Topical Therapy: Goals, Principles, Cleansing, and Debridement

Speaker A: 00:00:10

Okay, in this class, we're going to talk about topical therapy. So we're going to begin the discussion of how you manage wounds in terms of dressing selection, infection control, when to debride, how to debride.

So, basically, we're going to talk about how you use your assessment data to construct an appropriate management plan. It's going to be divided into two sections and we're going to cover the following things.

We're going to describe the four priorities in wound management, esp plus e. We talked about this earlier.

We're going to identify situations in which wound management goals should focus on maintenance or comfort rather than healing. Well. Describe the principles of moist wound healing using the acronym Dwemapi. We'll compare guidelines for cleansing of clean and dirty wounds.

We'll describe indications and options for wound debridement to include advantages and disadvantages of each approach.

We'll describe the impact, clinical presentation and management options for each of the following wounds complicated by osteomyelitis, wounds complicated by cellulitis, wounds complicated by critical colonization or biofilm formation. We'll also describe the indications, data provided and procedural guidelines for wound culture. And we'll discuss qualitative and quantitative.

We'll explain the negative impact of closed wound edges and hypergranulation tissue and options for management. And we'll discuss management and assessment of wound related pain. So, as I said, it's going to be divided into two parts.

at relate to this content are: 4789

So in part one, we're going to talk about establishing appropriate wound management goals. We're going to talk about the principles of topical therapy. We're going to talk about wound cleansing guidelines and management of necrotic wounds.

So let's talk first about wound care priorities. We know this is ESP plus E. So number one, we want to identify etiologic factors and we want to correct those factors if at all possible.

We've already spent time discussing that in previous classes when we talked about friction damage, moisture damage, pressure injuries. We're going to spend time in future classes talking about management of lower extremity wounds and how we correct those etiologic factors.

We're going to assess the patient's ability to heal, and we're going to determine what types of systemic support are needed to promote healing. We're going to determine appropriate goals for care. Then we're going to provide principle based topical therapy.

We're going to make sure that our topical therapy is consistent with our goals of care, and we will be evaluating progress on a routine basis. So let's talk about management goals. We haven't really talked about that at all yet, but it's an important thing for you to stop and determine.

So you've done your assessment at this point, you should have a pretty good idea of the etiologic factors for the wound and whether they can be corrected.

You should have a pretty clear picture of where the patient is in terms of systemic support for healing and whether or not they have the capacity to heal the wound. Hopefully you have some information about the patient's priorities.

You know where the wound is to in the wound healing process, and so is it in the inflammatory phase, is it in the proliferative phase. This should allow you to move forward with appropriate goal development. There's three potential goals.

A comfort goal, a maintenance goal, healing goal, critical to determine your goals before you move ahead with a management plan, because your goals will have an impact on your management plan. So let's talk about a comfort goal. If your goal is comfort, it means I'm not going to focus on wound healing.

What I'm going to do is I'm going to make sure that my wound management plan is consistent with the overall goal of maximizing comfort, minimizing discomfort. This is a very appropriate goal for patients at end of life.

So if you're caring for patients in hospice or palliative care, this might be the most appropriate goal. You focus on factors that contribute to discomfort for the patient. So you try to minimize pain, you try to manage odor, you try to manage exudate.

You think about a wound management program that would reduce the frequency of dressing changes. Since dressing changes are usually a source of discomfort and pain. Now, we know that at end of life, wounds frequently deteriorate.

We also know that some goals, I mean, some wounds just remain the same and some wounds actually improve. I've talked to people who work a lot with hospice patients and they'll tell me sometimes our wounds actually heal.

For our hospice patients, it's uncommon, but it does happen. However, it's not our focus.

So if your patient's end of life, if they have defined comfort as their primary goal, that should be your goal in wound management. Another potential goal is maintenance. Maintenance goals are appropriate when you cannot correct the underlying pathology.

So what if you have a patient with diabetes, longstanding diabetes, known lower extremity arterial disease, and an ischemic wound involving the lower extremity or the foot. What if vascular has already done a workup and they've said, we cannot bypass the obstructed artery, we can't stent it?

There's nothing that can be done to improve perfusion. This wound is not going to heal. We've talked to the patient about amputation. The patient does not want amputation.

They want to do everything possible to maintain their leg and their foot for as long as possible. Okay, in that case, we would establish a maintenance goal, and our goal would be to minimize pain, prevent infection, prevent deterioration.

We're not trying to get it to heal. We're just trying to maintain stable state. So that's an appropriate goal for situations in which we cannot correct the underlying etiologic factors.

It's also an appropriate goal if you have patients for whom you cannot provide adequate systemic support.

What if I have a patient who is no longer eating because of dementia, advanced dementia, and the patient had told the family they do not want tube feedings. So the family is adhering to their wishes. They are not providing tube feedings.

