Combined debridement in chronic wounds:A literature review

Wn-Lin Liu,Yun-Ln Jing,Yn-Qio Wng,Ying-Xin Li,Yi-Xin Liu

aNursing Department,Chengdu University of Traditional Chinese Medicine,Chengdu,Sichuan 611137,China

bTeaching Hospital,Chengdu University of Traditional Chinese Medicine,Chengdu,Sichuan 610072,China

Combined debridement in chronic wounds:A literature review

Wan-Lin Liua,Yun-Lan Jiangb,*,Yan-Qiao Wangb,Ying-Xin Lia,Yi-Xian Liua

aNursing Department,Chengdu University of Traditional Chinese Medicine,Chengdu,Sichuan 611137,China

bTeaching Hospital,Chengdu University of Traditional Chinese Medicine,Chengdu,Sichuan 610072,China

a r t i c l e i n f o

Article history:

Combined debridement

Chronic wounds

Review

Necrotic tissue

Ulcer

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 classi fi cations.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.

?2017 Shanxi Medical Periodical Press.Publishing services by Elsevier B.V.This is an open access article under the CC BY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1.Introduction

Chronic wounds are wounds that cannot heal within 2 weeks because of the in fluence of such factors as infection and foreign objects.1Diabetic footulcers,pressure ulcers,arterialulcers,venous ulcers and fungus-infected wounds are the primary types of the chronic ulcers.1,2Chronic wounds represent a large health care burden.3The reasons for chronic wounds are complex.Chronic disease,vascular insuf fi ciency,diabetes,neurologic defects,nutritionalde fi ciency,advanced age,and localfactors such as pressure, infection,and edema can allimpair healing.4The 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.5e7

Debridement is removal of necrotic tissue and foreign objects from the wound to expose the underlying viable tissue in an effortto promote and expedite wound healing.8It is a major component of the overallmanagementofthe wound and the patient.9Many types of traditionaldebridement methods are available such as autolytic, enzymatic,biodebridement,mechanical,conservative sharp and surgical.10e12In recent decades,many new types of debridement were invented such as a Versajet d kinds of fluid jet technology, ultrasound debridement therapy,hydrosurgery debridement and Mono fi lament polyester fi ber pad debridement.13e16

Combined debridement is a concept brought forward in 200617,18and 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 fi nd the best way of dealing with different parts of eschars and their different pathological tissues.Combined debridementcan take advantages ofmore 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.

2.Description of chronic wounds

An accurate description of the tissue is important.The wound healing continuum20classi fi es wounds appearance according to color21and 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 signi fi es the in flammatory 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 beenadded to this theory in order to describe wounds better.22As debridement mainly addresses black and yellow wounds,this review focuses on these wounds.

Fig.1.The wound continuum.20

3.Search strategy

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;CNKIdatabase was also searched using these search terms.In addition,references of all relevant papers identi fi ed from these databases were examined for any related publications.

4.Speci fi c methods and reasons

4.1.The black wounds

4.1.1.Speci fi c methods for black wounds See Table 1.

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”.9For black and hard crusting wounds,using conservative sharp debridement fi rst combined with autolytic hydrogel debridement has a good effect.The key of this combined debridement lies in“dissolve while pruning”.This method notonly 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 removalofnecrotic tissue timely,the in flammatory reaction is controlled which can help the healing of wounds.23

4.1.2.2.The reason for effectiveness ofcombination of ultrasound and enzymatic debridement.Demir et al25concluded 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.26Ultrasound 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.27e29

4.2.Both yellow and black color in one wound

4.2.1.Speci fi c methods for both yellow and black color in one wound

See Table 2.

4.2.2.Result reasons analysis

4.2.2.1.The reason for effectiveness of combination of hydrogel and sharp debridement.This type ofwound also contains necrotic tissue in the form ofslough.This may range in color from white to yellow to black.Hydrogeldebridement method belongs to the category of autolytic debridement.Autolytic debridement is the gentle separation of slough and necrotic tissue from the wound bed,whichoccurs slowly in a moist wound environment.Hydrogel wound dressings promote autolytic debridement by rehydrating desiccated and devitalized tissue,aiding its separation from healthy tissue.4It is not suitable for doctors to choose autolytic debridement when only dealing with black tissue because it will take a long time to fi nish.Yellow tissue is suitable because itis 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 bacterialbio fi lm,reducing in flammation and controlling infection. Autolytic debridementis more suitable for shallow damaged tissue, such as pressure ulcer degree II and degree III,33so surgical debridement combined with autolytic debridement in the wounds works well.

Table 1 Speci fi c methods for black wounds.

Table 2 Speci fi c methods for both yellow and black color in one wound.

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.34Surgical debridement is the fastest and usually most thorough method available.20Pressure 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 vacuumassisted closure)dressing subsequently applied.4Regarding fungus-infected wounds,palliative treatment is another choice beside curative treatment.Debridement has the effect of reducing the stench and pain.22

5.Conclusions

At present the choice of debridement method largely rests on each clinician's experience35;therefore,an acknowledgment ofthe 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.36The color of the wounds is a basic frame of reference for choosing the method of debridement in addition to the importance ofthe overallassessmentofthe patient.

Conflict of interest

All contributing authors declare no con flicts of interest.

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How to cite this article:Liu W-L,Jiang Y-L,Wang Y-Q,et al. Combined debridement in chronic wounds:A literature review. Chin Nurs Res. 2017;4:5e8. http://dx.doi.org/10.1016/ j.cnre.2017.03.003

15 January 2016

*Corresponding author.

E-mail address:18980880152@163.com(Y.-L.Jiang).

Peer review under responsibility of Shanxi Medical Periodical Press.

http://dx.doi.org/10.1016/j.cnre.2017.03.003

2095-7718/?2017 Shanxi MedicalPeriodical Press.Publishing services by Elsevier B.V.This is an open access article under the CC BY-NC-ND license(http://creativecommons. org/licenses/by-nc-nd/4.0/).

Received in revised form 19 April 2016

Accepted 19 June 2016

Available online 31 March 2017