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1/4Wounds InternationalVol 3 | Issue 2 | Wounds International 20121

Technology and product reviews

INTRODUCTIONSince the concept of wound bed preparation

arose[3], striving to achieve a wound

environment that is conducive to healing

has become increasingly important[4].

Debridement plays a crucial role in this

concept, eliminating non-viable tissue

from the wound bed, which would act as

a significant barrier to wound repair if notremoved[5].

Although the term wound bed preparation

is relatively modern[3], its underlying

theoretical principles are not new[6] after all,

Hippocrates, the 'father of Western medicine',

was the first to stress that the body heals

itself[7]. However, healthcare providers are

charged with enabling the process of healing

to occur unhindered[8]. This, Hippocrates

argued, takes place only through accurate

assessment and diagnosis[7].

In modern terms, practitioners use the TIMEacronym[9]to accurately assess the wound,

identify the presence of devitalised tissue and

plan appropriate interventions[9,10]:

T= tissue (non-viable or deficient)

I= infection/inflammation

M = moisture (imbalance)

E= edge (non-advancing or undermined).

Wound bed preparation provides a

structured approach to the management

of non-healing wounds, and the removal of

barriers through the principles of TIME can

encourage endogenous wound healing

THE CRUCIAL ROLE OFDEBRIDEMENT

The process of wound repair involves a finely-

balanced sequence of events, each stage

controlled by stimulators and inhibitors that

are naturally produced by the body [11]. In order

for wound healing to progress, cells need to

migrate into the wound bed and multiply[12].

Devitalised tissue is a barrier to cell

migration and provides an ideal environment

for bacterial proliferation[13]. The devitalised

tissue prolongs the inflammatory response,enhancing the excess production of pro-

inflammatory cytokines[14].

Cytokines, which are signalling proteins

produced by cells, are a large family of

diverse regulators that play an important

role in wound healing[15]. They carry signals

between cells, thereby stimulating the influx

of other cells required for tissue repair.

Over- or under-production of cytokines will

have a detrimental effect on wound healing.

This, in turn, locks the wound into a state

of chronicity, thereby impeding the woundhealing process[13].

Understanding the adverse impact devitalised

tissue has on wound healing emphasises

the importance of debridement in wound

management[10]. For wounds to heal successfully,

the wound bed needs to be adequately prepared

and debridement is central to this process[16].

Current methods of debridementDebridement may be conducted in a variety

of different ways and choosing the most

appropriate method depends on:

n The patient: for example, any presenting

condition that may be a contraindication

for use of a specific method of

debridement. In addition, the patient's

The important role of debridementin wound bed preparation

Although the literature highlights the importance of wound

debridement, there is often confusion around selecting the most

appropriate method[1]. In addition, concerns around competence

and scope of practice are an important factor when discussing this

technique[2]

. The author aims to clarify the fundamentals of successfuldebridement in the clinical practice setting.

Author:Zena Moore

References1. Cuddigan JE, Ayello EA. Clinical

decision making for debriding

chronic wounds. World Council of

Enterostomal Therapists Journal

2004; 24: 8.

2. Dowsett C. The role of the nurse

in wound bed preparation. Nurs

Stand2002; 16: 69.

3. Schultz GS, Sibbald RG,Falanga V, Ayello EA, et al.

Wound bed preparation: a

systematic approach to wound

management. Wound Rep Regen

2003; 11: S128

4. EWMA. EWMA position document:

wound bed preparation in

practice. 2004; MEP, London, UK.

5. Dowsett C, Claxton K. Reviewing

the evidence for wound bed

preparation.J Wound Care2006;

15: 43942.

6. Hampton S. Some simple

solutions to wounddebridement. Nurs Res Care 2011;

13: 378.

T E C H N O L O G Y U P D A T E :

Useful links

Wound bed preparation revisited

Wound bed preparation in practice


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Technology updateThe importance of debridement in wound bed preparation

References7. Garrison FH. History of Medicine.

1966; W.B. Saunders Company,

Philadelphia.

8. Ayello EA, Cuddigan JE. Conquer

chronic wounds with wound bed

preparation. Nurs Pract2004; 29: 8.

9. Schultz GS, Barillo DJ, Mozingo DW,

Chin GA. Wound bed preparation

and a brief history of TIME. Int

Wound J 2004; 1, 1932.

10. Fletcher J. Wound bed preparation

and the TIME principles. Nurs Stand

2005; 20: 57.11. Hopkinson I. Molecular

components of the extracellular

matrix.J Wound Care1992; 1:

5254.

