Clinical REVIEW SAFE DEBRIDEMENT IN THE COMMUNITY SETTING

It is widely accepted that wound debridement is necessary for optimal wound healing (Haycocks and Chadwick, 2012). Debridement has become an accepted part of wound bed preparation with the ultimate aim of achieving a clean, healthy, granulating wound bed (Benbow, 2011a,b). Th is article examines the way in which debridement can be conducted safely in the community setting.

aycocks and Chadwick (2012) 8 Shortening the extended defi ne debridement as the infl ammatory phase of the healing removal of dead or necrotic process and thus preventing tissueH or foreign material from and wound chronicity (Baharestani et around a wound to expose healthy tissue. al, 1999). Th is includes the hyperkeratotic skin that often surrounds venous leg ulcers and Identifying the wounds the callus found on the feet of diabetic that need debridement/ patients with motor neuropathy. debridement assessment Any assessment should be systematic Debridement removes potential and comprehensive. Th e patient’s obstacles to healing, including slough underlying medical conditions and and necrotic tissue (Benbow, 2011a,b). current state of health should be Additional reasons for removing non- determined. Th e presence of any viable tissue from a wound include: localised or systemic infection should 8 Reducing the bacteria count in be diagnosed along with issues such the wound bed (Best Practice as peripheral arterial disease, which Statement, 2011) would complicate and even preclude 8 Reducing wound malodour debridement wounds of the lower (Vowden and Vowden, 1999) limb. Th e assessment may result in the 8 Promoting advancement of correction or alleviation of the factors epithelial cells and thus restoring responsible for the necrotic wound the epidermis (European Wound (Benbow, 2011a,b). Management Association [EWMA] 2004) In certain circumstances, the function 8 Facilitating the absorption/action of debridement is symptom control, of topical preparations e.g. topical for example, in individuals with antimicrobial agents (Weir et al, malignant wounds in a palliative care 2007) setting. Wound healing is not usually TRUDIE YOUNG 8 Allowing a thorough wound the aim of wound management for Tissue Viability Nurse (Hon) assessment (Stephen-Haynes and people with malignant wounds and Aneurin Bevan Health Board Wales Callaghan, 2012) debridement of the non-viable tissue 82 Wounds Essentials 2012, Vol 2 244 Wounds Essentials 2012, Vol 1 Clinical REVIEW will help to remove any offensive A common way of removing this is 8 The time/speed that is required to odour emanating from the dead soaking the leg in a bucket of water remove the devitalised tissue tissue. For individuals with malignant containing an emollient, followed by the 8 The pain caused during the wounds, the debridement process application of a variety of treatments, debridement process may take place on consecutive including paste bandages, hydrocolloid 8 The skill and knowledge of occasions due to the skin failure that dressings and wiping with gauze. The the person undertaking the accompanies the progression of the time taken to complete this procedure debridement (Young, 2011). disease process (Young, 2011). can range from 10–30 minutes. The practitioner, in conjunction Tissue type The disadvantages of these methods with the patient, should set short- It is important that non-viable tissue are the time taken to complete the and long-term objectives for the is recognised and not confused with procedure and the potential for debridement process. The setting of other tissue types, such as exposed cross infection and trauma. There debridement objectives should lead tendon. Gray et al (2011) described is no standard practice for dealing to the development of a debridement six different manifestations of with hyperkeratosis and the current treatment plan (Gray et al, 2011). devitalised tissue likely to require methods are not ideal, therefore, there debridement in a wound bed — wet is the potential to develop a more Frequently-used methods slough, superficial wet slough, dry patient and nurse-friendly method of of debridement in the slough, wet necrosis, dry necrosis de-scaling the legs (Young, 2011). community setting and haematoma. Hampton (2011) Autolysis suggests that the slough may be either Clinicians cannot assess a wound Autolytic debridement will occur soft and easily removed or thick and properly until they have removed all naturally if a passive stance is taken tenacious. Necrotic eschar is where necrotic devitalised tissue (Haycocks as an individual’s immune system the tissue has dried out and has a and Chadwick, 2012). This is extremely will phagocytose the non-viable thick, leathery, brown or black texture important in tissue viability when tissue (Ayello et al, 2004). Phagocytic (Benbow, 2011a,b). trying to accurately establish the stage/ cells, such as macrophages and the category of pressure ulcers (Stephen- destructive (proteolytic) enzymes in In certain circumstances, necrotic Haynes and Callaghan, 2012). the wound bed, liquefy and separate tissue should not be debrided, such as necrotic tissue from the wound bed. in gangrenous toes or necrotic pressure Method Evidence of the separation is usually ulcers on the heel of patients with A clear understanding of the need seen at the wound edges (Figure 1) ischaemic limbs. Diabetic patients who for debridement and available (Haycocks and Chadwick, 2012). have wet necrotic tissue (wet gangrene) options is necessary for the require immediate debridement to clinician to be able to make the prevent the rapid spread of infection appropriate choice of debridement (Haycocks and Chadwick, 2012). technique.

