WOUND DEBRIDEMENT

____________________

A Report Presented to

the Nursing Faculty of San Pedro College, Davao City to

Ms. Charmaine Orocio, RN

____________________

In Partial Fulfillment

of the Requirements in NCM-216 RLE

OPERATING ROOM/ PERCEPTION AND COORDINATION

NURSING ROTATION

  

By:

Daño, Francheska Marie P.

Go, Reinel R.

Saliot, Mareanne Gabrylle

February 26, 2021

Introduction

The concept of wound bed preparation is to promote reepithelialization of chronic

wounds has been applied to wound management for more than a decade. The
treatment is necessary for wounds that don't get any better and also for risk of infection.
Typically, the wounds are stuck in the first step of healing. When the tissue is removed,
the wound will begin the healing process. The clinical significance of necrotic tissue
ulcers and wound debridement, regardless of infection status, cannot be overstated and
should not be overlooked. Debridement for most wounds is known to be a norm in the
approach to wound care. It provides the advantages of the elimination of necrotic tissue
and bacteria and senescent cells, as well as the stimulation of growth factors. It is the
process of removing dead tissue from wounds. The dead tissue may be black, gray,
yellow, tan, or white. Foreign material may also be on the wound and it may need to be
removed. It is an important stage in the regimen for the treatment of diabetic foot ulcers
that occur in at least 15 percent of patients with diabetes and precede 84 percent of all
diabetes-related lower leg amputations. The technique changes the environment of
chronic wounds and facilitates healing. There are several types of debridement; these
include surgical debridement, biological debridement, enzymatic debridements, and
autolytic debridement. There are hundreds of ways to treat wounds, but the aim is to
ensure that the wound stays free from infection and bacteria. The result of chronic
wounds depends on the cause of the injury. Most chronic wounds can take weeks,
months, or years to finally close. At the same time, the diet and functional potential of
the patient must be constantly evaluated.

Definition

Debridement is a method for the treatment of wounds in the skin. It requires a

thorough cleaning of the wound and the removal of all hyperkeratotic (thickened skin or
callus), infected and non-viable (necrotic or dead) tissue, foreign particles and residual
material from the dressing. Debridement can be accomplished either surgically or
through alternate methods such as use of special dressings and gels.
There are several types of debridement, these include biological debridement,
enzymatic debridements, autolytic debridement, mechanical debridement and surgical
debridement,
1. Biological debridement
Biological debridement is the use of maggots, Lucilia sericata (green bottle fly), that
are grown in a sterile environment and digest dead tissue and pathogens.
 Sterile larvae of the Lucilia sericata species of the green bottle fly 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.
 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 maggots)
 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.
2. 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.
 Performed by the application of a prescribed topical agent that chemically
liquefies necrotic tissues with enzymes. These enzymes dissolve and engulf
devitalized tissue within the wound matrix.
 Antimicrobial agents used in conjunction with collagenase can decrease the
effectiveness of enzymatic debridement.
 This method can be used in conjunction with surgical and sharp debridement.
 This method can be expensive.
 Enzymatic debridement is commonly used in the long-term care setting because
there is less pain and nurses can apply it daily.

3. Autolytic Debridement
 Most conservative type of debridement.
 Natural process by which endogenous phagocytic cells and proteolytic enzymes
break down necrotic tissue.
 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.
 4. Mechanical Debridement
Mechanical debridement is a nonselective type of debridement, meaning that it will
remove 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.

5. 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.

Indication

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.
  Acts as a physical barrier for reepithelialization (restoration of epithelium over
a denuded area by natural growth or plastic surgery) preventing
applied topical compounds to make direct contact with the wound bed to
provide their beneficial properties.
 Necrotic tissue prevents angiogenesis, granulation tissue formation,
epidermal resurfacing, and normal extracellular matrix formation.
 May prevent the clinician from making an accurate assessment of the extent
and severity of the wound, even masking possible underlying infections.

According to 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.

Contraindication:

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.

According to Sibbald, et al. the contraindications for surgical debridement of wounds

includes the following;

 Lack of staff expertise in procedure

 Nonhealable ulcer (i.e., insufficient vascular supply to allow healing)
 Septicemia in the absence of systemic antibacterial coverage
 Medically unfit patient
Reference:

Nunez, K. (2019). What Is Wound Debridement and When Is It Necessary?. Healthline.

Retrieved 25 February 2021 from: https://www.healthline.com/health/debridement

Manna, B. Nahirniak, P. & Morrison, C. (2021). Wound Debridement. StatPearls

Publishing LLC. Retrieved 25 February 2021 from:
https://www.ncbi.nlm.nih.gov/books/NBK507882/