debridement - HEMI Australia

DEBRIDEMENT
Professor Donald G. MacLellan
Executive Director
Health Education & Management Innovations
DEBRIDEMENT
• Principles - CSD
• Methods of Debridement
• Biopsy options
PRINCIPLES OF WOUND
MANAGEMENT
1.
2.
3.
4.
DEFINE THE AETIOLOGY
CONTROL FACTORS
AFFECTING WOUND HEALING
SELECT APPROPRIATE
WOUND DRESSING / BANDAGE
PLAN WOUND HEALING
MAINTENANCE
Wound Management
• Identify and address underlying
pathology
• Provide systemic support for wound
healing
• Identify and treat infection
• Debride non-viable tissue
• Utilize appropriate topical therapy
WOUND BED
PREPARATION
OPTIMUM PREPARATION
of a wound bed for tissue repair
in the absence of vascular disease
or medical contraindications is
DEBRIDEMENT
WOUND BED
PREPARATION
DEBRIDEMENT
THE REMOVAL OF
+/- NON-VIABLE TISSUE
+/- NECROTIC TISSUE
+/- BIOFILM
+/- DEBRIS
+/- SENESCENT TISSUE
FROM A WOUND.
Rationale for Debridement
Non-viable Tissue:
• Is a culture medium for bacterial
growth incl biofilms
• Inhibits WBC phagocytosis
• Causes a prolonged inflammatory
response → impairs wound healing
Rationale for Debridement
Senescent Tissue:
• Impaired cell proliferation
• Decreased extracellular matrix
production
• May not respond to cytokine or
growth factor stimulation due to
receptor loss
Rationale for Debridement
Peri-wound Callus:
• Causes pressure to underlying tissue
during weight bearing/walking
• Impairs epithelialization from wound
edges
• Provides undermined area for
bacterial growth
Indications for Debridement
• Non-viable and/or senescent
tissue
• Excessive fibrin in wound
• Peri-wound callus
• Significant colonisation/biofilm
• Adequate healing potential
Contraindications for
Debridement
• Non-infected ischemic ulcer with dry
eschar
• Inadequate circulation
• No potential for healing
• Risk of deep structure exposure/damage
• Risk of uncontrolled bleeding
• Uncooperative patient/inadequate
facilities
WOUND BED
PREPARATION
DEBRIDEMENT
AUTOLYTIC
ENZYMATIC
MECHANICAL
CHEMICAL
BIOLOGICAL
SHARP
What method to choose?
• Wound characteristics:
- aetiology, size, infection, pain,
exudate, location, involved tissues
- required rate of debridement
• The patient's attitude
• Available skills & available resources
• Costs
Mechanical Debridement
•Wet-to-dry gauze
•Scrubbing wound
•Whirlpool
•Wound irrigation
Autolytic Debridement
Enzymatic Debridement
•Collagenase: Santyl
•Papain-Urea:
-Accuzyme
-Ethezyme™
-Ethezyme 830™
-Kovia
•Papain-Urea:Chlorophyllin
• Copper Complex:
-Panafil
-Ziox
Maggot Debridement
Therapy
Larvae of Lucilia sericata (greenbottle fly)
www.ucihs.uci.edu/com/pathology/sherman/maggots.htm
www.smtl.co.uk
Conservative
Sharp
Vascular Considerations
• Clinical Examination
• Ensure adequate local tissue perfusion
• ABI > 0.5
• TcPO2 > 30 mm Hg
Conservative Sharp
Debridement - Procedure
Instruments
Facilities
•
•
•
•
•
•
•
•
Consented, cooperative patient
Analgesia/anaesthesia assessment/Tx
Relatively undisturbed environment
Adequate lighting
Adjustable height of bed/trolley/couch
Sterile instruments & protective equipt
Scout
Dressings/bandages
Biopsy Techniques
What is a skin biopsy?
• Skin biopsy is a biopsy technique in which a
portion of or all of a skin lesion is removed.
• This is sent to a pathologist for microscopic
diagnosis.
• It is usually done under local anaesthetic in an
ambulatory setting.
• The pathology results are generally available
within 2-4 days.
• Commonly performed by medical practitioners.
• Important procedure for diagnosis of skin
conditions
Tissue Biopsy for Diagnosis
• Malignancies
• Inflammatory conditions
• Vasculitic syndromes
• Dermatological disorders
Types of Biopsies
• Shave
• Punch*
• Incisional*
• Excisional
*Used most commonly in wound care
Tissue Biopsy: Equipment
Shave Biopsy
Punch
Biopsy
Excisional Biopsy
Tissue Biopsy for Diagnosis
• Clinical information essential
• Location and timing are crucial to an
accurate diagnosis
• Biopsy newest lesions along the advancing
edge of the abnormal area, including a rim of
normal tissue
Biopsy: Histopathology
• Histology: light microscopy exam of
tissue for neoplastic & inflammatory
changes, microthrombi, necrosis of
vessels/tissue etc.
• Direct Immunofluorescence:
evaluation of tissue for presence of
autoantibodies, complement and
fibrin. Used to r/o immune-mediated
disorders.
Biopsy:
Relative Contraindications
• Bleeding disorders/anticoagulation
therapy
• Immunosuppression
• Severe peripheral arterial disease
• Known or possible underlying vital
structures
Debridement & Biopsy
Summary
• Understand the pathophysiology of wounds
• Determine patient eligibility for debridement
and biopsy
• Develop & follow protocols
• Acquire proper training/experience
• Understand your scope of practice