Amount of tissue to be debrided Unlike acute wounds, which usually A factor that will influence the choice only require debridement once if of debridement method is the amount at all, chronic wounds may require of non-viable tissue to be removed. repeated maintenance debridement If a large amount of non-viable tissue (EWMA, 2004). is present, serial debridement may be indicated. However, if the non- Therefore, the choice of debridement viable tissue is placing the individual technique is a risk assessment process at risk of a systemic infection, the that takes into account the following consequences of not immediately factors: debriding the tissue may be 8 Safety catastrophic and an urgent surgical 8 Patient choice referral is necessary (Young, 2011). 8 The amount of devitalised tissue to be removed Hyperkeratosis 8 The environment in which the Hyperkeratosis is the presence of dry debridement will be undertaken Figure 1. Necrotic heel scales found on the surrounding skin 8 The availability of debriding separating at the edges. of patients with venous leg ulcers. equipment

84 Wounds Essentials 2012, Vol 2 This debris is then cleared either by tissue using a scalpel or scissors, but near vascular structures, grafts, the dressing or by macrophages and without a general anaesthetic. For this prosthesis, dialysis fistula or joints neutrophils (Hampton, 2011). reason, unlike surgical debridement, (Fairbairn et al, 2002). the practitioner only removes non- Wound dressings, such as hydrogels viable material and halts the procedure Therefore, in the community setting, and hydocolloids facilitate the before living tissue is reached. CSD alternative debridement methods are autolytic process by providing a is often used by specialist podiatrists viewed as a safer option. moist environment at the wound bed when debriding non-viable tissue in and externally softening the issue. the diabetic foot (Young, 2011). Chemical debridement Wet sloughy wounds do not require Chemicals that debride devitalised additional moisture and alginate and It is imperative that clinicians who tissue include topical antimicrobials Hydrofiber® (ConvaTec) dressings are perform CSD have the knowledge and and honey, which can also be used for examples of dressings that are more skills to do so safely and effectively. this purpose (Thomas, 2010). suited to aid autolysis in this situation. These include a sound knowledge of the anatomy of the area being Honey is available on prescription in a The main advantage of autolytic debrided to prevent damage to local variety of formats, e.g. combined with debridement is that it is generally tendons, arteries, veins or nerves calcium alginate or in a gel format. It painless, however, the major (Haycocks and Chadwick, 2012). is important to realise that the type disadvantage is the length of time For many clinicians, this is difficult and amount of honey varies between needed to achieve the desired result, to achieve with few post-registration dressing products. In the presence of the increased exudate levels as the courses on debridement available wound exudate, the honey dilutes and wound debrides and, if not protected, (an example is the MSc module in as a consequence the enzyme glucose the maceration that can occur in the debridement available at Bradford oxidase is activated and hydrogen periwound skin (Benbow, 2011a,b). University). Once competence is peroxide is produced. The hydrogen It is important that practitioners achieved, the clinician may have peroxide component was thought to undertake autolytic debridement difficulty maintaining the skills if CSD work alongside the natural osomotic to achieve the optimal outcome for is not regularly undertaken. pull of the honey to debride non- the patient within an acceptable viable tissue. timeframe. However, it can be argued Clinicians need to have confidence that this method is commonly chosen in their ability to deal with any However, there is thought to be an because of its simplicity, rather than complications, such as, uncontrolled additional non-peroxide debriding to meet the needs of patients. When bleeding in the absence of surgical element to honey (Thomas, 2010). choosing autolytic debridement, and anaesthetic support in the Honey may appeal to patients due the practitioner may be confusing community setting (Haycocks and their perception of the product as a activity (autolytic debridement) with Chadwick, 2012). A subgroup of the natural remedy. Following a review achievement (removing the non- North West Clinical Effectiveness of the literature, Gethin (2008) viable tissue). Group developed an information recommends honey as an effective de- leaflet identifying the risks and sloughing agent for chronic wounds. It is important that clinicians question benefits of sharp debridement so whether autolytic debridement will that written informed consent This is in opposition to a Cochrane result in the removal of the non- can be obtained (Haycocks and Review, which stated that there was viable tissue in the most efficient Chadwick, 2008). insufficient evidence to guide the and timely manner (Young, 2011). use of honey in wounds other than Also, the perceived safety of this Sharp debridement is not superficial and partial thickness burns method must be balanced with the recommended in the following (Jull et al, 2008). risk to the patient of not removing situations: the non-viable tissue quickly enough, 8 Debridement of the hand or face, Antimicrobial dressings are chosen for which could lead to infection and foot (excluding heel region) their ability to debride and lower the an extended period of malodour 8 Debridement in patients with bacterial load in the wound bed. The and exudate as the non-viable tissue unstable clotting mechanisms antiseptic agents that are incorporated slowly debrides. 8 In the presence of localised into antimicrobial wound dressings wound infection include polyhexamethyl-biguanide Sharp debridement 8 In malignant wounds due to the (PHMB), chlorhexadine, povidone Conservative sharp debridement propensity of the tissue to bleed and cadexomer iodine, honey, (CSD) is the removal of non-viable 8 In areas that involve or are silver sulfadiazine, ionic silver and

