By the WoundSource Editors Wound debridement is often necessary to address the underlying causes of chronic wounds, remove non-viable tissue, manage biofilm, and ultimately promote and expedite the healing process.¹ There are multiple methods of debridement, including surgical/sharp, autolytic, mechanical, biological, enzymatic, ultrasonic, hydrosurgical, or synergistic (combination of debridement methods). Selecting the most appropriate methods of debridement is crucial in treating chronic and acute wounds successfully and optimizing the healing environment.

Indications for Each Debridement Type

Multiple factors must be considered when selecting a method of debridement. An overview of patient considerations for each method is provided here. Biological: Biological debridement uses live, sterile bottle fly larvae, which develop into maggots that consume the non-viable tissue without harming surrounding healthy tissue.² It is particularly effective in large wounds, when wounds have antibiotic-resistant bacteria, or when painless removal of necrotic tissue is necessary. This last trait means it can be considered for use in patients with a low pain tolerance or painful wounds where other forms of debridement are not tolerated and where expedited debridement is warranted, as opposed to using a slower method of debridement.

The use of this type of larvae for debridement may be advantageous when biofilm in the wound bed must be addressed, with some research suggesting the larvae are bactericidal, and they break down existing biofilm and inhibit new biofilm growth.³ Biological debridement is also a relatively quick method in comparison with other debridement methods. Large wounds that may take up to 72 days to debride fully using hydrogel autolytic debridement may be biologically debrided in as short a time as 14 days. It can also be considered when medical conditions prohibit the use of sharp debridement.³ This form of debridement does, however, carry a stigma. Patients may be opposed to the idea of putting maggots in their wound, or they may not be able to tolerate the feeling. The process should be explained fully to patients, with care taken to answer any and all questions fully. Sharp: With sharp debridement, the devitalized tissue is removed using sharp instruments such as scalpels and curettes. It can be done at the bedside, in clinical offices, or in operating rooms, depending on the need for anesthesia or control of complications such as bleeding. Sharp debridement is often selected for very large wounds with an excess of necrotic tissue or when the tissue needs to be debrided quickly, such as to prepare the wound for the application of a skin graft.³ This form of debridement may not be appropriate for patients with a low pain tolerance or those undergoing palliative care. Consider the patient goals and admission diagnosis to hospice, and speak with the primary care physician and/or responsible party to weigh options and choices. Autolytic: Autolytic debridement uses the body’s own endogenous enzymes to liquefy non-viable tissue. It is the most conservative type of debridement and should be used only in non-infected wounds, although it can be used as adjunctive therapy for infected wounds. It can also be used in combined debridement therapies. It often takes longer than other types of debridement, and this trait makes it less ideal for large wounds with extensive non-viable tissue to be removed. It also requires that the patient have a functional immune system, and it should not be considered in patients with underlying autoimmune conditions.³ This method is often used on older adults and those in long-term care, as it is relatively painless, and may be better for those patients undergoing palliative care. Mechanical: Mechanical debridement uses wet-to-dry dressings, tissue irrigation, monofilament polyester pads, and pulse lavage to remove unhealthy tissue by abrasive force.⁴ Mechanical debridement methods vary, and the methods may have different indications. It may not be the best method for patients with a low pain tolerance or those with poor perfusion.³ Wet-to-dry dressings have generally fallen out of practice, because though it is a relatively inexpensive process, it is a very painful process and must be performed frequently. Enzymatic: Enzymatic debridement uses proteolytic enzymes (such as collagenase-) to break down and dissolve non-viable tissue.⁵ It is frequently used to debride wounds containing Clostridium bacteria. It is not be an ideal treatment modality for large wounds or those with excessive amounts of unhealthy tissue. It should also not be considered in patients with sensitivity to the ingredients in the product.³ Moreover, silver dressings, certain wound cleansers, or other products may deactivate collagenase; if using this method, be aware of the potential interactions among topical therapies. Hydrosurgical: As a form of debridement, hydrosurgery uses a high-pressure fluid jet that runs parallel to the wound’s surface to draw non-viable tissue into a cutting chamber for excision and removal. It is often used as an alternative to sharp debridement.⁵ Although an expensive and time-consuming option, hydrosurgery is particularly effective for debriding burns.⁶Ultrasonic: Ultrasonic debridement uses low-frequency sound waves to remove non-viable tissue by emulsification of the tissue.⁷ This method is beneficial in treating wounds that are in locations that may be difficult to access or for wounds with deep cavities. It is often considered an alternative to sharp debridement.⁸

Conclusion

The management of acute or chronic wounds with necrotic and non-viable tissue can be complex. The mode of debridement should be selected depending on the wound characteristics, other comorbidities, and the patient-centered considerations. Please verify scope of practice and licensure restrictions before performing any method of debridement. Additional training or restrictions may limit the ability to perform certain methods of debridement.

References 1. Frykberg RG, Banks J. Challenges in the treatment of chronic wounds. Adv Wound Care. 2015;4(9):560-582. 2. Carpenter S, Shaffett TP. Choosing the best debridement modality to ‘battle’ necrotic tissue: pros and cons. Today’s Wound Clinic. 2017;11(7). https://www.todayswoundclinic.com/articles/choosing-best-debridement-mo…. Accessed April 8, 2020. 3. Manna B, Morrison CA. Wound Debridement. Treasure Island, FL: StatPearls; 2020. https://www.ncbi.nlm.nih.gov/books/NBK507882/. Accessed March 26, 2020. 4. Meads C, Lovato E, Longworth L. The Debrisoft monofilament debridement pad for use in acute or chronic wounds: A NICE medical technology guide. Appl Health Econ Health Policy. 2015;13(6):583-594. 5. Oosthuizen B, Mole T, Martin R, Myburgh JG. Comparison of standard surgical debridement versus the VERSAJET Plus Hydrosurgery system in the treatment of open tibia fractures: a prospective open label randomized control trial. Int J Burns Trauma. 2014;4(2):53-58. 6. Rees-Lee JE, Burge T, Estela CM. The indications for Versajet hydrosurgical debridement in burns. Eur J Plast Surg. 2008;31(4):165-170. 7. Chang YR, Perry J, Cross K. Low-frequency ultrasound debridement in chronic wound healing: a systematic review of current evidence. Plast Surg (Oakv). 2017;25(1):21-26. 8. Bruno A, Schmidt B, Blume P. Ultrasonic debridement for wounds: where are we now? Podiatry Today. 2015;28(7):62-66.