We know if we cannot provide nutritional support, the wound is not going to heal. So in that situation, it would be appropriate to establish a maintenance goal rather than a healing goal.

If you have a heel ulcer in a bed bound patient and that wound is covered with dry eschar, but it's uninfected, so it's not affecting the patient's health status, and it's not affecting their functional status, you might very well establish a maintenance goal. It's not critical to get that wound to heal. You just want to prevent deterioration. You want to prevent infection.

So if you're unable to correct the underlying pathology, either because it's uncorrectable or because it involves something the patient's not ready to do, like consistent offloading of a neuropathic wound or staying out of the wheelchair to heal an issue. A wound. A maintenance goal is appropriate. If you cannot provide systemic support, for whatever reason, a maintenance goal is appropriate.

And if you have a necrotic, uninfected heel ulcer in a bed bound patient, maintenance goal is appropriate. In all other situations, your goal is healing.

So if etiologic factors can be corrected and the patient is on board with the management plan, if systemic support can be provided, your goal is healing. So let's talk about what a topical therapy program can do, should do and what it involves.

The goal of topical therapy is to create a local environment that supports repair. So, number one, you want to eliminate known impediments to healing. So put yourself in the fibroblast shoes. So you're a fibroblast.

You're charged with promoting granulation tissue, producing granulation tissue to help heal this wound. What things would get in your way? Well, the first thing you would probably say to us is clear out all that dead tissue.

How can I work in here with all this dead tissue? It gets in the way, it smells bad. It maintains the wound in a continual inflammatory state. I can't work in these conditions.

So number one, we need to eliminate necrotic tissue, establish a clean wound bed that supports the repair process. What about high levels of bacteria? They also perpetuate an inflammatory state that delays the repair process. They get in the way of wound healing.

They get in the way of granulation tissue formation, because when you have very high bacterial loads, those bacteria compete with fibroblasts for nutrients and oxygen. They actively degrade growth factors and they can actively degrade newly formed collagen fibers. So you have to eliminate necrotic tissue.

You have to control your bacterial loads. You want to manage your exudate. If you were a fibroblast, you would not want to go to work in swamp like conditions.

So you do not want pooled exudate in the wound. What happens when exudate is allowed to pool within the wound bed? Well, first of all, it's a wonderful medium for bacterial growth.

So when you have pooled exudate, you're probably going to end up with high bacterial loads and a persistent inflammatory state.

In addition, high levels of exudate at the wound surface cause maceration of the cells within the wound bed and maceration and possible breakdown of the periwound skin. So you're trying to create a clean wound surface where bacteria are controlled. You want to manage your exudate.

And finally, remember that once the wound fills with granulation tissue, in order to get epithelial resurfacing, you have to have open wound edges.

So things to address eliminate necrotic tissue, manage bacterial loads, manage your exudate, monitor your wound edges, and make sure that the wound edges are open when the wound is ready to resurface. What type of environment promotes healing? Promotes fibroblast activity? A wound surface that is clean, moist and protected.

So that's always what we're aiming for. Now, there's a little acronym that we have developed to help you remember the key principles of topical therapy.

It's dwimify, and it doesn't stand for anything except. Except every letter reminds you of a critical principle.

So d reminds you that if your goal is healing and the wound is necrotic, you must begin by debriding that necrotic tissue.

I remind you to actively assess for any evidence of infection and to treat that infection to get bacterial loads under control so that you can establish a clean wound bed that promotes repair. W reminds you to wick fluid from tunneled or undermined areas.

Now, this is particularly important when you have areas that are tunneled, and especially if those tunnels are narrow. So you think, what can happen when you have narrow tunnels? You can get wound fluid that's trapped in the tunnel.

If you do not effectively wick the fluid from the tunnel into the wound bede, that fluid can get trapped and it can later on cause abscess formation.

The other thing is you want to make sure that the wound does not close off that tunnel, that you don't have granulation tissue forming, closing over the tunnel and leaving that fluid trapped in the tissues.

So when you have tunneled areas, you want to make sure that you select a wicking dressing that goes up into the tunnel, that keeps the tunnel open, and that wicks fluid out of the tunnel into the wound bed. Always you want to absorb excess exudate. You want to eliminate any pooled drainage within the wound bed.

But at the same time, you want to keep the wound surface clean and moist. Remember that a moist wound surface helps to maintain cell viability, helps to promote cell migration.

Remember, winter's work and subsequent researchers have shown in multiple studies that a moist wound surface promotes the repair process. A dry wound surface causes cell death.

You want to make sure that your wound edges are open, especially as the wound fills with granulation tissue and approaches readiness for resurfacing. You're a wound care clinician, so you want to protect the healing wound, protect it from trauma, protect it from contamination.

