Debridement
Principles of local wound
management (TIME)
• T -
tissue viability
– Debride non-viable tissue
– (unless contraindicated)
• I -
infection & inflammation control
– Look for clinical signs
– Antimicrobials, antibiotics
• M -
moisture control
– Dressings
• E -
edge
– Edge characteristics
– Edge advancement
Debridement Goals
• Wound cleansing
• Reduce bacterial contamination
• Provide an optimal wound environment for
healing
• Preparation of surgical intervention
Debridement Goals
• The decision to debride & which method to
use, is determined by:
– The patient condition
– Goal of care
– The wound assessment
– Environmental considerations
– Skill of the caregiver
– Frequency of the procedure/treatment
– Financial implication
– Time
Debridement Goals
• After debridement wounds often increase in
size and/or shape
• Using a combination of techniques will
expedite the process
• Debridement and healing often take place at
the same time
Methods of Debridement
•
Surgical/sharp
– Extends into healthy tissue
•
Conservative sharp
– Does not extend into nor excise healthy tissue
•
Autolytic
– Uses dressings to achieve the optimal moisture balance to facilitate the
body's processes
•
Enzymatic/chemical
– Use of enzymes or chemicals to break up non viable tissue
•
Larval
– Use of sterile blue-bottle fly maggots
–
Only commercially produced maggots should be used
•
Mechanical (including ultrasound and hydrosurgical)
–
Uses force Eg. Wet-to-dry gauze, hydrosurgery, dry gauze
Methods of Debridement
Methods of Debridement
•
Use mechanical, autolytic, enzymatic, and/or biological methods of
debridement when there is no urgent clinical need for drainage or
removal of devitalized tissue. • conservative sharp,
•
Surgical/sharp debridement is recommended in the presence of
extensive necrosis, advancing cellulitis, crepitus, fluctuance, and/or
sepsis secondary to ulcer-related infection.
•
Conservative sharp debridement and surgical/sharp debridement must
be performed by specially trained, competent, qualified, and licensed
health professionals consistent with local legal and regulatory statutes.
•
Use sterile instruments for conservative sharp and surgical/sharp
debridement
•
Use conservative sharp debridement with caution in the presence of:
– immune incompetence,
– compromised vascular supply, or
– lack of antibacterial coverage in systemic sepsis
Wound Assessment
•
Presence of eschar
– Slough, dead tissue, hard or soft, yellow
to black in color
•
Erythema
– Peripheral inflammation, local heat, swelling, pain
- ???infection
•
Induration
– Mushy boggy feel, may indicate deep tissue
death
•
Pigmentary changes
- ? chronic ischemia, venous disease,
prolonged edema
•
Purulence
– Differentiate this from tissue slough
•
Blistering
– Adjacent skin or that overlying the region of
tissue damage
•
Bleeding
– Presence or absence in portions of the wound
•
Pulses
– Check for adjacent pulses – confirm vascular flow
Indications for Debridement
• Presence of deep eschar – such that other
methods will not work
• Gross purulence, infection
• Quantity of dead tissue such that other methods
would be too slow
• As an adjunct to allow other methods to work
(following debridement)
Aggressiveness of
Debridement
• Depends on the “load” of devitalized tissue
• Consider patient tolerance limits
• Consider your time constraints, help
situation, etc
• Important to set limits:
– 15 – 30 minutes for each clinician
– plan for serial sessions
– limit patient and clinician fatigue/discomfort
– limit bleeding
When to Stop Debridement
• Impending exposure to bone, tendon, or
nerve
• Location of fascial plane
• “Finding” a named structure
• Excessive bleeding
• When you get nervous
When is a Physician
Required:
• Patient is febrile or on a downhill course
• No wound improvement over several weeks
or sessions
• New cellulitis
• Unexpected gross purulence
• Impending exposure of bone, tendon, nerve
• Abscess within tissues
• Encounter named structures, vessels
Warning Signs:
Consider asking for Reevaluation
• “Holes” places you don’t want to be
• Extensive undermining such that you can’t see
• Presence of gross purulence/ infection that was
unexpected
Bleeding during
Debridement
• “All bleeding stops eventually………”
• “If it doesn’t bleed it is already dead”
• Should not be a source of fear
• Causing bleeding does increase amount of
scarring
Methods to Stop Bleeding
• Pressure – simple, effective, and always with
you
• Electrocautery – superb but very unlikely to
be available
• Suture – Not likely to have or use
• Topical agents – Thrombin, Surgicel,
Gelfoam. All are expensive, ? available
• Silver nitrate sticks – for minor bleeding only
Bleeding to Fear
• Bleeding you can’t see source of……
• Bleeding you can hear…….help had better
be nearby
Pain Control in Debridement
• Topical methods have been fairly ineffective
• Oral/IM/IV methods work well, require some
advance preparation
• Medications given 30 minutes prior to
procedure increase tolerance
• Major debridement may need to be done in
the OR
Post Debridement Care
• Cleans the wound with saline/water
• Apply appropriate dressing for
location/wound
• Use of antibiotics varies with patient
Documentation
• Record in patient record or progress
notes, summary of procedure:
• Time and date
• Type and amount of drainage
• Condition of wound
• Problems during debridement
• Type of wound covering applied
Document Outline - Debridement
- Principles of local wound management (TIME)
- Debridement Goals
- Debridement Goals
- Debridement Goals
- Methods of Debridement
- Methods of Debridement
- Methods of Debridement
- Wound Assessment
- Indications for Debridement
- Aggressiveness of Debridement
- When to Stop Debridement
- When is a Physician Required:
- Warning Signs: Consider asking for Reevaluation
- Bleeding during Debridement
- Methods to Stop Bleeding
- Bleeding to Fear
- Pain Control in Debridement
- Post Debridement Care
- Documentation
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