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DEBRIDEMENT - A NURSING ISSUE?
Deborah Hofman BA Hons RGN
Oxford Department of Wound Healing
 It
is generally accepted that the presence of dead or necrotic material is
deleterious to wound healing as it increases the bacterial burden on the
wound and causes inflammation thereby delaying healing and heightening
the risk of infection.1 In most cases it should
be removed to enhance healing. Frequently it is the nurse, whether a tissues
viability specialist or a nurse working in the district who is making
day to day decisions on the management of chronic wounds.
There are several considerations to be made when making the decision whether
or not to debride a wound. Although the presence of slough or necrotic
tissue in a wound is normally considered to be deleterious to the healing
process, there are occasions when the wound is best left alone.
1. A patient who is terminally ill should have as few
interventions as possible and, unless the necrosis is causing unacceptable
odour, debridement should not be undertaken.
2. There is considerable debate as to whether black
heels should be debrided and the EPUAP Guidelines2
recommend that black eschar should be left until it shows signs of separation.
Where there is poor arterial supply to extremities necrosis should be
left until there has been surgical intervention. Moist dressings should
not be used.
3. There are certain conditions, eg, pyoderma gangrenosum,
where wound debridement is contra-indicated.3
It should always be born in mind that necrotic tissue
is present due to tissue death as a result of poor local perfu-sion. Unless
the underlying pathology is corrected necrotic tissue will rapidly reappear.
Any nurse attempting wound debridement of whatever nature should be able
to distinguish between different abnormal wound coverings and should have
an adequate knowledge of local anatomy. Nurses should be able to distinguish
between yellow slough, fibrin, tendon, ligament and fatty tissue. Black
necrotic tissue may be confused with heavy anaerobic contamination or
with dried blood.
Nurses should be aware of the limits of their expertise and be able to
decline intervention if they feel unsure of their competence. This is
of course of particular importance when a nurse is undertaking sharp debridement.4
Having identified the type of necrotic tissue and decided that it is appropriate
to debride a wound, the nurse must then consider which type of debridement
is appropriate. If very extensive debridement is required then a surgeon
should be consulted.
Sharp debridement, however, is within the remit of the nurse, depending
on the site and extent of the wound and the nurse's expertise. Most nurses
are capable of removing a piece of slough hanging from a wound bed, but
using a scalpel to remove necrosis from a deep wound requires greater
knowledge and expertise.
Prior to undertaking sharp debridement a full explanation must be given
to the patient, together with reassurance that if the procedure becomes
distressing it will be discontinued. When undertaking sharp debridement
the patient's comfort must be a primary consideration. Several trials
have shown that topical EMLA is effective in reducing pain during the
debridement procedure.5,6 Sharp debridement should
always be undertaken with another professional present. This assistant
can reassure the patient, observe for any distress and summon help should
the need arise.
Much has been written over the last few years on the subject of larval
debridement.7,8 Larval therapy has the great advantage
over sharp debridement in that the larvae are highly selective and are
far less likely to damage healthy tissue during the debridement procedure.
Moreover, early research indicates that larvae have an antibacterial effect.9
Larval therapy also would seem to promote healthy granulation tissue and
stimulate healing. Larval debridement is normally rapid - approximately
three days - which far outstrips the performance of any dressing. However,
there may be side effects and contra-indications:
1. It can sometimes be very difficult to contain the larvae in a wound
and patients and nurses may find wandering larvae distressing. This can
be resolved by application of a 'biobag', as opposed to 'free range' larvae.
However, where there are cavities and sinuses, loose maggots are almost
certainly more effective.
2. Some patients report increased levels of pain when larvae are in place.
When this is the case they should be removed.
3. Maggots should be applied to deep wounds in ischaemic limbs with caution
as they need oxygen to survive and where there is a lack of available
oxygen localised tissue ischaemia may ensue.
