Debridement masterclass <KOL>

Transcription

1 Debridement masterclass <KOL> The views expressed in this presentation are solely those of the presenter and do not necessarily represent the views of Smith & Nephew. Smith & Nephew does not guarantee the accuracy or reliability of the information contained in this presentation. Responsibility for obtaining permission to use images contained in this presentation is that of the presenter, not of Smith & Nephew.

2 Wound debridement Definitions Why debride? Types of debridement Your role in debridement

3 Access to debridement should be based on clinical need and not the skill of the clinician (sic) (Gray et al, 2011)

4 Definition debridement Taken from the French débridement, or débrider to remove adhesions. Collins, Hampton & White (2002) From the French desbrider, meaning to unbridle. Leaper (2002) Debridement is the removal of devitalised or infected tissue, fibrin, or foreign material from a wound. NICE (2001) Debridement is the removal of dead, non viable/devitalised tissue, infected or foreign material from the wound bed and surrounding skin. Wounds UK (2013)

5 Definition slough A mixture of dead white cells, dead bacteria, rehydrated necrotic tissue and fibrous tissue. Can be soft" slough and easily cleaned away, or fibrous slough which can resist even sharp debridement Collins, Hampton & White (2002)

6 Definition necrosis Death in a tissue or organ, which occurs in response to injury, disease or occlusion of blood flow. Continuity with neighbouring viable tissue is preserved. Can arise through infection, trauma such as pressure, and, localised ischaemia.the death of tissue, may appear blue black, grey, yellow and sloughy, often very painful, may have a halo of inflammation. Collins, Hampton & White (2002)

7 Why debride? Quicker healing Reduces risk of infection Dead tissue inhibits cell activity Dead tissue acts as physical barrier to epithelialisation Dead tissue can be malodorous Ongoing inflammation conversion of chronic into acute wound To aid full assessment Psychological stress Nutritional loss through exudate

8 Why don t we debride? Inability to access certain methods of debridement/services Inability to consult with the MDT Lack of knowledge around debridement Unclear referral pathways Funding issues/lack of access to services

9 Consider Type of wound to be debrided N.B. malignant wounds State of wound to be debrided Pain related to wound involved Past therapies/treatments Age of wound Exudate levels may increase in short term depending on technique used (e.g. larvae) Presence of infection in wound to be debrided and potential consequences Acceptability to patient of debridement method Combination of debridement methods?

10 Consider Define an aim E.g. does the wound need cleaning prior to grafting? Define a timescale How quickly does debridement need to happen? Define a method

11 Types of debridement Surgical Conservative sharp debridement Mechanical debridement Wet to dry dressings Monofilament soft pad High pressure fluid irrigation/hydrosurgical Enzymatic debridement Larval /biosurgical therapy Ultrasonic Autolytic debridement

12 How to choose method Wound characteristics Infection Pain Exudate Involved tissues Required rate of debridement The patient Available skills Available resources Products Costs

13 And assess/evaluate Amount of necrotic tissue should diminish/change if therapy appropriate Change in type of tissue in wound bed Dry, desiccated eschar soggy, so slough mucinous, easily dislodged tissue Brown/black yellow/tan Percentage of tissue types in wound bed Photography Linear measurement

