Optionen des Debridements in der Therapie chronischer Wunden. Options for debridement in the therapy of chronic wounds

Debridement is defined as the removal of non-vital tissue from wounds. In chronic wounds, debridement means the elimination of necrosis as well as the clearing away of wound dressings, foreign bodies, and other non-vital substances. Sufficient debridement represents one basic prerequisite for a non-delayed wound-healing process. In addition to treating the causal factors for delayed wound healing, debridement should be the first step in an adequate phase-adapted wound-bed preparation for chronic wounds. This report aims to review the different options available in the execution of debridement in chronic wounds. The following therapeutic measures are available for the debridement of chronic wounds: surgery, maggot therapy, laser, ultrasound, hydrotherapy, wet-to-dry method, autolysis, proteolytic enzymes, osmotic or chemical debridement. There is no single correct debridement for all patients! Patients are individuals and therefore different methods of debridement may make sense. Which therapeutic option is chosen is determined by multiple factors. Moreover, depending on the wound milieu, the successive application of different methods can be useful.

Low intensity laser therapy (830nm) in the management of minor postsurgical wounds: a controlled clinical study

BACKGROUND AND OBJECTIVE

The stimulatory effects of low intensity laser therapy (LILT) have been widely published for the treatment of chronic ulceration. In contrast to this previous work, the current study investigated its potential efficacy (by using a dosage of 9 J/cm2) in the management of acute wounds. For this purpose, uncomplicated postoperative wounds after minor podiatric surgery were examined.

STUDY DESIGN/MATERIALS AND METHODS

The study was designed as a controlled group study. Ethical approval was granted by the University of Ulster's Research Ethics Committee. Patients (n = 9) presenting with a total of 12 wounds after minor surgical procedures (partial/total nail avulsions/electrosurgery) were recruited from the Podiatry Teaching Clinic, Northern Ireland. Patients attended the clinic once per week for assessment and treatment. Weekly irradiation was performed by using a CBM Master 3 (CB Medico, Copenhagen, Denmark) diode laser (GaAlAs). The physical parameters of the output of this unit were as follows: wavelength, 830 nm; average power output, 30 mW; spot size, 0.1 cm2; irradiance, 300 mW/cm2; continuous wave output. Wound assessment and recording of pain levels were conducted weekly. Wound measurement was completed by using planimetry and digitising methods.

RESULTS

Current findings indicated no statistically significant differences between Laser and Control groups for wound closure (P = 0.28 digitising; P = 0.49 planimetry) nor for pain levels reported (P = 0.88).

CONCLUSION

It would seem that LILT provides no advantages in the management of minor postoperative wounds over current practice. Despite no apparent benefit of infrared laser at this dosage in the management of acute stage wounds, further research is required to determine its potential efficacy in the management of other wound types.

Wound measurement: the comparative reliability of direct versus photographic tracings analyzed by planimetry versus digitizing techniques

OBJECTIVE

To investigate two methods of wound measurement (planimetry and digitizing) performed on two routinely used techniques of clinical wound assessment, tracings taken directly from a patient's wound (raw tracing) and from photographs of the wound (photographic tracing).

DESIGN

We examined the level of repeatability and thus reliability of these methods, and determined if absolute measured wound size differed between the combinations of method and assessment procedures.

PATIENTS

Seven patients (4 women, 3 men; mean age +/- standard error of the mean = 63.1+/-5.0yrs) with a total of 11 wounds.

SETTING

Patients attended a podiatry outpatient department on two separate days for raw and photographic tracing of their wounds. For both of these trace types, a series of repeated recordings were conducted by a single investigator using planimetry and digitizing measurement methods.

MAIN OUTCOME MEASURE

Independent statistical analyses (analysis of variance, p < .05) were conducted on logged coefficients of variation and logged means data to investigate for repeatability and for size differences, respectively.

RESULTS

Planimetry produced a significantly larger degree of variability (thus less repeatability) than digitizing (p = .02) and also produced smaller readings (p = .00001). Averaging over methods also indicated that photographic tracings produced smaller readings than raw tracings (p = .019).

CONCLUSION

For the wound sizes and shapes examined, tracings taken directly from the patients were found to be an inexpensive clinical and research assessment tool on which digitizing was conducted with a higher level of repeatability than planimetry. Further research is needed to determine if the current findings apply to a wider population within wound management clinics.

A case report of low intensity laser therapy (LILT) in the management of venous ulceration: potential effects of wound debridement upon efficacy

OBJECTIVE

This single case report (ABA design) was undertaken as a preliminary investigation into the clinical effects of low intensity laser upon venous ulceration, applied to wound margins only, and the potential relevance of wound debridement and wound measurement techniques to any effects observed.

METHODS

Ethical approval was granted by the University of Ulster's Research Ethical Committee and the patient recruited was required to attend 3 times per week for a total of 8 weeks. Treatments were carried out using single source irradiation (830 nm; 9 J/cm2, CB Medico, Copenhagen, Denmark) in conjunction with dry dressings during each visit. Assessment of wound surface area, wound appearance, and current pain were completed by an independent investigator. Planimetry and digitizing were completed for wound tracings and for photographs to quantify surface areas. Video image analysis was also performed on photographs of wounds.

RESULTS

The primary findings were changes in wound appearance, and a decrease in wound surface area (range 33.3-46.3%), dependent on the choice of measurement method. Video image analysis was used, but rejected as an accurate method of wound measurement. Treatment intervention produced a statistically significant reduction in wound area using the C statistic on digitizing data for photographs (at Phase one only; Z = 2.412; p < 0.05). Wound debridement emerged as an important procedure to be carried out prior to measuring wounds. Despite fluctuating pain levels recorded throughout the duration of the study, VAS scores showed a decrease of 15% at the end of the study. This hypoalgesic effect was, however, statistically significant (using the C statistic) at Phase one only (Z = 2.554; p < 0.05).

CONCLUSIONS

Low intensity laser therapy at this dosage, and using single source irradiation would seem to be an effective treatment for patients suffering venous ulceration. Further group studies are indicated to establish the most effective therapeutic dosage for this and other types of ulceration.