DEBRIDEMENT Professor Donald G. MacLellan Executive Director Health Education & Management Innovations

DEBRIDEMENT Principles - CSD Methods of Debridement Biopsy options

PRINCIPLES OF WOUND MANAGEMENT * 07/16/96 PRINCIPLES OF WOUND MANAGEMENT 1. DEFINE THE AETIOLOGY 2. CONTROL FACTORS AFFECTING WOUND HEALING 3. SELECT APPROPRIATE WOUND DRESSING / BANDAGE 4. PLAN WOUND HEALING MAINTENANCE *

Wound Management Identify and address underlying pathology Provide systemic support for wound healing Identify and treat infection Debride non-viable tissue Utilize appropriate topical therapy

WOUND BED PREPARATION OPTIMUM PREPARATION of a wound bed for tissue repair in the absence of vascular disease or medical contraindications is DEBRIDEMENT

WOUND BED PREPARATION DEBRIDEMENT THE REMOVAL OF +/- NON-VIABLE TISSUE +/- NECROTIC TISSUE +/- BIOFILM +/- DEBRIS +/- SENESCENT TISSUE FROM A WOUND.

Rationale for Debridement Non-viable Tissue: Is a culture medium for bacterial growth incl biofilms Inhibits WBC phagocytosis Causes a prolonged inflammatory response → impairs wound healing

Rationale for Debridement Senescent Tissue: Impaired cell proliferation Decreased extracellular matrix production May not respond to cytokine or growth factor stimulation due to receptor loss

Rationale for Debridement Peri-wound Callus: Causes pressure to underlying tissue during weight bearing/walking Impairs epithelialization from wound edges Provides undermined area for bacterial growth

Indications for Debridement Non-viable and/or senescent tissue Excessive fibrin in wound Peri-wound callus Significant colonisation/biofilm Adequate healing potential

Contraindications for Debridement Non-infected ischemic ulcer with dry eschar Inadequate circulation No potential for healing Risk of deep structure exposure/damage Risk of uncontrolled bleeding Uncooperative patient/inadequate facilities

Indications for Specialist Referral N Necrotic tissue present, not removed by superficial debridement. O Osteomyelitis, presence of infected bone, including tendon or muscle involvement, may need to be surgically debrided to allow healing to occur. H Hidden sinus tracts and/or tunnel, which have increased in size or are infected. E Eschar not removable by conservative sharp debridement or other methods of debridement. A Abscesses present & requiring to be surgically incised and drained to decrease the chance of systemic infection. L Large defects too large to close by secondary intention. I lschaemia. N Non-healing wound in spite of appropriate treatment. G Graft ready wound bed.

WOUND BED PREPARATION DEBRIDEMENT AUTOLYTIC ENZYMATIC MECHANICAL ULTRASONIC BIOLOGICAL SHARP

What method to choose? Wound characteristics: The patient's attitude - aetiology, size, infection, pain, exudate, location, involved tissues - required rate of debridement The patient's attitude Available skills & available resources Costs

Autolytic Debridement

Enzymatic Debridement Collagenase: Santyl Papain-Urea: -Accuzyme -Ethezyme™ -Ethezyme 830™ -Kovia Papain-Urea:Chlorophyllin Copper Complex: -Panafil -Ziox

Mechanical Debridement Wet-to-dry gauze Scrubbing wound Whirlpool Wound irrigation

Maggot Debridement Therapy Larvae of Lucilia sericata (greenbottle fly) www.ucihs.uci.edu/com/pathology/sherman/maggots.htm www.smtl.co.uk

Conservative Sharp

Vascular Considerations Clinical Examination Ensure adequate local tissue perfusion ABI > 0.5 TcPO2 > 30 mm Hg

Conservative Sharp Debridement - Procedure

Instruments

Facilities Consented, cooperative patient Analgesia/anaesthesia assessment/Tx Relatively undisturbed environment Adequate lighting Adjustable height of bed/trolley/couch Sterile instruments & protective equipt Scout Dressings/bandages

Biopsy Techniques

What is a skin biopsy? Skin biopsy is a biopsy technique in which a portion of or all of a skin lesion is removed. This is sent to a pathologist for microscopic diagnosis. It is usually done under local anaesthetic in an ambulatory setting. The pathology results are generally available within 2-4 days. Commonly performed by medical practitioners. Important procedure for diagnosis of skin conditions

Tissue Biopsy for Diagnosis Malignancies Inflammatory conditions Vasculitic syndromes Dermatological disorders

Types of Biopsies Shave Punch* Incisional* Excisional *Used most commonly in wound care

Tissue Biopsy: Equipment

Shave Biopsy

Punch Biopsy

Excisional Biopsy

Tissue Biopsy for Diagnosis Clinical information essential Location and timing are crucial to an accurate diagnosis Biopsy newest lesions along the advancing edge of the abnormal area, including a rim of normal tissue

Biopsy: Relative Contraindications Bleeding disorders/anticoagulation therapy Immunosuppression Severe peripheral arterial disease Known or possible underlying vital structures

Debridement & Biopsy Summary Understand the pathophysiology of wounds Determine patient eligibility for debridement and biopsy Develop & follow protocols Acquire proper training/experience Understand your scope of practice