And as much as possible, you want to insulate the healing wound, because wounds heal faster if they're kept warm as well as clean. So you think about yourself. If you're freezing cold, you're not very focused on what it is you're supposed to do. You're just trying to get warm.

Same thing with those little fibroblasts. If the wound surface is cold, the fibroblasts are just trying to get warm. They're not focused on collagen synthesis.

So if you can warm your cleansing solutions before you clean the wound, that would be helpful.

Also helpful to reduce the frequency of dressing changes, because every time we do a dressing change, irrigate the wound expose the wound to the air, we drop the surface temperature, and then it takes several hours for it to return to baseline, to optimal temperature, and to optimal cellular activity. So do everything you can to keep the wound bed clean, moist, protected and warm.

Now, if we are managing a wound correctly, so we've looked at the wound critically. We have identified that, yes, the etiologic factors can be corrected. Yes, this patient has the systemic ability to heal the wound.

And I've implemented a topical therapy program that maintains a clean, moist, warm, protected wound bed. I should see consistent progress toward healing.

If the wound's in the inflammatory stage, I should see steady progress toward establishment of a clean wound bede. If the wound's in the proliferative stage, I should see it filling with granulation tissue and eventually covering with new epithelium.

I know that I have a problem if I see no measurable progress for two consecutive weeks or I see sudden deterioration. So failure to progress or sudden deterioration should prompt me to totally reevaluate my management plan.

Have I accurately identified etiologic factors, and are we consistently implementing measures to correct those etiologic factors? Are we providing consistent systemic support, nutritional support, glycemic control, support for perfusion?

Is my topical therapy appropriate, or do I need to relook at that? A lot of times, people assume that the problem resulting in failure to heal has to do with the dressing selection.

So they'll move from dressing a to b to c, when, in fact, that is not the reason for failure to heal. So if you see failure to progress or sudden deterioration, step back, relook at your whole plan. When should you change topical therapy?

Anytime there's a significant change in wound depth or volume of exudate, you should change therapy. And if there is a change in your goals.

So if you've been focused on debridement and now you have a clean wound bed, now you want to shift your focus and topical therapy to support for granulation tissue formation. So let's start with wound cleansing. That's how we start with wound care.

So we go in, we take off the old dressing, we assess the wound, we determine, is it progressing? Is it not progressing? Is there evidence of an issue I need to address? And then we move ahead with wound cleansing.

Now, wound cleansing guidelines for acute wounds, traumatic wounds. Cleansing guidelines for clean wounds and cleansing guidelines for dirty wounds are different.

So we're going to look at three different types of wounds. The first wound type we're going to look at is your acute traumatic wound.

That would be like a laceration or any wound where there is the potential for a retained foreign body. So if you have a patient with a diabetic foot ulcer, it's on the plantar surface. They don't know when it started, how it started.

You should probably x ray to rule out a foreign body. Many times, patients have things in their feet they know nothing about. So we see a needle on x ray, and they're like, oh, I wondered where that went.

So with a diabetic foot ulcer, unclear onset, you need to do an x ray. If there's any wound where you're concerned about a retained foreign body, do an x ray.

When you have an acute traumatic wound, like a laceration, you want to do thorough initial cleansing. You need to remove all debris. You want to reduce bacterial loads as much as possible.

So you think about a patient who comes in with the laceration, what caused the cut, how dirty is that wound? I. You think about a patient who comes in with road rash. They get drug along the pavement.

We've got to remove all of the debris, all of the gravel, all of the dirt. So typically, we'll do topical lidocaine, allow it to take effect so that we can cleanse the wound thoroughly.

You want to use a wound cleanser and a soft sponge.

So instead of using abrasive gauze, it's very helpful to use this soft topper type sponges or a soft surgical sponge to cleanse the wound to remove any debris without causing additional trauma to the wound bag. The other alternative is to use pulse lavage.

So if you have that as an option in your agency, and we'll talk a little bit more about pulse lavage later.

But, you know, basically what it is is either saline or an antiseptic solution delivered to the wound bed under pressure so that it forcefully irrigates the wound bed, and it's accompanied by suction. So you're irrigating and then sucking back. It's very much like cleaning your carpet.

So when you have a carpet cleaner and you're, like, propelling fluid into the carpet and then sucking it back, that's what pulse lavage is like. So you're actively lifting and removing debris and bacteria from the wound surface.

So anytime you have an acute traumatic wound with potential for foreign bodies, anytime you have a diabetic ulcer and you're concerned about foreign bodies, determine whether an x ray is needed.

Do thorough cleansing, topical lidocaine, if indicated, a soft sponge, but thorough cleansing, because you've got to remove all of the debris, any foreign bodies.

