DEBRIDEMENT. Professor Donald G. MacLellan Executive Director Health Education & Management Innovations

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1 DEBRIDEMENT Professor Donald G. MacLellan Executive Director Health Education & Management Innovations

2 DEBRIDEMENT Principles - CSD Methods of Debridement Biopsy options

3 PRINCIPLES OF WOUND MANAGEMENT 1. DEFINE THE AETIOLOGY 2. CONTROL FACTORS AFFECTING WOUND HEALING 3. SELECT APPROPRIATE WOUND DRESSING / BANDAGE 4. PLAN WOUND HEALING MAINTENANCE

4 Wound Management Identify and address underlying pathology Provide systemic support for wound healing Identify and treat infection Debride non-viable tissue Utilize appropriate topical therapy

5 WOUND BED PREPARATION OPTIMUM PREPARATION of a wound bed for tissue repair in the absence of vascular disease or medical contraindications is DEBRIDEMENT

6 DEBRIDEMENT WOUND BED PREPARATION THE REMOVAL OF +/- NON-VIABLE TISSUE +/- NECROTIC TISSUE +/- BIOFILM +/- DEBRIS +/- SENESCENT TISSUE FROM A WOUND.

7 Rationale for Debridement Non-viable Tissue: Is a culture medium for bacterial growth incl biofilms Inhibits WBC phagocytosis Causes a prolonged inflammatory response impairs wound healing

8 Rationale for Debridement Senescent Tissue: Impaired cell proliferation Decreased extracellular matrix production May not respond to cytokine or growth factor stimulation due to receptor loss

9 Rationale for Debridement Peri-wound Callus: Causes pressure to underlying tissue during weight bearing/walking Impairs epithelialization from wound edges Provides undermined area for bacterial growth

10 Indications for Debridement Non-viable and/or senescent tissue Excessive fibrin in wound Peri-wound callus Significant colonisation/biofilm Adequate healing potential

11 Contraindications for Debridement Non-infected ischemic ulcer with dry eschar Inadequate circulation No potential for healing Risk of deep structure exposure/damage Risk of uncontrolled bleeding Uncooperative patient/inadequate facilities

12 Indications for Specialist Referral N Necrotic tissue present, not removed by superficial debridement. O Osteomyelitis, presence of infected bone, including tendon or muscle involvement, may need to be surgically debrided to allow healing to occur. H Hidden sinus tracts and/or tunnel, which have increased in size or are infected. E Eschar not removable by conservative sharp debridement or other methods of debridement. A Abscesses present & requiring to be surgically incised and drained to decrease the chance of systemic infection. L Large defects too large to close by secondary intention. lschaemia. I N Non-healing wound in spite of appropriate treatment. G Graft ready wound bed.

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14 Hypergranulation Overgranulation is defined as an excess of granulation tissue. Overgranulation is also known as hypergranulation, exuberant granulation tissue, or proud flesh It usually presents in wounds healing by secondary intention.

15 a few common characteristics moist areas from exudates or bleeding prolonged physical irritation or friction with continued repetitive minor trauma or pressure excessive inflammation bacterial bioburden or infection a new scenario of negative pressure suction with microdeformation, particularly applicable to large pore foam dressings low oxygen levels

16 Hypergranulation: Treatment Options Silver nitrate. When activated, this is a caustic material that oxidises organic matter, coagulates tissue and destroys bacteria. Tissue dies almost immediately. Unfortunately, this sets up further inflammation and exudate formation. Vapour permeable dressing. A non-occlusive dressing, such as a foam dressing, with light pressure application can be effective. Hypertonic NaCl dressing products, such as Mesalt (Molnlycke Health Care)or Curasalt (Medline), use oncotic pressure to promote drying by managing exudates, promoting movement of fluid away from the wound and reducing tissue oedema. Sharp debridement of the area is extremely successful at removing the hypergranulation tissue but not successful at preventing recurrence. Low-dose cortisone cream or tape to promote collagen breakdown Topical corticosteroids are not approved or indicated for open wounds or hypergranulation tissue. This method of treatment is rarely successful. Surgical lasers. These devices not only remove overgranulation tissue but also cauterize small blood vessels. They are very selective, leaving healing cells alone.

