Cath Lab Digest

Appropriate debridement sets the stage for the conversion of chronic wounds into acute wounds, and eventual healing. With this in mind, these authors discuss essential patient considerations and offer a salient overview of debridement options ranging from sharp debridement to the emergence of ultrasonic debridement.

   Wound debridement is the first step to facilitating successful and swift wound closure in the care of acute and chronic wounds. Wound care physicians also use the phrase “wound bed preparation” to describe the process of preparing the wound for the use of skin graft and other topical wound therapy, or for healing by secondary intention.

   Common sense supports the removal of foreign substances such as dirt from acute traumatic wounds in order to minimize the risk of infection and facilitate wound closure. By the same token, it is important to remove any non-viable tissue, such as dry eschar, necrotic skin and desiccated tendon, in order to remove the physical barriers of reepithelialization over the skin defect. The buildup of callused skin around the wound, often seen in the plantar foot with diabetic neuropathic foot ulcers, also must undergo sharp debridement as the callused skin may inhibit the wound contraction.

   In heavily contaminated, infected or chronic wounds with biofilm and bacteria colonization, the debridement of infected tissues may help control infection and bioburden. Since tendons and fascias, abundant in the foot and ankle region, have relatively poor blood supply, physicians may have to sacrifice these structures and debride them aggressively to eliminate the infection in deeper wounds. In addition, one should consider exposed bone to be infected unless proven otherwise. A positive “probe to bone” test indicates an 85 percent chance of osteomyelitis.¹

   Another theory behind debridement contends that the process transforms a chronic wound into an acute wound. As the wound continues to stay open, the tissue surrounding the wound may get stuck in the state of chronic inflammation and cease to heal. This is referred to as a “stunned wound,” which may require the intentional trauma from sharp debridement and/or mechanical stimulation by ultrasound to initiate the healing process.²

Key Comorbidities You Should Know Before Performing Surgical Debridement

   Prior to any medical treatment, proper patient assessment is paramount. When considering wound debridement options, the physician must consider the etiology of the wound in question along with the patient’s past medical/wound history and comorbidities. Certain patient populations will require extra caution and special considerations when it comes to the possible use of surgical debridement.

   Peripheral arterial disease (PAD) and ischemic limbs. Peripheral arterial disease is often underdiagnosed. As the physical exam and pulse palpation are not adequate for the diagnosis of ischemia and PAD, objective Doppler tests are recommended for vascular assessment. Patients who are 50 years or older are at high risk for PAD, especially if they have a history of smoking, diabetes or known atherothrombotic disease (carotid, coronary or renal artery disease).³ The vascular assessment of microcirculatory skin perfusion is essential prior to sharp debridement as careless sharp debridement of the ischemic limb will result in enlargement and further necrosis of the wound.
   In our clinic, we use a laser Doppler-based skin perfusion pressure monitor (Sensilase, Vasamed) to rule out or diagnose ischemia using both pulse volume recordings (PVR) and skin perfusion pressure (SPP) tests. A peri-wound skin SPP value of 30 mmHg or below is diagnostic of severe PAD, also known as critical limb ischemia (CLI). This calls for immediate referral to vascular specialists such as vascular surgeons, interventional cardiologists and interventional radiologists. An SPP value above 40 mmHg is considered adequate for normal wound healing and indicative of good wound healing potential.