14 Checklist for debridement decisions (adapted from Wounds UK, 2013) The aim/goal for the wound Is debridement appropriate for this wound? NO KEEP DRY Should I take a conservative approach (stabilise the wound)? YES AUTOLYTICALLY DEBRIDE Do I need to change method of debridement? YES CONSIDER OTHER METHODS Should I actively try to accelerate the wound healing process? YES ACCELERATE DEBRIDEMENT Is non viable tissue delaying healing? Does the wound edge/periwound skin or wound bed require accelerated debridement? Is acceleration of debridement going to help the management of infection in this wound? Is acceleration of debridement in the best interests of the patient at the moment? Am I certain what to do? NO CONSULT MULTIDISCIPLINARY TEAM, DO NOT DEBRIDE Accelerate healing through debridement Have I discussed the debridement options with the patient/family members? Do I have the skills to perform the chosen method of debridement myself? Am I confident in what I am doing? NO REFER Can I make things worse/do harm? YES REFER Is the current environment safe to undertake debridement? YES DEBRIDE Have I got the resources/equipment necessary? YES DEBRIDE NO REFER or PLAN RESOURCES Expected outcome of debridement Will the intervention remove non viable tissue in one go? Will it be a gradual/staged process? Will the debrided wound be ready for another therapy, e.g. negative pressure wound therapy, skin grafting? YES SET DATE FOR REVIEW Options at every stage Check clinical guidelines/policies Seek advice from a specialist or colleagues in the MDT (as simple as making a call) Refer to another practitioner for debridement Debride wound, selecting the most appropriate method based on wound and patient need, speed with which debridement is necessary and patient preference

15 Types of debridement Surgical Conservative sharp debridement Mechanical debridement Wet to dry dressings Monofilament soft pad High pressure fluid irrigation/hydrosurgical Enzymatic debridement Larval/biosurgical therapy Ultrasonic Autolytic debridement

16 Surgical debridement excision of necrotic material up to and including viable tissue margins Vowden & Vowden (1999)

17 Surgical debridement Often carried out under anaesthetic in theatre Fastest way of debridement especially for large areas Can be aggressive & extensive Not appropriate for all Resources

18 Conservative sharp debridement Carried out in stages removing layers of necrotic tissues Available equipment Patient environment surface, lighting BUT N.B. clotting disorders, malignant wounds, Achilles N.B. pain N.B training and level of competence

19 Competence A good knowledge of relevant anatomy Ability to identify viable tissue Access to adequate equipment, lighting, assistance Ability to explain procedure & obtain informed consent Ability to manage pain and discomfort before, during and after procedure Ability to deal with complications, such as bleeding Ability to recognise his/her skill limitations and those of techniques used Ability to plan secondary debridement techniques if necessary Ability to recognise when not to undertake a technique and when to refer patient to another member of MDT Refer to local guidance/policy/protocol/professional code

20 Mechanical debridement Wet to dry dressings Monofilament soft pad High pressure fluid irrigation/hydrosurgical Enzymatic debridement Larval/biosurgical therapy Ultrasonic

21 Mechanical debridement : wet to dry dressings Used in USA Saline soaked gauze Removed when dries Mechanical removal of slough/necrosis Painful!!! Often standard treatment in studies!!!!!

22 Mechanical debridement: Debrisoft Monofilament soft pad Soft polyester fibres Gentle removal of devitalised tissue, debris and hyperkeratosis

23 Mechanical debridement: Debrisoft The Debrisoft monofilament debridement pad for use in acute or chronic wounds Medical technologies guidance [MTG17] Published date: March 2014

24 Mechanical debridement: Debrisoft Advantages Selective, quick and easy Can remove hyperkeratosis Causes little pain Can be used before or after other methods Can be used in any care environment Patient can use product with education and instruction Disadvantages Cannot be used on hard, dry eschar Do not use on painful wounds

25 Mechanical debridement high pressure fluid irrigation Fast moving water in bath whirlpool VERSAJET TM Jet acts as scalpel Target precisely Vacuum created & sucks up debris Venturi effect Environment clinic v theatre

26 Mechanical debridement high pressure fluid irrigation Advantages Selectively removes necrotic/devitalised tissue, while sparing healthy tissue (Matsumura et al) Shown to reduce debridement time by about 50% when compared to conventional sharp debridement (McAleer et al) VERSAJET TM can reduce the average time to achieve complete chronic ulcer debridement (Mosti et al) Has demonstrated a reduction in bacterial load in the wound following debridement (Mosti et al) Disadvantages Requires specialist training Not widely available Initial cost Matsumura, H. et al. The Estimation of Tissue Loss During Tangential Hydrosurgical Debridement. Ann. Plast. Surg. 69, (2012). McAleer, JP et al. A Prospective Randomized Study Evaluating the Time Efficiency of the VERSAJET Hydrosurgery System and Traditional Wound Debridement, 2005, Presented at ACFAS Conference. Data on File. Mosti G et al. The Debridement of Chronic Leg Ulcers by Means of a New, Fluidjet Based Device. Wounds, 2006, 18,

