Made EasyDebridement Made Easy

Debridement Made Easy

Complex wounds, Surgical wounds | Kathryn Vowden, Peter Vowden

WHEN TO DEBRIDE?
A structured approach to the assessment, diagnosis and management of any type of wound is essential to ensure appropriate review and achievement of desired outcomes (Gray et al, 2011). Careful assessment is essential before taking the decision to debride a wound.

Debridement is indicated when there is a build up of necrotic tissue, callus, slough or other non-viable tissue in the wound bed. It is important to recognise and differentiate between types of tissue. As part of the patient assessment, the clinician should consider the risk that the devitalised tissue presents to the patient, whether necrotic tissue should be left in situ such as in some cases of dry gangrene, and whether there is a need for rapid debridement to prevent infection and general sepsis (Gray et al, 2011).

Attention should also be paid to the patient's underlying comorbiditiesand his/her current status as there are situations when debridement of dry eschar would be inappropriate and involvement of the multidisciplinary team is vital. 

The practitioner should ask the following questions before making a decision:

  • What is the cause of the wound?
  • What is the aim of treatment?
  • What are the risks and benefits of performing debridement?
  • What speed of debridement is required?
  • Which method would be most appropriate?
  • Where are the skills and/or equipment required to perform the treatment?


If there are any doubts or concerns, specialist help should be sought prior to commencement of debridement. The ultimate aim of wound debridement is to obtain a clean healthy wound bed to allow rapid and effective healing.
Debridement is often the first component of care. However, debridement alone will not achieve healing and must be usedas part of an overall management plan involving the patient, his/her disease process and the wound itself. It is important to achieve the right balance in the amount of tissue removed. Removing viable tissue may prolong the healing process, while removing too little non-viable tissue will delay healing. Skilled reassessment will help to monitor progress. Complete debridement of a chronic wound is rarely obtained in a single episode. Adherent fibrinous tissue or slough can re-accumulate and further maintenance debridement is necessary and may continue to be needed as the wound reduces in size.

The need for further debridement is only eliminated when the wound bed is composed solely of healthy granulating tissue. Successful debridement is often associated with a progressive reduction in wound exudate, a reduction in odour and the appearance of a healthy granulating wound bed.

 

 

WHO SHOULD DEBRIDE?
The decision to debride a wound can be complex and may require the multidisciplinary team involvement. Once the decision to debride a wound is made and the method confirmed, clinicians should consider their own skills to perform the task. Further staff training or specialist referral may be a necessary consideration to provide safe and effective care.
Clinicians performing wound debridement are expected to have:

  •     Good knowledge of relevant anatomy
  •     Understanding of the range of wound debridement methods available
  •     Capability to identify viable tissue and differentiate non-viable tissue
  •     Ability to manage pain and patient discomfort prior to, during, and following the procedure
  •     Appropriate skills to deal with complications (eg bleeding)
  •     Awareness of infection control procedures.

Some methods of debridement require a lower level of skill to perform and are available to generalist nurses. These include autolytic methods, biosurgical therapy and the recently introduced mechanical method, Debrisoft® (Activa Healthcare).


WHEN IS REFERRAL NECESSARY?
If any doubt exists as to the diagnosis or treatment pathway, referral for assessment and advice from the specialist wound care or tissue viability team should occur prior to debridement.
Wounds that should not be debrided without specialist involvement are:

  • Wounds on the hands, feet or face. These wounds require multidisciplinary involvement
  • Lower limb wounds on patients with arterial disease who require the assessment and advice of the vascular team
  • Patients with inflammatory conditions such as pyoderma gangrenosum where active debridement may lead  to wound deterioration. These patients require review by the dermatology team
  • Wounds that are associated with congenital malformation or when malignancy is suspected or the normal anatomy is changed. The wound location will decide the correct team involvement - this will usually be the plastic surgical team
  • Patients with a prosthetic implant in the region of the wound require a review and advice from the appropriate surgical team.

Caution is advised when patients have clotting disorders or are on anticoagulant therapy. Patients who have active, untreated wound infection require urgent intervention covered by antibiotic therapy.