Key learning points:
- The different types of debridement methods available
- The role of the Wound Clinical Nurse Specialist in improving patient outcomes
- Choosing the most appropriate debridement methods
Debridement is the process of removing necrosis or foreign material from a wound in order to aid healing. There are many different debridement techniques and the evidence supporting one over the other is not conclusive1. The aim of this article is to demonstrate different debridement methods and the challenges faced when treating patients in a community setting.
Ben is a 78 year old gentleman who has atrial fibrillation (AF). He developed a spontaneous spinal haematoma resulting in Cauda Equine syndrome which left him paraplegic and unable to walk. He was discharged home with support from a home care and the District Nursing Team who referred him to the Wound Clinical Nurse Specialist (WCNS) when he was found to have a pressure ulcer to his right heel.
The wound was fully obscured by dry hard necrotic tissue and classified as unstageable2. Necrosis obscures the wound bed preventing clinicians from establishing the extent of soft tissue damage restricting a full comprehensive wound assessment. It can be a source of nutrients for bacteria, increasing the risk of infection3, therefore its swift removal is essential. Although, the European Pressure Ulcer Advisory Panel, (EPUAP)2 suggest that dry intact necrotic tissue on heels’ serves as the body’s natural dressing and should not be removed.
Presently no Randomised Control Trials (RCT) have been found that investigate the effectiveness of debridement versus no debridement1 and with this lack of evidence it is important that the decision regarding to debride or not to debride, should follow a comprehensive assessment by a skilled practitioner which includes the aetiology of the wound, pain, location, size, amount of necrotic tissue present and the expertise of the clinician prior to the debridement treatment selection.
A common method of debridement used by practitioners is autolytic debridement. It accelerates the body’s natural ability to breakdown and soften devitalised tissue. Moisture retentive dressings allow the phagocytic cells and proteolytic enzymes to soften the necrosis which is digested by macrophages4. As the necrotic tissue rehydrates it provides a moist environment for bacterial spores to become active, therefore, this method of debridement should be avoided when treating ischemic limbs where the infection risk is greater5. Ben had good circulation to both feet with no history of diabetes. The WCNS decided that autolytic debridement at this stage would not be conducive as providing moisture with the use of hydrogels or hydrocolloid dressings to rehydrate such an extensive area of necrotic eschar would have produced wet viscous slough. The presence of anaerobic bacteria found in devitalized tissue can cause malodour which is distressing for the patient, together with high levels of exudate which can be difficult to manage resulting in soiled clothing and bed sheets6. The relative slowness of the process has the potential to increase the risk of infection with the added possibility of maceration to the surrounding skin7.
A few weeks later the edges of the necrotic tissue began to loosen and lift. The exudate level was increasing and the odour was offensive, it was therefore, decided to assist debridement by removing the bulk of the devitalised tissue using sharp debridement procedures.
Before performing any treatments of this kind informed consent must be gained from the patient8. Ben was assessed to have mental capacity and was involved in the decision making. The procedure was explained clearly ensuring he understood the treatment aim allowing him to make an informed decision9.
Sharp debridement is a relatively quick and effective method that can be undertaken by a practitioner who is deemed competent in a variety of settings10. The removal of devitalised tissue is usually painless and any discomfort felt by the patient should be considered an alert to the practitioner that healthy vital tissue is present. Ben had no feeling below the waist, therefore, extra care was taken to ensure excessive healthy tissue was not removed11.
Releasing the eschar revealed soft fibrous devitalised tissue beneath which was difficult to grasp firmly using the forceps and made it hard to establish the true extent of the tissue damage.
The skin and underlying subcutaneous tissue varies in thickness in different parts of the body. The foot is one of the areas with minimal protection to the underlying structures, so consequently, there was concern that the calcaneal (Achilles) tendon and calcaneum (heel bone) would be exposed, increasing the risk of osteomyelitis. The WCNS considered it unsafe to carry on with the procedure.
Bio surgical debridement, the application of larvae into a wound was the next chosen method of debridement. This was due to the complexity and obscurity of the anatomy beneath the damaged tissue. The use of larvae in wound management dates back to the ancient times and has over the past 10 years become a more acceptable form of wound debridement12. Larval therapy is a comparatively costly treatment and its effectiveness is debatable due to the quality of data produced13. The GP was consulted and his treatment plan was discussed prior to application. The use of larval therapy is contraindicated for patients in the community taking anti-coagulant medication14, which he had previously been taking for his AF, but this had been discontinued following his spinal haematoma.
The larvae used in larval therapy are from the green bottle fly. When applied to a wound they secrete ‘proteolytic enzymes’ which liquefy the necrotic tissue enabling digestion, the movement of their bodies also assist with the breakdown of necrotic tissue15.
The larvae can be applied free ranged or contained in a polyester net bag. As Grassberger et al16 found the application of bagged larvae does not lose their effectiveness, these were therefore ordered to facilitate ease of application and removal. The larvae were left in place for four days and when removed healthy granulation tissue was visible.
Advances in technology have made alternative debridement therapies available for example MIST which delivers low energy ultrasonic waves using a fine mist spray to the wound bed breaking down dead tissue. Alternatively VERSAJET is a hydro surgery system which uses high pressure sterile water to wash away devitalised tissue. The disadvantages to these methods is the need for expensive equipment in a controlled environment and specialist training, therefore it would not be suitable for community patients in their own homes.
After consulting with the GP a joint decision was made to refer to the vascular consultant for surgical debridement in order to complete the debridement process.
Surgical debridement is performed in an operating theatre by a surgeon or specially trained clinician to remove devitalised tissue as well as healthy tissue until a granulating wound bed is achieved7. Following this procedure a healthy wound bed of 100% granulation was achieved and the wound continued to improve and heal.
There are many debridement techniques available to consider when designing treatment plans and as this case study demonstrates more than one may be appropriate to achieve the best outcome for the patient. The role of the WCNS plays a key part in supporting patients and clinicians with the assessment, implementation and choice of the most appropriate debridement method.
It is evident that more robust research is required to provide evidence of the efficacy of each method to assist clinicians with their decision making.
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