Introduction

Debridement is an essential component of wound care.¹ Put simply, it is the removal of devitalized tissue from a wound. As with any procedure, each form of debridement has its potential complications. The types of debridement include²:

• Biological
• Enzymatic
• Autolytic
• Mechanical
• Sharp
• Surgical
• Hydrosurgical

Wound care clinicians should understand the potential complications associated with the common types of debridement and the steps wound care providers can take to reduce the patient’s risk. Below the discussion highlights some of the possible complications that can arise from some of the various forms of debridement, and options to prevent or address them.²

Biological Debridement

Biological debridement, also known as maggot debridement therapy (MDT), involves the use of green bottle fly (Lucilia sericata) larvae. The larvae are applied to the wound bed, where the maggots release enzymes that digest necrotic tissue, slough, and bacteria.² One reported point of concern for biologic debridement use is an inability to tolerate the sensation of maggots in the wound.¹ Some patients may experience physical pain from biologic debridement, although this is cited as decreasing when the treatment ceases and as not impactful to quality of life.³

One must also consider the potential psychological impact of this type of therapy. One review noted that fear of deeper penetration of the maggots, "escaping," or general unpreparedness to undergo this treatment may indeed magnify the patient's pain experience.³ So, in addition to physical wound bed preparation, clinicians should take the time to educate and prepare patients on what to expect with this debridement method, dispel any myths and provide reassurance when indicated.³

Lastly, additional challenges associated with biological debridement can include potentially higher cost compared to other methods, availability, and provider experience with the process.³

Enzymatic Debridement

In enzymatic debridement, topical enzymes are applied to the wound to chemically liquefy and engulf necrotic tissue.² This method is often used to debride wounds containing Clostridium bacteria as well as burn wounds.¹ Enzymatic debridement is common in long-term care settings because it can be used daily and can be less painful than sharp debridement.^1,2

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Complications of this method include sensitivity to the product’s ingredients, and potential deactivation of collagenase by products containing silver and certain wound cleansers. In addition, it is not recommended for use in heavily infected wounds. To prevent complications, wound care providers can use an alternate debridement type, avoid agents that interact with the debridement’s enzymes, and avoid silver dressings and wound cleansers using hypochlorous acid.¹

One study of bromelain-based enzymatic debridement cited pain as a potential complication, however, this should be weighed as a factor in general when choosing a debridement technique.⁴ Providers should also be aware that patients may develop slight redness around the wound after using collagenase-based enzymatic debridement, particularly if the application was not limited to the wound bed and extended to healthy skin.⁵ Exercising proper application techniques, and educating patients on the same could mitigate this possibility.^4,5

Autolytic Debridement

As the slowest method, autolytic debridement uses the body's enzymes in combination with the moisture beneath an occlusive dressing to dissolve devitalized tissue.² These dressings can include alginates, hydrogels, and hydrocolloids. Often used in long-term care settings,² autolytic debridement is a good option to debride noninfected wounds or as an adjunctive therapy in infected wounds.¹

Possible complications associated with this technique include overhydration and maceration of the surrounding skin.⁶ Wound care professionals can prevent these complications by maintaining an appropriate moisture balance through the use of absorbent dressings that are changed frequently.^2,7

Mechanical Debridement

Mechanical debridement includes methods such as irrigation, wet-to-dry dressings, wet-to-moist dressings, and abrasion. Wet-to-dry dressings remove necrotic tissue and drainage from wounds but have fallen out of favor because they are painful, require frequent changes, and can damage healthy granulation tissue.¹ Wet-to-moist dressings are used to promote moist wound healing as well as remove wound drainage and dead tissue.²

Wet-to-moist dressings can be complicated by infection from inadequate packing of deep wounds.² Prevention includes preprocedural pain management,⁸ avoidance of wet-to-dry dressings,² and proper packing of deep wounds.²

Sharp (Surgical or Conservative Sharp) Debridement

To achieve either surgical or conservative sharp debridement, a skilled practitioner uses sterile instruments (scalpel, curette, medical scissors, forceps, etc) to remove biofilm and devitalized tissue.²

Surgical debridement must be performed in an operating room. Concerns may include bleeding, complications of anesthesia,² and general surgical risks. Providers should take measures to assess general surgical risk stratification prior to the procedure, control perioperative bleeding, and ensure a best-practice anesthesia protocol within one facility.⁹ Surgical sharp debridement is contraindicated for severe coagulopathy.¹⁰ Proper informed consent conversations with patients undergoing surgical debridement are also key.

