DEBRIDEMENT. In This Chapter. Chapter 8. Necrotic Tissue Eschar Slough Types of Debridement When Not to Debride...

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1 Chapter 8 DEBRIDEMENT In This Chapter Necrotic Tissue Eschar Slough Types of When Not to Debride Protocols

2 Chapter 8 is the removal of dead or devitalized tissue from the wound bed until healthy tissue is exposed. Nonviable or necrotic tissue can either be eschar or slough. Eschar and slough are both implicated in poor healing and increased bacterial load in the wound. Necrotic Tissue Worth remembering... A scab is dried blood and exudate, not dead tissue. A wound bed cannot be assessed when it is filled with necrotic tissue. Necrotic tissue harbors large numbers of bacteria, increases the threat of infection and delays healing. A scab is dried blood and exudate, not dead tissue. A scab does not imply tissue loss; in fact, it is usually related to a partial-thickness wound. The term scab is not interchangeable with eschar. Removal of devitalized tissue is necessary for wound healing. The wound can appear larger as the debridement progresses. Weekly wound assessments must include information on the percentage of necrotic tissue versus viable tissue present in the wound bed in order to monitor progress. When a pressure ulcer involves necrotic tissue, staging cannot be confirmed until the wound base is visible. Arterial blood flow, or perfusion, of the lower extremity should be assessed before the wound is debrided. If perfusion is inadequate, restoration of blood supply should be performed. If this is not an option, the eschar should be managed with dry dressings, pressure relief and nutritional support. Assessment should include frequent observation for signs of infection. Eschar Eschar is a form of necrotic tissue. Eschar is skin, subcutaneous tissue, and possibly muscle that has died and dried in layers. It is the leathery cover on the wound at the skin surface. It looks like a lid, and can be black, brown or tan, and can be either hard or pliable. 165

3 The Wound Care Handbook DID YOU KNOW AHRQ guidelines do not recommend debridement for heel ulcers with dry eschar if they do not have edema, erythema, fluctulance (sponginess) or drainage. The Agency for Healthcare Research and Quality (AHRQ) guidelines do not recommend debridement for heel ulcers with dry eschar if they do not have edema, erythema, fluctulance (sponginess) or drainage. Assess these wounds daily to monitor for pressure ulcer complications that would require debridement (e.g., edema, erythema, fluctulance, drainage). Elevating or off-loading heels is the standard of treatment and can be done with pillows. Slough Slough is a moist combination of fibrin, bacteria, cell debris, leukocytes and exudate. Essentially, it is necrotic or dead tissue inside the wound bed. Slough is not an organized tissue; it is a group of wound cells that the body cannot eliminate on its own. It can be white, beige, yellow or rust colored. Slough consistency can be dry, crusty, slimy, rubbery or moist. The wound should be reevaluated during the debridement process at each dressing change to ensure the chosen treatment is still appropriate. Types of Type of Surgical Sharp Description The most rapid of all debridement methods, surgical debridement converts the chronic wound to an acute wound. This method in particular should be employed when there are signs of advancing cellulitis or sepsis, extensive, thick or adherent eschar. However, this method requires an operating room or special procedure room and the expertise of a surgeon. This method can be quite costly and is not recommended if the patient is not a surgical candidate. Conservative Sharp This method can be performed by a physician or advanced practice clinician (check your state s practice act), and can routinely be done at the bedside. Conservative sharp debridement removes only devitalized or dead material. Insufficient perfusion and increased bleeding risks are some of the disadvantages of this method. 166

4 Chapter 8 Type of Autolytic Description Lysozymes, the body s own white blood cells and autolytic enzymes, break down necrotic tissue through liquification and rehydration. Any dressing that keeps the wound optimally moist will facilitate autolytic debridement. This method is selective and noninvasive. It is inexpensive, produces minimal discomfort, and requires minimal expertise. Autolytic debridement, however, can take longer than other methods. It is not recommended for patients with a decreased white blood cell (WBC) count. This method should not be used on infected or heavily draining wounds. Mechanical Wet-to-dry dressings Wet-to-dry dressings are painful and sometimes result in healthy tissue damage. The method is nonselective and can be time-consuming. Generally, there is a low cost for materials and it is easy to perform. Whirlpool Whirlpool is less painful than other methods; however, this method does not impact dry eschar. A whirlpool can dry out the skin and increase the risk of a nosocomial infection (facility-acquired). There is also a risk of increasing damage with some leg ulcers, especially those with venous disease. Irrigation or Wound Irrigation Irrigation is cleansing a wound with sufficient pressure to remove devitalized tissue. This can be achieved with commercial wound cleansers where the pounds per square inch (PSI) are between 4 and 15. Care should be taken in products with too much pressure as they could contribute to slower wound healing and possibly cause wound trauma. 167