Wounds Essentials 2012, Vol 2 85 Clinical REVIEW nanocrystalline silver (Wound Care therapy. This may have been influenced arterial ulcers, mixed aetiology ulcers, Handbook, 2011). by informing the patients that the pressure ulcers and traumatic wounds therapy may be painful, as well as a lack (Haemmerle et al, 2011; Johnson, The practitioner will have to ascertain of systematic assessment of pain levels 2011; Sharpe and Concannon, 2011; if the chosen antimicrobial debriding (Mumcuoglu et al, 2012). Green, 2011; Fumarola, 2012; Alblas dressing will also be able to manage and Klicks, 2012). other wound problems, e.g. hydrate Larval debridement is not suitable the wound bed, absorb exudate, for all patients, especially those with A number of smaller prospective remove wound odour (Vowden et al, dry necrotic tissue, highly exuding pilot, non-comparative studies and 2011). Long-term use of antimicrobial wounds, patients with clotting issues case series indicate good debridement dressings is not usually recommended and wounds requiring occlusion. results after single use on a variety and they should be discontinued Larvae are temporarily incompatible of tissue types, such as slough and once the wound infection has been with hydrogel dressings containing necrosis (Hamemmerle et al, 2010). successfully treated (Best Practice polyethylene glycol. Statement, 2011). The removal of hyperkeratosis A new debridement therapy as discussed earlier can be a long Larval debridement therapy for the community setting — and protracted process, however, Maggots from the Lucilia sericata Debrisoft® Debrisoft has been shown to be green bottle fly are used as debriding Debrisoft (Activa Healthcare) is a new a speedy and effective method of agents, although Paul et al (2009) report method of mechanical debridement removing hyperkeratotic scales on the Malaysian experience of larval for superficial wounds that removes (Collarte et al, 2011; Van den therapy using Lucilia cuprina. The debris, necrotic material, slough and Wijngaard and Andriessen, 2012). larvae produce secretions containing exudate (Haycocks and Chadwick, collagenases that break down the non- 2012). The advantage of this method is A larger study of 60 patients with viable tissue into a semi liquid form that that it is extremely simple and easy to chronic wounds, of which 57 were the maggots subsequently ingest along use causing little or no pain (Collarte et included in the analysis, found that with bacteria present in the wound bed al, 2011; Johnson, 2011; Flinton, 2011; the monofilament fibre pad was (Thomas, 2010). The maggots come in Hampton, 2011; Prouvost, 2012). effective in 93.4% (142/152) a free-range format or are contained of debridement episodes (Bahr within a dressing or bags (i.e. BioBag ; Debrisoft consists of soft, polyester et al, 2011). BioMonde®). fibres, which are secured and knitted together into a pad. The fibres are cut An advantage of mechanical The opportunity for clinicians to at a special angle, length and thickness debridement is that it can remove use maggots in the community has to ensure flexibility (see patient the non-viable tissue quickly. increased since their addition to the information here: http://www. A debridement technique that Drug Tariff. The practitioner may activahealthcare.co.uk/debrisoft). removes non-viable tissue rapidly is previously have had concerns about an attractive option to the patient sending a patient home with maggots Debrisoft has a wound contact side and the practitioner. It is reassuring in situ, however, the BioBags ensure that is fleecy in appearance and, to know that a product is available the maggots remain contained, once wetted, is gently wiped over on prescription in the UK that making the application and removal the surface of the wound. In the case allows clinicians to simply wipe an easier process. The maggots are of thick tenacious slough and hard the wound bed and immediately quick-acting and stay in place for 3–5 necrosis, it is recommended that the remove the devitalised tissue days (Mennon, 2012). There is plenty tissue is softened prior to using the pad without causing pain and trauma of evidence that larvae are an effective (Benbow, 2011a,b). The debridement (Bahr et al, 2011). debriding agent (Ahmad et al, 2012, process is also quick (ranges from 2–12 Gilead et al, 2012). minutes) (Bahr et al, 2011; Shepherd, Patient choice and 2011; Johnson, 2011; Whitaker, 2011; involvement A review of the evidence also suggests Fumarola, 2012; Prouvost, 2012). It is important to involve the patient in that larval debridement therapy should any decision regarding debridement of be used in practice for the treatment Debrisoft has been described in case his or her wound. Informed consent of infected chronic wounds (Blueman studies as effective in debriding a requires qualified professionals to discuss and Bousfield, 2012). However, a variety of wound types including the nature, indications, benefits and recent study reported pain as a major venous leg ulcers, diabetic foot ulcers risks of debridement with patients. This issue for patients receiving larval (neuropathic and neuro-ischaemic), conversation should include a discussion

