1. Debridement
Dr. Julia Overstreet
DPM, FAPWCA

2. 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

4. 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.

5. 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?

6. 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

7. 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

9. 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

10. 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

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

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

14. 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

15. 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

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

17. 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 ?

18. Pain during Debridement

19. 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.

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

21. 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

22. Autolytic Debridement
Hydrogel Sheets
Hydrogels
Other gel dressings

23. 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

24. 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

25. What are you cutting?

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

27. Cartilage
Connective tissue covering articular surface of bone at joint

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

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

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

32. 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

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

35. 4 3 2 1 1
1=Bone 2= Cartilage 3= Fascia 4= Fat

36. 3 3 1 2 1 4 1
1= Fascia & Sub Q Fat = Tendon 3= Nerve 4= Muscle

37. 1= Tendon 2= Ligament 3= SubQ Fat 4= Fascia

38. 1= Nerve in Fascia 2=Fascia over Muscle 3= Tendon

39. 4 4
1= Tendon 2= Bone =SubQ Fat 4= Fascia

40. 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

41. 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.

42. 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.

46. Iris Scissors
Forceps
Dermablade

47. Surgical Curette

48. Undermining & Tunneling

49. Undermining
Abrade (to increase contact/connection)

50. Dermal Curette
Surgical Curette