Made EasyDebridement Made Easy

Debridement Made Easy

Complex wounds, Surgical wounds | Kathryn Vowden, Peter Vowden

Debridement Made EasyDebridement is an integral part of wound management and all practitioners should be aware of the range of options available. Although it is not necessary for practitioners to always personally be able to perform debridement, they should have sufficient understanding to recognise which technique is the most appropriate for the individual patient and his/her wound. This made easy section looks at the reasons for debridement, the methods available and the skills required to manage the wound effectively.

What is debridement?
Debridement is the removal of non-viable tissue (see Box 1) from the wound bed to encourage wound healing. Wound debridement is an essential part of wound care and its role in the preparation of the wound bed is well documented (Falanga, 2001; EWMA, 2004; Wolcott et al, 2009).

Why debride?
Chronic wounds often contain necrotic or sloughy tissue, which can harbour bacteria and act as a barrier to healing. The availability of nutrients and oxygen and presence of ischaemic tissue make this an ideal environment in which both aerobic and anaerobic bacteria can multiply (White and Cutting, 2008), increasing the risk of malodour and infection. Debridement of sloughy/necrotic tissue is one of the cornerstones of good wound practice and vital when reducing the bacterial burden within the wound (Vowden and Vowden 1999a; Vowden and Vowden 1999b). 

For chronic wound healing to occur, the molecular and cellular environment of the wound must resemble that of a healing acute wound (Schultz et al, 2003). Non-viable tissue and slough produces an abnormal wound environment that may interfere with wound healing. Debridement removes this tissue to provide a wound environment that is less likely to support a heavy growth of bacteria. Reducing the bioburden and the presence of biofilms within the wound further inhibits the proinflammatory responses, encouraging formation of granulation tissue in the wound bed (Wolcott et al, 2009). Chronic wounds may require repeated debridement to prevent the wound reverting to a chronic unhealthy state. Falanga refers to this as maintenance debridement (EWMA, 2004).

 

 

What are the methods of debridement?
Evidence defining the best method of debridement is scarce. In clinical practice, a range of debridement techniques are in use in the UK:

  • Autolytic
  • Biosurgical
  • Hydrosurgical
  • Mechanical
  • Sharp
  • Surgical
  • Ultrasonic.

All methods require varying levels of expertise and have their advantages and disadvantages in terms of time taken, patient acceptability and ease of use (Table 1). Sharp debridement is a very quick method, but should only be carried out by a competent practitioner, and may not be appropriate for all patients. Autolytic debridement is most commonly practised in the UK and is often used before other methods of debridement. Products that can be used to facilitate autolytic debridement include hydrogels, hydrocolloids, cadexomer iodine and honey. In choosing dressings that promote autolytic debridement, it is important to consider the moisture balance in the wound and take necessary steps to avoid maceration by the use of a suitable skin protectant or barrier film. 

What are the newer methods of debridement? 
Hydrosurgery systems (eg Versajet™, Smith & Nephew) combine lavage with sharp debridement and provide a safe and effective technique, which can be used in the ward environment (Gray et al, 2011). This has been shown to precisely target damaged and necrotic tissue and is associated with a reduced procedure time (Granwick et al, 2006; Caputo et al, 2008). It may also provide an effective tool to remove biofilm contaminated tissues (Allan et al, 2010). Other innovative methods include low-frequency, low-dose ultrasound using either a contact (Sonoca™, Soring) or non-contact device (MIST® Therapy, Celleration Inc).

Ultrasonic assisted debridement is a relatively painless method of removing non-viable tissue and has been shown to be effective in reducing bacterial burden, with earlier transition to secondary procedures (Ennis et al, 2006; Gray and Stang, 2010). However, these methods are potentially expensive and equipment may not always be available. Although traditional methods of mechanical debridement are considered potentially harmful, newer methods have revolutionised practice. More recently, an active debridement pad (Debrisoft®, Activa Healthcare) has been introduced, which uses a fleece-like contact layer to mechanically remove debris, necrotic tissue, slough and exudate (Gray et al, 2011). This has been shown to be effective in 94% of cases in patients treated on three occasions, approximately four days apart (Bahr et al, 2011).

It is easy to use, can be used by generalist nurses on the ward or in the patient’s home and is available on Drug Tariff.

How to decide which technique to use?
One of the key findings of a multidisciplinary UK consensus was that access to debridement should be based on clinical need and not the skill of the clinician (Gray et al, 2011). It is important that the decision to debride and the method of debridement selected is the most effective for the patient, the amount of non-viable tissue to be removed and the anatomical location of the wound, and should form part of the overall wound management plan for the patient.