Describe the four different types of debridement surgical mechanical autolytic and enzymatic

Continuing Education Activity

Wound debridement is based on the premise that debridement will promote reepithelialization. Wound debridement has been utilized for more than a decade. This activity reviews the indications, contraindications, and technique involved in performing wound debridement and highlights the role of the interprofessional team in the care of patients undergoing this procedure.

Objectives:

• State the indications for wound debridement.

• Describe the techniques involved in performing wound debridement.

• Describe the contraindications to wound debridement.

• Employ a structured, interprofessional team approach to provide effective care to patients undergoing wound debridement.

Access free multiple choice questions on this topic.

Introduction

The concept of preparing the wound bed to promote reepithelialization of chronic wounds has been applied to wound management for more than a decade. The 4 general steps to follow for better preparation are compassed in the acronym DIME.[1][2][3][4][5]

• D: Debridement of nonviable tissue within the Wound. 

• I: Management of Inflammation and Infection

• M: Moisture control

• E: Environmental and Epithelialization assessment

The DIME  approach to chronic wound management is a global concept approach from which a more detailed pathway can be initiated to bring about wound resolution.

The primary goal of debridement is to remove all the devitalized tissue from the wound bed to promote wound healing. Debridement is also used for removal of biofilm, bioburden along with senescent cells, and it is suggested to be performed at each encounter.[6][7][8]

Anatomy and Physiology

The skin's 2 main layers are the epidermis and the dermis. The epidermis is composed up of closely packed epithelial cells, and the dermis is composed of dense, irregular connective tissue where the blood vessels, hair follicles, sweat glands, and other structures are housed. The hypodermis lies beneath the dermis. Its composition is mostly loose connective and fatty tissues. Muscle, tendons, ligaments, bone, and cartilage are all under the hypodermis.

The epidermis is composed of keratinized, stratified, squamous epithelium. The dermis contains blood and lymph vessels, nerves, and other structures, such as hair follicles and sweat glands.

Indications

In general, the indication for debridement is the removal of devitalized tissue such as necrotic tissue, slough, bioburden, biofilm, and apoptotic cells.

Debridement is recognized as a major component of wound management to prepare the wound bed for reepithelialization. Devitalized tissue, in general, and necrotic tissue, in particular, serve as the source of nutrients for bacteria. Devitalized tissue also acts as a physical barrier for reepithelialization, preventing applied topical compounds to make direct contact with the wound bed to provide their beneficial properties. Necrotic tissue also prevents angiogenesis, granulation tissue formation, epidermal resurfacing, and normal extracellular matrix (ECM) formation. Finally, the presence of necrotic tissue may prevent the clinician from making an accurate assessment of the extent and severity of the wound, even masking possible underlying infections.[9][10][11]

Schiffman et al. include the following as common indications for sharp surgical debridement.

1. Removal of the source of sepsis, mainly necrotic tissue

2. Removal of local infection to decrease bacterial burden, to reduce the probability of resistance from antibiotic treatment, and to obtain accurate cultures

3. Collection of deep cultures taken after debridement from the tissue left behind to evaluate persistent infection and requirements for systemic antibiotic treatment

4. Stimulation of the wound bed to support healing and to prepare for a skin graft or flap

Contraindications

Contraindication of wound debridement, in general, may be applied to dry and intact eschars with no clinical evidence of underlying infection such as with an unstageable pressure ulcer with an intact eschar at the sacrum or buttock or heel.

Other contraindications pertain to each particular method of debridement.

Technique

Several types of the debridements can achieve removal of devitalized tissue. These include surgical debridement, biological debridement, enzymatic debridements, and autolytic debridement.

Autolytic Debridement

This is the most conservative type of debridement. This type of debridement is a natural process by which endogenous phagocytic cells and proteolytic enzymes break down necrotic tissue. It is a  highly selective process whereby only necrotic tissue will be affected in the debridement.

It is indicated for noninfected wounds. It may also be used as adjunctive therapy in infected wounds. It can be used with other debridement techniques such as mechanical debridement in the case of infected wounds.

It requires a moist environment and a functional immune system. The use of moisture retentive dressings can enhance it. This type of debridement induces softening of the necrotic tissue and eventual separation from the wound bed.

The effectiveness of this type of debridement is mandated by the amount of devitalized tissue to be removed as well as the actual wound size.

Autolytic debridement will take a few days. If a significant decrease in necrotic tissue is not seen in 1 or 2 days, a different method of debridement should be considered.

Biological Debridement

Biological debridement, also known as larval therapy, uses sterile larvae of the Lucilia sericata species of the green bottle fly. It is an effective mode of debridement, particularly appropriate in large wounds where a painless removal of necrotic tissue is needed. The mechanism of action of mega therapy/debridement consists mainly of the release of proteolytic enzymes containing secretions and excretions that dissolve necrotic tissue from the wound bed. Other modes of action contributing to the overall result of larval therapy are:

1. Bacteriocidal, as the larvae ingest and digest bacteria

2. Inhibiting bacterial growth by producing in releasing ammonia into the wound bed which increases the wound pH

3. Breakdown of existing biofilm at the wound bed and inhibition of new biofilm growth

4. Direct ingestion of necrotic tissue

Maggots can be applied to the wound bed. They can be enclosed in a biological bag or are free range.

