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DEBRIDEMENT

Definition
Debridement is the process of removing dead (necrotic) tissue or foreign material
from and around a wound to expose healthy tissue. The word debridement is derived from the
French word to remove constraints. Within woundcare, debridement refers to the removal of
adherent, dead or contaminated tissue from the wound. It is clearly separated from the act of
wound cleansing which is defined as the removal of dirt, foreign material or metabolic waste.
The presence of dead/devitalised tissue hinders wound healing, so debridement
provides the foundation for subsequent tissue growth. Appropriate and early debridement
accelerates wound healing. This in turn delivers additional benefits of improved quality of
care, enhanced patient health and wellbeing and a reduction in treatment costs.
The bodys natural method of wound debridement is called autolysis. In acute
wounds, autolytic debridement occurs automatically. During the acute inflammatory state of
wound healing neutrophils and macrophages clear devitalised tissue, cell debris or
containments which prepares the wound bed to allow healing to occur. However, in chronic
wounds this autolytic process can be delayed because of the increased levels of endotoxins
released from damaged cells.
Consequently debridement is often a common goal in the management of chronic
wounds and has been included in many clinical guidelines from professional wound
organisations such as European Wound Healing Society and Wounds UK.

Purpose
An open wound or ulcer can not be properly evaluated until the dead tissue or foreign matter
is removed. Wounds that acontain necrotic and ischemic (low oxygen content) tissue take
longer to close and heal. This is because necrotic tissue provides an ideal growth medium for
bacteria, especially for Bacteroides spp. and Clostridium perfringens that causes the gas
gangrene so feared in military medical practice. Though a wound may not necessarily be
infected, the bacteria can cause inflammation and strain the body's ability to fight infection.
Debridement is also used to treat pockets of pus called abscesses. Abscesses can develop into
a general infection that may invade the bloodstream (sepsis) and lead to amputation and even
death. Burned tissue or tissue exposed to corrosive substances tends to form a hard black
crust, called an eschar, while deeper tissue remains moist and white, yellow and soft, or
flimsy and inflamed. Eschars may also require debridement to promote healing.

Wounds assessment
Therefore it is vital that all practitioners involved in wound care are able to confidently
perform holistic wound assessment. Holistic assessment of the patient and the wound is
needed to ensure accurate diagnosis of the underlying factors that could be the cause of the
wound and identity elements that could delay wound healing. To ensure effective treatment of
patients with wounds the diagnostic process should:

Determine the cause of the wound

Identify any co-morbidities/complications that may contribute to the wound or delay


healing

Assess the status of the wound including location and size, condition of wound bed,
signs of increased bacterial load, level of exudate, and condition

of peri wound skin

Establish appropriate aims of wound care.

Debridement is common practice for treating many wounds and it can be applied to any
wound type, irrespective of origin and diagnosis.
However, practitioners need to have a clear understanding of the underlying cause of the
wound and whether healing is the realistic/appropriate goal. In certain circumstances
debridement may not be beneficial for the patient and in some instances could be detrimental:
for example patients with peripheral arterial disease who develop distal gangrene. With dry
gangrene, it is better to leave these wounds without any dressings rather than promoting
debridement. This is because in the debridement process levels of moisture at the wound bed
will increase leading to a greater risk of infection. Combined with arterial disease this would
expose the patient to an increased risk of amputation.
In patients with peripheral arterial disease, debridement should only be initiated by
the specialist vascular team, ideally after adequate revascularisation has been established.

When to debridement
The type of tissue found in the wound bed often provides a clear indication as to
whether debridement is required but other factors such as bio-burden, wound edges and
condition of peri wound skin can also influence the decision of whether debridement is
required.
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There are relatively few wounds where it is not safe to debride, as long as the correct
method of debridement is chosen. Where there is any evidence of slough, necrotic tissue or
eschar, debridement of this non-viable tissue will help progress the wound towards healing.
The presence of non-viable tissue will delay wound healing as it hinders the formation of
granulation tissue but it can also be a cause of bacterial growth increasing the risk of
infection.
Debridement may also assist in wound assessment or pressure ulcer categorisation as
removing non-viable tissue, slough and excess exudate will help to visualise the wound bed
depth and condition more accurately.

