Why debride necrotic tissue

Enzymatic debridement, or chemical debridement, uses an ointment or gel with enzymes that soften unhealthy tissue. The enzymes may come from an animal, plant, or bacteria.

The medication is applied once or twice a day. The wound is covered with a dressing, which is changed regularly. Enzymatic debridement is ideal if you have bleeding problems or a high risk for surgery complications.

Autolytic debridement is best for noninfected wounds and pressure sores. Mechanical debridement is the most common type of wound debridement. It removes unhealthy tissue with a moving force. Conservative sharp debridement uses scalpels, curettes, or scissors. As a minor bedside surgery, it can be performed by a family physician, nurse, dermatologist, or podiatrist. Surgical sharp debridement uses surgical instruments. The cut might include healthy tissue around the wound.

A dental debridement is a procedure that removes tartar and plaque buildup from your teeth. A medical professional will apply the treatment, which is repeated for two to six weeks or longer. Sharp debridement is quick. During the procedure, the surgeon uses metal instruments to examine the wound. The surgeon cuts out old tissue and washes the wound. Often, debridement is repeated until the wound heals. Depending on your wound, your next procedure might be a different method.

Local anesthesia will numb the wound. Sometimes it can hurt when the dressing is changed. Less pain involved. Can be utilized in any type of setting. Topical applications are usually less expensive than other dressing selections. CONS : Risk of periwound maceration. Slow method of removing nonviable tissue.

Odor typically present and can increase risk of infection. Biosurgical debridement, also known as sterile medical maggot therapy, involves placing live, sterile bottle fly larvae Lucilia sericata into chronic, necrotic wounds of the extremities. Maggots eat only necrotic tissue and will not harm healthy tissue. The question that is often asked is — How are the larvae sterilized? For clarification, they do not undergo miniature hysterectomies and vasectomies, but, rather, they are born hatched into a sterile environment before being placed into a wound.

The maggots serve three basic functions: 1 debridement, 2 disinfection of the wound with biofilm inhibition, and 3 stimulation of wound improvement. Typically, there is no need to count the number of larvae that go into the wound bed or count the number that come out, although the recommendation is to apply larvae per cm 2 of wound.

Generally, they are left in place for 72 hours before removal and then discarded in a standard biohazard bag. Does not remove viable tissue. Best performed in the inpatient setting to maintain control of maggots.

CONS : Should only be used on extremities. Contraindicated in or near body cavities such as the abdomen and thorax or around necrotic blood vessels. It takes two weeks for a maggot to transform into a fly under ideal circumstances, which should never happen in a controlled hospital setting.

Enzymatic debridement utilizes enzymes to degrade and remove necrotic tissue. These enzymes digest and dissolve necrotic tissue in the wound bed by breaking down collagen, elastin, and other parts of the devitalized wound matrix found within the wound bed.

Most of these enzyme types have been removed from the commercial market, with the exception of those that target nonviable collagen known as collagenases. This enzymatic debridement selection, while targeting the nonviable collagen tissue, spares viable tissue, making it beneficial in necrotic wounds with slough in the base of the wound. Collagenase is derived from Clostridium histolyticum and is a prescription medicine. It is believed to upregulate the migration of keratinocytes over the wound bed and stimulate granulation development while it degrades nonviable tissue.

Reduces scarring. Can be used in conjunction with routine surgical debridement. Works faster than most autolytic options. Best when used in conjunction with weekly selective debridements. CONS : Very slow action. Cannot eliminate large amounts of necrotic tissue. Expensive when compared to autolytic debridement items. Not as effective as surgical debridement alone. Clinicians sometimes rely solely on enzymatic debridement instead of aggressively excising necrotic tissue early in treatment course.

Antimicrobial agents, such as silver and iodine, when used in conjunction with collagenase can decrease enzymatic debridement effectiveness. It is common knowledge that ischemic wounds of the extremities with critically compromised blood flow should not be debrided until adequate revascularization has been achieved. Post-revascularization microangiographic diagnostic studies are sometimes inconclusive, with transcutaneous oximetry readings or skin perfusion pressure values yielding borderline results.

Many wound specialists would err on the side of caution and withhold debridement of necrotic extremity ulcers. The diagnostic aspect of this type of approach allows the wound specialist to determine if there is enough blood flow to heal the skin in that specific angiosome based on clinical observation post-debridement. If after one week post-debridement the wound appears to be improving, keep debriding.

If the wound maintains a dry, nonviable status, paint daily with an antimicrobial solution eg, povidine and manage conservatively or refer for amputation, if appropriate. This old rule has become controversial, as a patient with adequate blood flow to the foot and heel can be carefully debrided with excellent results, especially if care is taken not to expose healthy calcaneal bone.

Diagnostic debridement can be beneficial with this type of patient. After initial debridement of the eschar edges, if the wound worsens, discontinue further procedures. If the wound edges fill in with each debridement, continue weekly procedures until closure. Debridement is contraindicated when there is expanding tissue necrosis with violaceous border. Once the patient has been successfully treated with sodium thiosulfate therapy and the necrosis expansion and violaceous border has subsided, the wound may be surgically debrided.

The diagnostic debridement approach can be used with repeat procedures being performed only if the wound responds positively to the initial debridement.

Debridement is contraindicated when there is a raised, active border. Once the patient has been successfully treated with immunosuppressive therapy and the raised, erythematous border has subsided, the wound may be surgically debrided.