5 The Wound Care Handbook Types of (continued) Type of Polyacrylate Description Dressings containing specific polymers, known as polyacrylates, attract and retain large-molecule proteins such as slough and eschar, bacteria, and wound toxins. Polyacrylates have demonstrated the ability to bind harmful proteins such as matrix metalloproteases (MMPs) in the wound bed. This method of debridement facilitates autolytic as well as mechanical debridement, and has the ability to break up bacterial biofilm. Enzymatic The goal of enzymatic debridement is to liquefy necrotic tissue or destroy the adhesion between necrotic tissue and the underlying tissue with the use of enzymes. Enzymes should be discontinued as soon as the wound is free of necrotic tissue. Eschar must be cross-hatched (check your state s practice act) with a scalpel prior to enzyme application. This method is not indicated for infected wounds. It may cause bleeding and can be painful. Enzymatic debriding agents are available through the pharmacy by prescription only. Biological Medical-grade maggots are used to digest necrotic material. Farm-grown sterile maggots are placed into the wound bed and consume the necrotic material. Maggots are selective in that they focus only on dead, not viable, tissue. Patients report a moving or tingling sensation while the maggots are in place, but the sensation appears to be well tolerated. Furthermore, the enzymes secreted by the maggots may enhance healing. Ultrasound An emerging method of debridement is using ultrasound waves. Low-frequency ultrasound creates cavitation by the formation of mini gas bubbles. At certain amplitudes of sound waves these bubbles implode, causing necrotic tissue to liquefy. This method is selective because only viable tissue is destroyed at much higher levels than those required for destruction of necrotic tissue. 168

6 Chapter 8 When Not to Debride According to the AHRQ guidelines, stable heel eschar, dry gangrene, and lower extremities without adequate perfusion should not be debrided. These wounds should be monitored closely for signs and symptoms of infection or complications. Protocols ALGINATE Used for: Eschar Moderate to Heavily-Draining Slough 1. Clean the surface of the slough tissue with a wound cleanser (Skintegrity ) at each dressing change. 2. Pat the periwound skin dry. 3. Apply a dimethicone barrier (Remedy Nutrashield) to the intact periwound skin. This protects the surrounding skin from becoming macerated. 4. Apply an alginate dressing, sheet or rope (Maxorb Extra) and allow the dressing to overlap slightly onto the intact skin. 5. Heavily draining: consider using a foam dressing to cover the alginate for added absorbency. (Gentleheal Standard, Gentleheal Extra or Optifoam ). 6. Secure the dressing with a composite island (Stratasorb ), bordered gauze (Bordered Gauze), retention tape (Medfix Retention Dressing Sheet) or net dressing (Elastic Net). 7. Change the dressing every 1 to 5 days, or as needed. Note: All products shown in italics are distributed by Medline Industries, Inc. and are used for example purposes only. 169

7 The Wound Care Handbook Protocols (continued) ENZYMATIC DEBRIDEMENT Used for: Eschar Slough 1. Clean the surface of the eschar or slough with a wound cleanser (Skintegrity) at each dressing change. 2. Pat the periwound skin dry. 3. Eschar: Score or cross-hatch the eschar. 4. Apply an enzyme generously to the eschar or slough surface. 5. Cover and secure the surface with an appropriate secondary dressing such as a composite island (Stratasorb), bordered gauze (Bordered Gauze), retention tape (Medfix Retention Dressing Sheet) or net dressing (Elastic Net). 6. Change the dressing daily or more frequently according to the enzyme instructions, if the enzyme dries out, or as drainage requires. Eschar Special Consideration: Scoring or cross-hatching (check your state s practice act) of eschar MUST occur if the benefit of the enzyme is to be achieved. If this is not possible, choose another debridement option. 170 Note: All products shown in italics are distributed by Medline Industries, Inc. and are used for example purposes only.