12. Iocono JA, Erlich HP, Gottrup F,

Leaper DJ. The biology of healing.

In: Leaper DJ, Harding KG (eds).

Wounds Biology and Management.

1998; Oxford Medical Publications,

Oxford: 1022.

13. Young T. Debridement is it time

to revisit clinical practice? Br J Nurs

2011; 20(suppl): 2428.

14. Young T. Reviewing best practicein wound debridement. Prac Nurs

2011; 22: 48892.

15. Slavin J. The role of cytokines

in wound healing.J Pathology

Bacteriol1996; 178, 5-10

16. Kirshen C, Woo K, Ayello EA,

Sibbald RG. Debridement: a

vital component of wound bed

preparation.Adv Skin Wound Care

2006; 19: 50619.

17. Granick M, Boykin J, Gamelli R,

Schultz G, Tenenhaus M. Toward

a common language: surgical

wound bed preparation anddebridement. Wound Repair Regen

2006; 14(suppl): 110.

preferences for a specific mode of

treatment

n The wound and its aetiology

n The environment in which care is beingprovided, eg the facilities, equipment and

resources

n The competence of the practitioner

n The availability of particular treatment

options[14].

The debridement methods most frequently

seen in current practice are outlined below.

Surgical/sharp debridementExcision of devitalised tissue using a scalpel

or scissors[17]. This method requires skill and

competence and an awareness of the potential

for excess bleeding in certain patient groups[18].

Training in surgical/sharp debridement is

required in order to practise safely.

Mechanical debridementThis involves the use of wet to dry dressings.

The dressing adheres to the wound bed as it

dries, thus removing the top layer of tissue as

the dressing is pulled away[19]. This method

is not selective, in that healing tissue may be

removed alongside dead tissue[19].

Furthermore, it is a painful procedureand, as such, is likely to cause the patient

distress[19]. It is worth considering that

patients rate comfort above healing in the

selection of wound treatments[20]. Thus, this

method of debridement may be unacceptable

to some patients.

Autolytic debridementAutolysis is the process of removing dead

tissue from the wound using the body's

production of enzymes. These enzymes

degrade the dead tissue in the presence ofmoisture [21]. It requires moisture, thus topical

treatments that create a moist wound-dressing

interface are needed. Although this method

is selective, in that only devitalised tissue is

removed, it is slow. However, it is considered

to be relatively safe[22]. Thus, when speed

is needed, this is not the most appropriate

method to choose.

Enzymatic debridementThis involves specific enzymes being applied

to the wound bed. The enzymes, such as

collagenase, are similar to those that occur

naturally during the wound healing process.

Their primary function is to degrade the

damaged extracellular matrix[23]. In order for

wound healing to progress, damaged tissue

needs to be removed. If this does not occur,

the dead tissue acts as a barrier to cell-to-cell

migration. If cells cannot communicate witheach other, the production of new tissue, to

replace the tissue that has been lost, will be

impaired.

A systematic review by Ramundo and Gray[24]

suggests that enzymatic debridement is a

useful alternative to sharp debridement, which

carries the risk of bleeding. However, more

often, enzymatic debridement may be used in

combination with sharp technique, especially

when a series of debridement treatments is

required[24].

Larval therapyThis method involves the use of sterile

maggots from the larvae of the green bottle

fly[25]. The larvae only target devitalised tissue,

which they dissolve due to the presence

of proteolytic enzymes in their saliva. The

dissolved tissue is then used by the maggots as

a source of nutrients[26]. One survey identified

that patients were not resistant to the use of

larvae as a treatment for leg ulcers[27]. Larvae

may increase the rate of debridement of

sloughy or necrotic leg ulcers compared with

autolytic debridement, however, the methodcan be more painful[28].

Innovative developmentsThere are a number of new products focused

on wound debridement[29]. For example,

the UK's National Insti tute for Health and

Clinical Excellence (NICE) recently reviewed

a therapy known as MIST[30], which delivers

low-energy, low-intensity ultrasound to the

wound bed through a continuous saline

mist. The ultrasonic energy delivered to

the wound is thought to stimulate woundhealing, by removing devitalised tissue

and bacteria, thereby enabling the wound

to progress through the healing process.

NICE suggests that this therapy may be a

promising adjunct to current debridement

methods, potentially enhancing the healing

of complex, non-healing chronic wounds,

when compared with standard methods of

wound management[30].

