Keys To Ensuring Optimal Wound Debridement

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

   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.

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