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...
Sharp debridement is by far the fastest way to remove non-viable tissue from a wound bed. This modality must be performed by a licensed skilled practitioner using sharp instruments or tools to remove unhealthy tissue. It is reimbursed by most payers when documentation and medical necessity support its use. There are times when sharp debridement is contraindicated, however. This blog reviews the contraindications and alternatives to sharp debridement.
Contraindications to Sharp Debridement
Sharp debridement may be contraindicated in the presence of anticoagulant use. Laboratory test results should be checked before debridement initiation, and ample supplies should be available to control bleeding if needed. Some literature recommends ensuring adequate blood flow to an ischemic limb before using a sharp instrument on a wound. Patient preference, such as palliative wound care or hospice status, could be a reason to consider other forms of debridement. Aversion to sharp instruments or wound pain that cannot be controlled at the bedside can also be a concern. Having a tumor or uncertain tissue type in the wound bed should also be a reason to explore other avenues to remove unhealthy or non-viable tissue.
Alternatives to Sharp Debridement
Autolytic debridement uses topical dressings to create a moist wound healing environment while supporting the “body’s natural debridement ability.”1 This method of debridement is slow and requires the use of patients’ own enzymes to help clean up the wound bed. This form of non-viable tissue removal is favored for palliative wound care or hospice care, and multiple dressings on the market are used for this method. Contraindications to autolytic debridement are allergy or sensitivity to the prescribed product and the need for fast debridement. If the desired outcome has not occurred or the wound is not progressing in 10-14 days, other methods of debridement should be explored.
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Biological debridement uses sterile larvae or maggots to feed on dead or devitalized tissue while sparing healthy tissue. The use of maggots for wound debridement is fast and effective and does not harm healthy tissue. However, maggot therapy can be poorly tolerated by staff, family, or patients. This modality may have limited effect on venous ulcers or wounds infected with Pseudomonas aeruginosa.1 Maggots should not be considered for open abdominal wounds, pyoderma gangrenosum, fungating tumors, or other cancerous lesions. Staff education and training should be required, as well as diligent oversight, to ensure that maggots do not get lost or mature to their adult form.
Enzymatic debridement consists of using a biological enzyme to degrade denatured protein in the wound bed. This form of debridement does not harm healthy tissue but does require a prescription. Contraindications to use are allergy or sensitivity to the enzyme and pairing the enzyme with other products that may inactivate the biological product. An inhibition level of less than 20% is considered acceptable to maintain the enzymatic mechanism of action activity when used with other dressings and topical agents. This form of debridement is generally considered easy to apply at the bedside and should typically be applied daily to facilitate the enzymatic action, unless otherwise indicated by the prescriber.
Mechanical debridement uses force to remove devitalized tissue. Examples of mechanical debridement are as follows: wet to dry techniques; use of gauze to scrub the wound bed, to loosen and remove devitalized tissue; use of pulse lavage; and use of microfiber pads to remove devitalized tissue. This debridement modality is often non-selective in tissue type, meaning that it can remove healthy tissue. Certain modalities, such as pulsed lavage, may require additional equipment and training. Considerations for this method of debridement are overexposed vessels, embedded metal or pacemakers, pain, and concerns about increased bleeding, such as with wet-to-dry techniques or scrubbing.
Surgical debridement in a controlled environment, such as an operating room and with the patient under general anesthesia, is generally associated with the best healing outcomes, especially with a graft applied immediately following the debridement.1 The patient must be medically cleared for surgery, and this method can be high risk for older adults or other patients who do not tolerate anesthesia well. Bleeding and pain can easily be controlled when this method of debridement is performed.
Synergistic debridement is a technique combining more than one method of debridement to achieve optimal debridement outcomes. By combining more than one debridement modality, the outcome is often improved by achieving and maintaining debridement.
With so many options available for wound debridement, wound care personnel can mix and match them to best suit the patient’s wound needs. Achieving complete debridement and keeping the wound bed optimal for healing help clinicians achieve the goal of wound closure or maintenance when needed. Having options to treat patients means meeting the needs of the patient and the wound.
1. Milne CT, Krasner, DL, Ayello E, Chapman F, Kelso MR, et al. Quality assurance and performance improvement: clinician’s resource guide. 2016. Professionals Dedicated to Quality Wound Care. Available at https://www.smith-nephew.com/documents/us/wound%20education/qapi%20clini.... Accessed April 21, 2021.
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.