Debridement options
Various factors influence the choice of debridement methods such as wound type,
anatomical location, extent of devitalised tissue, pain, patient environment, resources and
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patient choice. Debridement may only need to be performed once, but more commonly
episodic or continual debridement may be required over a number of weeks.
Therefore there needs to be consideration of the risk that the devitalised tissue
presents to the patient to help determine the speed of debridement required. Wound
debridement remains a generalist nursing skill and all practitioners involved in wound care
need to be aware of the wide range of debridement options. However, certain methods of
debridement, such as sharp debridement, can only be performed by clinicians with
appropriate knowledge and clinical skills.
Nevertheless, it is important that the most appropriate debridement method selected is
based on it providing the best outcomes for the patient and not limited to the skills of the
practitioner. If the practitioner feels they do not have the knowledge/skills to perform certain
methods of debridement, they should seek support from others or refer the patient on to
someone with the requisite skills, such as specialist wound nurses.
There are five main methods of debridement: surgical or sharp, autolytic, enzymatic,
mechanical, and biosurgery. The choice of debridement method will depend upon many
factors, including the size, position, and type of wound, efficiency and selectivity of
debridement method, pain management, exudate levels, risk of infection, and the cost of the
procedure. In some cases, it may be appropriate to use more than one method of debridement.
a. Surgical Debridement
Surgical or sharp debridement is not a new technique, and historical texts show that
ancient civilizations often made surgical changes to the wound bed. Surgical debridement is
the fastest way to remove dead tissue. It causes considerable pain, and hence, it was earlier
restricted to the treatment of neuropathic diabetic ulcers where the use of anesthesia and pain
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management was not necessary. However, this problem could be overcome with the use of
topically applied local anesthetics (e.g., combination of lidocaine [lignocaine] and
prilocaine), applied 30 to 45 minutes prior to debridement. It is usually performed in an
operating theatre and involves an anaesthetist and a surgical practitioner resulting in this
being a high cost option.
In many instances it results in a larger wound being created as surgical debridement is not
as selective as some other methods, and frequently an element of viable tissue is also
removed. Due to these issues surgical debridement tends to be reserved for patients with
extensive tissue damage or those facing risk from increasing virulent infection such as
diabetic foot ulceration or necrotising fasciitis. Although surgical debridement is thought to
be selective, there may be some damage to viable tissue, and bleeding is likely. Nevertheless,
this may help to revitalize the wound and encourage healing by inundating the wound bed
with growth factors and cytokines. Mild to moderate bleeding could be controlled by the
application of pressure and a hemostatic calcium alginate dressing.
b. Autolytic
Autolytic debridement is the most commonly used method of debridement. It uses the
bodys own enzymes and moisture to rehydrate, soften and liquefy devitalised tissue. The
majority of wound dressings, such as hydrogels, hydrocolloids, and hydrofibres, debride by
the process of autolysis.
Wound dressings facilitate debridement by either donating moisture or maintaining a
moist wound environment which provides the optimal environment for the bodys enzymes to
break down the non-viable tissue.

The advantages of autolytic debridement is that there is relatively little pain associated
with this form of treatment, it is versatile, selective and requires minimal skill/training.
Autolytic debridement is useful where there are small volumes or superficial slough, however
it can be a slow process often taking weeks to achieve a clean wound bed. This slow rate of
debridement may raise the potential for infection and maceration of the peri-wound skin9.
ll wounds experience some level of autolytic debridement, which is the natural and highly
selective process by which endogenous proteolytic enzymes break down necrotic tissue.
These endogenous enzymes are mainly produced by neutrophils and include elastase,
collagenase, myeloperoxidase, acid hydrolase, and lysosomal enzymes.
Autolytic debridement may not take place fast enough to encourage rapid wound
healing and closure, but the use of occlusive dressings can enhance this natural process, while
maintaining a moist wound bed and managing excess exudate. This allows painless, selective
debridement and promotes the formation of healthy granulation tissue.
Autolytic debridement can result in the production of significant quantities of exudate.
Typical practice for autolytic debridement involves the use of a hydrogel to soften and break
down necrotic tissue covered with an absorptive, occlusive dressing to absorb the excess
exudate.
With an increase in antibiotic-resistant pathogens, there has been a renaissance in
recent times in the use of honey for the treatment of wounds and ulcers. As well as having an
antibacterial action, honey provides rapid autolytic debridement and deodorizes wounds, in
addition to having anti-inflammatory properties and stimulating immune responses. Though
the exact mode of action remains unclear, Tonks, et al., observed that reactive oxygen

intermediate production was significantly decreased (p < 0.001), and TNF-a release was
significantly enhanced (p < 0.001) by pasture honey and manuka honey.
Although on practical grounds, autolytic debridement is the easiest method of
debriding wounds, it usually takes a prolonged period of time to achieve complete removal of
necrotic tissue.
c. Enzymatic
Enzymatic debridement is a highly selective method of wound debridement that uses
naturally occurring proteolytic enzymes that are manufactured by the pharmaceutical and
healthcare industry specifically for wound debridement. These exogenously applied enzymes
work alongside the endogenous enzymes in the wound. Several enzyme debriding agents
have been developed including bacterial collagenase, papain/urea, fibrinolysin/DNAse,
trypsin, streptokinase-streptodornase combination, and subtilisin. Only the first three products
are widely available commercially in those markets where they are registered, although
availability varies geographically.
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Collagenase-based

debridement.