8 Chapter 8 HYDROGEL HYDROGEL IMPREGNATED GAUZE Used for: Eschar Dry-to-Moist Slough 1. Clean the surface of the eschar or slough with a wound cleanser (Skintegrity) with each dressing change. 2. Pat the periwound skin dry. 3. Apply a dimethicone barrier (Remedy Nutrashield), to the periwound skin. This protects the periwound skin from the effects of adhesives and picks up excess oils to promote product adhesion. 4. Cover the eschar or slough with hydrogel impregnated gauze (Skintegrity Hydrogel Impregnated Gauze), or a hydrogel (Skintegrity Hydrogel). 5. Apply dampened gauze to the eschar or slough with a wound cleanser (Skintegrity) or normal saline if necessary. 6. Eschar: Apply a transparent dressing (Suresite), allowing at least a 1¼-inch overlap. The transparent dressing will hold in more moisture and enhance softening of the eschar. 7. Slough: Secure the dressing with a composite island (StrataSorb), bordered gauze (Bordered Gauze), retention tape (Medfix Retention Dressing Sheet) or net dressing (Elastic Net). 8. Change the dressing every 1 to 3 days. POLYACRYLATE DEBRIDER Used for: Eschar Slough 1. Apply a dimethicone barrier (Remedy Nutrashield) to the periwound skin. 2. Apply a super absorbent polymer pad (TenderWet Active). 3. Secure the dressing with a composite island (Stratasorb), bordered gauze (Bordered Gauze), retention tape (Medfix Retention Dressing Sheet) or net dressing (Elastic Net). 4. Change the dressing daily. Note: All products shown in italics are distributed by Medline Industries, Inc. and are used for example purposes only. 171

9 The Wound Care Handbook Protocols (continued) TRANSPARENT FILM Used for: Eschar 1. Clean the surface of the eschar tissue with a wound cleanser (Skintegrity) at each dressing change. 2. Pat the periwound skin dry. 3. Apply a dimethicone barrier (Remedy Nutrashield) to the periwound skin. This protects the periwound skin from the effects of adhesives and picks up excess oils to promote product adhesion. 4. Apply a transparent dressing (Suresite ), allowing at least a 1¼-inch overlap. The transparent dressing will hold more moisture and enhance softening of the eschar. 5. Change the dressing every 1 to 7 days. Frequency will depend on the amount of fluid in the wound. Expect an increase in drainage as necrotic tissue liquefies. Special Considerations: Tunneling 1. Avoid occlusive dressings. 2. Without drainage: Loosely pack the tunneling loosely with gauze saturated with normal saline or hydrogel. 3. With drainage: Loosely pack the tunneling loosely with gauze packing. 4. Continue to dress the wound according to your facility s protocol. Special Considerations: Undermining 1. With drainage: Loosely fill the undermined area with an alginate (Maxorb Extra) sheet or rope, or gauze packing. 2. Without drainage: Loosely fill the undermined area with gauze packing saturated with hydrogel. 3. Continue to dress the wound bed according to your facility s protocol. 172 Note: All products shown in italics are distributed by Medline Industries, Inc. and are used for example purposes only.

10 Chapter 8 References: Bates Jensen B, eds. Management of necrotic tissue. Wound Care: A Collaborative Practice Manual for Physical Therapists and Nurses. 2nd ed. Gaithersburg, Md: Aspen Publishers, Inc; Bergstrom N, Bennet MA, Carlson CE, et al. Treatment of pressure ulcers in adults. Clinical practice guideline, number 15. AHCPR Publication No Boynton P, Paustian C. Wound assessment and decision making options. Critical Care Nursing Clinics of North America. 1996;8(2): Dow G, Browne A, Sibbald RG. Infection in chronic wounds: controversies in diagnosis and treatment. Ostomy Wound Management. 1999;45(8):23-7, Fleck, CA. No pain no gain? Addressing pain in patients with wounds. ECPN. 2003;90: Flemister B. The Use of a Superabsorbent Wound Dressing Pad for Interactive Moist Wound Healing. Presented at the 13thAnnual Symposium on Advanced Wound Care. Dallas, Texas. April Morrison M, Moffatt C, Birdel-Nixon J, Bale S. Nursing Management of Chronic Wounds. 2nd ed. Mosby International Limited; Paustian C, Stegman MR. Preparing the wound for healing: the effect of activated polyacrylate dressing for debridement. Ostomy Wound Management. 2003;49(9): Robson M. Wound infection: a failure of wound healing caused by an imbalance of bacteria. Surgical Clinics of North America. 1997;77(3): Sibbald, Orsted, Schultz, Coutts, Keast. Preparing the wound bed 2003: focus on infection and inflammation. Ostomy Wound Management. 2003;49(11): Weir D, Blakely M, Chakravarthy D. Enhanced Wound Bed Preparation and Healing Outcomes Utilizing Low-frequency Ultrasound Assisted Wound Treatment (UAWT). Presented at the 10th Annual Wound Care Congress. Colorado Springs, Colo. November