If that patient has not had tetanus prophylaxis in the last five to ten years, then you're probably going to need to assure that they receive tetanus prophylaxis if they have sustained a traumatic wound, a laceration, anything that involves foreign bodies. What about clean wounds? So most of the wounds you care for will be chronic wounds.

So they'll be your dehist incisions, your pressure wounds, your venous wounds, your neuropathic wounds.

And if your wound looks very much like the wound on the top slide, where it's filled with granulation tissue and the entire wound bed is clean, then you want to do very gentle flushing with a non cytotoxic solution, like saline or a commercial wound cleanser. You don't want to do anything aggressive, because everything that's going on on the wound surface is what you want. You've got active granulation.

Do you want to aggressively remove newly formed collagen fibers? No. Do you want to flush away as many fibroblasts as possible? No. So all you're trying to do is remove excess exudate and maintain a clean surface.

So you flush or you blot, and you use non cytotoxic solutions. It is okay if you have a patient with, like, a dehised wound, they can get in the shower and they can stand with their back to the shower.

And the last thing before they get out, they can allow the shower water to just run over the wound and flush out exudate and bacteria. What about dirty wounds, wounds that are infected? So look at the wound on the bottom. You can see that there's evidence of cellulitis.

You can see there's a lot of loose slough in the wound. You might see large volumes of exudate.

So now I want to remove as much of the slough as possible, as many of the bacteria as possible, as much of the exudate as possible. So here's where you want to use forceful irrigation, but you have to pay attention to the amount of force.

Current recommendations are eight to 15 pounds per square inch. That's enough force to eliminate exudate, reduce bacterial loads, but not so much force that you'll be driving bacteria into the surrounding tissue.

So irrigate with eight to 15 pounds per square inch when you have a dirty wound.

And a lot of your commercial products now come in spray bottles, and you can turn the nozzle to a level that will give you eight to 15 pounds per square inch irrigation force. Now, obviously, you will need personal or protective equipment you'll probably need a gown, and you'll need a mask.

What about using antiseptics for cleansing?

So there haven't been a lot of studies on this, but it certainly makes sense that when you have a dirty wound, you might want to use an antiseptic product for cleansing the wound, because then in addition to mechanically cleansing the wound, you'll be killing some of the bacteria. Also, many times with dirty wounds, we use antiseptic solutions to soak galls and to pack the wound.

That's actually our dressing, but we'll come back to that. Right now, we're just talking about cleansing. So can antiseptics be used for cleansing?

Yes, and that might be helpful in establishing a clean wound bed. So dacins or acetic acid. What about hydrogen peroxide? You have to be really careful in using hydrogen peroxide because, you know, it's effervescent.

That's why we tend to like it. But, you know, it forms air bubbles.

So you never use it for forceful irrigation because you don't want to run even the slightest risk of an air embolus. So you can use peroxide to gently flush a dirty wound.

You just don't use it for forceful irrigation, you don't use it for packing, and you don't use it for clean wounds because it can ulcerate new granulation tissue. So we've talked about wound cleansing. Before you go to clean a wound, you stop and think, is this a traumatic wound?

Do I have to worry about a foreign body? Do I have to worry about removing all debris? Is it a clean wound? I want to be very gentle. I want to use non cytotoxic solutions. Is it a dirty wound?

Then I want to use forceful irrigation. Remove as much of the exudate, as many of the bacteria, as much of the soft slough as I can. Okay, so now let's move ahead to wound management.

So remember, our first thing on d with my thigh was d, should I debride this wound? So if you have a necrotic wound, you have two important questions to ask and to answer. The first question is, should this wound be debrided?

And if the answer is yes, the second question is, if so, what is the best approach to debridement of this wound? So we know that there are multiple approaches to debridement.

If you look at broad categories, you've either got instrumental debridement, which could be surgical or conservative, sharp wound debridement, and you've got non instrumental debridement options, which would include enzymatic, autolytic, chemical, and larval. We'll talk about each of those. So, question number one. Should I debride this wound? There are three situations in which the answer is yes.

So if you say yes to any one of these, the wound should be debrided. So you should debride if your goal is healing. You know that necrotic tissue delays the repair process.

So if your goal is healing, yes, you should definitely move ahead with removal of the necrotic tissue. What if your goal is maintenance or comfort? But you're dealing with a wound that is already open. So look at this wound.

It's maybe 70% necrotic tissue, maybe 75, 80% necrotic tissue. Maybe your goal is maintenance or comfort if this patient is end of life, but this wound is open.

So you ask yourself, what is to be gained by leaving necrotic tissue in an open wound? And the answer is, there's nothing to be gained.

If you leave necrotic tissue in an open wound, it increases the risk of infection, which increases the risk of pain and sepsis. So, yes, you should debride if your goal is healing, yes, you should debride if the wound is open.

And you should debride if the wound is clinically infected, even if your goal is comfort or maintenance, because infected wounds increase pain, increase odor. So if your wound is clinically infected, you should initiate measures to eliminate the necrotic tissue.

