Words on Wounds

A forum to discuss the latest news and ideas in skin and wound care.

Wednesday, January 16, 2013

Wound Debridement

Debridement is a crucial component to prepare a clean wound bed and promote healing. The term debridement was initially introduced in the 18th century by French surgeons referring to the practice of making incisions into the skin and deep fascia to release pressure from localized swelling following war injury. Debridement in modern wound care involves various modalities to remove necrotic or devitalized tissue, hyperkeratotic epidermis, foreign debris, dysfunctional cells (cellular burden), bacteria sequestrum and other undesirable material in the wound bed. In general, necrotic tissues have been described in the form of eschar and slough. Although eschar is often depicted as dark, desiccated, hard, and leathery tissue, it could also appear wet, soft, and spongy. Slough, on the other hand, tends to be stringy, mucinous, and slimy in consistency. A build-up of these devitalized materials that contain mainly of denatured protein activates the immune system to trigger an inflammatory response. Dead tissue also provides an ideal and fertile medium for the bacterial to proliferate. Overall, the potential benefits of debridement may include:

  • Restoration of a healthy wound base for granulation
  • Reduction of bacterial burden and risk of infection
  • Removal of senescent cells that lack normal cellular functions
  • Removal of foreign materials and denatured protein that perpetuate an excessive inflammatory response
  • Evacuation and drainage of an abscess
  • Proper determination of the wound depth and tissue types
  • Elimination of the source of odor

Not all wounds, however, need and benefit from debridement. The decision to perform debridement should take into account whether complete wound closure is realistic and achievable. Aggressive debridement to the vascular layer is not recommended in nonhealable wounds where causative factors that preclude healing cannot be addressed. Under judicious deliberation, conservatively debriding nonhealable wounds—trimming loose-hanging fibrin to reduce necrotic mass and associated odor—may be appropriate. The goal of conservative debridement is to enhance quality of life and decrease the risk of infection, but not to facilitate healing. For healable wounds, different debridement methods have been described: mechanical (wet-to-dry dressing), enzymatic, autolytic (endogenous enzymes from dressings), biological (maggots), and sharp/surgical. Where appropriate, the choice of debridement method depends on the urgency, resources, or expertise available, and patient preference.