Debriding and then suturing a chronic wound closed should never be done. This should not be confused with the delayed primary closure technique that surgeons use to close acute wounds, which has been proven to work quite well. Nonhealing, chronic wounds are stalled in the inflammatory phase of wound healing. Thus, suturing a chronically inflamed wound traps drainage and eventually leads to dehiscence, usually with infection.

Definitively knowing which debridement modality to use and how often to debride when it comes to certain types of wounds is critical for any wound care clinician and will always be a challenge because each clinician has a different comfort level regarding aggressive debridement. With all the questions surrounding debridement, however, one thing is clear: inadequate debridement delays wound healing and patients become less forgiving the more time it takes to heal.

Maximizing each modality, whether alone or in combination, is the key to winning each fight in the battle against the 6 million chronic wounds affecting patients in this country. Shaun Carpenter is chief executive officer and co-founder of MedCentris, TM a multi-specialty practice group based in Hammond, LA, that focuses on wound healing and limb salvage.

He is also the inventor of the Carpenter Curette, TM a surgical instrument used to debride necrotic wounds. Todd Shaffett is president and co-founder of MedCentris and co-founder of Healtec, TM an advanced medical device company. Acute and impaired wound healing: pathophysiology and current methods for drug delivery, part 1: normal and chronic wounds: biology, causes, and approaches to care. Adv Skin Wound Care.

Skin Wound Healing. Biofilms made easy. Wounds Int. Differentiate Between Types of Wound Debridement. Accessed online: www. Clean vs. Wickline S. JAMA Dermatol. Press CD. Topical Anesthesia. Moses S. Local Skin Anesthesia. Family Practice Notebook. Ultrasonic debridement for wounds: where are we now? Podiatry Today. Low-frequency ultrasound debridement in patients with diabetic foot ulcers and osteomyelitis.

These eat only the dead skin and produce chemicals that promote healing. Benefits Surgical debridement of a diabetic foot ulcer stimulates the edge of the wound, releases growth factors and reduces inflammation. Removing dead, diseased and infected tissue allows healthy tissue to heal. Eliminates conditions for bacterial overgrowth and other disease processes that could lead to pain, sepsis, and eventually, amputation. Clinical Team Michael S. Conte, M. Gasper, M. Methods of debridement commonly used in the UK include:.

Autolytic Autolytic debridement is the most commonly used method of debridement. Autolytic debridement is useful where there are small volumes or superficial slough, however it can be a slow process often taking weeks to achieve a clean wound bed. This slow rate of debridement may raise the potential for infection and maceration of the peri-wound skin 9. Larval Larval therapy maggots is a form of biological debridement Figure 5.

The larvae of the greenbottle fly has been bred in sterile conditions for medical use for a number of years, and the maggots debride by secreting a proteolytic enzyme which liquefies the dead tissue.

Once this tissue is dissolved the maggots then ingest the fluid neutralising any bacteria in their gut. They do not, as commonly believed, bite or chew the dead tissue. Other benefits of larvae therapy have been published including increased irrigation of the wound bed by the movement of the larvae stimulating exudate production 10 and increased granulation growth rates through the changes in PH level on the wound bed increasing oxygenation and a number of growth factors.

Larval therapy offers a fast selective method of debridement but is not suitable for all wounds. The effectiveness solely relies on the survival of the larvae, so there needs to be consideration of whether they may be squashed, for instance if used on a heel of an active patient or if exudate levels are very high that they may drown. Not all patients accept the idea of maggots on their wound and detailed conversations with the patient must take place prior to their application to ensure the patient is fully informed and consents to treatment.

This non-discriminatory method resulted in damage to the healthy tissue and significant pain for the patient so has not been used for many decades within the UK. However, in recent years mechanical debridement is on the rise with the use of monofilament debridement pads Debrisoft. Debrisoft is a single use, soft, polyester fibre pad which is wiped across the wound in either circular or vertical motions depending on tissue type , dead cells and wound debris are caught within the fibres and removed from the wound bed 1.

The advantages of debridement using Debrisoft is that it is easy to perform, requires little training, it is a fast effective method which causes no damage to the healthy underlying or surrounding tissue.

After reviewing the published evidence NICE supported the use of Debrisoft as an effective method of wound debridement which additionally could reduce costs of patient care in the community setting.

Sharp debridement Sharp debridement involves the removal of dead tissue with a scalpel, pair of scissors or forceps In many cases the level of debridement is just above the level of viable tissue. Sharp debridement can only be performed by practitioners who have undergone appropriate training and who are able to prove competency in this area.

In experienced hands sharp debridement is a fast, selective and effective means to remove de-vitalised tissue which it is often pain free for the patient. Surgical debridement Surgical debridement is the fastest and usually the most thorough method available.

It is usually performed in an operating theatre and involves an anaesthetist and a surgical practitioner resulting in this being a high cost option. In many instances it results in a larger wound being created as surgical debridement is not as selective as some other methods, and frequently an element of viable tissue is also removed. Due to these issues surgical debridement tends to be reserved for patients with extensive tissue damage or those facing risk from increasing virulent infection such as diabetic foot ulceration or necrotising fasciitis.

Conclusion Debridement is an integral part of wound management. The aim of debridement is to remove non-viable tissue allowing wound healing to occur. Many different methods of debridement are available each with their own specific advantages and disadvantages. Nurses based in the community continue to provide the majority of wound care to patients. In order to deliver high quality care they need to be confident that they posess the required knowledge and skills to accurately assess the wound, to formulate appropriate aims of care and to select the most applicable method of debridement.