Can New Hemostatic Dressings Facilitate Sharp Debridement In High-Risk Patients?

Author(s): 
Clark Schierle, MD, PhD, and Julie Krol, MS, PA-C

   Sharp debridement is a critical step to promote healing and allow the body to repair chronic wounds as naturally and healthily as possible. Removing necrotic tissue and biofilm from the surface of chronic wounds converts chronic wounds into acute ones, effectively “resetting” the wound healing cascade and allowing the healing process to take place.

   Successful debridement and subsequent wound closure reduce the risk of infection, reduce hospital stays and improve a patient’s overall quality of life. Sharp debridement requires the surgical experience, skills and tools to safely manage potential complications, control bleeding and prevent additional infection. Using chitosan-based hemostatic bandages, wound care specialists can perform more sharp debridements on high-risk patients in a convenient, safe outpatient setting or in an inpatient setting as needed.

   Wounds such as diabetic ulcers, pressure sores and venous stasis ulcers often present wound care specialists with necrotic eschar that requires aggressive debridement. These wounds often occur in patients with multiple comorbidities, making a general anesthetic dangerous. By the time one recommends debridement, the wounds are usually at a serious, complex stage. Patients are often on anticoagulant therapy, making bedside debridement risky prior to the advent of effective hemostatic dressing options.

   Traditionally, surgeons performed sharp debridement in hospital operating rooms but more procedures are now taking place in the ambulatory setting.
   Until recently, many patients with coagulopathies or those on significant antithrombotic therapies could not get debridement in time to prevent further deterioration of necrotic tissue. They were either too sick to get clearance for the procedure in the OR or the procedure was too dangerous to execute at the bedside. Bedside debridements are an ideal option for debilitated patients but the procedure was often discouraged due to the risk of hemorrhaging outside of the OR’s controlled setting. Effective hemostatic bandages now solve this problem.

   The availability of chitosan-based hemostatic dressings allow for safe, effective and thorough debridement of necrotic chronic wounds in an ambulatory setting or for inpatients at the bedside. This improves patient safety and wound care. The bandages are ideal for wounds that are prone to acute bleeding after mechanical and surgical debridement, and quickly stop a wide range of bleeding, from oozing to severe arterial bleeds.

How Do Chitosan-Based Hemostatic Dressings Work?

   In regard to chitosan-based hemostatic wound dressings, chitosan is a naturally occurring biocompatible and biodegradable polysaccharide derived from chitin, the structural element in the exoskeleton of crustaceans. Chitosan-based bandages control hemostasis and stop bleeding within minutes. The bandages’ antibacterial barrier properties may also help prevent infection at the incision site.

   Chitosan, in a freeze-dried form, provides primary hemostasis by sealing the wound and stopping the bleeding. Specific chitosan dressings can create an adhesive structure with a positive charge that attracts red blood cells and platelets, which have a negative charge. As the red blood cells and platelets are drawn towards the chitosan through this ionic interaction, a strong seal forms at the dermal wound site. The platelets and red blood cells continue to be drawn towards the chitosan and form the frontline hemostatic support structure. The platelets and red blood cells will continue to aggregate until hemostasis and clotting occur.

   Chitosan-based dressings have rapidly gained acceptance in military and traumatic wound settings where massive hemorrhage often leads to the depletion of clotting factors. Chitosan’s mechanism of action functions independently of either the intrinsic or extrinsic clotting cascades, and forms an immediate seal on wounds. This allows time for the patient’s native coagulation pathway to take effect. Furthermore, the use of chitosan has been implemented in order to address bleeding specifically while minimizing collateral tissue injury inherent with electrocautery.

   One generally uses hemostatic bandages in the first 24 hours after removing the necrotic tissue and there is substantial bleeding at the wound site. After getting the initial heavy bleeding under control, one may apply moist dressings to promote wound healing. Wet-to-dry wound dressings can prevent infection but recent studies have shown that this method may actually enable bacterial proliferation. Chitosan-based hemostatic bandages offer physicians an added advantage because they also have an antibacterial barrier.

What One Study Reveals

   In a study conducted last year, we found that chitosan-based hemostatic bandages are an ideal choice for sharp debridements.1 The study involved 44 wounds in 35 patients undergoing sharp debridement. We applied HemCon Bandages (HemCon Medical Technologies) to the wounds along with two minutes of direct pressure. After two minutes, we packed the wounds with a dry dressing and left the dressing in place for a full 24 hours. We then changed the dressings to routine wound dressings and assessed the wounds for successful hemostasis.

   The results showed that the bandages allowed for safe yet adequately aggressive sharp debridement. The patients’ wounds could not have otherwise been adequately debrided due to bleeding concerns or the procedure would have required a trip to the OR. All patients underwent successful debridement at the bedside without the need for electrocautery.1

Are These Dressings A Cost-Effective Option?

   Using chitosan-based hemostatic bandages after sharp debridement is advantageous for several reasons. Wound care specialists can now perform bedside debridement, in an ambulatory or inpatient setting, in a more timely and safe manner. If there is a complication like unexpected severe bleeding, one can stabilize the wound until the patient receives emergency care.

   On-call caregivers now have an alternative to staying at the bedside holding bandages on the wound for long periods. This saves both time and money. In the past, if there was a chance of heavy bleeding, doctors were usually more conservative and did not cut out as much of the dangerous, necrotic tissue. Now more patients can have clean wounds with a minimal amount of necrotic tissue, reducing the need for additional debridement and expensive dressings.

   The lower overall costs associated with chitosan-based hemostatic wound dressings also make the bandages advantageous in terms of dealing with possible reimbursement issues. The Office of the Inspector General has seen a dramatic increase in the number of Medicare claims submitted for surgical excisional wound debridement (CPT code 11042). In addition, with the advent of pay for performance measures, the Centers for Medicaid and Medicare Services (CMS) recently announced that it will no longer pay hospitals for additional costs associated with treating patients for certain hospital-acquired infections. The safety, efficacy and antibacterial indications of these bandages make them an advantageous choice in the stringent reimbursement environment.

Final Notes

   Chitosan-based hemostatic dressings, such as the HemCon Bandage, offer a safe, cost-effective alternative to operative debridement for deep or superficial wounds in non-operative or coagulopathic patients. These bandages allow specialists to perform more sharp debridements at the bedside, increase patient comfort and improve healing outcomes. With this new wound care technology, patients with hazardous comorbidities can have unprecedented access to convenient, safer and more comfortable bedside debridement.

Dr. Schierle is affiliated with the Division of Plastic and Reconstructive Surgery, Department of Surgery, at the Northwestern University Feinberg School of Medicine.

Ms. Krol is affiliated with the Division of Plastic and Reconstructive Surgery, Department of Surgery, at the Northwestern University Feinberg School of Medicine.

Dr. Steinberg is an Assistant Professor in the Department of Plastic Surgery at the Georgetown University School of Medicine in Washington, D.C. Dr. Steinberg is a Fellow of the American College of Foot and Ankle Surgeons.

For further reading, see “Assessing Debridement Options For Diabetic Wounds” in the March 2007 issue of Podiatry Today.




References:

1. Schierle CF, Krol J, Galiano RD. Maximizing bedside debridement utilizing chitosan-based hemostatic dressings. Abstract, Diabetic Foot Global Conference 2009, Los Angeles, March 2009.

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