Debridement Dr. Julia Overstreet DPM, FAPWCA

Debridement Why debride? Wound assessment (Appropriate staging of wound) Remove medium for bacterial growth Facilitate wound healing. (Necrotic tissue delays formation of granulation and epithelial tissue) Control odor Expose underlying abscess/pockets

Debridement All wounds with devitalized tissue should be debrided at each visit (except intact eschar on heels) as this material delays wound healing and predisposes to infection.

Decision to Debride The importance Must evaluate Removes debris that blocks healing steps Places wound on positive healing trajectory Must evaluate Wound etiology Wound size Infection Necrotic tissue Patient tolerance Is there tunneling, undermining present?

Indications for Debridement : in presence of necrotic, senescent tissue or biofilm when there is excessive fibrotic tissue if callus surrounds wound when circulation is adequate with advancing cellulitis refer appropriately

Responsibilities Before Beginning Debridement Seek appropriate education & practice Know YOUR parameters State Nurse Practice Act Position Papers Learn tissue types Review facility Policy/ Procedures Evaluate benefits of debridement to client Select time and conditions carefully Explain procedure to client

Methods of Debridement Available Mechanical wet -to-dry irrigation Hydrotherapy Ultrasound Autolytic neutrophils and macrophages Chemical enzyme bleach Conservative Sharp No “live” tissue cut Sharp Surgical most aggressive, fast most expensive Other maggots

Mechanical Debridement Wet-to-dry Totally non-selective Painful Time consuming Not always the best choice • Use of external substance to remove devitalized tissue – Wet/dry gauze – Irrigation – Hydrotherapy

Mechanical Debridement (new school!) Pulse Irrigation Vacuum-Assisted Closure/Negative Pressure Removes: Devitalized tissues Bacteria and proteolytic enzymes Senescent cells

VERSAJET◊ Hydrosurgery System The VERSAJET◊ Hydrosurgery System utilizes a high-pressure jet of sterile saline that travels parallel to the wound surface.

General Therapeutic Ultrasound This drawing depicts the effects of low frequency, non-contact, non-thermal ultrasound on human fibroblasts Please note the cavitation on and near the cell surface Please note the acoustic microstreaming along the cell surface Ultrasound and its effects on wounds have been studied for more than 40 years. These are the effects of therapeutic both thermal and nonthermal ultrasound reported in the literature 14 14

NPWT is particularly effective at: Negative Pressure NPWT is particularly effective at: Promoting granulation tissue formation Reducing bacterial burden Restoring moisture balance Improving perfusion Addressing all 4 barriers to healing in a single therapy NPWT is particularly useful in: Wounds that fail to close when other barriers are addressed Infected and highly contaminated wounds Wounds with heavy to extra-heavy exudate Difficult-to-heal wounds with multiple barriers to healing

Surgical Sharp Debridement Fastest so sometimes necessary to address infection from devitalized tissue Most expensive since done in OR

Conservative Sharp Debridement Is cutting dead tissue from dead tissue Should be bloodless, according to WOCN Should be painless, according to WOCN Pain… Medicate as needed Topicals eg 4% lidocaine gel Oral eg ?

Pain during Debridement

Conservative Sharp Debridement Best Uses: Wounds with a large amount of necrotic tissue. In conjunction with infected tissue. Advantages: Fast and Selective Can be extremely effective Disadvantages: Painful to patient Must be in scope of practice of provider Costly, especially if an operating room is required Requires transport of patient if operating room is required.

Autolytic Debridement Autologous enzymes debride tissue Moisture retentive dressings Leukocytes collect in wound Upon cell death – lysosomal enzymes released – degrading proteins and mucopolysaccharides

Autolytic Debridement Best Uses: In stage III or IV wounds with light to moderate exudate Advantages: Very selective, with no damage to surrounding skin. Effective, versatile and easy to perform Little to no pain for the patient Disadvantages: Not as rapid as surgical debridement Wound must be monitored closely for signs of infection May promote anaerobic growth if an occlusive hydrocolloid is used

Autolytic Debridement Hydrogel Sheets Hydrogels Other gel dressings

Enzymatic Debridement Best Uses: On any wound with a large amount of necrotic debris. Eschar formation Advantages: Fast acting Minimal or no damage to healthy tissue with proper application. Disadvantages: Expensive Requires a prescription Application must be performed carefully only to the necrotic tissue. May require a specific secondary dressing Inflammation or discomfort may occur Eg. Collagenase, an FDA-licensed biologic

Maggot Debridement Clinical benefits: • Highly effective debridement tool • Effective against wound pathogens - e.g.MRSA • Reported to be mostly pain-free A few patients experience adverse reaction to the enzymes created by maggots

What are you cutting?

Bone Hard, white if healthy Very vascular periosteum NOTE: Must keep bone moist to prevent necrosis

Cartilage Connective tissue covering articular surface of bone at joint

Fatty Tissue Fat – shiny, globular, yellow when viable - dull grey/brown to black when not viable

Skeletal Muscle Healthy dull red contractile vascular Unhealthy dark red/brown avascular

Fascia Shiny, white, surrounds muscle Grey to black if dying

Tendons Tendon Strong, elastic, fibrous tissue – attaches muscle to bone Shiny & white Poorly vascularized, becomes infected easily Has paratenon covering to carry blood flow Removal causes loss of function

Ligaments Band or sheet of strong fibrous CT Connects articular ends of bones, binds them together Important in movement

4 3 2 1 1 1=Bone 2= Cartilage 3= Fascia 4= Fat

3 3 1 2 1 4 1 1= Fascia & Sub Q Fat 2= Tendon 3= Nerve 4= Muscle

1= Tendon 2= Ligament 3= SubQ Fat 4= Fascia

1= Nerve in Fascia 2=Fascia over Muscle 3= Tendon

4 4 1= Tendon 2= Bone 3=SubQ Fat 4= Fascia

AFTER DEBRIDEMENT Patient observation -most important factor Documentation is next most important factor Primary provider must enter specific documentation to receive payment Tools used, process, amount of tissue removed, address bleeding /comfort Details must be fully addressed Re-evaluate patient condition post-debridement for safety

Example of Charting Saw this 78 year old male patient with Stage IV pressure ulcer. On sacrum. Current conditions impacting wound closure include A1c of 10.2 and severe atherosclerosis, both of which impede blood supply to soft tissue. He is malnourished with a pre-albumin of 13, decreasing bodies ability to build tissue and is S/P CVA causing limited mobility. On assessment, his wound was covered with yellow, tightly adherent slough.

Example of Charting This was debrided through skin and subcutaneous tissue to a clean base using a # 15 scalpel and curette. The wound was cleansed with NS and alginate layers applied to absorb the exudate. This was covered with absorbent pad and secured with tape. The dressing can be left in place until saturated, the outer pad changed. Patient reports only mild discomfort during procedure. He will be followed-up in 2 days.

Iris Scissors Forceps Dermablade

Surgical Curette

Undermining & Tunneling

Undermining Abrade (to increase contact/connection)

Dermal Curette Surgical Curette