Key Points

1. Debridement describes the removal of necrotic or foreign material from and

around a wound to optimise wound healing.
2. There are many different methods that can be used to debride a wound. They
can be broadly classified as surgical/sharp, mechanical, biological, chemical,
enzymatic and autolytic. However, evidence supporting one method over
another is lacking.
3. Sharp debridement produces rapid results. It requires a high level of skill and
experience and practitioners must have the necessary knowledge and training
to complete the task safely and effectively and be able to deal with any
complications as they arise.
Abstract
When necrotic or foreign material is present in a wound, sharp or surgical debridement can
reduce the risk of infection and sepsis and aid wound healing. In this article the author
considers the various methods of debridement and concludes that sharp debridement should
be considered as the 'gold standard'.

Introduction
The term debridement comes from the French desbrider, meaning to unbridle. It was
probably first used as a medical term by surgeons working several hundred years ago in war
zones, who recognised that grossly contaminated soft tissue wounds had a better chance of
healing (and the soldier surviving) if the affected tissue was surgically removed to reveal a
healthy bleeding wound surface.
A modern definition for such sharp methods of debridement is the removal of dead or
necrotic tissue or foreign material from and around a wound to expose healthy tissue using
a sterile scalpel, scissors or both. It can be performed as a surgical procedure in the
operating theatre, involving extensive and aggressive removal of tissue with or without
general anaesthesia (surgical debridement), or be more conservative, involving repeated
minor tissue sparing debridement that can be performed at the bedside or in a procedure
room (sharp debridement).
Although surgical debridement is rapid and can involve the removal of large volumes of
tissue at one time, sharp debridement should be considered as the gold standard as it can
reduce the risk of wound complications and aid the healing process.
Which wounds need debridement?
Acute and chronic wounds have different requirements and heal in different ways.
Generally speaking, acute wounds, such as surgical wounds, have not been present
long enough to develop dead tissue and debridement is more likely to be needed to
remove foreign bodies and tissue that has become necrotic. Often, this only needs
to be performed once.
Chronic wounds, such as leg ulcers or pressure ulcers, often contain dead tissue
and bacteria. This can be either: dry and leathery in appearance, known as eschar
(Fig 1); or soft and brown, grey or yellow in colour, known as slough. Slough is
made up of white blood cells, bacteria and debris, as well as dead tissue, and is
easily confused with pus, which is often present in an infected wound (Figs 3 and
4). Chronic wounds are likely to need repeated debridement as part of ongoing
wound care as slough tends to reappear due to the underlying cause of the wound.
Wound assessment
The decision whether to debride a wound must be based on a comprehensive
wound assessment performed by a competent practitioner (Ousey and Cook, 2012).
The assessment must be documented fully and should consider:
The patients general condition;
The cause of the wound;
The patients circulation and, therefore, the chances of the wound healing;
The size and location of the wound;
The presence and amount of exudate;
Possible infection.
When choosing a debridement method, the patients views and general health
condition must be taken into account. For example, it would not be appropriate to
debride a pressure ulcer if the patient is in the last few days of life or if
debridement would increase pain.
The practitioner must also assess whether the patients circulation is good enough
to support healing once the wound has been debrided. If it is unlikely that the
wound will heal, treatment should be aimed at reducing the symptoms, such as
odour or heavy exudate.
After debridement, the wound may appear to deteriorate and seem larger initially;
the patient must be prepared for this.

Why debride?
An ulcer or open wound cannot be properly assessed until all the devitalised tissue is
removed. Dead or foreign material in a wound also adds to the risk of infection and sepsis
and inhibits wound healing. A number of mechanisms are involved:
Dead tissue acts as a medium for bacterial growth, particularly anaerobes such as
Bacteroides species and gas gangrene caused by Clostridium perfringens in military
surgical practice
Excessive inflammatory response, which results from the presence of necrotic or
foreign material, adds to the systemic release of cytokines such as tumour necrosis
factor and interleukins which promote a septic response
Necrotic tissues retard wound contraction, the principle contribution to wound
closure when wounds are left to heal by secondary intention.
It can sometimes be difficult to determine whether the tissue covering a wound is
physiological, such as a scab, or a pathological eschar, which is having a negative impact on
healing. Attempts to aid clinical recognition have included the injection of supravital dyes,
tissue oximetry, Doppler techniques, and even biopsy. Gangrenous, necrotic, ischaemic and
devitalised tissue all need to be removed by debridement.
Evidence for debridement
Although it is widely accepted that wound debridement is necessary for optimal wound
healing, evidence for the effectiveness of different methods of debridement (Box 1) from
randomised controlled trials is lacking and methods of measurement are poorly developed.
If dressings or enzymatic agents are to be compared with surgical and sharp debridement,
careful definitions will need to be agreed upon which are reproducible and measurable.
Box 1: Methods of wound debridement
Surgical and sharp using scalpel and scissors. Highly selective with rapid results.
Should only be undertaken by a skilled practitioner.
Mechanical such as hydrotherapy and wound irrigation. Rehydration can ease
removal of the surface eschar and removes surface debris. However, these are
relatively slow techniques and there is little evidence to support their use. Potential
for cross infection needs to be considered if using hydrotherapy. There is also a
theoretical risk of fluid embolism and promotion of infection if irrigation is too
vigorous.
Autolytic using hydrocolloids and hydrogels. Rehydration of necrotic tissue through
the use of a hydrogel or by keeping the wound moist, and removal of devitalised
tissue using the body's own enzymes. This method is in common use but prolongs
the time needed for debridement.
Enzymatic using preparations such as streptokinase or streptodornase or bacterial-
derived collagenases. Streptokinase and streptodornase aim to break down and
rehydrate necrotic tissue, but despite being available for more than 30 years, there
is little evidence to support their use over alternative methods. Also, the need to
score the eschar before application may increase the risk of damage. Bacterial-
derived collagenases show great potential and may promote healing.
Biological such as maggot therapy. The larvae of Lucilia sericata (greenbottle fly)
digest necrotic tissue and pathogens. This technique is rapid and selective, although
much of the evidence to support its use is derived from anecdotal reports.
Chemical such as hypochlorite. No longer widely used as application can be painful
and underlying tissue is damaged.

