Approximately 2 million people in the United States are living with limb loss, and this figure is expected to double by 2050. Lower-limb amputation accounts for the vast majority of all amputations, and diabetes—specifically, diabetic foot ulcers (DFUs)—is the leading cause of nontraumatic...
By James McGuire, DPM, PT, LPed, FAPWHc
Editor's note:This blog post is part of the WoundSource Trending Topics series, bringing you insight into the latest clinical issues and advancement in wound management, with contributions by the WoundSource Editorial Advisory Board.
In my recent WoundSource webinar, I discussed the topic of debridement strategies and chronic wounds. The webinar is still available for viewing on WoundSource.com. Wound debridement is the foundation for healing in chronic wounds. Excessive debridement is a detriment to healing, whereas proper removal of accumulated non-viable tissue or foreign material from the wound bed maintains a healthy progressive healing trajectory and avoids wound chronicity.
In the webinar, I addressed:
- The different methods of debridement
- What tissue types these methods should be used on, and when they should be withheld in favor of other techniques
- The new Temple University slough classification to aid clinicians in the identification and removal of non-viable tissues
- Various clinical situations relevant to physicians, nurses, and other health care professionals who care for patients with chronic wounds
Below are answers to some of the frequently asked questions that were submitted during the webinar.
Frequently Asked Questions
Question: Do you have suggestions for situations when it is difficult to convince Surgery to debride recalcitrant, chronic wounds that look stable and clean but have epibole margins in an acute care setting? These patients are typically extended care facility patients. Thank you.
Answer: My first suggestion is to educate your surgeons or link up with a wound care specialist who can help you. Off-label use of a sterile enzymatic debriding ointment containing collagenase and white petrolatum actually aids in encouraging epithelial cells to migrate across the wound if the bed has been properly prepared. Consider wound edge feathering or small vertical cuts in the wound edge with a scalpel to encourage primary healing there and a spillover effect onto the wound.
Question: If a resident is admitted to the facility with calluses and states "I've had these a couple of months or years," do the calluses need to be debrided by wound care?
Answer: Not necessarily. Are the calluses ulcer prone or pre-ulcerative? If not, they are protective and pose no immediate risk.
Question: Don't you need a saline-moistened gauze placed on the collagenase ointment to activate it?
Answer: It requires moisture and does not work well in a dry wound without additional moisture. That said, most of the wounds I treat are very moist, and saline is not required. Saline doesn't actually "activate" the enzyme.
Question: Is silver nitrate used only by a doctor or licensed wound care professional, or can any licensed nurse or just a wound care provider use it?
Answer: I once had to defend a DPM in a lawsuit regarding his use of silver nitrate to stop bleeding, let alone cauterize a significant amount of tissue. I would let your doctor do it to be safe.
Question: What is your opinion of needle debridement using the edge of the needle to debride? How about creating microbleeders to increase vascularity of the wound?
Answer: That would be a very time-consuming microdebridement. I usually take a 3- or 2-mm circular curette and squeeze it with a hemostat to make it oval and use the edge. The tip of a scalpel works, too, but if you like needles, have at it. If you are removing that small an amount of tissue, try collagenase ointment. Remember you can only bill for tissue debrided. Microbleeders to stimulate platelet activation is great; also consider wound edge feathering or small vertical cuts in the wound edge to encourage primary healing there and a spillover effect onto the wound.
Question: You mentioned that pulsatile lavage is not used very much nowadays. Why do you think it is not used? Can mist therapy be used for deep tissue injury?
Answer: It is messy, and there is a risk of infection with multidrug-resistant organisms. It is usually reserved for the operating room. Mist with hypochlorous acid or saline works well but on a micro level, to be coupled with macrodebridement of some sort. Bill for debridement once per week and then mist the other one or two visits that week. You are also controlling all the dressings. I find that a real advantage for us.
Question: In chronic wounds cared for in the community, would you routinely use polyhexamethylene biguanide or hydrochlorous acid?
Answer: Hypochlorous acid, hands down. Polyhexamethylene biguanide is nowhere near as tissue friendly. You can gargle with hypochlorous acid or put it in your eye with no bad effects. That is very tissue friendly.
Question: Before removing biofilm, do you always take a biopsy sample or swab to identify the germs?
Answer: No. It depends on your goals. If you suspect local or spreading infection, possibly, or if it is to determine the presence of multidrug-resistant organisms on admission, yes.
Question: What is the best practice for diabetic foot ulcers?
Answer: See the most recent International Working Group guidelines for the diabetic foot.
Question: We have some physicians who are debriding granulation tissue weekly. There is no visual evidence of slough or eschar. Is this a good practice?
Answer: No. It is only to make money if it is truly granulation tissue, unless it is hypergranulation tissue. Why remove what you work SOOOOOO hard to create?
Question: Is negative pressure wound therapy also a debridement method?
Answer: Yes, it has an autolytic effect but should be coupled with debridement if needed.
Question: How do you feel about the use of 0.125% sodium hypochlorite solution daily wet to dry for 10-14 days to debride necrotic tissue?
Answer: Why, when hypochlorous acid does it just as well and has no negative side effects? That said, short-term use of povidone-iodine or sodium hypochlorite solution has never been shown to clinically slow wound healing. It is an assumption. Why wet to dry? Just autolytically soften it and surgically or mechanically remove it.
Question: When is it correct to use medical maggots?
Answer: Whenever you want to… and the patient agrees. You need a significant percentage of necrotic material on the wound.
Question: Do you refresh the wound edge after removing the callus?
Answer: After the edge is debrided, there is no edge to refresh. It should be part of a good debridement.
Question: Should we dilute hypochlorous acid when it is used for debridement?
Answer: No, never. It has no negative effect at full strength.
Question: I have seen new skin grow through/under fibrin, so should we always remove fibrin?
Answer: No. Sometimes the "fibrin" is the collagen base laid down by the fibroblasts, and a light debridement to encourage bleeding and a collagen dressing such as an extracellular matrix dressing over it can granulate up into it. Try becaplermin with it if the patient has diabetes mellitus.
Question: Dr. McGuire, are you concerned about the use of lidocaine changing the wound pH with its use?
Answer: Not really. We wash it off with saline after using it, and it is infrequent.
About the Author
Dr. James McGuire is the director of the Leonard S. Abrams Center for Advanced Wound Healing and an associate professor of the Department of Podiatric Medicine and Orthopedics at the Temple University School of Podiatric Medicine in Philadelphia. Dr. McGuire has over 30 years of experience in wound management and lectures both nationally and internationally in the areas of wound healing, diabetic foot management, off-loading, and biomechanics of the at-risk foot.
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.