Qualified practitioners can perform conservative sharp debridement in the outpatient setting or at the bedside.² Conservative sharp debridement, may, in some cases, result in pain² or bleeding.² Wound care providers can reduce these complications with topical anesthetics, preprocedural pain management,⁸ and measures that control periprocedural bleeding, such as the use of products like silver nitrate² or other topical procoagulants.

Hydrosurgical Debridement

This method uses a high-pressure liquid jet to debride nonviable tissue while irrigating the wound bed. The solutions used can include saline, hypochlorous acid, or other fluids. Unlike sharp debridement, hydrosurgical debridement has minimal impact on viable tissue and may cause less bleeding. It is effective in burn wounds and other wounds where the preservation of viable tissue is especially crucial.^1,11 Cross-contamination from water vapor spray can occur during the procedure, and the use of personal protective equipment is recommended as a preventive measure.¹²

Conclusion

Although each form of debridement has pros, cons, and potential complications, wound care professionals can mitigate the risks to their patients and themselves by knowing what to look for and following evidence-based preventive practices. Careful considerations of the unique features of each debridement method combined with thoughtful incorporation of patient- and wound-based factors can allow providers to choose the best treatment scenario in each case.

References

1. Manna B, Nahirniak P, Morrison CA. Wound debridement. In: StatPearls. StatPearls; 2024. Accessed February 5, 2024. https://www.ncbi.nlm.nih.gov/books/NBK507882/
2. Wound debridement options: the 5 major methods. Practice Accelerator. WoundSource.com. 2018. Accessed February 5, 2024. https://www.woundsource.com/blog/wound-debridement-options-5-major-meth…
3. Thomas DC, Tsu CL, Nain RA, Arsat N, Fun SS, Sahid Nik Lah NA. The role of debridement in wound bed preparation in chronic wound: A narrative review. Ann Med Surg (Lond). 2021;71:102876. doi:10.1016/j.amsu.2021.102876
4. Shoham Y, Krieger Y, Tamir E, et al. Bromelain-based enzymatic debridement of chronic wounds: A preliminary report. Int Wound J. 2018;15(5):769-775. doi:10.1111/iwj.12925
5. A patient’s guide Collagenase SANTYL Ointment. Smith & Nephew. Published 2016. https://santyl.com/sites/default/files/2020-06/SAPE38-21675-0420-SANTYL…
6. Vowden P. Autolytic debridement. In: Téot L, Banwell PE, Ziegler UE, eds. Surgery in Wounds. Springer; 2004:77-80.
7. Pargi AK, Pachole V, Yadav R. To compare the efficacy of four conventional and contemporary methods of debridement I.e. surgical, autolytic, enzymatic and mechanical, in the healing of wounds of various etiology. J Cardiovasc Dis Res. 2021;12(6):333-339.https://jcdronline.org/admin/Uploads/Files/6287730db9d2b9.48238772.pdf
8. Sibbald RG, Elliott JA, Persaud-Jaimangal R, et al. Wound bed preparation 2021. Adv Skin Wound Care. 2021;34(4):183-195.
9. Anesthesiology Risk Stratification. UCLA Health. Accessed February 1, 2024. https://www.uclahealth.org/departments/anes/referring-providers/risk-st…
10. Tran DL, Ren-Wen H, Chiu ES et al. Debridement: technical considerations and treatment options for the interprofessional team. Adv Skin Wound Care. 2023;36(4):180-187. https://journals.lww.com/aswcjournal/Fulltext/2023/04000/Debridement__T…
11. Wormald JCR, Wade RG, Dunne JA, Collins DP, Jain A. Hydrosurgical debridement versus conventional surgical debridement for acute partial-thickness burns. Cochrane Database of Syst Rev. 2020; https://doi.org/10.1002/14651858.CD012826.pub2
12. Atkin L. Understanding methods of wound debridement. Br J Nurs. 2014;23(suppl 12):10-15.

Further Reading

Álvaro-Afonso FJ, Flores-Escobar S, Sevillano-Fernández D, García-Álvarez Y, García-Madrid M, Lázaro-Martínez JL. A deeper look at low-frequency contact ultrasonic debridement in the clinical management of patients with diabetic foot ulcers. Wound Repair Regen. 2023;31(6):745-751.

Legemate CM, Kwa KAA, Goei H, et al; HyCon Study Group. Hydrosurgical and conventional debridement of burns: randomized clinical trial. Br J Surg. 2022;109(4):332-339.