debridement

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Debridement

 

Definition

Debridement is the process of removing nonliving tissue from pressure ulcers, burns, and other wounds.

Purpose

Debridement speeds the healing of pressure ulcers, burns, and other wounds. Wounds that contain non-living (necrotic) tissue take longer to heal. The necrotic tissue may become colonized with bacteria, producing an unpleasant odor. Though the wound is not necessarily infected, the bacteria can cause inflammation and strain the body's ability to fight infection. Necrotic tissue may also hide pockets of pus called abscesses. Abscesses can develop into a general infection that may lead to amputation or death.

Precautions

Not all wounds need debridement. Sometimes it is better to leave a hardened crust of dead tissue, called an 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.

Description

In debridement, dead tissue is removed so that the remaining living tissue can adequately heal. Dead tissue exposed to the air will form a hard black crust, called an eschar. Deeper tissue will remain moist and may appear white, or yellow and soft, or flimsy. 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 dead 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 infection (sepsis) that has entered the bloodstream. The procedure can be performed at a patient's bedside. If the target tissue is deep or close to another organ, however, or if the patient is experiencing extreme pain, the procedure may be done in an operating room. Surgical debridement is generally performed by a physician, but in some areas of the country an advance practice nurse or physician assistant may perform the procedure.
The physician will begin by flushing the area with a saline (salt water) solution, and then will apply a topical anesthetic gel to the edges of the wound to minimize pain. Using a forceps to grip the dead tissue, the physician will cut 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 cross-hatched 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.

Key terms

Eschar — A hardened black crust of dead tissue that may form over a wound.
Pressure ulcer — Also known as a decubitus ulcer, pressure ulcers are open wounds that form whenever prolonged pressure is applied to skin covering bony outcrops of the body. Patients who are bedridden are at risk of developing pressure ulcers. Pressure ulcers are commonly known as bedsores.
Sepsis — A severe systemic infection in which bacteria have entered the blood stream.

Preparation

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 area may be flushed with a saline solution before debridement begins, and a topical anesthetic gel or injection may be applied if surgical or mechanical debridement is being performed.

Aftercare

After surgical debridement, the wound will be 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.

Risks

It is possible that underlying tendons, blood vessels or other structures will 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.

Resources

Organizations

American Academy of Wound Management. 1255 23rd St., NW, Washington, DC 20037. (202) 521-0368.〈http://www.aawm.org〉.
Wound Care Institute. 1100 N.E. 163rd Street, Suite #101, North Miami Beach, FL 33162. (305) 919-9192. http://woundcare.org.

débridement

 [da-brēd-maw´] (Fr.)
the removal of all foreign material and all contaminated and devitalized tissues from or adjacent to a traumatic or infected area until surrounding healthy tissue is exposed.

dé·bride·ment

(dā-brēd-mawn[h]'),
Excision of devitalized tissue and foreign matter from a wound.
[Fr. unbridle]

débridement

/dé·bride·ment/ (da-brēd-maw´) [Fr.] the removal of foreign material or devitalized tissue from or adjacent to a traumatic or infected lesion until surrounding healthy tissue is exposed, either by cutting (surgical d.) or by application of an enzyme able to lyse devitalized tissue (enzymatic d.).

debridement

(dā′brēd-mäN′, dĭ-brēd′mənt)
n.
Surgical excision of dead, devitalized, or contaminated tissue and removal of foreign matter from a wound.

de·bride′ v.

debridement

[debrēdmäN′]
Etymology: Fr, debridle, remove
1 the removal of dirt, foreign objects, damaged tissue, and cellular debris from a wound or a burn to prevent infection and to promote healing. In treating a wound, debridement is the first step in cleansing. It also allows thorough examination of the extent of the injury. In treating a burn, debridement of the eschar may be performed in a hydrotherapy bath. debride, v.
2 (in dentistry) the removal of all supragingival and subgingival biofilms, calculus, plaque-retentive anomalies, and diseased root surfaces that harbor bacteria.

debridement

Surgery The cleansing of wounds, by excising 'dirty' edges, producing fresh margins, while removing necrotic tissue and foreign debris. See Wound care.

dé·bride·ment

(dā-brēd-mawn[h]')
Excision of devitalized tissue and foreign matter from a wound.
[Fr. unbridle]

debridement

The radical surgical removal of all contaminated tissue, such as the damaged edges of wounds and, especially, of all muscle suspected of being dead. After effective debridement, healing and recovery are usually rapid.

debridement

excision of devitalized and/or necrotic tissue, to promote healing

debridement

Removal of dead or infected tissue or foreign material until surrounding healthy tissue is exposed. This is done to facilitate healing. Corneal debridement is usually performed with a cotton-tipped applicator, a spatula or with a sharp instrument. Example: debridement of some of the corneal epithelium in dendritic keratitis or in corneal erosion.

dé·bride·ment

(dā-brēd-mawn[h]')
1. Removal of foreign matter and devitalized tissue from a wound.
2. In dentistry, scaling, root planing, and ultrasonic instrumentation of root surfaces subgingivally to attain healthy gingival tissue.
[Fr. unbridle]

debridement (dabrēd´mənt),

n the removal of foreign material and/or devitalized tissue from the vicinity of a wound.
debridement, epithelial (deepithelization),
debridement, nonsurgical periodontal,
n the removal of deposits on the tooth surface. See also scaling.

débridement

[Fr.] the removal of all foreign material and all contaminated and devitalized tissues from or adjacent to a traumatic or infected lesion until surrounding healthy tissue is exposed.

block débridement
a method in which the wound is packed with gauze or toweling, sutured together and then the entire mass is removed surgically. Usually reserved for badly damaged tissues.
enzymatic débridement
use of enzymes such as trypsin and chymotrypsin, usually applied topically, to achieve débridement.