Enzymatic debridement is only available in this country in the
form of a product containing streptokinase. Some research suggests that
this product is not particularly effective and, moreover, is not advisable
for patients to whom the drug may have to be given systemically in the
future. Collagenase enzymatic debriding agents have been available for
many years in mainland Europe and are reportedly more effective.10
Dressings which maintain a moist environment and thereby promote
autolysis, e.g., hydrogels, hydrocolloids and, depending on the degree
of exudate, alginates, cellulose dressings, and cadexomer iodines, have
been used for over a decade to promote de-sloughing, and there is a wealth
of literature on the subject. Chosen correctly, dressings can be an effective,
albeit slow, debriding method. However, it is vital that nurses are aware
of the indications for the dressings that they select. Frequently we see
hydrogels applied to a heavily exuding sloughy wound which increases damage
caused by maceration. Conversely alginates applied to dry necrosis have
little benefit and can be difficult to remove. Dressing choice is sadly
lacking in nurse education which sometimes results in suboptimal wound
management.
Water is now widely used in wound cleansing.11
Wounds can be showered or irrigated which will help remove loose debris.
Whirlpools and jacuzzi foot baths are used in leg ulcer management with
similar effect. More high-tech equipment for water debridement has yet
to be fully evaluated but anecdotal reports suggest that the method is
cumbersome and can cause considerable discomfort and pain for the patient.
Moreover, there remains some concern that there is a possibility of bacteria
from the wound being forced further into the tissues and spread further
into the environment.12
Hypochlorite Solutions were at one time the only dressing available
in the management of sloughy/contaminated wounds, but following Leaper's
animal studies in 198513 to illustrate the inhibition
of angiogenesis when applied to healthy tissue, its use was largely discredited.
However, hypochlorites are cheap and effective wound cleansers and many
plastic surgeons advocate their use in wound bed preparation. If surrounding
skin is protected while a hypochlorite dressing is being used, and if
it is discontinued as soon as the wound bed is clean, there would appear
to be indication for re-evaluating its use.
Recently there has been much research on the use of honey, an even
older wound remedy. Honey is reported to resolve infections, promote debridement
and stimulate tissue regeneration.14,15
There are constant shifts in opinion about how to manage complex chronic
wounds and it is up to nurses involved in wound care to keep up-to-date
in all aspects of wound management and to maintain a flexible approach.
References
1. ETRS Bulletin, 1995, 2:4, 104-111.
2. European Pressure Ulcer Advisory Panel Guidelines on the treatment
of pressure ulcers. EPUAP Review, 1999; 1:2, 31-33.
3. Coady K., The diagnosis and treatment of pyoderma gangrenosum. J.Wound
Care, 2000; 9: 282-285.
4. Ashworth J. and Chivers M., Conservative sharp debridement: the professional
and legal issues. Prof Nurse, 2002; 17:10, 585-588.
5. Hansson C., Holm J., Lillieborg S. and Syren A., Repeated treatment
with Lidocaine/Prilocaine Cream (EMLA) as a topical anaesthesic for the
cleansing of venous leg ulcers. Acta Derm Venereal (Stockh) 1993;
73: 231-233.
6. Ohlsen L., Grafford K. and Evers H., EMLA cream as a topical anaesthetic
for ulcer debridement and simultaneous split-skin grafting. Eur J.
Plastic Surg, 1994; 17: 277-282.
7. Thomas S., Using Larvae in modern wound management. J. of Wound
Care, 1996; 5:2, 60.
8. Church J., Maggot debridement therapy for chronic wounds. The Int.
J. of Lower Extremity Wounds, 2002; 1 2: 129-133.
9. Thomas S., Andrews A., Nigel P. et al.The antimicrobial activity
of maggot secretions a result of a preliminary study. J. of Tissue
Viab. 1999 9: 127-132.
10. Martin S., Corrado O. and Kay E. Enzymatic debridement for necrotic
wounds. J. of Wound Care, 1996 5:7, 310-313.
11. Angeras M., Brandberg A., Falk A., et al, Comparison between sterile
saline and tap water for the cleaning of acute traumatic soft tissue wounds.
European J. of Surgery, 1992, 158:33, 347-350.
12. Dow G., Browne A. and Sibbald R. Infection in chronic wounds: controversies
in diagnosis and treatment. Ostomy Wound Management, 1999; 45:8,
23-40.
13. Cameron S. and Leaper D., Antiseptic toxicity in open wounds. Nurs.
Times 1988; 84: 25:77.
14. Molan P., The role of honey in the management of wounds. J.Wound
Care, 1999; 8: 8, 415-418.
15. Allen K. and Molan P., A survey of the antibacterial activity of some
New Zealand honeys. J Pharm Pharmacol, 1991; 43:12, 817-822.
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