Current And Emerging Modalities In Wound Debridement

Author(s): 
Thomas Belken, DPM, and Neal Mozen, DPM, FACFAS

When Do You Debride?

Studies by Steed, Williams and their respective colleagues found that sharp debridement of wounds resulted in increased healing rates in comparison to wounds that were not debrided.6,7 These well-known studies validated our debriding of wounds but again, are we debriding too much?

   There are no concrete guidelines on wound debridement. In May of this year, the European Wound Management Association put out a nearly 50-page document on debridement.1 They recommend a debridement algorithm based on the consensus opinion of the authors. The reality is that there is a lack of standardized guidelines for wound debridement.

   On a microscopic level, the cells at the wound edge are not functioning properly and the wound pathway has been disturbed. Keratinocytes at and beyond the callused wound edge have become disoriented and have lost their ability to communicate. Researchers have shown that these chronic wound keratinocytes do not have receptors for growth factors.8

   The thought is that biomarkers can identify these dysfunctional keratinocytes. Early evidence has identified three of these biomarkers that may act as a “molecular scalpel.”8 This scalpel would give us a cellular/molecular basis for debridement. As exciting as this is, the practicality of its use will depend on the cost-to-benefit ratio and only time will tell. Regardless of whether we ever get to use a molecular scalpel, re-establishing the normal physiological function of the cells at the wound edge is essential for healing of the ulcer.

   So how do we accomplish this objective? Sharp debridement and other direct debridement techniques are effective but again, there are questions on frequency and to what extent.

   At what point do we stop debriding? Do you start with aggressive sharp debridement? This initial procedure along with appropriate copious lavage provides a “complete” debridement that helps to manage infection, bioburden and a chronic wound. Clinicians would subsequently follow this with maintenance debridement and aggressive wound cleansing (e.g. slough removal with gauze). These subsequent debridements require greater thought and consideration of options. Debridement that is too aggressive, especially at the wound edge, can damage the framework for healing.

   A consensus guidance from the United Kingdom in 2010 attempted to address this lack of standardization.9 In terms of debridement, the authors recommended that prior to debridement, the clinician should consider the following:

   What is the goal of debridement?

   How quickly does one need to achieve this goal?

   What is the best modality for accomplishing the debridement?

   Not all wounds need debridement and we as wound care specialists need to avoid tunnel vision. A well-adhered eschar that is not infected will be better served if we leave it alone. If the wound has minimal devitalized tissue, even the most skilled doctors cannot be 100 percent sure of the precision of their debridement.

   When the tissue within the wound bed is devitalized, how do we get the benefits of debridement without inhibiting wound healing by being too aggressive? This is where newer technologies shine. Products like DermaPACE (Sanuwave) and low energy ultrasound may obviate the need for mechanical or surgical debridement by stimulating an inflammatory response and causing the release of growth factors that lead to angiogenesis and cell proliferation.

Considering The Potential For Trauma From Debridement

Iatrogenic trauma of “healthy” tissue due to overly aggressive wound debridement can delay the healing process.

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