Studies have shown that free-range maggots can debride a wound at least twice as fast as bag-pain maggots. Comparison studies of either free-range maggots treatment versus bio bag contained maggots versus hydrogel autolytic debridement shows days to complete debridement to be 14 versus 28 versus 72 days respectively.

Contraindications to biological debridement are an abdominal wound contiguous with the intraperitoneal cavity, pyoderma gangrenosum in patients with immunosuppression therapy, and wounds in proximity to areas afflicted by septic arthritis.

Enzymatic Debridement

This is a selective method for debridement of necrotic tissue using an exogenous proteolytic enzyme, collagenase, to debride Clostridium bacteria. Collagenase digests the collagen in the necrotic tissue allowing it to detach.

Enzymatic debridement is a slow method of the debridement as from hair to mechanical and sharp debridement.

Collagenase and moisture retentive dressings can work in synergy enhancing the debridement.

Enzymatic debridement is not recommended for an advanced process, or in patients with known sensitivity to the product's ingredients.

A relative contraindication of enzymatic debridement is its use in heavily infected wounds. Furthermore, collagenase should not be used in conjunction with silver-based products or with Dakin solution.

Surgical Debridement with Sharp Instruments

This is a type of debridement where devitalized tissue (slough, necrotic, or eschar) in the presence of underlying infection is removed using sharp instruments such as a scalpel, Metzenbaum, curettes, among others. This can be done bedside, in the office or wound care center, or in the operating room depending on the adequacy of anesthesia and the ability to control perioperative complications like bleeding. The healthcare professional should be skilled and trained and qualified and licensed to provide surgical treatment.

Sharp-instrument debridement can be combined with all the other methods of debridement during the perioperative period.

Disadvantages of surgical debridement include adverse events from the debridement itself, for example, bleeding and possible general complications from the anesthesia.

Contraindications for surgical debridement in the operating room would have to take into account the particular surgical risk stratification of the patient. Sharp surgical debridement is contraindicated in patients with an intact eschar and no clinical evidence of an underlying infection because in these cases, the intact eschar functions as a biological covering for the underlying skin defect. This is usually seen in unstageable pressure injuries at the sacrum or buttocks or heels with intact and/or dry eschars.

Mechanical Debridement

Mechanical debridement is a nonselective type of debridement, meaning that it will remove both devitalized tissue and debris as well as viable tissue. It is usually carried using mechanical force: wet-to-dry, pulsatile lavage, or wound irrigation.

It is indicated for both acute and chronic wounds with moderate to large amounts of necrotic tissue, regardless of the presence of an active infection.

The contraindications include, depending on the modality of mechanical debridement used, the presence of granulation tissue in a higher amount than the devitalized tissue, inability to control pain, patients with poor perfusion, and an intact eschar with no gross clinical evidence of an underlying infection.

Complications

Depending on the type of debridement chosen, complications range from local irritation to major bleeding.

Surgical debridement and mechanical debridement will have a higher risk for bleeding, along with peri-procedural pain.

Surgical debridement done in the operating room must account for morbidity and mortality due to the anesthesia used. A study by J. Shiffman et al. has shown operative mortality to be 2% with long-term mortality, and as high as 68% following debridement.

Clinical Significance

The clinical significance of wound debridement and ulcers with necrotic tissue, regardless of the infection status, cannot be overstated and should not be underestimated. Debridement for most wounds is considered a standard in the approach to wound management. It provides the benefits of removal of necrotic tissue and bacteria and senescent cells, as well as the stimulating activity of growth factors.  Sharp surgical debridement has been shown to reset the proper timing of the phases of wound reepithelialization by providing the initial trauma seen in the hemostasis phase of wound healing. Angiogenesis has also been shown to be stimulated by sharp surgical debridement.

Of course, not all forms of debridement will have the same impact on the wound or the ulcer as the mode of action differs; however, either sharp surgical debridement or nonsurgical debridement is fundamental to wound reepithelialization.

A critical concept of debridement is the dry eschar such as in unstageable pressure ulcers with no overt signs of infection, where debridement is not always indicated because the dry eschar will act as a biological covering.

The mode of debridement should be tailored to the particular wound presentation taking into account factors such as comorbidities, other lower-risk options, and the patient's comfort and desires.[12][13]

Enhancing Healthcare Team Outcomes

The management of chronic wounds is done by an interprofessional team that consists of a general surgeon, vascular surgeon, wound care nurse, infectious disease expert, physical therapist, dietitian, and an internist. There are many types of wounds caused by a number of factors. When wounds do not heal, it is important to consult with a wound care specialist. There are dozens of methods of treating wounds but the key is to ensure that the wound remains free of contamination and bacteria. The outcome of chronic wounds depends on the cause. Most chronic wounds can take weeks, months or years to finally close. At the same time, the patient's nutrition and functional ability must be continually assessed. [14][15]

Review Questions

Figure

Necrotizing Fasciitis Appearance of lower leg after serial debridements of skin and fascia. Contributed by Mark A. Dreyer, DPM, FACFAS

References

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What are the four methods of debridement?

What is enzymatic debridement?

What is a mechanical debridement?

What is autolytic debridement?