Role of wound debridement

1. GENERAL GUIDE
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KEYWORDS: Wan Zuraini, Wound Debridement

2. From the stump of the arm, the amputated leg, I undo the clotted lint,
remove the slough, wash the matter and blood. Back on his pillow the
soldier bends with curv’d neck and side falling head. His eyes are closed,
his face is pale, he dares not to look on the bloody stump, and has not
yet look’d on it.
The Wound Dresser, Leaves of Grass,
Walt Whitman, 1819 - 1892

4. Outline
• Definition
• Identifying materials to debride
• Reasons of debridement
• Option of Debridement
• Which one to choose? – The Debridement
Algorithm
• Conclusion

5. Original
Definition
• Sir Pierre-Joseph Desault (1744 – 1795), Paris
• Surgical removal of necrotic material from open
wound
Dorland’s Medical Dictionary
• “The removal of foreign material and devitalized or
contaminated from or adjacent to a traumatized or
infected lesion, until surrounding [and underlying in
the case of cutaneous ulcer] healthy tissue is
exposed”

6. My simplified definition of
debridement
[Remove] + [whatever not supposed to be there]

7. To remove
whatever not
supposed to be
there:
1. Foreign material
• Hair
• Composed thread
• Dead skin
2. Necrotic material on ulcer
surface
• Slough
• Eschar
• Crust
3. Others
• Bone fragments
• Hyperkeratosis
• Callous

8. SLOUGH
• Yellow
devitalized
tissue
• Stringy, thick,
adhere to
wound bed
ESCHAR
• Dry,
desiccate,
harden
• Brown or
black
• Devitalized
protein and
collagen
• Cellular
debris and
solidified
secretions
CRUST
• Secretions
that have
dried out
• Does not
contain dead
tissue
NECROTIC MATERIALS (nə-krō'sĭs) The death of cells or tissues from severe injury or disease, especially in a localized
area of the body. Causes of necrosis include inadequate blood supply (as in infarcted tissue), bacterial infection, traumatic
injury, and hyperthermia.)
Debridement, Wound Healing & Ulcers of The Skin, Avi Shai by Springer page 135

9. Reasons of
Debridement
Presence of NM enhance bacterial colonization and infection
via activation of alternative pathway of complement system –
ongoing inflammation, tissue destruction, delay healing
Foreign matter act as physical barrier, prevent normal wound
contraction and re-epithelialization
Decrease odor, excess moisture, risk of infection
Other reasons – preparation for skin transplant and topical
application of growth factor
Improve quality of life

10. Option of
debridement
1. Surgical & sharp
2. Mechanical
3. Autolytic, enzymatic, absorptive
dressing & honey
4. Larvae Debridement Therapy
5. Technical Solutions
EWMA Document: Debridement, 2013

11. Mechanism of action focus on debridement
Contraindication and limitation

12. 1. Sharp debridement
i. MOA - cutting
ii. Indication - solid layer of necrotic tissue
iii. Contraindication – presumed involvement deep
structure – vessels, nerve, blood coagulation
disorder
iv. Limitation – spread of infection, pain, patients
fear, requires special skills, risk of over-excision,
specific area (neck, joint, face)
v. Benefit – the fastest for WBP

13. 2. Mechanical debridement (The Old Army)
Wet-to-dry Paraffin tulle Gauze Monofilament fibre pad
Background Commonest Comparator in wound
studies, limited
information as debriding
agent
Mechanism of Action Moist gauze pad
applied, tissue dries and
hardened – pulled off
Indication Short term therapy for
infected necrotic wound
Limitation Time consumed, cost,
lack of concordance
procedure, FB from
gauze remnants, pain,
increased risk of
infection
Pain, damage tissue
upon removal, increased
risk of infection, delay
RE
Pain, frequent dressing
changes needed

15. 3. Autolytic, enzymatic, absorptive dressing & honey
I. AUTOLYTIC
a. Hydrogels
b. Hydrocolloids
c. Hydrofibers
d. Multicomponent dressings
hydration response technology
(HRT), iodine pair, alginogel
Dual MOA:
1. Donate water, absorb exudates
2. EPE release – collagenase,
elastase, myeloperoxidase,
hydroxylase, lysozyme, phagocyte
activation
Indication - remove fibrin
coatings, eschar, slough.
Selection depends on exudates
level
Contraindication – presumed
involvement deep structure –
vessels, nerve, blood
coagulation disorder, sensitive
to propylene glycol, deep
cavity, bleeding wounds,
necrotic digit
Occlusive + high exudates >
p.aeroginosa
Limitation – HG for low
exudates, control minimal
infection, slow action,
maceration, pain with iodine,
cost
Easiest and safest
Take note: 1. HG – coat 2mm,
sheets 2 cm peri
2. Highly absorptive – 3mm
3. Cadexomer iodine –
150mg/wk, no longer 3mths.
CI in iodine sensitivity – HTX,
Hashimoto, thyroiditis. Tissue
reaction HK
Cooling effect HG sheets
PMMD – glycerin / starch

