Debridement as a Fundamental Principle of Wound Treatment

Why clinicians debride

Debridement is a core component of a comprehensive wound treatment plan and is outlined in most wound treatment models. This is because delayed debridement delays healing time^1-3 and places the patient at risk for negative outcomes including infection,⁴ sepsis, osteomyelitis, hospitalization, and amputation. Inadequate debridement potentiates the inflammatory environment of chronic wounds by the continued presence of necrotic tissue, proteolytic enzymes and inflammatory cytokines, and bacterial bioburden including biofilm. The capillary exposure that occurs during some forms of debridement reinitiates the healing cascade and assists with transitioning wounds out of the inflammatory stage back onto a healing trajectory. A thorough surgical debridement can remove senescent cells, preventing the senescence-associated secretory phenotype positive feedback loop that can be prominent in disease states like diabetes.^5,6 Surgical debridement also prepares the wound bed for other advanced interventions including negative pressure wound therapy and cellular and/or tissue-based products. 

Who clinicians don’t debride 

Debridement is a standard of care, but there are patient presentations where debridement is contraindicated including stable eschar on ischemic limbs, malignant tumors, and wounds at risk of pathergy.

Stable eschar on ischemic limbs

The impaired blood flow that accompanies lower extremity arterial disease can prevent wounds from healing and leaves them vulnerable to infection. In some patients an eschar will form over ischemic wounds which can be left intact providing it is stable. It is important to note the definition of stable eschar. Stable eschar is completely dry eschar without evidence of infection. Eschar that is weeping, lifting, or surrounded by erythema is unlikely to be stable, and the risk of infection it poses is greater than the risk of debridement.

Malignant tumors

A good rule of thumb is to not sharp debride fungating tumors. Cancer is dysfunctional cell death and cell replication at baseline and encouraging cell replication through capillary exposure initiating the healing cascade could encourage tumor growth. Conservative sharp debridement is sometimes performed on fungating tumors to remove frank necrosis with the intention of minimizing bioburden and its associated odor. If suspicion of malignancy within a wound exists sharp debridement should be held until the results of a wound biopsy are available.

Wounds at risk of pathergy

Clinicians who perform surgical debridement and observe pathergy should be suspicious of underlying disease states and alternative pathologies. Pathergy is a phenomenon where even minor trauma can lead to an acute exacerbation including wound enlargement¹. It can occur in disease states including untreated calcific uremic arteriolopathy (also known as calciphylaxis) and pyoderma gangrenosum. Surgical debridement is avoided until the underlying disorder is treated.

Sharp debridement

Sharp debridement is the fastest method of debridement and is used to rapidly remove material from the wound bed.¹ Sharp debridement can be divided into surgical and conservative categories. Both surgical and conservative sharp wound debridement utilize tools such as scalpels, curettes, irises, and tissue nippers to remove material from wounds. Conservative sharp debridement differs from surgical debridement in that the intent is to only remove non-viable tissue and in doing so the wound specialist would cause neither bleeding nor pain. Conservative sharp debridement can minimize necrotic tissue and its associated bioburden in wounds but does have limitations. Wounds with epibole require sharp debridement to remove the epithelialized edges. Acutely infected wounds benefit from surgical debridement to rapidly remove infectious materials¹, and surgical debridement acts as a form of infection source control.⁴

Patient-reported pain can limit the use and extent of surgical debridement performed outside the operating room. To optimize debridement clinicians can utilize debridement technique that prioritizes tissue depths and locations with less sensory nerve fibers, beginning in the center of the wound where tissue loss is often deepest and debriding the wound edge where pain can be greatest at the end of the procedure. Therefore, if the patient requests cessation of the procedure due to pain, more of the wound bed has been treated.

Due to the low risk of conservative sharp debridement, you do not need to be a provider to perform this procedure. However, wound nurses should consult their state nurse practice act and institutional policies. Conservative sharp wound debridement should only be performed by wound specialists with documentation referencing appropriate didactic and clinical education, as well as demonstrated competence.^1,4 With projected shortages in providers, specialists, and nurses, all wound specialists should be educated and trained to increase patient access to this important component of wound care.

Non-instrumental debridement

Multiple other forms of non-instrumental debridement exist, including micellar surfactants, enzymatic debridement, maggot/larval debridement, chemicals such as desiccants and sodium hypochlorite, hydrotherapy, mechanical debridement, microfiber pads, wet-to-dry gauze, ultrasound, and dressings to facilitate autolysis.¹ Non-instrumental modalities of debridement can be used as either standalone interventions or in concert with sharp debridement as a method to continue debridement between visits. These modalities vary in the tissue depth removed, expected procedural pain, speed, cost, and whether or not they also assist in the removal of biofilm. Wet-to-dry dressings are usually avoided due to their non-selective nature, pain, and potential for inflammatory potentiation that occurs when fibers remain in the wound bed. Sodium hypochlorite, or Dakin’s solution, is a controversial agent that is typically reserved for severely infected wounds due to its negative effects on fibroblasts^1,4 and availability of less cytotoxic options to decrease microbial counts such as hypochlorous acid. Silver nitrate is a commonly used chemical debridement agent for hypergranulation and can be effective when used for mild epibole.⁴ Clinicians can choose amongst the available debridement options, which are often used in combination and modified as the wound bed presentation changes.

Conclusion

Debridement is a standard of care for non-palliative wound patients. Having knowledge and access to the myriad of debridement modalities allows the wound specialist to select appropriate therapies for patients in consideration of the varied clinical presentations, comorbidities, pain, treatment setting, and goals of care.

References

1.         Doughty DB, McNichol LL, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum + Ostomy Management + Continence Management + Wound Management. Lippincott Williams & Wilkins; 2015.

2.         Wickline S. Wounds heal better when debrided often. MedPage Today. Published July 26, 2013. Accessed March 2021. https://www.medpagetoday.org/dermatology/generaldermatology/40692?vpass=1.

3.         Wilcox JR, Carter MJ, Covington S. Frequency of debridements and time to heal: a retrospective cohort study of 312 744 wounds [published correction appears in JAMA Dermatol. 2013;149(12):1441]. JAMA Dermatol. 2013;149(9):1050-1058. doi:10.1001/jamadermatol.2013.4960.

4.         Bryant RA, Nix DP. Acute & Chronic Wounds: Current Management Concepts. 4th ed. Elsevier/Mosby; 2012.

5.         Shakeri H, Lemmens K, Gevaert AB, De Meyer GRY, Segers VFM. Cellular senescence links aging and diabetes in cardiovascular disease. Am J Physiol Heart Circ Physiol. 2018;315(3):H448-H462. doi:10.1152/ajpheart.00287.2018.

6.         Regulski M. Understanding diabetic induction of cellular senescence: a concise review. Wounds. 2018;30(4):96-101.