86 Wounds Essentials 2012, Vol 2 Debrisoft was used to try and remove the hyperkeratosis and this was very successful (Figure 3), causing no pain or discomfort (according to a visual analogue pain assessment — score 0) while the skin and wounds were being cleansed.

Case study 2 (courtesy of Rosie Callaghan) Mrs M is a 72-year-old woman with a history of heart and renal failure. She has also suffered for some years with swollen oedematous legs that ‘weep’ on occasions. She is mobile with the aid of a Zimmer frame and at the time of writing was on warfarin following a deep vein thrombosis some months previously. Figure 2. Case study 1 — Figure 3. Five minutes hyperkeratosis. after using Debrisoft. The injury featured here was caused when Mrs M banged her shin on the Zimmer frame, resulting in a of various debridement options and wash them off thoroughly enough. haematoma that ran almost the full potential outcomes for debridement As a result, there was a build-up of length of her shin (Figure 4). techniques, e.g. reduction in risk of skin and emollients and when she wound infection and the possibility removed her compression hosiery at One option was to transfer Mrs M of the wound becoming larger in size night she experienced severe itching. to A&E to have the wound debrided. (Haycocks and Chadwick, 2012). However, this would have been costly Because the hyperkeratosis was and traumatic, with increased risk of All too often, the choice of so thick, the emollients were not infection. Also, to use conventional debridement technique is made getting through. Following consent, debriding methods involves by the practitioner and is limited by their past experience, skill- set and availability. Rarely is the patient an active participant in the debridement process, however, with the new debridement option — Debrisoft — the patient and/ or carer is able to undertake the debridement process themselves, allowing for full participation in the procedure. However, this will not be feasible for all patients, but offers an exciting development in self-care (a video showing Debrisoft in action can be accessed at http://www. activahealthcare.co.uk/products).