Collagenase,

derived

from

Clostridium

histolyticum, is the best characterized of all of the enzyme debriding agents. It


specifically digests all triple helical collagen and will not degrade any other proteins
lacking the triple helix. This is a unique feature of bacterial collagenase, since none of
the other available proteases can digest collagen. It has been used for over 25 years
and has a number of clinical advantages, including selectively removing dead
tissue, being painless, and causing the least amount of blood loss. This type of
debridement can be appropriate to use in long-term care facilities and in the home

care setting. Clinical research has shown that bacterial collagenase is an effective and
selective enzyme debriding agent in a range of wound types.
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Papain-based debridement. Papain is a nonspecific proteolytic enzyme derived from


the fruit of the papaw tree (Carica papaya). Papain breaks down fibrinous material in
necrotic tissue and requires the presence of sulfhydryl groups, such as cysteine, for its
activity. It does not digest collagen, and it requires specific activators that are present
in necrotic tissue in order to be stimulated. Urea is combined with papain because
urea is able to expose the activators of papain in necrotic tissue. Urea also denatures
proteins, making them more susceptible to proteolysis by papain. The combination of
papain and urea is approximately twice as effective at digesting protein compared
with papain alone. Papain use is known to produce an inflammatory response and
possibly as a result of this, considerable pain is often experienced with the use of this
method. Therefore, chlorophyllin, an anti-agglutinin, has been added to preparations
of papain/urea in an attempt to reduce the pain. Current preparations containing the
above combination tend to cause less pain. Papain/urea preparations, however, may be
particularly useful in patients with pressure ulcers combined with a loss of sensation
(e.g., spinal injuries), as pain may not be a limiting factor for its use in such instances.

d. Mechanical
Mechanical debridement is a nonselective, physical method of removing necrotic tissue
and debris from a wound using mechanical force. This debridement method is generally easy
to perform and is more rapid than autolytic and enzymatic debridement. However, this
nonselective method can damage healthy granulation tissue both in the wound bed and at the
margins of the wound thus causing significant discomfort to the patient. Despite these
disadvantages, there are a number of mechanical debridement methods that are in use.
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Wet-to-dry dressings are the simplest method of mechanical debridement, but due to the
frequent dressing changes, it can require considerable nursing time and hence is costly. Wet
gauze dressings are placed onto the wound bed and allowed to dry, trapping the necrotic
debris within the gauze. Upon removal of the dressing, embedded necrotic tissue and debris
are mechanically separated from the wound bed. Pressurized irrigation involves applying
streams of water, delivered at either high or low pressure, to wash away bacteria, foreign
matter, and necrotic tissue from the wound. However, if the pressure is too great, there may
be a risk of forcing bacteria and debris deeper into the wound or damaging viable tissue.
Whirlpool therapy uses powered irrigation and can be very effective at loosening and
removing surface wound debris, bacteria, necrotic tissue, and exudate from the wound.
Ultrasound treatment has been used to remove necrotic tissue and has been shown to
effectively debride wounds and reduce infection caused by bacteria. Vacuum-assisted closure
is a noninvasive form of mechanical or physical debridement that exposes the wound bed to
negative pressure (approximately 125mmHg below ambient pressure) by way of a closed
system. It helps healing of chronic wounds by minimizing exudate and slough in the wound
bed, reducing tissue edema, increasing peripheral blood flow, improving local oxygenation,
and promoting angiogenesis and good quality granulation tissue.
However, in recent years mechanical debridement is on the rise with the use of monofilament
debridement pads (Debrisoft).
Debrisoft is a single use, soft, polyester fibre pad which is wiped across the wound in
either circular or vertical motions (depending on tissue type), dead cells and wound debris are
caught within the fibres and removed from the wound bed.
The advantages of debridement using Debrisoft is that it is easy to perform, requires
little training, it is a fast effective method which causes no damage to the healthy underlying
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or surrounding tissue. Debrisoft has recently been included in a technology appraisal


conducted by the National Institute for Health and Care Excellence (NICE).
After reviewing the published evidence NICE supported the use of Debrisoft as an
effective method of wound debridement which additionally could reduce costs of patient care
in the community setting. NICE calculated that Debrisoft could save the NHS up to 484 per
patient of completed debridement episode compared to standard practice. However,
effectiveness is dependent on tissue type; debridement with monofilament pads is not
effective on dry eschar, hard necrotic tissue or thick dehydrated slough.

