Keys To Ensuring Optimal Wound Debridement

Author(s): 
Clinical Editor: Kazu Suzuki, DPM, CWS

Wound debridement is the foundation for successful and swift wound healing. Appropriate and timely wound debridement facilitates infection control by removing the biofilm over wound surfaces. Our expert panelists discuss best practices in wound debridement by reviewing the clinical evidence for wound debridement, patient education and insights on the vascular workup of patients with wounds.

Q:

What is the current clinical evidence and rationale of wound debridement?

A:

Richard Brietstein, DPM, notes that clinical evidence supports the importance of wound debridement. He stresses the necessity of reducing bacterial burden and removing senescent cells. Doing so stimulates normal cytological activity to rid the wound bed of matrix metalloproteinases (MMPs) and other inhibitory agents in order to develop granulation tissue, according to Dr. Brietstein.

   When it comes to evidenced-based medicine (EBM), Kazu Suzuki, DPM, CWS, notes the absence of definitive randomized controlled studies (RCTs) on wound debridement. Based on a recent Cochrane Review, he says there is enough clinical evidence to suggest that wound debridement using hydrogel was more effective than placebo for diabetic foot ulcers.1

    “Having said all of that, we may never establish excellent EBM on wound debridement as the standard of care practice denotes that most, if not all, wound patients should receive appropriate serial wound debridement on a weekly basis,” says Dr. Suzuki. “In other words, it is probably unethical not to provide wound debridement to wound patients as a control group.”

   Dr. Suzuki and David G. Armstrong, DPM, PhD, MD, both cite the diabetic foot ulcer study by Steed and colleagues for the becaplermin (Regranex, Healthpoint Biotherapeutics) gel trial, a multicenter trial based on 118 patients with diabetic foot wounds.2 The study authors established that a center that provided wound debridement 20 percent of the time healed the wounds approximately 20 percent of the time while another center that provided debridement 80 percent of the time healed approximately 80 percent of the patients.

   Dr. Armstrong also notes that subsequent studies, including those from his group, were able to control for other potentially confounding factors and support Steed and colleagues.3

    “To date, though, all of these have been post hoc in nature,” he cautions. “It is admittedly tough to do a robust randomized study effectively subjecting half of patients to what most believe is inferior care.”

   More recently, Dr. Suzuki says Cardinal and colleagues came to the same conclusion based on 366 venous leg ulcers and 310 diabetic foot ulcers, which showed higher healing rates with more frequent debridement.3

Q:

What do you tell your patient regarding the debridement?

A:

Dr. Suzuki tells patients that their wounds cannot heal unless physicians remove all the dead skin along with the bacteria that feeds on dead skin and old blood. He might educate patients on recent research into bacteria biofilm and its effect on chronic wounds. Dr. Suzuki says most of his patients get the concept of serial wound debridement.

   Dr. Brietstein informs patients there are many types of cells with different functions that exist at the bottom of their wound and that if the infected tissue and dead cells are not removed, normal healing cannot take place.

   Dr. Armstrong compares debridement to removing what is not viable and uses the analogy of pruning a tree. Similarly, with respect to perfusion deficit, Dr. Brietstein explains that “if you don’t water the lawn, the grass dies.” As he notes, patients understand this analogy and this makes it easier for patients to accept when he recommends an angiogram to help determine if they need an angioplasty or a formal bypass surgery to help facilitate wound healing.

   Dr. Brietstein also emphasizes that it is essential to address infection, perfusion deficits, pressure, edema, nutritional status and assess for possible malignant transformation as these are all factors that can adversely affect healing.

Q:

Do you perform the appropriate vascular workup of lower extremity wounds prior to aggressive surgical wound debridement?

A:

At the initial visit, Dr. Suzuki uses SensiLase (Vasamed) to check skin perfusion pressure (SPP) and pulse volume recording (PVR) to make sure the patient has enough blood flow to heal the wound after sharp debridement. If the patient is critically ischemic (SPP below 30 mmHg), he provides minimal and conservative debridement, and then refers the patient to a vascular specialist immediately.