Case Studies Case study 1 (courtesy of Collarte A, Loty L, Alberto A, et al, 2011) This woman suffered from very thick hyperkeratosis and also had a small Figure 4. Case study 2 — Figure 5. The wound during ulcer (Figure 2). She applied her own Haematoma caused by debridement with Debrisoft. trauma. emollients on a daily basis, but did not

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patient. Patients should have access ficacy of a monofilament fibre wound to the most appropriate method of debridement product for trauma debridement at the time they require wounds and bites. Poster at EWMA removal of devitalised tissue from Conference, Vienna, 23–25 May, 2012 their wound. Ayello AE, Baranoski S, Kerstein MD, The previous hierarchy of Cuddington I (2004) Wound Debride- debridement, which placed surgical ment. Wound Care Essentials: Practice debridement at the top of the ‘pecking Principals. Lippincott, Williams and order’, is now under question and Wilkins, Springhouse, Pennsylvania the speed of debridement in the community setting is becoming Baharestani MM (1999) The clinical a priority to prevent patients relevance of debridement. In: Ba- having extended periods with harestani MM, Gottrup F, Holstein non-viable tissue in their wound, P, Vanscheidt W (eds). The Clinical which ultimately delays healing and Relevance of Debridement, Springer puts them at an increased risk of Verlag, Heidelberg, Germany developing a wound infection. Bahr S, Mustafi N, Hattig P (2011) However, for certain clients autolytic Clinical efficacy of a new monofila- debridement might suit their individual ment fibre-containing wound debri- needs following an open discussion dement product. J Wound Care 20(5): and exploration of potential methods. 242–48

There is the need for practitioners to Benbow M (2011a) Using Debrisoft revisit their skill-set to ensure they for wound debridement. J Comm are equipped to offer patients the Nurs 25(5): 17–18 appropriate debridement method for their needs. Benbow M (2011b) Available options for debridement. Independent Nurse Figure 6. The wound following Periwound skin and wound bed Available at: http://www.independent- debridement with Debrisoft. preparation are essential components of nurse.co.uk/cgi-bin/go.pl/library/ar- wound management. These need to be ticlehtml.cgi?uid=84294;type=Clinical significant cost and time. undertaken as soon as possible by the (accessed 6 November, 2012) assessing health clinician, without the Instead the team used Debrisoft to delay of referral to a specialist team. Best Practice Statement (2011) The debride the haematoma, which took Use of Topical Antiseptic/antimicrobi- under 10 minutes. The pad was easy The new debridement system al Agents in Wound Management. 2nd to use, caused no pain to the patient highlighted in this article can be edition. Wounds UK, London and successfully lifted the haematoma applied to many sloughy and necrotic (Figures 5 and 6). wounds and hyperkeratotic skin. This Blueman D, Bousfield C (2012) The makes it ideal for use in the non- use of larval therapy to reduce the Before commencing the procedure, specialist area and it has been shown to bacterial load in chronic wounds. J the team checked Mrs M’s warfarin be fast, safe and effective at wound and Wound Care 21(5): 244–53 levels and there was no further periwound skin debridement. WE bleeding during the debridement Collarte A, Loty L, Alberto A (2011) procedure. Evaluation of a new debridement References method for sloughy wounds and hy- Conclusion perkeratotic skin for a non-specialist Debridement has become part of Ahmad I, Akhtar S, Masoodi Z (2012) setting. Poster Presentation at EWMA the recognised wound care routine. Role of early radical debridement and Conference, Brussels, May 2011 However, autolytic debridement skin cover in diabetic foot ulceration. J has become routine practice and Wound Care 21(9): 442–47 EWMA (2004) Position Document: this requires revisiting as it may not Wound Bed Preparation in Practice. always be the best option for the Alblas J, Klicks RJ (2012) Clinical ef- London: MEP Ltd

