recent years, new types of debridement technology have been introduced, such as fluid jet technology, ultrasound debridement therapy, hydrosurgery, and monofilament polyester fiber pad debridement.^1,2 Combining debridement methods has been found to be an advantage in managing complex wounds and different pathological tissues since 2006.³

One common method of combining debridement techniques is using enzymatic debridement first to liquefy the tissue and then following with sharp debridement. Combining debridement methods in this way can ensure that you are removing as much dead tissue from the wound as possible and helping to promote wound healing. Chen and Wang studied chronic pressure ulcers that were described as dry, hard, black, crusting eschar.⁴ Conservative sharp debridement was performed using an eye vascular clamp to separate necrotic tissue from the wound bed. The necrotic tissue was then cut or trimmed with sterile scissors, and 5mm thick hydrogel was then applied to promote autolysis. Results – All wounds healed.⁴ Reuven Gurfinkel et al. studied burns with eschar.⁵

Both wounds were of the dry and liquefied necrosis type. Combined methods used were ultrasonic and enzymatic debridement. Anesthetic gel (esracaine 2%) was applied, followed by combined ultrasonic and enzymatic debridement in flap perforation within 2 to 5 minutes. Result – This combined approach was more rapid and effective than either method alone.⁵

Considerations in Selecting Debridement Methods

To assess or evaluate a wound properly, we must first be able to visualize the wound bed tissue level. Dead tissue obscures the healthy tissue in a wound bed. Healthy tissue is clinically identified as red, pink, granulation. Necrotic tissue can present either as a yellow, tan, gray, green or brown slough; or as a tan, brown or black eschar.

Non-viable or devitalized tissue not only slows down the wound healing process, but also increases the risk of infection and sepsis. Dead tissue or foreign material is a vehicle for bacterial growth.⁶ Sequential sharp debridement of wounds also disrupts biofilm growth and inhibitory factors that can promote faster healing. However, there are cases where certain debridement methods are not indicated. Current standard of care guidelines recommend that stable, intact (dry, adherent, intact without erythema or fluctuance) eschar on the heels should not be removed. Poor blood flow beneath the eschar leads to high susceptibility to infection. Eschar works as a natural barrier or biological dressing by protecting the wound bed from bacteria.

If the eschar becomes unstable (wet, draining, loose, boggy, edematous, red), it should be debrided according to the clinic or facility protocol. Autoimmune and pyoderma gangrenosum wound types tend to worsen with sharp debridement when there is a prominent, active border because debridement triggers an inflammatory response known as "pathergy."⁷ Patients receiving immunosuppressive therapy, with non-active border clinical signs as mentioned, may have surgical debridement performed. Calciphylaxis wounds with expanding tissue necrosis and a violaceous border should not be surgically debrided. The patient must also complete sodium thiosulfate therapy, along with clinical observations that necrosis expansion and violaceous border formation have stopped.⁸ Additionally, biofilm formation is present in 60% to 90% of chronic wounds. Developed biofilms harbor physical and metabolic defenses.

These defenses enable the biofilm to resist antimicrobials that usually alienate planktonic cells and include resistance to host defenses, biocides, antibiotics, and ultraviolet light. Sequential sharp debridement of wounds disrupts biofilm growth and inhibitory factors and can promote faster healing . It is difficult to predict the outcome because we still do not know the depth needed to remove the entire biofilm colony.⁶

A Few Key Points

Several things should be kept in mind when you use debridement to treat a wound, such as:

1. The wound size may measure greater in length, width, and especially depth after debridement.
2. Weekly wound assessments should be performed to monitor wound healing progress.
3. Wound assessments should include tissue percentages, which should equal 100% (70% granulation, 30% slough).
4. Unstageable pressure ulcers/injuries cannot be restaged until viable tissue is visible.⁹
5. Combine debridement methods when possible to enhance healing time.

Debridement continues to be a standard of care, utilizing surgical or non-surgical methods. Removing non-viable or devitalized tissue encourages granulation and epithelialization. By combining debridement methods, using advanced wound care products, and keeping our patients involved in the plan of care, we have a better chance of tackling chronic wounds with a higher success rate.

References

1. Mosti G, Iabichella ML, Picerni P, Magliaro A, Mattaliano V. The debridement of hard to heal leg ulcers by means of a new device based on Fluidjet technology. Int Wound J. 2005;2:307–14.

2. Vowden KR, Vowden P. Debrisoft: revolutionising debridement. AActiva Supplement Edition. London, United Kingdom: MA Healthcare, Ltd.; 2011.

3. Liu WL, Jiang YL, Wang YQ, Li YX, Liu YX. Combined debridement in chronic wounds: a literature review. Chin Nurs Res. 2017;4(1):5–8. Available at: https://www.sciencedirect.com/science/article/pii/S2095771817300063. Accessed April 15, 2018.

4. Chen MH, Wang YM. The treatment and nursing care methods of combined debridement in pressure ulcer. J Nurs Train. 2010;25:478–9.

5. Gurfinkel R, Lavon I, Cagnano E, et al. Combined ultrasonic and enzymatic debridement of necrotic eschars in an animal model. J Burn Care Res, 2009;30:505–13.

6. Grey JE, Harding KG. ABC of wound assessment. BMJ. 2006;332(7536):285–8. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1360405/. Accessed April 15, 2018.

7. Suzuki K, Cowan L. Current concepts in wound debridement. Podiatry Today. 2009;22(7):40–8. Available at: https://www.podiatrytoday.com/current-concepts-in-wound-debridement. Accessed April 15, 2018.

8. Carpenter S, Shaffett TP. Choosing the best debridement modality to 'battle; necrotic tissue: pros & cons. Today's Wound Clinic. 2017;11(7).

9. Debridement. Chapter 8. Medline University. Available at: https://www.medlineuniversity.com/DesktopModules. Accessed April 15, 2018.