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.

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