    “I believe it is a ‘cardinal sin’ not to check the baseline leg perfusion status prior to sharp debridement of lower extremity wounds,” emphasizes Dr. Suzuki.

   As far as “aggressive” debridement goes, Dr. Brietstein says it is paramount to assess patients for adequate perfusion. He notes that he palpates for pulses while speaking to patients. If patients are not fully perfused, he will debride their wounds, albeit in a less aggressive fashion, just to cleanse the wound bed or to obtain a culture.

   “It makes little sense to be aggressive and create a larger defect that won’t heal,” maintains Dr. Brietstein. He notes an exception in that when patients are septic and/or have gas gangrene, they are clearly in an emergent situation that is both life and limb threatening.

   Dr. Armstrong cites his “Toe and Flow” model of diabetic foot care and amputation prevention (see http://bit.ly/kLca7Z ).

Q:

Do you have other “pearls” of wisdom regarding wound debridement?

A:

Dr. Suzuki suggests trying to determine the wound etiology prior to sharp debridement and being vigilant for inflammatory conditions (specifically pyoderma gangrenosum) that cause skin breakdown. He notes that aggressively debriding these ulcers can only enlarge the wound by worsening the inflammatory condition.

   Dr. Armstrong concurs. “While we are very aggressive with surgical debridement, we believe that there are (rare) times when less is more,” notes Dr. Armstrong.

   If the wounds look atypical or a patient has rheumatologic conditions (such as rheumatoid arthritis, inflammatory bowel disease or Crohn’s disease), Dr. Suzuki says podiatrists should have higher degree of suspicion for pyoderma gangrenosum.

   In regard to managing pain patients may experience with debridement, Dr. Brietstein uses 4% lidocaine solution or 2% lidocaine gel as a topical agent. He says these modalities seem to suffice in most cases. For patients in whom lidocaine is inadequate, Dr. Brietstein will inject anesthetic agents. If a patient is problematic, he will prescribe a pain medicine and tell him or her to take it 30 minutes before presenting at the clinic or office.

   For debridement, Dr. Brietstein uses either #15 or #10 scalpels with #15 predominating for wounds without depth or sinus tracts. He uses curettes for wounds with significant depth or undermining.

   If the wound dimensions have reduced by 50 percent at the second visit, Dr. Brietstein continues with the same wound care regimen. He uses various bioengineered skin substitutes if the wound meets appropriate criteria.

   Dr. Armstrong is a Professor or Surgery at the University of Arizona College of Medicine in Tucson, Ariz. He is the Director of the Southern Arizona Limb Salvage Alliance (SALSA).

   Dr. Brietstein is the Residency Director of the Northwest Medical Center Podiatric Medicine and Surgery Training Program in Margate, Fla. He is a Clinical Professor in the Department of Geriatrics at the Nova Southeastern College of Osteopathic Medicine in Davie, Fla. Dr. Brietstein is the Clinical Director of the University Hospital Wound Healing Center in Tamarac, Fla. He is a Fellow of the American Professional Wound Care Association.

   Dr. Suzuki is the Medical Director of the Tower Wound Care Center at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo, Japan.

References
1. Edwards J, Stapley S. Debridement of diabetic foot ulcers. Cochrane Database Syst Rev. 2010 Jan 20;1:CD003556.
2. Steed DL, Donohoe D, Webster MW, Lindsley L. Effect of extensive debridement and treatment on the healing of diabetic foot ulcers. Diabetic Ulcer Study Group. J Am Coll Surg. 1996; 183(1):61-4.
3. Cardinal M, Eisenbud DE, Armstrong DG, et al. Serial surgical debridement: a retrospective study on clinical outcomes in chronic lower extremity wounds. Wound Rep Reg. 2009; 17(3):306-11.
4. Abraham M, Ahlman JT, Boudreau AJ, Connelly JL. 2011 (CPT) Current Procedural Terminology. American Medical Association, Chicago, 2011.

   For further reading, see “Current Concepts In Wound Debridement” in the July 2009 issue of Podiatry Today or “Assessing Debridement Options For Diabetic Wounds” in the March 2007 issue.

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