17. a) MOA - proteolytic enzymes – hydrolyse peptide bonds, MMPs
endocollagenases triple helix structure colagen (necrotic tissue in ECM
contain type IV collagen, glycoproteins, proteoglycans)
b) Indication - mechanical CI, bleeding disorder
c) Contraindication – dry wound
d) Limitation – periwound irritation, fever and leukocytosis (streptodornase)
absorption of purine / pyrimidines, costly
e) Benefit – applied 2 – 3 mm thickness in moist wound, easy, safe
ii. Enzymatic

18. ORIGIN ENZYME SOURCE Example
ANIMAL Fibrinolysin Bovine plasma Elase, Fibrolan
Desoxyrbonuclease Bovine pancreas
Krill multienzyme Antarctc krill
Collagenase Paralithodes
camtshatica
Catalase Equine liver
PLANT Papain Carica papaya Accuzyme
Bromelain enzyme complex Pineapple
BACTERIA Collagenase Clostridium hystiliticum
Streptokinase Streptococcus
hemolyticus
Varidase
Streptodomase Streptococcus
hemolyticus
Varidase
Sutilain Bacilus subtilis
PROTEOLYTIC ENZYME FOR WOUND TREATMENT

20. a) MOA - Dextranomer – 3D dextran porous
hydrophilic polymer. (1GM dextran to 4GM
fluid)
b) Indication - moderate to high exudates
c) Contraindication – mucosal surface,
bottleneck wound
d) Limitation – pain, erythema, blister
e) Benefit – easy to handle
iii. ABSORPTIVE

22. a) MOA - 30% glucose, 40% fructose, 5% sucrose, 20% water – osmotically draw
fluid for autolytic debridement. Antimicrobial when osmotic dehydration – low
pH 3 – 5 and release of hydrogen peroxide and methylglyoxal. Anti-inflammatory
stimulate immune response – decrease ROS and TNF release
b) Indication - low to moderate exudates
c) Contraindication – dry, necrotic wound, sensitive to bee venom
d) Limitation – natural honey contaminated with pesticides, clostridia spores,
allergic reaction as in pollen. Pain due to acidity
e) Benefit – antimicrobial, deodorize agent
20ml of honey on 10cm2 dressing
IV. HONEY

23. 4. Larvae
debridement
therapy
•
• Indication - exudatives chronic wound, loose or
biobag 10 – 15/ cm2 (biobag reduce yuks factor).
Loose larvae are quicker than biobag but time of
healing same
• Contraindication – vermiphobia, not to use on
mucosal surface, allergy to fly larvae, yeast, soy-bean,
patients with decrease perfusion, exposed vessels
• Limitation – not to put on pressure area, too much
exudates, suffocated larvae, cause pain
• Benefit – cost effective, reduce odor,
• Hydrocolloid strip or zinc paste to protect periwound
• Allantoin

24. Trifold Debridement System
a. Mouth – saliva secrete proteolytic enzyme and
collagenases, altering wound Ph (alkaline saliva)
b. Hollow – ingest necrotic tissue and neutralizing
bacteria in their gut. Prevent contamination via
peritrophic membrane (acidic gut)
c. Body – movement increase exudate production
and irrigation, wider distribution of fibroblast
within wound bed
MECHANISM OF ACTION
– LUCILIA SERICATA

26. The
Debridement
Algorithm
• A suggested algorithm based on consensus of expert opinion
• To guide the choice of debridement technique
• Start with – time consumed, then – technology available
• Consider following parameters that may influence the decision-
Pain
Patients environment
Patients' choice
Age
Comorbid
Quality of life
Skill of caregiver
Resources of caregiver
EWMA Document: Debridement, 2013

27. The Debridement Algorithm
MECHANICAL
•Fast
•No
expertise
needed
•Not
efficient
SHARP
•Fast
•Risk of
infection in
non-sterile
environme
nt
NO LARVAE
•Reduce
pain and
odor
NO AT /
ENZYMATC
•Safest
NO JET /
USOUND
•Equipment
not
generally
available
NO SURGICAL
•Required
skill
LESS TIME CONSUMING MORE TIME CONSUMING
EWMA Document: Debridement, 2013

28. Conclusion
YES, compulsory to debride when you need to, according to The
Debridement Algorithm and NOT TO when the contraindication and
limitation is there.

29. Thank You
Dr Wan Zuraini Mahrawi
Wound Care Clinician
MSc Wound Healing & Tissue
Repair (UK), GCFM
mrs.wanzu@gmail.com
+6011-33515410