Vowden and Vowden[31]recently reviewed

another addition to the debridement armoury

a pad comprising polyester fibres that loosen

devitalised tissue, while absorbing exudate and

binding debris to the dressing. This method

is preferable to mechanical debridement

because healthy tissue is not removed with the

Page Points1. Debridement plays a crucial role

in eliminating non-viable tissue

from the wound bed, aiding

wound repair

2. When selecting the most

appropriate debridement

technique, the competence of

the practitioner is central to the

decision-making process

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3/4Wounds InternationalVol 3 | Issue 2 | Wounds International 20123


dressing[32]. Furthermore, pain and discomfort are

not an issue for the patient[32]. It is an easy-to-use,

relatively quick and efficient method.

However, Vowden and Vowden[31]

suggestthat the product is more readily placed

as an adjunct to current methods of

debridement. The product may also be used

effectively for maintenance debridement,

avoiding the need for specialised

debridement techniques[31].

CLEANSINGAntiseptic cleansing is also considered to

be an important component of wound bed

preparation[33]. The purpose of this method

of cleansing is to remove bacteria and

debris from the wound the cleansing

also disrupts biofilms present on the wound

surface [34]. A biofilm is the name given to

bacteria living within an extra polymeric

substance[35]. This substance enables bacteria

to attach to the wound and assists the

bacteria in resisting invasion[35].

Though water is commonly used

for wound cleansing, more recently, it

has been suggested that non-healing

wounds may benefit from the use of more

targeted cleansing solutions[34]. One suchsolution (Prontosan; B. Braun) contains

polyhexamethylene biguanide (PHMB)

an antimicrobial agent and betaine, a

surfactant. It has been shown to be effective

in removing debris and bacteria, while

disrupting wound biofilms[34]. In this way, the

use of antiseptic cleansing contributes to the

overall goals of wound bed preparation[36).

SELECTING THE RIGHT

METHODThe competence of the practit ioner iscentral when it comes to selecting the most

appropriate method of debridement[13).

Indeed, competence is defined as the ability

to 'practise safely and effectively within

ones own scope of practice'[37]. Clearly,

each clinician has a duty to provide wound

management services in a manner that

is safe and appropriate for the individual

needs of the patient[38]. Importantly,

education provides the framework to

ensure that actions taken are justifiable and

appropriate[39].

Young[13]suggests that a number of key

factors should be considered when selecting

the most appropriate method of debridement.

References18.The Johanna Briggs Institute. Surgical and conservative sharp wound debridement for

chronic wounds. Wound Prac Resear 2011; 19: 2931.

19. Ovington LG. Hanging wet-to-dry dressings out to dry. Home Health Nurse2001; 19:111.

20. Vermeulen H, Ubbink DT, Femke de Zwar F, Goossens A, de Vos R. Preferences of

patients, doctors, and nurses regarding wound dressing characteristics: A conjoint

analysis. Wound Rep Regen 2007; 15: 30207.

21 Knig M, Vanscheidt W, Augustin M, Kapp H. Enzymatic versus autolytic debridement of

chronic leg ulcers: a prospective randomised trial.J Wound Care2005; 14: 32023.

22. Young T. Skin failure and wound debridement. Nurs Res Care2012; 14: 74.

23. Hart J. Inflammation 1: its role in the healing of acute wounds.J Wound Care 2002; 11:

20509.

24. Ramundo J, Gray M. Collagenase for enzymatic debridement: a systematic review. J

Wound, Ostomy Contin Nurs 2009; 36(suppl): 411.

25. Acton C. A Know-how guide to using larval therapy for wound debridement. Wound

Essentials2007; 2: 15659.

26. Jones J, Green J, Lillie AK. Maggots and their role in wound care. Br J Comm Nurs 2011; 16

(suppl): 2433.

27. Petherick E, O'Meara S, Spilsbur y K, Iglesias CP, Nelson EA, Torgerson DJ. Patient

acceptability of lar val therapy for leg ulcer treatment: a randomised survey to inform the

sample size calculation of a randomised trial. BMCMed Res Method2006; 6: 43.

28. Dumville J, Worthy G, Bland J, et al. Larval therapy for leg ulcers ( VenUS II): randomised

controlled trial. Br Med J2009; 338: b773.

