Combined debridement in chronic wounds: a ...

Accepted Manuscript Combined debridement in chronic wounds: a literature review Wan-Lin Liu, Yun-Lan Jiang, Yan-Qiao Wang, Ying-Xin Li, Yi-Xian Liu PII:

S2095-7718(17)30006-3

DOI:

10.1016/j.cnre.2017.03.003

Reference:

CNR 78

To appear in:

Chinese Nursing Research

Received Date: 15 January 2016 Revised Date:

19 April 2016

Accepted Date: 19 June 2016

Please cite this article as: Liu WL, Jiang YL, Wang YQ, Li YX, Liu YX, Combined debridement in chronic wounds: a literature review, Chinese Nursing Research (2017), doi: 10.1016/j.cnre.2017.03.003. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT *Corresponding author. E-mail address: [email protected] (W. -L. Liu). Peer review under the responsibility of Shanxi Medical Periodical Press

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Cited information: Liu WL, Jiang YL, Wang YQ, Li YX, Liu YX. Combined debridement in chronic wounds: a literature review. Chin Nurs Res. 2017; 1: xx-xx. Review article

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Combined debridement in chronic wounds: a literature review Wan-Lin Liu a, Yun-Lan Jiang b*, Yan-Qiao Wang b, Ying-Xin Li a, Yi-Xian Liu a a Nursing Department of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan 611137, China b Teaching Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan 610072, China

ARTI C LE I N FO Article history: Received 15 January 2016 Received in revised form 19 April 2016 Accepted 19 June 2016 Published 20 March 2017

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Keywords： Combined debridement Chronic wounds Review Necrotic tissue Ulcer

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ABSTRACT Wounds debridement is important for healing of chronic wounds. Combined debridement is a new technique to deal with the complex chronic wounds. This review introduces several topical methods of combined debridement according to the various color classifications. Methods include combined sharp and hydrogel debridement, combined ultrasonic and enzymatic debridement, ultrasonic debridement combined with surgical debridement and vacuum aspiration on debridement, and other types of debridement. This article also explores why each combined debridement mentioned above can achieve a good effect. 1. Introduction Chronic wounds are wounds cannot heal within 2 weeks because of the influence of such factors as infection and foreign objects. 1 Diabetic foot ulcers, pressure ulcers,

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arterial ulcers, venous ulcers and fungus-infected wounds are the primary types of the chronic ulcers. 1, 2 Chronic wounds represent a large health care burden. 3 The reasons for chronic wounds are complex. Chronic disease, vascular insufficiency, diabetes, neurologic defects, nutritional deficiency, advanced age, and local factors such as pressure, infection, and edema can all impair healing. 4 The characteristics of chronic wounds are complex too. Unlike acute necrotic wounds that are covered with a fresh moist eschar where the denatured collagen still maintains its structure, chronic wounds are often covered with dry, leather-like, thick plaques. The characteristics of the eschars are different even within one wound, therefore choosing more than one type of debridement method when dealing with a chronic wound is necessary. 5-7 Debridement is removal of necrotic tissue and foreign objects from the wound to expose the underlying viable tissue in an effort to promote and expedite wound healing. 8 It is a major component of the overall management of the wound and the patient. 9 Many types of traditional debridement methods are available such as autolytic, enzymatic, biodebridement, mechanical, conservative sharp and surgical. 10-12 In recent decades, many new types of debridement were invented such as a Versajet—kinds of fluid jet technology, ultrasound debridement therapy, hydrosurgery debridement and Monofilament polyester fiber pad debridement. 13-16 Combined debridement is a concept brought forward in 2006 17, 18 and is developing quickly. The primary purpose of combined debridement is to use more than one type of debridement method in chronic wounds in order to find the best way of dealing with different parts of eschars and their different pathological tissues. Combined debridement can take advantages of more than one type of debridement when dealing with a complex wound. 19 The purpose of this article is to review different types of combined debridement in dealing with different types of chronic wounds.

