Debri
Debri
Debridement
Content Creators:
Members of the South West Regional Wound Care Program’s Clinical
Practice and Knowledge Translation Learning Collaborative
Care Program
South West Regional Wound
including:
1. Mechanical debridement
2. Enzymatic debridement
3. Sharp debridement
4. Autolytic debridement
5. Biologic Debridement
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South West Regional Wound
3
SIGNIFICANCE OF NECROTIC TISSUE
Care Program
Necrotic Tissue1-4
• Necrotic tissue impairs wound healing as it is a physical barrier
to:
• Granulation tissue formation
• Wound contraction
• Re-epithelialization
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South West Regional Wound
• Necrotic tissue may also harbor bacteria, which could lead to
wound infection, thus impairing wound healing
• Color
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• Consistency
• Adherence
6
Necrotic Tissue: Color1
• As the depth/severity of the wound increases, the color of the
necrotic tissue changes:
• White/gray
• Tan/yellow
• Brown/black
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South West Regional Wound
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Yellow Black
White/Gray
Necrotic Tissue: Consistency1
• As the tissues dry out, the consistency of the necrotic tissue
changes:
• Mucinious
• Soft, stringy
•
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Soft, soggy
• Hard
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• Slough: yellow/tan, thin, mucinious or stringy partial thickness
damage
• Eschar: brown/black, soft of hard full-thickness damage
9
Necrotic Tissue: Adherence1
• Adhesiveness of the debris to the wound bed and the ease
with which the two are separated
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South West Regional Wound
• The deeper or more severe the damage is
• The less moist the wound is
10
Summary of Necrotic Tissue
Characteristics
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South West Regional Wound
Yellow fibrinous Soft, stringy Loosely attached
Yellow/tan
Soft, soggy Attached at the base only
(slough)
Black/brown Firmly adherent to base
Hard
(eschar) and edges
11
Types of Necrotic Tissue
• Predominant types of necrotic tissue include:
• Slough
• Fibrin
• Eschar
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South West Regional Wound
• Gangrene
• Hyperkeratosis
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Description of Necrosis Types
Slough Fibrin Eschar Gangrene Hyperkeratosis
• Mucinious • Mucinious • Soft, soggy Hard • Soft, soggy
• Soft, stringy • Soft, stringy • Hard • Hard
• Soft, soggy • Soft, soggy
White/yellow White/yellow Black/brown Black/brown White/gray
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• Clumps • Clumps • Attached at Firmly Firmly attached
• Loosely • Loosely base attached
attached attached • Firmly
• Attached at • Attached at attached
base base
25-100% 25-100% 50-100% 50-100% Surrounds wound
covered covered covered covered edges
13
Type of Necrosis By Wound
Etiology
• Arterial/ischemic wounds:
• Dry gangrene
• Thick, dry, desiccated black/gray appearance
• Firmly adherent
• May be surrounded by an erythematous halo
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South West Regional Wound
• Neurotropic wounds:
• Do not present with necrotic tissue in wound typically
• Have hyperkeratosis surrounding wound
• Pressure Sores: 14
• Relates to the depth of the injury
Care Program
South West Regional Wound
DEBRIDEMENT: INTERVENTION FOR 15
NECROTIC TISSUE
What is Debridement?
