Debridement

Wound healing requires a moist environment, free of necrotic tissue and infection, which allow for granulation and reepithelialization. Debridement is often needed to remove necrotic tissue, slough, and eschar, which can be accomplished by sharp, mechanical, enzymatic, and/or autolytic techniques. The technique used depends on the patient's condition, location, clinical urgency and overall goals for patient care. Debridement is not recommended for heel ulcers that have stable, dry eschar without edema or signs of infection (AHCPR, 1994; NPUAP, 2007).

Sharp debridement is appropriate for removing areas of thick eschar and necrotic tissue in extensive ulcers. Care must be taken to control pain when using this technique. Also, surgical debridement may cause transient bacteremia, and prophylactic antibiotics may be needed for high-risk patients.

Mechanical debridement includes wet-to-dry dressings, hydrotherapy, wound irrigation, and dextranomers, which are small beads of highly hydrophilic dextran polymers (e.g., Debrisan). Wet-to-dry dressings may be painful when changed and need be discontinued when the wound bed is clean to avoid desiccation (Ovington, 2001). Hydrotherapy is appropriate for pressure sores with thick exudate or necrotic tissue. Care must be taken not to place the wound too close to the jets. Irrigation pressures need to be high enough to adequately cleanse the wound, but not too high to potentially cause tissue trauma. Safe and effective pressures are between 4-15 pounds per square inch (psi). Examples of safe irrigation devices include 35-mL syringe with 19-gauge needle or angiocatheter, water-jet device at the lowest setting, and saline squeeze bottle (250 mL) with irrigation cap.

Enzymatic debridement is accomplished by products that have proteolytic enzymes such as papain and urea (e.g., Accuzyme, Panafil) and collagenase. Typically used once daily, these products may damage healthy tissue and should not be used if infection is present. Thus, special care is needed in application, and use should be limited to short periods (<2 weeks).

Autolytic debridement involves the use of occlusive synthetic dressings that allow enzymes normally present within wounds to self-digest necrotic tissue. Occlusive dressings should not be used if the wound is infected or if there is a moderate amount of exudate (AHCPR, 1994; Cervo et al., 2000; Goode and Thomas, 1997).

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