Wound Debridement & Wound Debridement & Adjunctive Wound CareAdjunctive Wound Care

Wound Care Management2-4th October 2012HRPZ II KOTA BHARUDR MOHAMMAD IZANI BIN

IBRAHIM

What is DEBRIDEMENT?What is DEBRIDEMENT?Removal of dead, damaged, dying

or unhealthy tissue from the wound bed to promote healing

3 main types

1.Active2.Autolytic(moisture donation)3.Autolytic(moisture absorption)4.Enzymatic

Active DebridementActive DebridementSharp debridement

Biological debridement

Chemical debridement

Mechanical debridement

Surgical DebridementSurgical 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 DebridementReasons for DebridementRemoves 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 WoundAssessment of Wound1.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 When Consultation Needed?Needed?

Vascular insufficiency

Gangrenous digit/wound

Unidentifiable structure(eg:neurovasc structures)

Coagulopathy

When Consultation When Consultation Needed?(2)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 Indications

Extensive devitalized tissue

Signs advancing soft tissue infections or sepsis

Presence of thick adherent eschar

Callous formation

Principals of Surgical Principals of Surgical DebridementDebridementDebride 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

Pain control

Tissue Viability Tissue Viability DifferentiationDifferentiation

Necrotic Viable

Fat DullGraybrown to black

ShinyYellow

Fascia DullGraybrown to black

GlisteningWhite

Muscle Dark redbrown to gray

Dull redContraction when pinched

All Tissue InsensateAvascular- no bleedingFoul odor

Vascular – bleedingLittle or no odor

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

Chemical DebridementChemical DebridementHydrogen peroxide and sodium

hypochlorite (EUSOL)

Has bactericidal effects

Unfortunately they have toxic effects on healthy tissue and fibroblast

Also painful

Mechanical DebridementMechanical DebridementNecrotic tissue can be physically

pulled from the wound bed

Methods availablea)Wet to dry gauzeb)Scrubbing wound with scalpelc)Whirlpool (hydrotherapy/pulse lavage)d)Wound irrigatione)Ultrasonic debridement

High Power Hydrostatic High Power Hydrostatic DebriderDebrider

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 DebridementUltrasonic 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 probe’s tip as a coupling medium, coolant, wound lavage or flush.

Autolytic (moisture Autolytic (moisture donation)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 Autolytic (moisture absorption)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 DebridementEnzymatic 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?When NOT TO DEBRIDE?Necrotic tissue = BAD =To DebrideBut there are exceptionsIn 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 TreatmentsAdjunctive Treatments

Honey dressing

Hyperbaric Oxygen Therapy

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

Honey DressingHoney DressingHoney is mainly used to promote

granulation and epithelization of a wound

Types- raw honey Supermarket honeyTherapeutic honey- Manuka,

Tualang etc

Honey Dressing (2)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)Honey Dressing(3)promote enzymatic debridementdeodorize malodorous woundsstimulate growth of wound tissues to

accelerate healingstimulate anti-inflammatory activity that

reduces pain, edema and exudates.minimizes hypertrophic scar promote moist wound healingcontains low level hydrogen peroxide

which stimulates fibroblast proliferation and angiogenesis

HONEY DRESSING

Hyperbaric Oxygen TherapyHyperbaric Oxygen TherapyIntermittently breathing pure(100%)

oxygen at greater(2-3 times) atmospheric pressure

Used for decompression disease, necrotizing fascitis and carbon monoxide poisoning

MOA in Wound MOA in Wound ManagementManagementAngiogenesis in ischemic tissues

Bacteriostatic and bactericidal

Inhibit C. perfringes alpha toxin synthesis

Leukocyte oxidative killing

Negative Pressure Wound Negative Pressure Wound Therapy (NPWT)/VAC- Vacuum Therapy (NPWT)/VAC- Vacuum Assisted ClosureAssisted Closure

Indicated for huge, clean, exudative wound while waiting for definitive wound closure.

Also for fixation of skin grafts.

How VAC Works?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?VAC Contraindicated in?Necrotic wound bed or aschar

Untreated osteomyelitis

Clotting disorders

Neoplastic tissue in the wound

Contraindicated in

TAKE HOME MESSAGETAKE HOME MESSAGESharp debridement- fastest and

gold standard for wound with active infection/ sepsis

Recognize wound which can/don’t need debridement

Adjuvant therapy mainly for clean wound- promote granulation/epithelization

THANK YOUTHANK YOU