You want to think about the relationship between dead tissue, necrotic tissue, and bacteria, that dead tissue is a lifeline for the bacteria. It's like an all you can eat diner that's open 24/7 with no charges, right? Dead tissue feeds bacteria.

So if you have a clinically infected wound causing pain and odor, you want to use some approach to debridement to break down that necrotic tissue, to reduce bacterial loads, to improve comfort, and to reduce odor. So you always ask yourself, should I debride? If your goal is healing, yes. If the wound is open, yes. If the wound is clinically infected, yes.

If you answer yes to any of those, you move ahead with debridement. When should you leave a wound alone? When is it not a good idea to debride a wound? So, in this case, the wound has to meet all of these criteria.

If your goal is comfort or maintenance and the wound is closed and sealed and protected by the necrotic tissue, there is no drainage or seepage, and there are no signs of clinical infection, then you can leave it alone. But it has to meet all of those criteria, your goal is comfort or maintenance. The wound is closed and sealed.

No drainage, no seepage, and the wound is not clinically infected, then it's very safe and very appropriate to leave that necrotic tissue alone. Think about a dry, necrotic, uninfected heel ulcer in a bed bound patient. Okay. In this case, it's creating no functional issues, no health issues.

If I try to debride that wound and I remove the eschar now I have an open wound on the heel. We know that that tissue is poorly perfused. We know it's going to be very difficult to get that wound to heal.

So, essentially, we've taken a dry, protected, uninfected wound, turned it into an open, vulnerable wound where infection is very likely. So, yes, if your goal is healing, yes. If the wound is open, yes. If the wound is clinically infected, no.

If your goal is comfort or maintenance and the wound is dry, sealed, protected, and there are no signs of infection, you want to be very clear about indications and contraindications. These are decisions you'll make probably every week in clinical practice.

Okay, so let's say that you decided, yes, we should debride this wound because our goal is healing. Because the wound is already open. Because the wound is clinically infected. Now, let's talk about our options.

So we have our instrumental options, which include surgical or conservative sharp debridement, and we have our non instrumental options. What's the advantage of surgical debridement?

Well, first of all, if we do surgical debridement, the surgeon is going to take the patient to the operating room. So under very controlled conditions, the surgeon will excise all of the necrotic tissue.

So it's definitely the fastest way to debride and the most controlled environment. Also, if the surgeon does excisional debridement, excises, the necrotic tissue goes down to healthy, well vascularized tissue. There will be bleeding.

If there's bleeding, there will be clotting. If there's clotting, there will be release of growth factors. Now, you have growth factors on the ground in the wound, directing the repair process.

That's a huge potential advantage. So it's a great option for wounds with large amounts of necrotic tissue. It's a great option for wounds with bone or joint involvement.

So many times, if you have patients with diabetic foot ulcers, surgical debridement is the preferred approach. If you have trunk wounds with extensive necrotic tissue, surgical is frequently the preferred approach. If the patient is a surgical candidate.

So that brings us to the next bullet point. You do have to consider the potential risk associated with anesthesia and surgery.

So sometimes you would like for the wound to be surgically debrided, but the patient's a very poor candidate. They're high risk, and the surgeon will say, no way we're taking that patient to surgery. Look at your other options.

So let's look at conservative sharp wound debridement. This is something that most of you will be covered to do in your own state.

Now, you always do want to check your state nurse practice act to make sure that as a wound care nurse, you are covered to do conservative sharp wound deprecment. What does that mean? It means that you're removing loose avascular tissue, dead tissue, at the bedside with sterile instruments.

It's usually a very good option when you have loose necrotic tissue in an uninfected wound, and it can tremendously accelerate the rate at which you establish a clean wound bede. Now, obviously, you have to be qualified, so you have to go through clinical instruction. We'll do that during bridge week.

You have to be aware of what your state nurse practice act says, and your facility policies and procedures have to identify you as a clinician who's covered to do conservative sharp wound debridement. You'll also need a physician order, unless you're advanced practice or you're covered by established protocols.

And most of the time, you'll end up using conservative sharp wound debridement in conjunction with other approaches. So, in other words, maybe every day I'm applying an enzymatic ointment, or maybe every day I'm applying day concoction galls.

But once a week, I come back and reassess and determine what can be removed instrumentally at this point.

So if I'm going to do conservative sharp wound debridement, critical for me to do a very thorough pre procedural assessment to make sure this patient is a good candidate for conservative, sharp debridement. First of all, I want to rule out any contraindications, general contraindications.

We've already covered a dry, closed, uninfected wound when the goal is comfort or maintenance. But there are some contraindications that are specific to conservative shark debridement. Maybe, you know, you want to debride the wound.