27 Mechanical debridement enzymatic debridement Varidase Topical Papain papaya Collagenase Antarctic krill Burning sensation Skin erythema Use at least once daily Labour intensive/resource heavy Reaction with thrombolytic agents (Varidase) All Trademarks acknowledged

28 Mechanical debridement larval/biosurgical therapy Larvae of Lucilia sericata common greenbottle Loose or bagged dressing Feed on necrotic tissue Role in removing bacteria Acute & chronic wounds Patient acceptance? Peri wound prep Cost versus speed

29 Mechanical debridement larval/biosurgical therapy Advantages Selective Quick debridement Can be used on infected wounds Minimal training required Cost effective compared with standard treatment Disadvantages Will not remove callus (NB neuropathic diabetic foot ulcers) Patient acceptance Plan in advance Not suitable for dry eschar Use with caution in highly exuding wounds, wounds requiring occlusion, patients with clotting issues, malignancies, close to large vessels

30 Ultrasonic debridement Ultrasound delivered direct to wound bed or via atomised solution Low frequency ultrasound provides a gentle maintenance debridement

31 Ultrasonic debridement MIST Therapy The MIST Therapy system for the promotion of wound healing Medical technologies guidance [MTG5] Published date: July 2011

32 Ultrasonic debridement Advantages Selective and immediate Can be used for excisional debridement Can be used for maintenance debridement Has some antimicrobial activity Does not require specialist training if low frequency Disadvantages High cost Set up time consuming as well as decontamination following procedure High frequency ultrasound requires specialist training Contraindicated in vascular abnormalities, haemorrhagic conditions, malignancies, tissue previously treated with radiation, deep x ray or irradiation

33 Autolytic debridement Wound macrophages produce collagenase & proteases Split & breakdown proteins which hold eschar on the wound When proteins broken down, become detached and debridement occurs Process also stimulates neutrophils which increase debridement process Called autolytic debridement Is a natural process relies on warm, moist environment Dressings key role in creating & sustaining environment Stimulation enzymatic activity has potential to affect all tissue important to protect peri wound skin from moisture

34 Autolytic debridement Advantages Can be used before or between other methods of debridement Can be used on painful wounds Can be used in any care environment No special skills required Disadvantages Slow method of debridement Can cause peri wound maceration Can increase risk of infection May require frequent dressing changes

35 Autolytic debridement dressings Promote wound moisture: Hydrogels Films Hydrocolloids Maintain moist wound bed/absorption: Foam Alginate Hydrofiber Rehydrate necrotic tissue Use on wet, sloughy tissue Cadexomer iodine dressings

36 Autolytic/chemical debridement honey Autolytic effect Honey facilitates proteases proteases in extra fluid honey draws from wound tissue (osmotic effect) Proteases break down slough/necrosis Protease activity enhanced as hydrogen peroxide inactivates inhibitors of proteases

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38 When not to debride Dry necrosis or gangrene without infection in the ischaemic diabetic foot Inadequate blood supply Terminally ill N.B. In some cases debridement may be appropriate but location of wound requires specialist input

39 Think about referring on No wound improvement over several weeks Dry gangrene/dry ischaemia Evidence of cellulitis or gross infection/purulence Impending exposed tendon or bone Evidence of abscess or undermined areas What if wound resloughs?

40 Access to debridement should be based on clinical need and not the skill of the clinician (sic) (Gray et al, 2011)

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42 Any questions?