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18 Hypergranulation: Treatment Options Silver nitrate. When activated, this is a caustic material that oxidises organic matter, coagulates tissue and destroys bacteria. Tissue dies almost immediately. Unfortunately, this sets up further inflammation and exudate formation. Vapour permeable dressing. A non-occlusive dressing, such as a foam dressing, with light pressure application can be effective. Hypertonic NaCl dressing products, such as Mesalt (Molnlycke Health Care)or Curasalt (Medline), use oncotic pressure to promote drying by managing exudates, promoting movement of fluid away from the wound and reducing tissue oedema. Sharp debridement of the area is extremely successful at removing the hypergranulation tissue but not successful at preventing recurrence. Low-dose cortisone cream or tape to promote collagen breakdown Topical corticosteroids are not approved or indicated for open wounds or hypergranulation tissue. This method of treatment is rarely successful. Surgical lasers. These devices not only remove overgranulation tissue but also cauterize small blood vessels. They are very selective, leaving healing cells alone.

19 WOUND BED PREPARATION DEBRIDEMENT AUTOLYTIC ENZYMATIC MECHANICAL ULTRASONIC BIOLOGICAL SHARP

20 What method to choose? Wound characteristics: - aetiology, size, infection, pain, exudate, location, involved tissues - required rate of debridement The patient's attitude Available skills & available resources Costs

21 Autolytic Debridement

22 Enzymatic Debridement Collagenase: Santyl Papain-Urea: -Accuzyme -Ethezyme -Ethezyme 830 -Kovia Papain-Urea:Chlorophyllin Copper Complex: -Panafil -Ziox

23 Mechanical Debridement Wet-to-dry gauze Scrubbing wound Whirlpool Wound irrigation New Products

24 Maggot Debridement Therapy Larvae of Lucilia sericata (greenbottle fly)

25 Conservative Sharp

26 Curettage Curettage (French, meaning scoop) - the use of a curette to remove tissue by scraping or scooping

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28 Vascular Considerations Clinical Examination Ensure adequate local tissue perfusion ABI > 0.5 TcPO 2 > 30 mm Hg

29 Conservative Sharp Debridement - Procedure

30 Instruments

31 Facilities Consented, cooperative patient Analgesia/anaesthesia assessment/tx Relatively undisturbed environment Adequate lighting Adjustable height of bed/trolley/couch Sterile instruments & protective equipt Scout Dressings/bandages

32 Biopsy Techniques

33 What is a skin biopsy? Skin biopsy is a biopsy technique in which a portion of or all of a skin lesion is removed. This is sent to a pathologist for microscopic diagnosis. It is usually done under local anaesthetic in an ambulatory setting. The pathology results are generally available within 2-4 days. Commonly performed by medical practitioners. Important procedure for diagnosis of skin conditions

34 Tissue Biopsy for Diagnosis Malignancies Inflammatory conditions Vasculitic syndromes Dermatological disorders

35 Types of Biopsies Shave Punch* Incisional* Excisional *Used most commonly in wound care

36 Tissue Biopsy: Equipment

37 Shave Biopsy

38 Punch Biopsy

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40 Excisional Biopsy

41 Tissue Biopsy for Diagnosis Clinical information essential Location and timing are crucial to an accurate diagnosis Biopsy newest lesions along the advancing edge of the abnormal area, including a rim of normal tissue

42 Biopsy: Relative Contraindications Bleeding disorders/anticoagulation therapy Immunosuppression Severe peripheral arterial disease Known or possible underlying vital structures

43 Debridement & Biopsy Summary Understand the pathophysiology of wounds Determine patient eligibility for debridement and biopsy Develop & follow protocols Acquire proper training/experience Understand your scope of practice