Maybe conservative sharp debridement is not a good option. What if the eschar is very adherent to the wound bed? That's what you see on the bottom in that case, you cannot see where you're cutting.

You would be cutting blind.

You would be high risk for vascular access, which has a whole set of negatives, so you would never go to the bedside with a scalpel and start to debride.

If you had adherent asthma, you would instead begin with dakins or an enzyme or whatever to soften and loosen the eschar, and then once it starts to separate from the underlying wound bed, now you can get out your instruments and start to trim the loosened avascular tissue. You don't want to do instrumental debridement at the bedside if the patient has clotting disorders and is high risk for bleeding.

The only time in which you would think about instrumental debridement is if you have a large mass of soft avascular tissue that you can easily pull away from the wound bed. You can cut away with absolutely no risk of vascular access.

Also, you typically would not do instrumental debridement if you have systemic or soft tissue infection, because anytime you do instrumental debridement, there is a slight risk of vascular access.

And if you have a patient with localized infection and you inadvertently access the bloodstream, you nick a vessel, then you're going to get a bacteremia, and that patient may not be able to handle that bacteremia if their immune status is challenged. There have been situations where surgeons took patients to the operating room and debrided necrotic tissue in the presence of infection.

In the presence of cellulitis, for some of those patients, has resulted in sepsis and death. So, clotting abnormalities, a contraindication, cellulitis, a contraindication. General sepsis, a contraindication.

And adherent eschar, contraindication.

Now, again, if you had very loose avascular tissue and you could easily separate it from the wound bed, cut it away, you could safely do that even in the presence of infection. But you would never proceed to debride partially or fully adhere an eschar until infection was resolved.

Clotting abnormalities were resolved, and you had softened and separated the eschar enough to be able to see where you were going. What are the critical skills for safe performance of conservative, sharp wound debridement? Well, we're going to address this during bridge week.

Basically, it's critically important for you to be able to identify the structures in the wound bed. So you need to be able to differentiate slough tendons, slough, and ligaments. So you need to know what it is you're looking at in the wound bed.

If you have any doubt about what you're seeing, you're going to stop. You need to be able to establish a plain of dissection that allows you to take non viable tissue off of viable tissue.

Again, we'll address that during bridge week, the procedure itself. You're going to prep the wound with an antiseptic. You're going to follow your safety guidelines. You're going to use sterile instruments.

You're going to hold the avascular tissue away from the wound surface so you can see where you're cutting, and you're going to remove as much avascular tissue as you can safely. Then you'll flush the wound thoroughly.

Okay, well, let's say you've determined that, yes, this wound needs to be debrided, but the patient is not a candidate for surgical debridement.

And you don't feel comfortable doing conservative, sharp wound debridement because of infectious complications, because of bleeding abnormalities, or because the eschar is still too adherent to the wound bed. So in this case, you're going to move to non instrumental debridement. So anytime you need to debride surgical debridement, not an option.

Conservative, sharp wound debridement, not a good option. You're going to use one of your non instrumental approaches as a category.

Non instrumental debridement is slower because you're breaking the necrotic tissue down gradually instead of just cutting it away many times. You are using non instrumental approaches in conjunction with instrumental debridement.

As we said, you might be doing non instrumental debridement every day, enzymatic, autolytic chemical, and then instrumental debridement once a week. The specific options that we're going to talk about are enzymatic chemical, autolytic hydrotherapy, larval therapy, and ultrasonic.

So what about enzymatic? I am betting that all of you have access to collagenase or Santill. That's the one enzymatic ointment on the market.

So on the positive side, on the pro side, enzymatic agents are selective. They target only dead tissue, and they will not damage good tissue. On the negative side, enzymatic agents are very, very slow.

Also, look at the last bullet point. They're very costly.

So in many settings, wound care clinicians are being asked to use enzymatic debridement very selectively to be very clear that that's the best option for that patient. If you are going to use enzymatic debridement, these are the guidelines you should follow. These are the manufacturer's recommendations.

You're going to apply the enzyme in a nickel thick layer that gives you 24 hours of activity. You're going to cover it with moist galls so that you maintain a moist wound surface. You're going to apply the enzymatic daily.

You're going to be very careful in selecting the dressing that goes over the enzymatic. You're going to avoid iodine because it inactivates the enzyme. You're going to be aware of silver dressings that are contraindicated as well.

So some silver dressings are safe, some are not. You have to use manufacturer's guidelines. It is safe to use an enzymatic in conjunction with a Dakins type solution.

So the manufacturer has stated, yes, you can use enzymatic and dakins. You can use enzymatic in combination with your pigmented antimicrobial dressings, your hydrophoblu type dressings.

The other thing you have to think about if you're using enzymatic, you should cross hatch dry Eschar or thick slough so that the enzyme can penetrate to a moist tissue layer where it will be more active and more effective. What about autolytic? What is autolytic? Break it down. Auto. Do it myself. Lytic breaks down necrotic tissue.