43 References Anderson, I. (2006) Debridement methods in wound care. Nursing Standard 20, Collons,F, Hampton, S. & White, R. (2002) A Z Dictionary of Wound Care. Quay Books, London Gray, D., Acton, D, Chadwick, P. et al (2011) Consensus guidance for the use of debridement techniques in the UK. Wounds UK 10, Houghton, D. (2015) Using newly acquired skills to debride a heel ulcer: a reflective account. Wounds Essentials 10, Leaper, D. (2002) Sharp technique for wound debridement. Available at: Debridement.html Lloyd Jones, M. (2015) Should necrotic wounds always be debrided? Wounds Essentials 10, National Institute for Health and Clinical Excellence (2014) The Debrisoft monofilament debridement pad for use in acute or chronic wounds. NICE, London Price, B. & Young, T. (2013) Debridement consensus: recommendations for practice. Wounds Essentials 8, Stephen Haynes, J. & Callaghan, R. (2012) A new debridement technique tested on pressure ulcers. Wounds UK 8,3 S6 S12 Young, T. (2012) Safe debridement in the community setting. Wounds Essentials Vol Wounds UK (2013) Effective debridement in a changing NHS: a UK consensus. London, Wounds UK ( uk.com) Wounds UK (2014) Quick Guide Debridement. London, Wounds UK TM Trademark of Smith & Nephew All Trademarks acknowledged June 2017 Fiona Kelly 09197

44 Smith & Nephew Croxley Park Building 5, Lakeside Hatters Lane, Watford Hertfordshire WD18 8YE T +44 (0) F +44 (0) nephew.com/uk Trademark of Smith & Nephew All Trademarks acknowledged June 2017 Smith & Nephew Supporting healthcare professionals for over 150 years

45 Questions

46 According to its most recent definition, debridement is 0 1 The removal of dead, non viable/devitalised tissue, infected or foreign material from the wound bed and surrounding skin 2 The removal of devitalised or infected tissue, fibrin, or foreign material from a wound 3 The medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue

47 According to its most recent definition, debridement is 1 The removal of dead, nonviable/devitalised tissue, infected or foreign material from the wound bed and surrounding skin 2 The removal of devitalised or infected tissue, fibrin, or foreign material from a wound 3 The medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue 0% 0% 0%

48 How would you describe slough? 0 1 A creamy, shiny, yellow/greyish substance containing bacteria 2 A mixture of dead white cells, dead bacteria, rehydrated necrotic tissue and fibrous tissue 3 A yellow, fibrinous tissue that consists of fibrin, pus, and proteinaceous material

49 How would you describe slough? 1 A creamy, shiny, yellow/greyish substance containing bacteria 0% 2 A mixture of dead white cells, dead bacteria, rehydrated necrotic tissue and fibrous tissue 0% 3 A yellow, fibrinous tissue that consists of fibrin, pus, and proteinaceous material 0%

50 What do you need to consider before debriding? 0 1 Define an aim, timescale and method 2 Establish a plan, assign roles and pick a debriding method 3 Assess the wound, define a method and select the correct dressing

51 What do you need to consider before debriding? 1 Define an aim, timescale and method 0% 2 Establish a plan, assign roles and pick a debriding method 0% 3 Assess the wound, define a method and select the correct dressing 0%

52 Which of the following methods of debridement are mistakenly thought to be the same? 0 1 Surgical and mechanical debridement 2 Mechanical and autolytic debridement 3 Sharp and surgical debridement

53 Which of the following methods of debridement are mistakenly thought to be the same? 1 Surgical and mechanical debridement 0% 2 Mechanical and autolytic debridement 0% 3 Sharp and surgical debridement 0%

54 In most cases, when should you avoid debriding? 0 1 When there is necrosis or gangrene 2 When there is an inadequate blood supply 3 When the patient cannot stand the pain

55 In most cases, when should you avoid debriding? 1 When there is necrosis or gangrene 0% 2 When there is an inadequate blood supply 0% 3 When the patient cannot stand the pain 0%