• The process of removing dead, contaminated, or adherent
tissue and/or foreign material from a wound
Care Program
South West Regional Wound
• Mechanical Debridement
• Enzymatic Debridement
• Sharp Debridement
• Autolytic Debridement
• Biologic Debridement
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Mechanical Debridement1
• “The use of some outside force to remove dead tissue”, i.e.:
• Wet to dry gauze dressings
• Wound irrigation
• Whirlpool
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• Wet to dry gauze continues to be the most commonly used
debridement technique despite it’s multiple disadvantages
17
Click on the picture of the Versajet for a video of jet lavage
Mechanical Debridement
Continued1
• Advantages:
• Familiar to health care providers
• Wound irrigation can reduce bacterial burden
• Whirlpool may soften necrotic debris
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South West Regional Wound
• Disadvantages (wet-to-dry gauze):
• Non-selective
• Rarely applied correctly
• Painful
• More costly (labor and supplies)
• May cause maceration
• Releases airborne organisms and causes cross-contamination9 18
Enzymatic Debridement1
“Applying a concentrated, commercially prepared
(proteolytic) enzyme to the surface of the necrotic tissue, in
the expectation that it will aggressively degrade necrosis by
digesting devitalized tissue”
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South West Regional Wound
Requires a physician order and must be used according to the
manufacturers instructions
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Enzymatic Debridement
Continued1
Advantages:
Selective
Effective in combination with other debridement techniques
Disadvantages:
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South West Regional Wound
Enzymatic use is prolonged more than necessary, increasing
costs
Can be slow – 3-30 days to achieve a completely clean wound
bed (it is faster than autolysis however)
Requires a specific pH range (may cause local irritation due to pH
changes)
May be inactivated by contact with heavy metals (zinc or silver)
Risk of maceration and infection
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Requires frequent dressing changes (1-3 times per day)
Sharp Debridement1
• Performed either one time (surgical) or sequentially
(conservative)
• Surgical sharp debridement:
• Use of scalpel, scissors, or other sharp instruments
• Removal of viable and non-viable tissue
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South West Regional Wound
• Most rapid and effective
• May convert chronic wound into an acute wound
• Requires analgesics and availability of cautery equipment
• Indicated for removal of thick, adherent and/or large amounts of
non-viable tissue and when advancing cellulitis or signs of sepsis
are present
• Requires a certain level of expertise, education and skill
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• Risk of bleeding
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South West Regional Wound
necrotic debris/tissue
• Can be performed in any health-care setting by non-physician
clinicians (if they have the knowledge, skill, judgment and
authority to do so)
• Does not require transfer to an acute facility
22
Autolytic Debridement1
“The process of using the body’s own mechanisms (enzymes)
to remove nonviable tissue”
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South West Regional Wound
rehydration of the dead tissue and allows enzymes within the
wound to digest necrotic tissue”
23
Autolytic Debridement
Continued1
Advantages:
Painless in the majority of people with wounds
Effective, versatile, and easy to perform
Selective
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South West Regional Wound
Low cost
Can be used in conjunction with other debridement techniques
Disadvantages:
Slow
Caregiver education required for compliance
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Biologic Debridement1
A.k.a. larval/maggot debridement therapy (use of medical
grade green bottle fly larvae/maggots)
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South West Regional Wound
to remove the nonviable tissue”10
Regulated by the FDA as a prescription only medical device
Maggots are left in the wound for 2-3 days . They secrete
“proteolytic enzymes that break down necrotic tissue and
then ingest the liquefied tissue”10
Advantages:
Reduces bacterial burden
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South West Regional Wound
Growth-stimulating effects
Selective
Click on the maggots to see a
short video on this therapy
Disadvantages:
Limited number of studies
‘Yuck factor’
Availability of sterile medical grade maggots
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Lack of policies and procedures
Review of Types of
Debridement
Debridement
Definition Examples
Type
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South West Regional Wound
Application of a concentrated, commercially
Enzymatic Collagenase
prepared enzyme to digest non-viable tissue
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South West Regional Wound
• To convert a chronic wound to an acute wound by stimulating
the healing cascade
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Who Can Debride?
• Under the 1991 Regulated Health Professions Act (Ontario),
debridement is within the controlled acts authorized for
nursing
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South West Regional Wound
knowledge, skill, judgment and authority, can initiate and/or
provide an order for an RN or RPN to perform care of wound
below the dermis or mucous membrane, which includes
cleansing, soaking, irrigating, probing, debriding, packing,
dressing8
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Who Can Debride: CSWD
• The Long Term Care Homes Act and the Public Hospitals Act
do not allow a nurse to initiate CSWD in the absence of a
physician order
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South West Regional Wound
performing CSWD in the absence of a physician order, but it is
STRONGLY suggested that the nurse communicates her intent
to perform CSWD to the primary care physician BEFORE doing
so
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Who Can Debride
Continued
• Specialized practice skills such as CSWD are not generally
included in the RN’s basic preparation; therefore additional
instruction and supervision are necessary to ensure the
individual is competent to perform the identified skills or acts
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South West Regional Wound
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Who Can Debride Wounds
• The nurse who performs CSWD is expected to have:
• A good knowledge of relevant anatomy
• The ability to identify viable tissue
• Access to adequate equipment, lighting and assistance
• The capacity to explain the procedure and obtain informed
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South West Regional Wound
consent
• The ability to manage pain and discomfort prior to, during, and
following the procedure
• The skill to deal with complications such as bleeding
• The ability to recognize their skill limitations and those of the
technique
• Knowledge of infection control practices
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• The ability to utilize secondary debridement techniques if needed
How Do We Debride?
