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Debride or not to debride

Discussion in 'General Issues and Discussion Forum' started by xxVixx, Apr 6, 2013.

  1. xxVixx

    xxVixx Member

    Members do not see these Ads. Sign Up.
    Should you debride an ischaemic ulcer if a patient has PVD and what is the evidence behind it? The patient has RA and PVD. The ulcer is on the apex of 4th digit, it is dry and superficial, about 10mm in diameter, clearly demarcated with overlying eschar. Area around is inflamed. The ulcer is present for the past 6 months and failed to respond to treatment which up to date included hydrogel dressings. I think, due to PVD and poor vascular status, it should be left un debrided and I would apply a dry dressing like cadexomer iodine or some other dry anti microbial dressing, what do you think?
  2. David Smith

    David Smith Well-Known Member



    Debridement is the process of removing dead (necrotic) tissue or foreign material from and around a wound to expose healthy tissue.


    An open wound or ulcer can not be properly evaluated until the dead tissue or foreign matter is removed. Wounds that contain 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.


    The four major debridement techniques are surgical, mechanical, chemical, and autolytic.

    Surgical debridement

    Surgical debridement (also known as sharp debridement) uses a scalpel, scissors, or other instrument to cut necrotic tissue from a wound. It is the quickest and most efficient method of debridement. It is the preferred method if there is rapidly developing inflammation of the body's connective tissues (cellulitis) or a more generalized alized infection (sepsis) that has entered the bloodstream. The physician starts by flushing the area with a saline (salt water) solution, and then applies a topical anesthetic or antalgic gel to the edges of the wound to minimize pain. Using forceps to grip the dead tissue, the physician cuts it away bit by bit with a scalpel or scissors. Sometimes it is necessary to leave some dead tissue behind rather than disturb living tissue. The physician may repeat the process again at another session.

    Mechanical debridement

    In mechanical debridement, a saline-moistened dressing is allowed to dry overnight and adhere to the dead tissue. When the dressing is removed, the dead tissue is pulled away too. This process is one of the oldest methods of debridement. It can be very painful because the dressing can adhere to living as well as nonliving tissue. Because mechanical debridement cannot select between good and bad tissue, it is an unacceptable debridement method for clean wounds where a new layer of healing cells is already developing.

    Chemical debridement

    Chemical debridement makes use of certain enzymes and other compounds to dissolve necrotic tissue. It is more selective than mechanical debridement. In fact, the body makes its own enzyme, collagenase, to break down collagen, one of the major building blocks of skin. A pharmaceutical version of collagenase is available and is highly effective as a debridement agent. As with other debridement techniques, the area first is flushed with saline. Any crust of dead tissue is etched in a crosshatched pattern to allow the enzyme to penetrate. A topical antibiotic is also applied to prevent introducing infection into the bloodstream. A moist dressing is then placed over the wound.

    Autolytic debridement

    Autolytic debridement takes advantage of the body's own ability to dissolve dead tissue. The key to the technique is keeping the wound moist, which can be accomplished with a variety of dressings. These dressings help to trap wound fluid that contains growth factors, enzymes, and immune cells that promote wound healing. Autolytic debridement is more selective than any other debridement method, but it also takes the longest to work. It is inappropriate for wounds that have become infected.

    Biological debridement

    Maggot therapy is a form of biological debridement known since antiquity. The larvae of Lucilia sericata (greenbottle fly) are applied to the wound as these organisms can digest necrotic tissue and pathogenic bacteria. The method is rapid and selective, although patients are usually reluctant to submit to the procedure.


    The physician or nurse will begin by assessing the need for debridement. The wound will be examined, frequently by inserting a gloved finger into the wound to estimate the depth of dead tissue and evaluate whether it lies close to other organs, bone, or important body features. The assessment addresses the following points:

    the nature of the necrotic or ischaemic tissue and the best debridement procedure to follow the risk of spreading infection and the use of antibiotics
    the presence of underlying medical conditions causing the wound
    the extent of ischaemia in the wound tissues
    the location of the wound in the body
    the type of pain management to be used during the procedure
    Before surgical or mechanical debridement, the area may be flushed with a saline solution, and an antalgic cream or injection may be applied. If the antalgic cream is used, it is usually applied over the exposed area some 90 minutes before the procedure.


    After surgical debridement, the wound is usually packed with a dry dressing for a day to control bleeding. Afterward, moist dressings are applied to promote wound healing. Moist dressings are also used after mechanical, chemical, and autolytic debridement. Many factors contribute to wound healing, which frequently can take considerable time. Debridement may need to be repeated.


    It is possible that underlying tendons, blood vessels or other structures may be damaged during the examination of the wound and during surgical debridement. Surface bacteria may also be introduced deeper into the body, causing infection.

    Normal results

    Removal of dead tissue from pressure ulcers and other wounds speeds healing. Although these procedures cause some pain, they are generally well tolerated by patients and can be managed more aggressively. It is not uncommon to debride a wound again in a subsequent session.


    Adjunctive therapies include electrotherapy and low laser irradiation. However, at present, insufficient research has been completed to recommend their general use.

