Debridement

Recommendations

Identify and Treat the Cause
1 Obtain a careful history and assess the patients’ ability to heal before debridement Level of Evidence
Not Assessed
2 Optimize the wound environment to support healing - ensure adequate blood supply, control infection and inflammation, provide moisture balance Level of Evidence
Not Assessed


Address Patient Centered Concerns
3 Assess /prevent and control pain: persistent (chronic) and procedural wound pain by using appropriate pain management techniques. Level of Evidence
Not Assessed
4 Consider patient preferences and establish realistic expectations for wound pain management. Level of Evidence
Not Assessed


Provide Local Wound Care
5 Assess the wound; Document baseline wound size and characteristics along with changes on reassessment. Level of Evidence
Not Assessed
6 Ensure bleeding control and use of appropriate haemostatic technique. Level of Evidence
Not Assessed
7 Cleanse wounds with low-toxicity solutions such as normal saline or water. Topical antiseptic solutions should be reserved for wounds that are non healable or those in which the bacterial burden is of greater concern than the stimulation of healing. Level of Evidence
Not Assessed
8 Select an appropriate method of wound debridement for each wound. Level of Evidence
Not Assessed
9 Debride healable wounds: remove nonviable, contaminated or infected tissue (surgical, autholytic, enzymatic, mechanical, and larval).Non healable wounds should have only non viable tissue removed; active debridement to bleeding tissue is contraindicated. Level of Evidence
Not Assessed
10 Assess and control increased bacterial burden and infection Level of Evidence
Not Assessed


Provide Organizational Support
11 Develop an inter professional approach with appropriate consultation to improve patient outcomes. Level of Evidence
Not Assessed
12 Consider cost effectiveness of proper debridement and their potential to promoting wound healing and wound closure over time. Level of Evidence
Not Assessed


Background

Debridement is the process of removing slough, non viable tissues and scars in order to permit healing. Wound debridement is a crucial step in wound management and an essential component of wound bed preparation paradigm. Debridement enhances healing by providing the possibility for accurate wound assessment, decreasing the risk of infection and activating cells by removing senescent fibroblast and non migratory epithelial cells from the wound; this has the benefit of converting chronic wounds to acute wounds with improved wound bed perfusion. Devitalized tissue on chronic wounds enhances bacterial growth, inhibits the formation of granulation tissue and prevents the closure of wound edges. Prior to performing debridement, vascularity of the wound must be assessed.

The types of debridement currently used in clinical practice include sharp, mechanical, enzymatic, autholytic and biotherapy. In sharp debridement which is a rapid and precise method, non viable tissue are removed until normal vascularised tissue appears. Sharp debridement is cost effective and preferred method for appropriate patients. Mechanical debridement including wet to dry gauze involves placing saline gauze over the wound and then removing the dried gauze with tissue adhered. This method is often questioned due to association with high degree pain and limited selectivity of non viable tissue. Autholytic debridement is separation of necrotic tissue from wound bed in a moist wound environment. Enzymatic debridement involves placing exogenous enzymes on wound bed to remove necrotic tissue. Overall, debridement is part of best standard care in the treatment of chronic wounds.

