To Debride or Not to Debride: That is Not the Question… Protection Status
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scapel for debridement

by Michel H.E. Hermans, MD

There are a number of general rules in surgery. Among these: dead space has to be avoided. interestingly enough, there is virtually no real scientific documentation about this topic but everybody knows this to be true (in ulcers this, of course, applies to fistulae, crevices, etc.).

Another general rule is that dead tissue and foreign bodies have to be removed since they are dangerous to the body. Dead tissue (necrosis and slough) is a breeding ground for bacteria, leading to infection (and sepsis) and releases toxins into circulation. As an example: a regular-size adult with a 50% total body area full-thickness burn has 5 kilos (approximately 11 pounds) of dead tissue, and the absorbed toxins rapidly lead to burn disease, a systemic phenomenon. Similarly, in patients with necrotizing fasciitis, an infection that starts as a localized one but very rapidly expands, the mortality is very high when excision is not performed quickly and radically. Both are examples of why debridement is necessary. So why, then, is debridement performed less frequently on many chronic wounds?

The Role of Debridement in Wound Treatment

In patients with ulcers, sepsis rarely occurs which may be one of the reasons why debridement, getting rid of dead tissue with the associated bacteria (and biofilm), is not performed as often as it should be. When I did a photographic review of a number of clinical cases of patients who had been treated for sometimes years without significant signs of progress, it became rapidly clear that many of the ulcers, covered with slough and necrosis, had been treated with more or less sophisticated dressings but without frequent debridement.

It often surprises me at chronic wound care conferences that debridement per se still needs to be discussed: with few exceptions it is not an option but should be an integral part of wound care (as the TIME acronym indicates). Unfortunately, it often is not. Its importance cannot be stressed enough. It is probably even fair to say that, without proper and frequent debridement, even the most sophisticated dressings and treatment mechanisms fail to do their job properly or optimally.

Barriers to Success for Different Debridement Techniques

In looking at the various techniques available for wound debridement, we may also look at some of the barriers each method presents, perhaps lending reason to the frequency of performance. Autolytic debridement works somewhat but is slow. Certain enzymes have shown to be effective but not all of them are and if they work they are also slow. Wet to dry technique does work well but is painful and harms the wound surface since it is indiscriminate. Biomechanical debridement (with maggots) is very effective but the psychological impact of having crawling creatures in one's wound should not be underestimated. Surgical debridement is by far the quickest way but has to be performed carefully to avoid damage to the tissues and may only be used by specifically trained health care providers. And then, of course and as always, reimbursement issues may play a significant role.

Still, whatever debridement methodology is chosen: it should always be at the top of the list of wound care interventions and not an afterthought. Following the general rule, careful consideration should be given to all wounds that may benefit from having debridement performed to optimize the effectiveness of the overall treatment regimen.

About the Author
Michel H.E. Hermans, MD, is an expert in wound care and related topics, trained in general surgery, trauma care and burn care in the Netherlands. He has more than 25 years of senior management experience in the wound care industry. He has conducted a large number of clinical trials relating to devices and drugs aimed at wound care and related indications and diseases. Dr. Hermans speaks internationally and has authored many published works relating to wound management.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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Great and timely

I like to consider the "why" rather than just focusing on the "what." If we understand how wounds heal, we can make better intervention decisions. For example, dead space should be lightly filled so that the wound's surface tissue does not close prior to the deeper tissue closing, leading to an inaccessible non-healing cavity wound, or abscess. Slough is caused by the body's inflammatory response to foreign bodies and microbes in the wound bed. Many methods of debridement remove slough while increasing inflammation. This leads to a need for repeated debridement as the slough recurs. "

I think of the wound bed as a nursery for granulation buds. When I first evaluate a wound, usually it is avascular, and often it contains a lot of slough or eschar. This empty nursery can be cleaned pretty thoroughly with relatively harsh antiseptics, sharp debridement, whatever the patient will tolerate, because there are no babies in the nursery yet, anyway. The cleaner I get the wound bed at this point the less work the body will have to do. My final rinse is with water or saline, and after this initial wound cleansing, I treat that wound bed gently, because now it is housing growing baby granulation buds, and they are easily harmed. I am usually able to prevent new slough from forming by keeping inflammation in check. I do this by using dressings that continuously cleanse the wound bed so that at dressing changes I simply remove the old dressing, assess the wound, and apply and new dressing - I do not even rinse routinely.

Expert opinion" says that autolytic debridement is slow - too slow - but there is little evidence to support this. I have found that "experts" are often so nervous about the slightest maceration that they keep wounds too dry for autolytic debridement to take place efficiently. Keeping wounds quite moist while preventing maceration - the best of both worlds - is possible with modern dressings which wick moisture vertically (away from the periwound) and have an "intelligent" protective outer thin-film membrane that adjust the moisture vapor transmission rate depending upon the levels of moisture the dressing encounters.

I totally agree with your analogy. I do not do sharp debridement every week like so many do. I agree it is important to be gently on that new granulation tissue. Could money be a factor in why some do it so often?

At our facility, we have a very effective collaborative team effort and approach when it comes to wound care. Becuase of this, the Physical Therapists are asked to evaluate wounds often. As sharp debridement is one aspect of our scope of care and covered under our license, the PT's will debride when indicated. It is surprising how few doctors and nurses know that sharp debridement is one of our many skills. I agree that debridement (sharp, in particular) is an important part of wound healing.

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