So it's using the body's own white blood cells to debride the necrotic tissue. Here's what you have to think about. The active agent in autolytic debridement is the white blood cell.

So you have to have adequate numbers of white blood cells. You have to have adequate perfusion so that you can get the white blood cells to the wound bed.

So if you have a poorly perfused wound bed, autolytic is not a good choice. If you have a neutropenic patient, low levels of white blood cells, autolytic is not a good choice.

And remember that if you have very poorly controlled diabetes with high glucose levels, your white blood cells become much less active. So autolytic might not be a great choice in a poorly controlled diabetic. When is autolytic usually a good option? Look at the wound on top.

You still have some necrotic tissue, but the wound bed is primarily viable. Maybe 40 45% is slough okay. Autolytic would be very appropriate in that situation.

So you could select a dressing that maintained a moist, protected wound surface and allow the white blood cells to continue to break down the necrotic tissue.

It can also be very effective if you have dry adherent eschar, you can put on a dressing that traps wound fluid and creates a moist wound surface that will help to soften the eschar. And then the white blood cells can help to separate the eschar from the underlying tissue.

What dressing should you use if you're going to do autolytic debridement?

Well, the nice thing is that you can use the dressing that is most appropriate for the volume of exudate, because all you have to do for autolytic debridement is make sure you have enough white blood cells. Make sure the white blood cells can get to the wound bed and can function normally, and then maintain a moist wound surface.

So if you have a very wet wound, you might use an alginate. We'll talk about this more under dressing selection. You might use something like aqua cell. If you have aquacel, you might use damp gauze.

If you have a dry wound, you might use some kind of gel dressing so that you're adding moisture to the wound bed. You might use something like oxide or tegaderm, a transparent film that traps moisture.

So your goal always is to create a layer of moisture, a layer of fluid at the wound surface. That layer of fluid promotes white blood cell migration, which promotes autolytic debridement. What about chemical debridement?

So what do we mean when we say chemical debridement? Chemical debridement uses dilute bleach solutions. So this is like Dakin solution, chlorpactin, Bosch, antisept purosin.

We have a lot of these available to us. These solutions as a category.

So all of your dilute bleach and related solutions, they have the capacity to break down necrotic tissue, to kill bacteria, and to eliminate odor. So they're very commonly used for management of dirty wounds.

We have the best level of evidence for their ability to kill bacteria and eliminate odor. Our data about their ability to break down necrotic tissue is heavily anecdotal.

But in general, these solutions are considered to be a good approach for wounds that are necrotic and infected. One good thing is they're relatively inexpensive.

One bad thing is that you have to change the dressing every twelve to 24 hours depending on the specific agent you're using. So with daikins, you get peak effectiveness between eight and 10 hours. So you need to be changing the dressing every 12 hours.

With foch, with antisept, you can change it every 24 hours. So that would be much easier on the caregiver or the nursing staff.

In general, you should discontinue use of chemical debridement agents once you establish a clean wound bed, and it's critical to pay attention to concentrations.

.: 0125

That's a commercially available daikin solution that has already been diluted and that is delivered in an opaque container so that it will protect that bleach product from exposure to light. Antisept is commercially available as a gel or as a solution solution. It comes in an opaque container.

It's already been diluted, so you get it in the form that you need it. So look at what's available in your agency, identify any gaps in your formulary, and move to fill those gaps. What about hydrotherapy?

Well, we used to do a lot of whirlpool. We hardly ever do whirlpool anymore due to concerns about infection control.

Hydrotherapy is not a primary debriding agent, but it can be used to soften and loosen necrotic tissue. Pulse lavage can be used to help eliminate loose slough from the wound bed.

If you're using pulse lavage, remember we said it's very much like a carpet cleaning system where you're delivering fluid to the wound bed under pressure and sucking it back. So you're loosening necrotic tissue, pulling it out, loosening and removing.

So you would definitely need personal protective equipment to protect you against any aerosolized bacteria. So you would need mask and hood and gown.

Typically, we only provide pulse lavage to patients in private rooms so that we don't put anyone else at room. And you want to make sure you use safe levels of pressure, which is less than 15 pounds per square inch.

The other thing in thinking about using pulse lavage, it's not recommended for wounds with exposed blood vessels. It's too harsh. There's too much risk that you could cause damage to the blood vessels. It's not recommended for graft sites.

And if your patient's anticoagulated, you start low and go slow and monitor for bleeding. Now, the last few types that we're going to talk about are not as commonly used. I'm just going to mention them so you know they're out there.

So what about ultrasonic debridement? So this is use of either an ultrasound powered saline mist, or it's a little contact wand that you move across the wound surface.