• After a thorough holistic assessment of the person and their
wound, and determination that debridement is indicated, you
must first choose the most appropriate type(s) of
debridement. This is dependent on the:
• Knowledge, skill and authority of the health care practitioner
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South West Regional Wound
• Availability of required resources
• Overall condition of the person with the wound, and their
‘healability’
• Characteristics of the wound and wound tissue
• Presence of wound related pain
• Required speed and tissue selectivity of debridement
• Costs associated with available debridement techniques
33
• Presence of wound infection
• Physical environment
Choosing How to Debride7
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South West Regional Wound
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Canadian Association of Wound Care
Red/Yellow/Black System
• The type of non-viable tissue present can help identify the
phase of wound healing and as such, the most appropriate
debridement options13:
Wound bed is clean and wound tissue is red/pink
Red
Goal: maintain moist wound healing environment
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South West Regional Wound
Wound bed has slough/fibrin present and tissue may be a combo of red/pink +
ivory/canary yellow/green (depending if infection is present)
Not all yellow is bad – granulation grows through yellow fibrin. Healthy tendon
Yellow* may appear white/yellow
Goal: maintain moist wound healing environment whilst managing excessive
exudates and removing slough via sharp, mechanical, enzymatic, and/or
autolytic debridement
Wound bed has non-viable tissue present. Tissue combo may be dark brown/
grey/ black +/- red/pink +/- ivory/canary yellow/green.
Black* Goal (healable wound and eschar is not stable and on heel): remove non-viable
tissue via sharp, mechanical, enzymatic and/or autolytic debridement 35
*If more than one color of tissue is present in the wound bed, target treatment based on the tissue type that is present in the
greatest amount
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OUTCOME MEASUREMENTS OF DEBRIDEMENT 36
AND REFERRAL CRITERIA
Outcome Measures1
• Three appropriate characteristics for evaluating the
effectiveness of debridement are the:
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• Amount of necrotic tissue
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Amount of Necrotic Tissue1
• Amount should diminish progressively if therapy appropriately
• Can be measured:
• Using linear measurements (length x width)
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South West Regional Wound
• By determining percentage of wound bed covered
• By photography
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South West Regional Wound
dry/black, to soggy/soft/yellow, to mucinous easily dislodged
tissue
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South West Regional Wound
lifting (usually at edges first), and eventually disengages from
the base of the wound
40
Referral Criteria1
• Dry gangrene or dry ischemic wounds
• Elevated temperature
• No wound improvement
• Evidence of cellulitis or gross infection
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South West Regional Wound
• Exposed bone or tendon
• Evidence of abscess
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Resources
SWRWCP Debridement
Care Program
Review
1. The significance of necrotic tissue
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South West Regional Wound
2. Enzymatic debridement
3. Sharp debridement
4. Autolytic debridement
5. Biologic Debridement
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South West Regional Wound
6. Witkowski JA, Parish LC. Histopathology of the decubitus ulcer. J Am Acad Dermatol. 1982;6:1014-
1021.
7. Sibbald RG, Williamson D, Orsted HL, et al. Preparing the wound bed: Debridement, bacterial balance
and moisture balance. Ostomy/Wound Management. 2000;46(11):14-35.
8. College of Nurses of Ontario. Decisions about procedures and authority. Pub. No. 41071. Toronto.
Last retrieved October 21, 2014 from: http://www.cno.org/Global/docs/prac/41071_Decisions.pdf
9. Lawrence JC, Lilly HA, Kidson A. Wound dressings and airborne dispersal of bacteria. Lancet.
1992;339(8796):807.
10. Zacur H, Kirsner RS. Debridement: Rationale and therapeutic options. Wounds: Compendium of
Clinical Research and Practice. 2002;14(7Suppl E):2E-7E.
11. Prete PE. Growth effects of Phaenicia sericata larval extracts on fibroblasts: Mechanism for wound
healing by maggot therapy. Life Sci. 1997;60(8):505-510.
12. Mumcuoglu KY. Clinical applications for maggots in wound care. Am J Clin Dermatol. 2001;2(4):219-
45
227.
13. Krasner D. Wound care: how to use the red-yellow-black system. Am J Nurs. 1995:95(5):44–47.