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2. Description of Chronic Wounds

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An accurate description of the tissue is important. The wound healing continuum classifies wounds appearance according to color 21 and it is seen as a practical way of guiding chronic wounds assessment and intervention. The three-color concept is used to describe the wounds (Fig. 1). Those three colors are red, yellow and black. Red wounds indicate healthy granulation tissue. The yellow signifies the inflammatory exudate and damaged tissue and black wounds are characterized by necrotic tissue, however, sometimes this is brown. In recent years, the colors pink and white have been added to this theory in order to describe wounds better. 22 As debridement mainly addresses black and yellow wounds, this review focuses on these wounds. 20

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Fig. 1. The wound continuum. 20

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3. Search Strategy

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A systematic search of two electronic databases, PubMed and CNKI, was undertaken on Dec, 2015. PubMed was searched using the MeSH search terms: combined OR hybrid AND debridement AND chronic AND wound; CNKI database was also searched using these search terms. In addition, references of all relevant papers identified from these databases were examined for any related publications. 4. Specific Methods and Reasons

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4.1. The black wounds 4.1.1. Specific methods for black wounds (Table 1) Table 1 Specific methods for black wounds. Wound

Wound

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Authors

Debridement

Debridement steps

Result

Sharp

Chose conservative sharp

The wounds

debridement and

debridement with an eye

all healed

autolytic

vascular clamp to separate hard

hydrogel

necrotic tissue from the wound

debridement

bed and cut it down with sterile

etiology

characteristics

methods

Meihong

Chronic

Dry hard black

Chen 23

pressure

crusting

ulcer

scissor first. Then used autolytic hydrogel debridement. Smeared hydrogel approximately 5 mm thick. Reuven

Burn

Both black

Combined

First applied anesthetic gel

This therapy

Gurfinkel

eschars,

dry and

ultrasonic and

(esracaine 2%). Then, used

is more rapid

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liquefied

enzymatic

combined ultrasonic and

and effective

necrotic

debridement

enzymatic debridement in flap

than either

eschars

therapy

perforation within 2 to 5 minutes

method alone

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4.1.2. Reason analysis 4.1.2.1. The reason for effectiveness of combination of sharp and autolytic debridement A black wound indicates the presence of necrotic tissue which may be hardened and is known as “eschar”. 9 For black and hard crusting wounds, using conservative sharp debridement first combined with autolytic hydrogel debridement has a good effect. The key of this combined debridement lies in “dissolve while pruning”. This method not only prevents damage to the normal tissue but also will not cause bleeding and pain while accelerating the process of debridement. Hydrogel has unique gel particles. It can increase the activity of organization, thus generate the phenomenon of both debridement and growth at the same time. Due to the removal of necrotic tissue timely, the inflammatory reaction is controlled which can help the healing of wounds. 23

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4.1.2.2. The reason for effectiveness of combination of ultrasound and enzymatic debridement Demir et al. 25 concluded that ultrasound improves wound healing, probably due to its mechanical effects. The effects of the ultrasound include heat generation, a promotion of cell proliferation, improvement of local circulation and oxygenation, wound cleansing, and inhibition of bacterial growth, all of which contribute to improved wound healing. 26 Ultrasound induces the formation of pinpoint depressions or micro channels in the tissue through which the enzymatic debridement is forced into the eschar, so this combination has better effects. 27-29 4.2. Both yellow and black color in one wound 4.2.1. Specific methods for both yellow and black color in one wound (Table 2)

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Table 2 Specific methods for both yellow and black color in one wound. Authors

Qixia Jiang

30

Wound

Wound

Debridement

Dealing steps

Result

aetiology

characteristics

methods

Chronic

According to

Combined

First used autolytic

The method of

pressure

Pressure ulcer

hydrogel

debridement method.

combined

ulcer

classification

debridement

After 2-3 days, then

debridement

31

and conservative

used the conservative

method has a

degree, both

sharp

sharp debridement

shorter time of

yellow and black

debridement

method. Hydrogel was

debridement

applied to the wounds

period than the

each time after the

single hydrogel

conservative sharp

debridement and

debridement, then

single sharps

standard

wounds

II-IV

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surgical

the hydrogel with

debridement.

moisturizing saline gauze.