e. Biosurgery (Myiasis)
For a decade since its introduction in 1931, fly maggots have been known to help debride
and heal wounds. This technique uses sterile maggots, which digest sloughy and necrotic
material from the wound without damaging the surrounding healthy tissue. In the study by
Mumcuoglu, et al., complete debridement was achieved using maggots in 38 of the 43
patients (88%) with chronic leg ulcers and pressure ulcers. Among them, five patients had
their limbs salvaged after being referred for amputation of the leg. Likewise, Sherman in a
cohort of 103 patients with pressure ulcers observed that 80 percent of maggot-treated
wounds were completely debrided compared to only 48 percent of wounds that were treated
by conventional therapy alone (p = 0.021).
The precise mechanism by which maggots debride the wound and promote wound
healing remains unclear. However, there is speculation that they probably act by ingesting
and killing bacteria, exerting a bacteriostatic effect by increasing wound pH, secreting

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proteolytic enzymes that are important in eschar degradation, and increasing tissue
oxygenation.
The maggots debride by secreting a proteolytic enzyme which liquefies the dead tissue.
Once this tissue is dissolved the maggots then ingest the fluid neutralising any bacteria in
their gut. They do not, as commonly believed, bite or chew the dead tissue. Other benefits of
larvae therapy have been published including increased irrigation of the wound bed by the
movement of the larvae stimulating exudate production and increased granulation growth
rates through the changes in PH level on the wound bed increasing oxygenation and a number
of growth factors.
Larval therapy offers a fast selective method of debridement but is not suitable for all
wounds. The effectiveness solely relies on the survival of the larvae, so there needs to be
consideration of whether they may be squashed, for instance if used on a heel of an active
patient or if exudate levels are very high that they may drown.
The application of loose maggots can be tricky and does require previous training, but the
marketing of bagged maggots has reduced the level of specialist skill previously required.
Not all patients accept the idea of maggots on their wound and detailed conversations with
the patient must take place prior to their application to ensure the patient is fully informed
and consents to treatment. Nevertheless, despite recent encouraging reports, some patients
complain of increased pain with maggot therapy. Likewise, the potential psychological and
aesthetic considerations cannot be ignored.

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References

1. Strohal, R., Apelqvist, J., & Dissemond, J. (2014). EWMA Document: Debridement: An
updated overview and clarification of the principle role of debridement. Journal of wound
care, 22(sup1), S1-S49.
2. OBrien, J. (2003). Debridement: ethical, legal and practical considerations. British journal
of community nursing, 8(Supplement 3), 23-25.
3. Wounds UK. (2013). Effective debridement in a changing NHS: a UK consensus.
4. Broadus, C. (2013). Debridement options: BEAMS made easy. Wound Care Advisor, 2(2),
15-18.
5 Cook, L. (2012). Wound Assessment. British journal of nursing, 21(20a), 4-6.
6. World Union of Wound Healing Societies. (2008). Principles of Best Practice: Diagnostics
and Wounds. A consensus document
7. Ousey, K., & Cook, L. (2011). Understanding the importance of holistic wound
assessment. Practice nursing, 22(6), 308-314.
8.Ousey, K., & Cook, L. (2012). Wound Assessment: made easy. Wounds UK, 8(2), 1 - 4.

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9. Gray, D., Acton, C., Chadwick, P., Fumarola, S., Leaper, D., Morris, C., . . . Young, T.
(2010). Consensus guidance for the use of debridement techniques in the UK. Wounds UK,
6(4).
10. Sherman, R. A. (2002). Maggot versus conservative debridement therapy for the
treatment of pressure ulcers. Wound Repair and Regeneration, 10, 208-214.
11. Wollina, U., Liebold, K., & Schmidt, W. (2002). Biosurgery supports granulation and
debridement in chronic wounds - clinical data and remittance spectroscopy measurements.
International Society Dermatology, 41, 635-639.
12. Atkin, L. (2014). Understanding methods of wound debridement. British Journal of
Nursing, 23(12).
13.NICE. (2014). National Institute for Heath and Care Excellence medical technology
guidance 17: The Debrisoft monofilament debridement pad for use in acute or chronic
wounds. .
14. Stephen-Haynes, J., & Thompson, G. (2007). The different methods of wound
debridement. British journal of community nursing, 12(sup3), S6-S16.

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