88 Wounds Essentials 2012, Vol 2 Fairbain K, Grier J, Hunter C, Preece ation of a new active debridement A new debridement technique tested J (2002) A sharp debridement pro- system. Poster Wounds UK, Harrogate on pressure ulcers. Wounds UK 8(3 cedure devised by specialist nurses. J 2011 Suppl): S6–11 Wound Care 11(10): 371–75 Jull AB, Rodgers A, Walker N (2008) Thomas S (2010)Surgical Dressings Flinton R (2011) A new solution to Honey as a topical treatment for and Wound Management. Medetec, an old problem – an innovative ac- wounds. Cochrane database of sys- Cardiff tive debridement system. Poster at tematic reviews 2008, Issue $, Art. No.: Wounds UK Harrogate, 2011 CD005083. DOI: 10.1002/14651858. Van den Wijngaard A, Andriessen A CD005083.pub2. (2012) Clinical efficacy of a mono- Fumarola S (2012) A study to review filament fibre debridement product the practice of wound cleansing, Lloyd-Jones M (2009) An overview evaluated in clients with skin lesions, debridement and removal of foreign of maggot therapy used on chronic scales, rhagades and hyperkeratosis. bodies from acute wounds in an ac- wounds in the community. Br J Comm Poster, EWMA Conference, Vienna, cident and emergency department. Nurs 14(3 Suppl): S16–S20 23–25, May, 2012 Poster EWMA Conference, Vienna, 23–25 May, 2012 Mennon J (2012) Maggot therapy: a Vowden KR, Vowden P (1999) Wound literature review of methods and client debridement, part 1: non-sharp tech- Gethin G (2008) Efficacy of honey as experience. Br J Nurs 21(5) S38–42 niques J Wound Care 8(5): 237–40 a desloughing agent: overview of cur- rent evidence. EWMA Journal 8(2): Mumcuoglu KY, Davidson E, Avidan Vowden KR, Vowden P (2011) De- 31–35 A, Gilead L (2012) Pain related to bridement made easy. Wounds UK maggot debridement therapy. J Wound Available at: http://www.wounds- Gilead L, Mumcuoglu KY, Ingber A Care 21(8): 400–05 uk.com/made-easy/debridement- (2012) The use of maggot debride- made-easy (accessed 6 November, ment therapy in the treatment of Paul AG, Ahmad NW, Lee HL, et al 2012) chronic wounds in hospitalised and (2009) Maggot debridement therapy ambulatory clients. J Wound Care with Lucilia cuprina: a comparison Vowden P, Vowden K, Carville K 21(2): 78–85 with conventional debridement in dia- (2011)Antimicrobials Made Easy. betic foot ulcers. International Wound Wounds International Available at: Gray D, Acton C, Chadwick P, et al Journal 6(1): 39–46 http://www.woundsinternational. (2011) Consensus guidance for the com/made-easys/antimicrobial-dress- use of debridement techniques in the Prouvost L (2012) A monofilament ings-made-easy (accessed 6 Novem- UK. Wounds UK 7(1): 77–84 product as an alternative to mechani- ber, 2012) cal debridement of the wound bed Haemmerle G, Duelli H, Abel M, and peri-wound skin. Poster, EWMA Weir D, Scarborough P, Niezgoda JA Strohal M (2011) The wound debrid- Conference, Vienna 23–25 May, 2012 (2007) Wound debridement. In: Kras- er: a new monofilament fibre technol- ner DL, Rodeheaver GT, Sibbald RG ogy. Br J Nurs 20(6 Suppl): S35–42 Sharpe AM, Concannon M (2011) (eds). Chronic Wound Care: A Clinical Debrisoft: Revolutionising debride- Source Book for Healthcare Profession- Hampton S (2011) Some simple solu- ment. Br J Nurs (Suppl) 20: 20 als. 4th edn. HMP Communications, tions to wound debridement. Nursing Malvern and Residential Care 13(8): 378–83 Shepherd J (2011) Debrisoft: Revolu- tionising debridement. Br J Nurs 20 Whitaker JC (2011) Debrisoft: Revo- Haycocks S, Chadwick P (2008) Sharp (Suppl): 20 lutionising debridement. Br J Nurs debridement of diabetic foot ulcers (Suppl) 20: 20 and the importance of meaningful Stephen-Haynes J, Callaghan R (2012) informed consent. Wounds UK 4(1): The role of an active debridement Wound Care Handbook (2011) 51–56 system is assisting the experienced cli- Wound Care Handbook. Mark Allen nician to undertake an assessment and Group, London Haycocks S, Chadwick P (2012) determine appropriate wound man- Debridement of diabetic foot wounds. agement objectives. Poster, EWMA Young T (2011) Reviewing best Nurs Stand 26(24): 51–58 Conference, Vienna, 23–25, May, 2012 practice in wound debridement. Pract Nurs 22(9): 488–92 Johnson S (20111) A 10-client evalu- Stephen-Haynes J, Callaghan R (2012)

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