Chen

23

Chronic

The wound with

Sharp

Chose autolytic

The clinical trial

pressure

yellow part and

debridement and

debridement method

shows a good

ulcer

soft black scab

autolytic

first, and then applied

effect of this type

shell part

debridement

hydrogel on the

of combined

damaged tissue directly.

debridement

It was smeared

method

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Meihong

approximately 5 mm thick, then used

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conservative sharp

debridement method to address the black scab

shell part, Lastly, select

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hydrocolloid dressings

used to cover the wound surface.

Longyuan

Chronic

Wagner

Ultrasonic

First conducted surgical

The effect of the

diabetic

classification

debridement

debridement by scalpels

combination

foot ulcer

III-IV both black

machine

to fully expose the

debridement

and yellow

combined with

wound. Then used

groups are better

wounds

surgical

ultrasonic debridement

than those of the

debridement and

machine to address the

either method

vacuum

tissue nearest to the

alone

aspiration

normal part. Lastly,

debridement

connected to the vacuum

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Han

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aspiration machine (Suction pressure：-125 mm Hg, 1 mm Hg = 0.133 KPa)

4.2.2. Result reasons analysis 4.2.2.1. The reason for effectiveness of combination of hydrogel and sharp debridement This type of wound also contains necrotic tissue in the form of slough. This may range in color from white to yellow to black. Hydrogel debridement method belongs to the category of autolytic debridement. Autolytic debridement is the gentle separation of slough and necrotic tissue from the wound bed, which occurs slowly in a moist wound environment. Hydrogel wound dressings promote autolytic debridement by rehydrating desiccated and devitalized tissue, aiding its separation from healthy tissue 4. It is not suitable for doctors to choose autolytic debridement when only dealing with black tissue because it will take a long time to finish. Yellow tissue is

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5. Conclusions

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suitable because it is softer than black tissue. A shorter debridement period is mainly caused by the “dissolve while pruning” method. For yellow wounds, this method not only has the effect of removing scab shell but also removes bacterial biofilm, reducing inflammation and controlling infection. Autolytic debridement is more suitable for shallow damaged tissue，such as pressure ulcer degree Ⅱ and degree Ⅲ, 33 so surgical debridement combined with autolytic debridement in the wounds works well. 4.2.2.2. The reason for effectiveness of combination of ultrasonic, surgical debridement and vacuum aspiration debridement The theory of ultrasonic debridement is based on transmitting a certain dose of ultrasonic waves to human tissue, creating a biological effect, and changing the organization status and functions of its components, resulting in treatment of the disease. 34 Surgical debridement is the fastest and usually most thorough method available. 20 Pressure suction can remove the damaged tissue as well as wound exudate timely and thoroughly. It also has the effect of reducing the number of bacteria, destroying the bacterial survival environment and preventing bacteria from invading deep tissue. The combined use of the two debridement methods has a better effect on wound healing and pain relief. 30 4.3. For other types of chronic wounds If the wound edges have rolled and become quiescent, the patient should be taken to the operating room for surgical wound edge debridement and a topical negative pressure (or vacuum-assisted closure) dressing subsequently applied. 4 Regarding fungus-infected wounds, palliative treatment is another choice beside curative treatment. Debridement has the effect of reducing the stench and pain. 22

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At present the choice of debridement method largely rests on each clinician’s experience; 35 therefore, an acknowledgement of the best way of dealing with different types of chronic wounds is needed. Although this review introduced the different types of combined debridement according to the different color of the wounds, debridement still requires a full assessment of both the wound and the patient by a holistic framework, identifying wound etiology and other factors that may be hindering healing, such as pain, nutrition, and anemia. 36 The color of the wounds is a basic frame of reference for choosing the method of debridement in addition to the importance of the overall assessment of the patient. Acknowledgment

The authors declare that there is no any conflict of interest relevant to this manuscript. Conflict of interest All contributing authors declare no conflicts of interest.

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