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Wound Debridement & Adjunctive Wound Care2

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Wound Debridement & Adjunctive Wound Care

Wound Care Management 2-4th October 2012 HRPZ II KOTA BHARU DR MOHAMMAD IZANI BIN IBRAHIM

What is DEBRIDEMENT?Removal of dead, damaged, dying or unhealthy tissue from the wound bed to promote healing 3 main types 1. 2. 3. 4.

Active Autolytic(moisture donation) Autolytic(moisture absorption) Enzymatic

Active Debridement

Sharp debridement Biological debridement Chemical debridement

Mechanical debridement

Surgical DebridementDebridement using surgical intruments such as scalpels and forceps either in operating theatre or in the ward ( procedure room or bedside)

Involves removal of all non viable and compromised tissue until a healthy bleeding wound bed is achieved.This causes an inflammatory response from the wound which stimulates healing.

Reasons for Debridement

Removes necrotic and infected tissue and callus Decreases bacterial burden, allows deep tissue culture Turns chronic wound to acute and resets stage towards normal wound healing Allows application of bioengineered products

Assessment of Wound

1.Nature of the necrotic/ischemic tissue and the best debridement procedure to follow 2.The risk of spreading infection and use of antibiotic 3. Underlying medical condition

4. Extent of ischemia in the wound tissues 5. Location of the wound on the body

When Consultation Needed?

Vascular insufficiency Gangrenous digit/wound Unidentifiable structure(eg:neurovasc structures) Coagulopathy

When Consultation Needed?(2)

Stable heel ulcer-firmly adherent, lack of inflammation, lack of drainage, eschar that does not feel soft or boggy)

Fungating/malignant like wounds Necrotic tissue near neurovascular structure Wounds of hand and face

Indications

Extensive devitalized tissueSigns advancing soft tissue infections or sepsis

Presence of thick adherent escharCallous formation

Principals of Surgical Debridement

Debride in stages to minimize damage to healthy tissue Stay within a fascial plane during debridement to avoid spreading bacteria into the lower layers Small bleeders stopped by applying pressure, larger ones require diathermy or ligations

Tissue Viability DifferentiationNecrotic Viable Fat Dull Graybrown to black Dull Graybrown to black Dark redbrown to gray Shiny Yellow Glistening White Dull red Contraction when pinched Vascular bleeding Little or no odor

Fascia

Muscle

All Tissue

Insensate Avascular- no bleeding Foul odor

Biological DebridementMaggot Debridement Therapy (MDT) Lucilia Cuprina- sterile maggots MOA -remove slough -stimulate wound healing -disinfect the wound CI -Wound needing urgent debridement -Poor vascularity, abscess -entomophobia

Chemical Debridement

Hydrogen peroxide and sodium hypochlorite (EUSOL) Has bactericidal effects Unfortunately they have toxic effects on healthy tissue and fibroblast Also painful

Mechanical Debridement

Necrotic tissue can be physically pulled from the wound bed

Methods available a)Wet to dry gauze b)Scrubbing wound with scalpel c)Whirlpool (hydrotherapy/pulse lavage) d)Wound irrigation e)Ultrasonic debridement

High Power Hydrostatic Debrider

Jets of warmed solution are used to loosen the bonds between the adherent necrotic material and the viable tissue. Effective, but expensive and has problem about equipment cleansing and cross infection

Ultrasonic Debridementutilizes low frequency pulsed ultrasound directed to the wound surface via an ultrasound probe. Wound irrigation fluid (0.9% Normal Saline) is directed through an opening in the probes tip as a coupling medium, coolant, wound lavage or flush.

Autolytic (moisture donation)

Hydrocolloids, hydrogels, honey and silver sulphadiazine donate moisture to the wound and enhance the process of debridement However care must be taken to prevent surrounding tissue becoming macerated.

Autolytic (moisture absorption)

Alginates, cadexomer iodine and Hydrofiber facilitate autolytic debridement by absorbing moisture(exudate) from the wound while ensuring that necrotic tissue does not dry out.

Enzymatic Debridement

Uses topically applied enzymatic agents to stimulate the breakdown of non-viable tissue

Faster debridement process compared to Autolytic Eg: Clostridiopeptidase A, honey and fibrinolysin with DNAse

When NOT TO DEBRIDE?Necrotic tissue = BAD =To Debride But there are exceptions In cases with inadequate blood supply, tissue regeneration can be poor or absent Debridement will expose underlying structures to dessicate and bacterial ingress In certain cases the necrotic tissue is left in situ

Adjunctive Treatments

Honey dressingHyperbaric Oxygen Therapy Negative Pressure Wound Therapy(NPWT)- VAC( Vacuum Assisted Closure)

Honey Dressing

Honey is mainly used to promote granulation and epithelization of a wound

Types raw honey Supermarket honey Therapeutic honey- Manuka, Tualang etc

Honey Dressing (2)

Honey has antibacterial effects which are attributed to its high osmolarity, low pH, hydrogen peroxide content, and presence of other uncharacterized compounds.

Honey Dressing(3)promote enzymatic debridement deodorize malodorous wounds stimulate growth of wound tissues to accelerate healing stimulate anti-inflammatory activity that reduces pain, edema and exudates. minimizes hypertrophic scar promote moist wound healing contains low level hydrogen peroxide which stimulates fibroblast proliferation and angiogenesis

HONEY DRESSING

Hyperbaric Oxygen Therapy

Intermittently breathing pure(100%) oxygen at greater(2-3 times) atmospheric pressure Used for decompression disease, necrotizing fascitis and carbon monoxide poisoning

MOA in Wound Management

Angiogenesis in ischemic tissues Bacteriostatic and bactericidal Inhibit C. perfringes alpha toxin synthesis Leukocyte oxidative killing

Negative Pressure Wound Therapy (NPWT)/VAC- Vacuum Assisted ClosureIndicated for huge, clean, exudative wound while waiting for definitive wound closure. Also for fixation of skin grafts.

How VAC Works?

Provides a closed and moist wound healing environment Removes excess fluids that can inhibit wound healing Helps remove interstitial fluids Promotes granulation and decreases wound volume

VAC Contraindicated in?

Necrotic wound bed or aschar Untreated osteomyelitis Clotting disorders

Neoplastic tissue in the wound

Contraindicated in

TAKE HOME MESSAGE

Sharp debridement- fastest and gold standard for wound with active infection/ sepsis

Recognize wound which can/dont need debridementAdjuvant therapy mainly for clean wound- promote granulation/epithelization

THANK YOU

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