Assessing Debridement Options For Diabetic Wounds

Start Page: 101

Continuing Education Course #150—March 2007

I am pleased to introduce the latest article, “Assessing Debridement Options For Diabetic Wounds,” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education (NACCME), consists of complimentary CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.
When debriding diabetic wounds, one must consider several variables to help facilitate optimal wound healing. With that said, Eric H. Espensen, DPM, denotes the advantages and disadvantages of several types of debridement. He also explores the question of whether or not one should debride a diabetic wound.
At the end of this article, you’ll find a 10-question exam. Please mark your responses on the enclosed postcard and return it to NACCME. This course will be posted on Podiatry Today’s Web site (www.podiatrytoday.com) roughly one month after the publication date. I hope this CE series contributes to your clinical skills.

Sincerely,

Jeff A. Hall
Executive Editor
Podiatry Today

INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 101 and successfully answering the questions on pg. 106. Use the enclosed card provided to submit your answers or log on to www.podiatrytoday.com and respond via fax to (610) 560-0502.
ACCREDITATION: NACCME is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by NACCME are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Dr. Espensen has disclosed that he has no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of the subject of his presentation.
GRADING: Answers to the CE exam will be graded by NACCME. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam.
TARGET AUDIENCE: Podiatrists
RELEASE DATE: March 2007
EXPIRATION DATE: March 31, 2008
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• discuss the importance of debridement for diabetic wounds;
• summarize proper techniques for surgical, sharp, mechanical, autolytic, enzymatic, biological and chemical debridement;
• describe the factors that affect whether one should or should not perform debridement;
• discuss the importance of maintaining a sterile environment during various types of debridement; and
• discuss options for pain relief during different debridement procedures.

Sponsored by the North American Center for Continuing Medical Education.

Note the distal fifth digit eschar, which is dry, stable and well attached with no signs of active infection.
Here one can see the same patient after debridement of the poorly adhered eschar. Debridement revealed a stable, healing wound beneath the eschar.
This hallux ulcer shows signs of shear and macerated hyperkeratosis, which is amenable to sharp debridement.
This large heel ulcer with eschar shows signs of liquefaction around the eschar edges. Debridement allows for exposure of the underlying tissue. After debridement, one can continue wound care.
A Comparison Of Debridement Methods For Diabetic Wounds
106
Author(s): 
By Eric H. Espensen, DPM

      Diabetic wounds are a common occurrence in wound care centers and private practice. With the escalating rate of diabetes, more and more patients are developing wounds that require care. Wound care for diabetic wounds routinely includes debridement. The term debridement comes from the French desbrider, meaning “to unbridle,” and was probably first used as a medical term by surgeons working in war zones. The medical personnel and surgeons likely recognized that contaminated wounds had a better chance of healing if one surgically removed the damaged tissue to reveal a healthy, bleeding wound surface.

      The modern definition of debridement is the removal of dead or necrotic tissue and foreign material from and around the wound with a sterile scalpel, scissors or other methods to expose healthy tissue. Surgical debridement involving extensive and aggressive removal of tissue with or without general or local anesthesia would take place in the operating room. Podiatric physicians may utilize more conservative (sharp) debridement, involving repeated minor tissue sparing debridement, at the bedside or in a procedure room.

      Other methods of debridement include mechanical, biological, chemical, enzymatic or autolytic debridement. In 1962, Winter offered one of the earlier profound observations in wound care when he noted that moist wounds heal better in comparison to desiccated wounds.1 Proper debridement allows for exposure of the moist tissues and subsequently allows the practitioner to maintain a proper wound environment.

Underscoring The Importance Of Proper Debridement

      The clinician cannot properly assess or document the status of a diabetic wound until he or she has removed all necrotic, hyperkeratotic and devitalized tissue. Dead tissue acts as a medium for bacterial growth. Dead spaces within the tissue allow for abscess formation which can, in turn, allow for anaerobic bacterial growth such as Bacteroides species or Clostridium perfringens.

      The presence of necrotic or foreign material provokes an inflammatory response, which adds to the systemic release of cytokines such as tumor necrosis factor and interleukins, which promote a septic response.

      Necrotic tissues can retard wound contraction, the principle contribution to wound closure, when wounds are left to heal by secondary intention.

      Diabetic wounds are often covered by scab, eschar or hyperkeratosis. Accordingly, it can sometimes be difficult to determine whether the tissue covering a wound is physiological or pathological. Indeed, podiatric physicians need to remove gangrenous, necrotic, ischemic and devitalized tissue by some method of debridement. Failure to debride diabetic wounds appropriately when necessary could be considered failure to render proper treatment.

      It is a widely accepted premise that wound debridement is necessary for optimal wound healing. Surgical or sharp debridement has long been viewed as the “gold standard” for debridement. Unfortunately, the evidence for the effectiveness of different methods of debridement from randomized controlled trials is lacking and an evidence-based treatment algorithm has yet to be established. Oftentimes, the treating practitioner chooses the method of debridement based on his or her individual experience and level of comfort with the chosen method instead of an established treatment algorithm or other evidence-based rationale.

A Guide To Methods Of Wound Debridement

      Surgical and sharp debridement. For these types of debridement, one would use a scalpel, scissors or other instrumentation. Podiatrists may perform these debridements in many different settings. The results are immediately notable. However, these types of debridement require specific training and specialized equipment. One must control pain with some degree of anesthesia, whether it is general or local.

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