    Not all wounds need debridement. Sometimes it is better to leave a hardened crust of dead tissue (eschar), than to remove it and create an open wound, particularly if the crust is stable and the wound is not inflamed. Before performing debridement, the physician will take a medical history with attention to factors that might complicate healing, such as medications being taken and smoking. The physician will also note the cause of the wound and the ways it has been treated. Some ulcers and other wounds occur in places where blood flow is impaired, for example, the foot ulcers that can accompany diabetes mellitus. In such cases, the physician or nurse may decide not to debride the wound because blood flow may be insufficient for proper healing.


    Falanga, V., and K. G. Harding, eds. The Clinical Relevance of Wound Bed Preparation. New York: Springer Verlag, 2002.

    Harper, Michael S. Debridement. Berkeley, CA: Paradigm Press, 2001.

    Maklebust, JoAnn and Mary Y. Sieggreen. Pressure Ulcers: Guidelines for Prevention and Nursing Management. 2nd ed. Springhouse, PA: Springhouse Corporation, 1996.

    Dervin, G. F., I. G. Stiell, K. Rody, and J. Grabowski. "Effect of Arthroscopic Debridement for Osteoarthritis of the Knee on Health-Related Quality of Life." The Journal of Bone and Joint Surgery (American) 85-A (January 2003): 10–19.

    Friberg, T. R., M. Ohji, J. J. Scherer, and Y. Tano. "Frequency of Epithelial Debridement During Diabetic Vitrectomy." American Journal of Ophthalmology 135 (April 2003): 553–554.

    Attached Files:

  3. xxVixx

    xxVixx Member

    Thank you very much for your reply David! :) I see the importance of debridement now. But seeing as the patient has arterial insufficiency I think sharp debridement is a bad option, chemical/enzymatic debridement is used on dry wounds according to EWMA, and the maggot therapy is quite costly. Do you think that if the patient failed to respond to autolytic debridement (hydrogel dressing covered by a secondary dry dressing) for the past 6 months would it be a good idea to stick with the same regime for another while? Or maybe just make a small change and use hydrogel covered by a film dressing to lower chances of infection?
  4. Ros Kidd

    Ros Kidd Active Member

    Osteomyelitis would be running through my mind plus referral to a High Risk foot clinic.
  5. Jill

    Jill Member

    I like the adage "if there is no blood supply keep it dry" - therefore the use of hydrocolloids and hydrogels is not appropriate for the wound you describe and infact the skilled used use of a scalpel by a skilled clinican who has experience in managing high risk feet is less likely to cause harm to the tissues. Cadexemer Iodine (Iodoflex?) is designed, as I understand it, to manage wounds with moderate to high levels of fluid - ie slough, exudate, pus not dry tissue. If you wish to use an antimicrobial dressing for the sort of area you describe I would suggest, honey light, Inadine or Urgotulle SSD - there are other such antimicrobial products available for wounds with minimal / low levels of exudate, and of course these are less likely to adhere to the wound bed - minimising trauma and pain on dressing change.
    However referral for a vascular opinion , if the patient has not already had one, is imperative.
    Best wishes
  6. xxVixx

    xxVixx Member

    Ok so sharp debridement, dry dressing and a referral to High Risk Foot Clinic. There is no clear signs of infection like slough/malodour but since the area is inflamed and well demarcated would you use an antimicrobial dressing? Or just stick with dry melolin/mefix kind of dressing?
  7. damien101

    damien101 Member

    i would stick with dry dressings inadine has some antimicrobial action also request for x-ray of the toe for Osteomyelitis also look at pressure redistibution and footwear
  8. bob

    bob Active Member

    Although - I would not get an x-ray while the toe is dressed with inadine as it will compromise your x-ray detail if you are checking for signs of osteomyelitis. So maybe use a simple dry dressing (or no dressing at all) while it is x-rayed, then put your inadine on after that?

    What vascular checks has the patient had? Do you have a clinical picture you could post up on here?
  9. xxVixx

    xxVixx Member

    The patient has been diagnosed with peripheral arterial disease. I attached an image of the ulcer with the post.

    Attached Files:

  10. David Smith

    David Smith Well-Known Member

    Are you sure that's not an lesion caused by chilblains?

    Dave Smith
  11. damien101

    damien101 Member

    how did they lose the 3rd toe and looking at the toe how are you off loading the apex
  12. damien101

    damien101 Member

    i was thinking about chilblaines on the 2nd and 5th toes as looks like may be near break down but for the 4th toe i would surgest more likely due to the location and the shape of the toe and the loss of the 3rd toe would be looking at pressure redistrobution and weekly returns
  13. David Smith

    David Smith Well-Known Member

    Yes I agree, From the photo, which may be misleading, I would debride to healthy tissue, dress with your favourite dressing, I like alginate, and off load with a silicon mould.

  14. blinda

    blinda MVP

    Personally, I wouldn`t use an anti-microbial dressing on a wound that does not present with clinical signs of infection. I agree with the others; offloading, debridement and a multi-disciplinary approach is essential for Rheumatoid vasculitis (which is indicated here). Pts with autoimmune disorders tend to have wounds that become stalled in the inflammatory stage of repair (hence your observation of inflammation and demarcation) when the body normally develops new blood vessels. Getting that `abnormal` inflammatory stage under control is key, thus the requirement for an MDT approach.
    Last edited: Apr 17, 2013

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