So some of them use the ultrasound powered mist, and some of them literally deliver the ultrasound to the wound surface.

The goal of ultrasonic debridement, what it does very well is it helps to remove thin layers of slough, it helps to remove fibrinous exudate, and it reduces bacterial loads of. But it requires specialized equipment. It's much more expensive than the other commonly used methods. So that's why I said it's not used as widely.

If you're in a wound clinic and you have access to this, you definitely want to use it. When it's indicated, patients will tell you that it's less painful than other approaches, such as instrumental debridement.

Now, we said there are two types of ultrasonic debridement, contact and non contact.

You have a wand that you move right over the wound surface, where you have that layer of adherent film, where you have ultra, where you have slough, and the ultrasonic waves break down the slough, break it up so you can then flush it out. Non contact, the mist may be effective with loose avascular tissue, is less effective with adherent slough or adherent biofilm.

What about wet to dry galls? We used to do that all the time. We would put galls in the wound wet, allow it to dry, and then remove it.

No longer recommended because when you allow the gauze to dry and then you rip it out, you cause a lot of tissue trauma. You rip out good tissue as well as the bad tissue, and it's very painful.

So now the recommendations are, instead of wet to dry, use moist to moist, put the gauze in moist, moisten it before you remove it. That doesn't do mechanical debridement, but it does support autolytic debridement.

Now, one thing that is a newcomer to the world of debridement options are the debriding sponges and swabs. So you see those on top. So the major two manufacturers are Deborah Soft Debrisoft and Debra Mitt.

They look like they're just very soft sponges or very soft wands, but actually those are filaments. And the filaments can cut through slough, cut through that layer of adherent film and help to clean up a wound bed.

Also very effective at removing dried hyperkeratotic skin from the peri wound.

So if you have access to those debriding swabs, to those debriding mitts, you're going to moisten them with saline, use a light buffing motion against the wound bed, or moisten your swab. And do this to remove thin layers of slough with minimal pain to the patient.

So patients tell us that was not nearly as uncomfortable as when you tried to cut away. Not nearly as uncomfortable as when you used gauze to scrub the wound. So, usually effective and usually cause minimal pain to the patient.

So if you get the opportunity to evaluate those products, you want to do so. What about maggots? Is anyone using maggots for debridement? So this is now known as larval therapy or MDT. Maggot debridement therapy.

So what do we know about maggots? They were used way back when. And why were they used? Because they have a great appreciation for dead tissue.

They will break down in just necrotic tissue. They will not touch viable tissue. So they're very, very selective.

And a number of wound care centers are now using maggots for debridement of complex, difficult wounds.

They are available in two forms, so they're available free range, meaning that you get them in a little vial and you literally put the maggots in the wound bed. If you do that, you have to construct a retention dressing to keep the maggots in the wound bed.

So most centers are now using the contained dressing approach, where you get a little sachet that looks like a teabag and it's filled with maggots.

And so you put the appropriate number of sachets across the wound bed, and then you don't have to worry about, oh, some of the maggots got loose because that freaks people out when that happens. So free range or contained? The trend is to use contained. What will you get from maggot therapy?

You'll get pretty rapid debridement and totally selective debridement. For most wounds, it takes only one to two applications of the maggots. And as a side benefit, you get antimicrobial effects.

So I call that maggot magic. They ingest necrotic tissue and they secrete antimicrobial compounds. Pretty impressive, really. We definitely need more data.

We don't have a lot of controlled studies, but early data suggests that, yes, you can use medical grade maggots very safely to debride complex wounds. So, in summary, topical therapy goals you have to determine, are you trying to promote healing? Are you trying to maintain wound status?

Are you trying to maintain comfort? If you're trying to promote healing, what you want to do is create a local environment that supports the repair process.

So that means you want to eliminate necrotic tissue. You want to control your bacterial loads. You want to manage your exudate. You want to keep your wound surface clean, warm, moist, and protective.

You want to provide different cleansing approaches for clean wounds and dirty wounds and traumatic wounds. Clean wounds. You do gentle flushing, non cytotoxic solutions.

Dirty wounds, you do aggressive irrigation, typically eight to 15 pounds per square inch, and you might use antiseptics if it's a traumatic wound. If you're worried about a particular retained foreign body, you're going to do x ray.

You're going to use soft sponges, but thorough cleansing to eliminate all foreign bodies, all debris. And then the last thing we talked about is the d for D. Wamapi. When to debride anytime.

Your goal is healing, anytime the wound is already open, anytime the wound is infected, and then how to debride. You have instrumental approaches, surgical and conservative, sharp.

And you have non instrumental approaches, enzymatic, autolytic, chemical, hydrotherapy, ultrasonic and maggot debridement therapy. So you want to know the advantages and disadvantages of each approach available to you so you can select the best one for your patient.