DEBRIDEMENT Professor Donald G. MacLellan Executive Director Health Education & Management Innovations
DEBRIDEMENT Principles - CSD Methods of Debridement Biopsy options
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
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
WOUND BED PREPARATION OPTIMUM PREPARATION of a wound bed for tissue repair in the absence of vascular disease or medical contraindications is DEBRIDEMENT
DEBRIDEMENT WOUND BED PREPARATION THE REMOVAL OF +/- NON-VIABLE TISSUE +/- NECROTIC TISSUE +/- BIOFILM +/- DEBRIS +/- SENESCENT TISSUE FROM A WOUND.
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
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
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
Indications for Debridement Non-viable and/or senescent tissue Excessive fibrin in wound Peri-wound callus Significant colonisation/biofilm Adequate healing potential
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
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.
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.
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
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.
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.
WOUND BED PREPARATION DEBRIDEMENT AUTOLYTIC ENZYMATIC MECHANICAL ULTRASONIC BIOLOGICAL SHARP
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
Autolytic Debridement
Enzymatic Debridement Collagenase: Santyl Papain-Urea: -Accuzyme -Ethezyme -Ethezyme 830 -Kovia Papain-Urea:Chlorophyllin Copper Complex: -Panafil -Ziox
Mechanical Debridement Wet-to-dry gauze Scrubbing wound Whirlpool Wound irrigation New Products
Maggot Debridement Therapy Larvae of Lucilia sericata (greenbottle fly) www.ucihs.uci.edu/com/pathology/sherman/maggots.htm www.smtl.co.uk
Conservative Sharp
Curettage Curettage (French, meaning scoop) - the use of a curette to remove tissue by scraping or scooping
Vascular Considerations Clinical Examination Ensure adequate local tissue perfusion ABI > 0.5 TcPO 2 > 30 mm Hg
Conservative Sharp Debridement - Procedure
Instruments
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
Biopsy Techniques
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
Tissue Biopsy for Diagnosis Malignancies Inflammatory conditions Vasculitic syndromes Dermatological disorders
Types of Biopsies Shave Punch* Incisional* Excisional *Used most commonly in wound care
Tissue Biopsy: Equipment
Shave Biopsy
Punch Biopsy
Excisional Biopsy
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
Biopsy: Relative Contraindications Bleeding disorders/anticoagulation therapy Immunosuppression Severe peripheral arterial disease Known or possible underlying vital structures
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