Basics of Wound Debridement

Introduction

There are five main types of non-selective and selective debridement techniques, however other factors influence which procedure is most successful for your patient. BEAMS is a popular abbreviation for remembering the five types. Additionally, there are debridement techniques that may be frowned upon in particular sectors of health care. Due to the use of surgical instruments, surgical and conservative sharp methods of debridement are considered aggressive. Physicians, nurse practitioners, and physician assistants should adhere to their state licensing boards’ professional scope of practice and facility policy. To gain a thorough grasp and accurate knowledge of chronic wounds, it is necessary to first comprehend the three layers of the skin: the epidermis, dermis, and subcutaneous layer. Each layer of the skin structure is responsible for a specific function.

 

BEAMS

BEAMS is a helpful acronym for remembering the five different methods of wound debridement; Biological, Enzymatic, Autolytic, Mechanical, and Surgical/Sharp.

 

Biological

Biological debridement is the process of growing maggots, Lucilia sericata (green bottle fly), in a sterile environment and digesting dead tissue and bacteria. It is a highly effective mode of debridement, particularly useful in large wounds where painless necrotic tissue removal is required. Mega therapy/debridement is primarily a mechanism of action involving the release of proteolytic enzymes containing secretions and excretions that dissolve necrotic tissue in the wound bed. Other mechanisms of action that contribute to the overall success of larval therapy include ingestion of necrotic tissue, bacteriocidal effects, inhibition of bacterial growth by producing in releasing ammonia into the wound microenvironment to increase wound pH, and breakdown of existing biofilm. 

 

 

Enzymatic

Enzymatic debridement is accomplished through the application of a topical agent that chemically liquefies necrotic tissues through the action of enzymes. These enzymes disintegrate and engulf devitalized tissue contained within the wound matrix. Antimicrobial drugs used in conjunction with collagenase may reduce the efficiency of enzymatic debridement. This technique may be combined with surgical and sharp debridement. Collagenase and moisture-retentive dressings can be used in conjunction to enhance debridement. The use of enzymatic debridement in heavily infected wounds is a relative contraindication. 

 

Autolytic

Autolytic debridement is the most time-consuming procedure and is most frequently employed in long-term care. This procedure is completely painless. This approach utilizes the body’s own enzymes and moisture to liquefy non-viable tissue beneath a dressing. It is critical to maintaining a moist wound healing environment. The most often utilized dressings are hydrocolloids, hydrogels, and transparent films (semi-occlusive and occlusive). It is indicated for wounds that are not infected. Additionally, it may be used as adjunctive therapy in the treatment of infected wounds. In the case of infected wounds, it can be combined with other debridement techniques such as mechanical debridement. It necessitates a moist environment and a healthy immune system. It can be enhanced by the use of moisture-retentive dressings. This method of debridement causes the necrotic tissue to soften and eventually separate from the wound bed. The effectiveness of this method of debridement is determined by the amount of devitalized tissue to be removed and the size of the wound. Debridement via autolysis will take a few days. If no significant reduction in necrotic tissue is observed after one or two days, another method of debridement should be considered.

 

Mechanical

Mechanical debridement is a nonselective technique, which means that it will remove both devitalized and viable tissue. Mechanical debridement consists of the following methods: Irrigation, hydrotherapy, wet-to-dry dressings, and abraded technique. This procedure is economical, but it may cause harm to good tissue and is frequently uncomfortable. State surveyors in long-term care, especially frown on wet-to-dry dressings in the long-term care context due to the possibilities offered with advanced wound care dressings. Contraindications include the presence of more granulation tissue than devitalized tissue, inability to control pain, patients with poor perfusion, and an intact eschar without gross clinical evidence of an underlying infection, depending on the mode of mechanical debridement used.

 

Surgical/Sharp

Surgical/sharp and conservative sharp debridement is performed by a skilled practitioner using surgical equipment such as a scalpel, curette, scissors, rongeur, and forceps. By eliminating biofilm and devitalized tissue, this sort of debridement improves wound healing. Debridement is graded according to the amount of devitalized tissue removed. Surgical debridement is the most aggressive type of debridement and is conducted in the operating room of a surgical facility. With sterile equipment, sharp and conservative debridement can be performed in a clinic or at the patient’s bedside.

 

Why Is It Necessary to Debride Wounds?

To begin, we must be able to observe the wound bed tissue level in order to correctly assess or evaluate a wound. Not only does non-viable or devitalized tissue hinder wound healing, but it also raises the risk of infection and sepsis. Bacterial growth is facilitated by dead tissue or foreign substances. The purpose of debridement is to re-acute the wound and so expedite its healing in an orderly method. Second, biofilm formation occurs in the majority of chronic wounds. Physical and metabolic defenses are built into mature biofilms. These defenses enable the biofilm to withstand antimicrobial agents that are often toxic to planktonic cells, such as host defenses, biocides, antibiotics, and UV light. Sharp debridement of wounds in sequence interrupts biofilm formation and inhibiting factors, promoting quicker healing. Predicting the outcome is tricky since we do not yet know the depth required to eradicate the entire biofilm colony.

 

When Is Debridement Not Recommended?

The current standard of care recommendations recommend against removing stable, intact (dry, adherent, and without erythema or fluctuance) eschar from the heels. Inadequate blood supply beneath the eschar results in increased susceptibility to infection. Eschar acts as a natural barrier, preventing bacteria from entering the wound bed. If the eschar becomes unstable (wet, draining, loose, boggy, edematous, or red), it should be debrided in accordance with the clinic’s or facility’s policy. When a prominent, active border is present, autoimmune and pyoderma gangrenosum wound types likely to deteriorate with aggressive debridement. This occurs as a result of activating an inflammatory reaction referred to as “pathergy.” Patients on immunosuppressive therapy who exhibit the above-mentioned non-active border clinical symptoms may undergo surgical debridement. Surgical debridement of calciphylaxis lesions with increasing tissue necrosis and a violaceous border is not recommended. Additionally, the patient must complete sodium thiosulfate therapy and clinical observations indicating that necrosis expansion has halted and the violaceous border has disappeared.

 

Conclusion

To promote healing, decrease infection risks, and enhance patient outcomes, a variety of debridement techniques should be incorporated into the patient’s wound management plan of care. Using multiple debridement techniques will ensure consistency in wound bed preparation for healing. The progression of a wound through the cascade of healing does not always result in a smooth transition to wound closure. While the complexity of a chronic wound can be difficult, we as doctors must employ all available advanced wound care techniques to achieve successful healing outcomes.

 

Disclaimer

The views and opinions stated in this blog are exclusively those of the author and do not reflect those of iWound, its affiliates, or partner companies.

 

References

Manna B, Nahirniak P, Morrison CA. Wound Debridement. [Updated 2021 Sep 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507882/

Leaper D. Sharp technique for wound debridement. World Wide Wounds. 2002. Available at: http://www.worldwidewounds.com/2002/december/Leaper/Sharp-Debridement.html.

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