References

Essential Publications
1 Sharp debridement on recalcitrant nonhealing venous leg ulcer Quality Indicator
 Type: Cohort study (2 groups)
Williams D, Enoch S, Miller D, Harris K, Price P, Harding K. Effect of sharp debridement using curette on recalcitrant nonhealing venous leg ulcers: A concurrently controlled, prospective cohort study. Wound Rep Reg, 2005; 13(2):131-137.
This prospective cohort study was conducted to evaluate the effect of sharp debridement on the progression of recalcitrant chronic venous leg ulcers (CVLU) and to assess the feasibility of performing this procedure in an outpatient setting. The study group with sloth, nonviable tissue and no granulation tissue (n=28) underwent sharp debridement, while the control group (n=27) received the same but had minimal granulation tissue a not sloth or nonviable tissue. Between weeks 8 and 20 post-debridement 16% of the study group versus 4.3% of the control group ulcers achieved complete healing. The infection rates and antimicrobial usage were similar between the two groups. Based on these findings sharp debridement is effective in stimulating healing of recalcitrant CVLU and is safe, well tolerated and can be applied in an outpatient setting.
2 EMLA topical anesthetic for debridement of venous leg ulcers Quality Indicator
 Type: RCT
Lok C, Paul C, Amblard P, Bessis D, Debure C, Faivre B, Fuillot B, Ortonne JP, Huledal G, Kalis B. EMLA cream as a topical anesthetic for the repeated mechanical debridement of venous leg ulcers: A double-blind, placebo-controlled study. Journal of the American Academy of Dermatology, 1999; 40(2): 208-13
In this randomized, double-blind, placebo controlled study the effectiveness of EMLA cream was compared with placebo on the number of debridements required to obtain a clean ulcer, on pain during debridement and to determine its safety following repeated dosses. Results showed that application of EMLA cream prior to debridement decreased the medium number of debridements required for a clean ulcer (EMLA 11.5, placebo > 15, P = 0.019) and decreased pain by 50% (P = 0.003). Thus EMLA treatment provides effective pain relief for debridement of venous leg ulcers and decreases the time necessary to achieve a clean ulcer.
3 Chemical debridement ointment debridement of pressure ulcer Quality Indicator
 Type: RCT
Alvarez OM, Fernandez-Obregeon A, Rogers RS, Bergamo L, Masso J, Black M. A prospective, randomized, comparative study of collagenase and Papain-Urea for pressure ulcer debridement. Wounds, 2002; 14(8):293-301.
This prospective, randomized clinical trial compared two chemical debridement ointments, collagenase and Papain-Urea, for their effective removal of devitalized tissue and promotion of granulation in pressure ulcers requiring debridement. Two groups treated with one of the two ointments and results showed the papain-urea debriding ointment to be significantly more effective (p < 0.0167) than the collagenase ointment in reducing the amount of necrotic tissue. Development of granulation tissue in wounds treated with papain-urea was significantly enhanced as compared to wounds treated with collagenase. Despite the advantages exhibited from the papain-urea debriding ointment, a strong scientific conclusion cannot be made because of the small sample size (n=26).
4 Debridement of diabetic foot ulcers Quality Indicator
 Type: Systematic review
Edwards J. Debridement of diabetic foot ulcers. Cochrane Database of Systematic Reviews 2002, Issue 4.
The aim of this review was to access the effectiveness of debridement as treatment for diabetic foot ulcers. 12 RCTs measuring complete wound healing or rate of healing were examined. Only hydrogel proved more effective then gauze or standard care in healing diabetic foot ulcers (Relative Risk 1.84, 95% CI 1.30- 2.6). While surgical debridement or larval therapy showed no significant benefit over standard treatment and hydrogel treatment. Based on these finding hydrogel appears to increase healing rate of diabetic foot ulcers, but more research is needed to evaluate the effects of a range of widely used debridement methods.
5 Wound bed preparation Quality Indicator
 Type: Narrative Review
Kirshen C, Woo K, Ayello EA, Sibbald RG. Debridement: A Vital Component of Wound Bed Preparation. Adv Skin Wound Care, 2006; 19(9):506-17.
This recent overview aims to provide physicians and nurses with condensed information about debridement and its role in wound healing. It focuses on educating the practitioner on how to effectively choose a method of debridement whether it be surgical, autolytic, mechanical, maggot or enzymatic debridement based on the clinician, patient and the wound. In this paper the evidence supporting the role of debridement in the removal of nonviable necrotic tissue in order to effectively prepare the wound bed for healing is discussed.
6 MIST ultrasound therapy debridement for chronic wounds Quality Indicator
 Type: Non-randomized controlled trial
Ennis WJ, Valdes W, Gainer M, Meneses P. Evaluation of Clinical Effectiveness of MIST Ultrasound Therapy for the Healing of Chronic Wounds. Adv Skin Wound Care, 2006; 19(8):437-46.
This non-comparative clinical outcomes trial examines the effectiveness of using MIST Ultrasound Therapy for the cleaning, closure and debridement of chronic wounds. As well, this study aims at determining the optimal treatment duration and to analyze the impact of said treatment on the microcirculatory flow patterns within the wound bed. 23 outpatients were treated with low-frequency non-contact ultrasound therapy and compared with historical controls. It took 7 weeks for the treatment group to heal, compared to 10 weeks for the historical controls. Since the control group consisted of patients who required wound-related hospitalizations and surgical procedures to achieve complete closure its comparability with the study group is questionable. These results require further investigation to assess this technology via a well-designed health economic-based trial.
7 Debridement Quality Indicator
 Type: RCT
König M, Vanscheidt W, Augustin M, Kapp H. Enzymatic versus autolytic debridement of chronic leg ulcers: a prospective randomised trial. J Wound Care 2005;14(7):320-3
The efficacy of two debriding approaches for chronic leg ulcers were compared in this study. The two approaches were TenderWet 24, an autolytic degradation treatment (n=15), and Iruxol N (Santyl), an enzymatic approach (n=27). The authors were unable to recruit 29 subjects per group, the sample size required to detect 30% superiority. Therefore, the difference between the two products was not statistically significant. This article illustrates some of the difficulties researchers face in trying to compare the effectiveness of wound care products.


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