29. Benbow M. Debridement: wound bed preparation. J Comm Nurs2011; 25: 18.

30. NICE. The MIST Therapy System for the Promotion of Wound Healing. 2011; NICE, London.

31. Vowden P, Vowden K. Introduction to Debrisoft. Br J Nurs2011; 4: 4.

32. Haemmerle G, Duelli H, Abel M, Strohal R. The wound debrider: a new monofilament

fibre technology. Br J Nurs20: S3542.33. Falanga V. Classifications for wound bed preparation and stimulation of chronic wounds.

2000; Wound Repair Regen8: 34752.


Wounds InternationalVol 3 | Issue 2 | Wounds International 20123

Page Points

1. Antiseptic cleansing is also considered to be an important component of wound bed preparation

2. The purpose of this method of cleansing is to remove bacteria and debris from the wound the cleansing

also disrupts biofilms present on the wound surface

3. Though water is commonly used for wound cleansing, more recently, it has been suggested that non-healing

wounds may benefit from the use of more targeted cleansing solutions


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Technology updateThe importance of debridement in wound bed preparation

References34. Bradbury S, Fletcher J. Prontosan made easy. Wounds International2011; Available at: http://

www.woundsinternational.com/made-easys/prontosan-made-easy (accessed 3 May, 2012).

35. Wolcott RD, Rhoads DD, Bennett ME, Wolcott BM, Gogokhia L, Costerton JW, Dowd SE.Chronic wounds and the medical biofilm paradigm. J Wound Care2010; 19: 45.

36. Chin C, Schultz G, Stacey M. Principles of wound bed preparation and their application to the

treatment of chronic wounds. 2003; Primary Intention 11: 171.

37. An Bord Altranais. The Code of Professional Conduct for Each Nurse and Midwife.2000; An Bord

Altranais, Dublin.

38. Moore Z. Bridging the theory-practice gap in pressure ulcer prevention. Br J Nurs 2010;

19(suppl): 1518.

39. Moore Z, Price PE. Nurses attitudes, behaviours and perceived barriers towards pressure ulcer

prevention.J Clin Nurs2004; 13: 94251.

40. Department of Health and Children (2008)Building a culture of patient safety, report of the

comission on patient safety and quality assurance. Stationary Office, Dublin. Available at: http://

www.dohc.ie/publications/pdf/en_patientsafety.pdf (accessed on 1/12/ 2011).

41. Young T. Wound debridement in the community setting. Br J Comm Nurs2011; 16(6 Suppl):1420.

42. Muir Gray JA. Evidence-based Health Care.2001; Churchill Livingstone, Edinburgh

These include:

n The patient's perspective practitioners

should identify areas of concern to the

patient specialist and ensure he or she isinvolved in the decision-making process

n The patients medical state it is

important to ensure that the clinician

is fully aware of the patients medical

condition so that contraindications to

treatment methods may be accounted for

n The competency of the care provider

n The environment in which care is being

provided and the ease of access to

specialist services [13].

These considerations underline the

importance of competency and of ensuring

that the safety of the patient is paramount

throughout the decision-making process[40].

Indeed, Young argues that knowledge of

issues regarding patient safety and clinical

competence are central to the provision of

effective wound management services[41].

CONCLUSIONDebridement is a key component in the wound

management trajectory and today there are a

wide variety of treatment methods available,including surgical/sharp debridement,

mechanical debridement and autolytic

debridement. Other interesting treatment

choices include larval therapy and the use of

ultrasonic energy.

Assessment of the patient and

identification of any possible

contraindications to treatments is essential.

In addition, consideration of competency,

skills and access to specialist services is

vital in ensuring that the right form of

debridement is selected. Furthermore,to ensure that a patient-centred focus is

adopted, it is the author's opinion that

the patient should be included in a ll care

planning.

Central to wound management is patient

safety. Equally important is the efficiency

and effectiveness of the treatments used. By

adhering to these points, practitioners can

make the right choice for their patients[42].

AUTHOR DETAILSZena Moore, PhD, MSc, FFNMRCSI, PG Dip,

Dip Management, RGN, is a Lecturer in wound

healing and tissue repair at the faculty of Nursing

and Midwifery, RCSI, in Dublin, Ireland

Page Points

1. Debridement is a key component in the wound management trajectory and today there are a

wide variety of treatment methods available, including surgical/sharp debridement, mechanical

debridement and autolytic debridement

2. Asse ssmen t of t he pa tient and ident ificat ion of any poss ible contrai ndica tions to trea tments

is essential

3. Central to wound management is patient safety. Equally important is the efficiency and

effectiveness of the treatments used. By adhering to these points, practitioners can make the right

choice for their patients

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