Wound debridement: a clinical update

Debridement for surgical wounds

BACKGROUND

Surgical wounds that become infected are often debrided because clinicians believe that removal of this necrotic or infected tissue may expedite wound healing. There are numerous methods of debridement available, but no consensus on which one is most effective for surgical wounds.

OBJECTIVES

To assess the effects of different methods of debridement on the rate of debridement and healing of surgical wounds.

SEARCH METHODS

In October 2021, we searched the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL. To identify additional studies, we searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies, reviews, meta-analyses, and health technology reports. There were no restrictions on language, date of publication, or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that enrolled people with a surgical wound that required debridement, and reported time to complete wound debridement or time to wound healing, or both.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, risk of bias assessment using the RoB 1 tool, data extraction, and GRADE assessment of the certainty of evidence.

MAIN RESULTS

In this fourth update, we identified one additional study for inclusion. The review now includes six studies, with 265 participants, aged three to 91 years. Five studies were published between 1979 and 1990 and one published in 2014. The studies were carried out in hospital settings in China, Denmark, Belgium, and the UK. Six studies provided six comparisons. Due to the heterogeneity of studies, it was not appropriate to conduct meta-analyses. Four studies evaluated the effectiveness of dextranomer beads/paste; however, each study used a different comparator (Eusol-soaked dressings, 10% aqueous polyvinylpyrrolidone, 0.1% chloramine-soaked packs, and silicone foam elastomer dressing). One study compared streptokinase/streptodornase with saline-soaked dressings, and one compared endoscopic surgical debridement with conventional 'open' surgical debridement. Five studies reported time to complete debridement (reported as time to a clean wound bed) and three reported time to complete healing. One study reported effect estimates (surgical debridement via endoscopy versus surgical debridement) for time to a clean wound bed and time to complete wound healing, and it was possible to calculate effect estimates for one other study (dextranomer paste versus silicone foam elastomer) for time to complete wound healing. For the other four studies that did not report effect estimates, it was not possible to calculate time to a clean wound bed or time to complete wound healing due to missing variance and participant exclusions. None of the included studies reported outcomes pertaining to proportion of wounds completely healed, rate of reduction in wound size, rate of infection, or quality of life. All studies had unclear or high risk of bias for at least one key domain. Dextranomer paste/beads (autolytic debridement) compared with four different comparators Four studies compared dextranomer paste or beads with Eusol-soaked gauze (20 participants), 10% aqueous polyvinylpyrrolidone (40 participants), 0.1% chloramine-soaked dressings (28 participants), or silicone foam elastomer (50 participants). There is very low-certainty evidence that there may be no clear difference in time to a clean wound bed between dextranomer beads and Eusol gauze. The study did not report adverse events. There is very low-certainty evidence that there may be no difference in time to a clean wound bed between dextranomer paste and 10% aqueous polyvinylpyrrolidone gauze. There was low-certainty evidence that there may be no difference in deaths and serious adverse events. There may be a difference in time until the wounds were clinically clean and time to complete wound healing between dextranomer paste and 0.1% chloramine favouring 0.1% chloramine, but we are very uncertain. There is low-certainty evidence that there may be no difference in deaths and serious adverse events. There is very low-certainty evidence that there may be no difference in time to complete healing between dextranomer beads and silicone foam elastomer. The study did not report adverse events. Streptokinase/streptodornase solution (enzymatic) compared with saline-soaked dressings One study (21 participants) compared enzymatic debridement with saline-soaked dressings. There is low-certainty evidence that there may be no difference in time to a clean wound bed or secondary suture between streptokinase/streptodornase and saline-soaked dressings. There is very low-certainty evidence that there may be no difference in deaths and serious adverse events. Surgical debridement via endoscopic ('keyhole') surgery compared with surgical debridement by 'open' surgery (the wound is opened using a scalpel) One study (106 participants) reported time to complete wound healing and time to a clean wound bed. There is low-certainty evidence that there may be a reduction in time to complete wound healing and very low-certainty evidence that there may be no difference in time to a clean wound bed with surgical debridement via endoscopy compared to 'open' surgical debridement. The study did not report adverse events. Overall, the evidence was low to very low-certainty for all outcomes. Five included studies were published before 1991 and investigated treatments that are no longer available. Worldwide production of dextranomer products has been discontinued, except for dextranomer paste, which is currently only available in South Africa. Furthermore, Eusol, used in one study as the comparator to dextranomer, is rarely used due to risk of harmful effects on healthy tissue and the enzymatic agent streptokinase/streptodornase is no longer available worldwide.

AUTHORS' CONCLUSIONS

Evidence for the effects of different methods of debridement on complete wound debridement and healing of surgical wounds remains unclear. Adequately powered, methodologically robust RCTs evaluating contemporary debridement interventions for surgical wounds are needed to guide clinical decision-making.

Hydrosurgery as a safe and efficient debridement method in a clinical wound unit

OBJECTIVE

Hydrosurgical debridement allows removal of non-viable tissue, preserving healthy tissues. This study was designed to analyse whether hydrosurgery, used in a clinical wounds unit, is an effective and safe method that may reduce debridement time.

METHODS

Patients' wounds had the following characteristics: wounds with devitalised tissue needing rapid debridement, wounds with cavities, or non-healing wounds. Hydrosurgical debridement uses a pressurised stream of saline (0.9% sodium chloride) and a vacuum around this stream to remove the devitalised tissue of the wound, preserving healthy surrounding tissues.

RESULTS

This prospective study comprised of 53 wounds from 39 patients. The wound aetiology included 39.7% arterial insufficiency, 22.6% pressure ulcers (PUs), 15.1% diabetic foot ulcers (DFUs), 9.4% venous leg ulcers (VLUs), and 13.2% from other aetiologies. The percentage of wounds according the size was the following: 32.1% (<10cm²), 43.4% (10-49cm²), 15.1% (50-99cm²), and 9.4% (≥100cm²). Superficial wounds were 43.4% of the total and 56.6% of wounds had cavities. Pain associated with the hydrosurgery was mild to moderate. There were no hydrosurgery-related adverse events. For effective debridement, the required sessions were as follows: one procedure (73.6%), two procedures (18.9%) and three procedures (7.5%). There was a statistical significant direct correlation (r=0.307) between the number of required sessions and wound size. All patients improved in a week (>80% of granulation tissue).

CONCLUSION

We demonstrate that hydrosurgery is an effective and rapid debridement method that can be used safely in the outpatient setting.

Undertaking a person-centred assessment of patients with chronic wounds

Wounds have traditionally been classified as acute or chronic. While this classification is useful when attempting to estimate healing times, it might lead to an acceptance that some wounds will take longer to heal or might not heal at all. Chronic wounds can adversely affect patients' quality of life, and the management of these wounds may involve significant healthcare resources and costs. Chronic wounds rarely develop in healthy individuals and are often associated with pre-existing conditions that complicate wound healing, such as diabetes mellitus and vascular disease. This article discusses how acute wounds and chronic wounds are differentiated. It details the phases of wound healing and identifies potential barriers to progression through these phases. Enhancing nurses' understanding of chronic wounds will enable them to identify any potential barriers to wound healing early and remove or ameliorate them. While a holistic assessment should also include a thorough assessment of the wound itself, this is beyond the scope of this article.