4 Autolytic debridement: this is performed with an occlusive or semi-occlusive dressing, such as a
hydrogel, hydocolloid, alginate or film, and the aim is to rehydrate the necrotic tissue. This is a slow process
and can safely be undertaken by the majority of clinicians following a structured wound assessment. It can,
however, lead to malodour and maceration of the periwound skin.
This technique is usually used prior to another form of tissue debridement and softens devitalised tissue and
encourages autolysis. It should be used with caution on arterial and diabetic foot wounds.

5 Mechanical debridement: this is a wet-to-dry technique where the dressing sticks to the top layer of the
tissue, pulling it away when removed. However, mechanical debridement is not selective about the tissue it
removes and can be very painful, removing healthy tissue at the same time as necrotic tissue. Mechanical
debridement is very cheap, but can be time-consuming due to the frequency of dressing changes and can
also be very traumatic for the patient.
A debriding pad (Debrisoft; Activa Healthcare) has recently been introduced, which should be moistened
and gently applied to the wound bed in a rotational movement. The fibres (monofilaments) or hoops of the
pad retain the dead tissue and bacteria within pad, thus removing the debris.

6 Larval therapy: the larvae of the green bottle fly (Lucilia sericata) secrete an enzyme, which breaks
down necrotic tissue into a liquid. This is then ingested by the larvae. This particular larvae do not touch
healthy tissue and the technique can, therefore, be seen as a selective micro-debridement[3]. The larvae
are available 'free range' or bagged and must be applied to a moist wound bed to keep them alive. For
optimum results, the outer dressing should be moistened daily. The treatment can be used consecutively
without a break, although it is important to make sure that patients are comfortable with the procedure as
some can find it distasteful.
Free range larva can be used for digit removal if a bone is diseased and the patient is considered too high a
risk for theatre. Larvae also have the capacity to lower bacterial colonisation within the wound.
Larvae need to be double-bagged and burnt for disposal.

7 Sharp debridement: this is usually undertaken by a specialist or surgeon with training in debridement.
It can be performed in a treatment room or at the bedside. It is essential that the clinician knows which
structures are to be removed to avoid complications, such as excessive bleeding or ligament damage. If
excess bleeding does occur, it is useful to have an alginate dressing at hand to place upon the wound to aid
haemostasis. If a limb is involved, it should be elevated. This process should only be performed where
resources are available in case of complications[4]. It is not suitable as a home-based treatment.
The results of sharp debridement are fast, but may need to be repeated over time, for example, in the
treatment of diabetic feet where off-loading of pressure points on planter surfaces is not adequate. Topical
treatments will be ineffective against the repeated trauma of patients continuing to walk on wounds as they
do not feel any pain.
Essentially this process relies on the practitioner's understanding of the patient's diagnosis, thorough wound
assessment and the practitioner's clinical capabilities and knowledge of the process.

8 Surgical debridement: this process is usually undertaken within the confines of theatre, where large
amounts of necrosis or septic tissue need to be urgently removed, for example, in cases of necrotising
fasciitis. The process is not selective - healthy and necrotic tissue are often removed together as there is a
need for clear margins and large wounds are frequently exposed using this method. Theatre time is
expensive and the patient will need follow up treatments to achieve full healing. This process can be very
painful and expensive, but is often necessary in the case of bacterial sepsis.
Following this treatment, topical negative pressure is often used to speed up wound healing, control exudate
and prevent hospital-acquired infections, thereby allowing patients to go home quicker and reduce hospital
bed occupancy.

9 Hydrosurgical debridement: this is a simple and effective process, which uses pressurised water or
saline as a cutting/cleaning tool [Fig 1]. The pressure is controlled via a handpiece and should only be used
by a trained practitioner. The hand-held units can be expensive to buy or rent while the feeder heads have
to be bought separately. Disposal can also be costly.
The process is effective, however, protective clothing and goggles should be worn when undertaking this
process to protect from 'splash-back' and cross-contamination.
The technique is quick and can be used in most settings.
Types of Wound Debridement
Autolytic Debridement:
Description:
Autolysis uses the body's own enzymes and moisture to re-hydrate, soften and
finally liquefy hard eschar and slough. Autolytic debridement is selective; only
necrotic tissue is liquefied. It is also virtually painless for the patient. Autolytic
debridement can be achieved with the use of occlusive or semi-occlusive dressings
which maintain wound fluid in contact with the necrotic tissue. Autolytic debridement
can be achieved with hydrocolloids, hydrogels and transparent films.
Best Uses:
In stage III or IV wounds with light to moderate exudate
Advantages:
Very selective, with no damage to surrounding skin.
The process is safe, using the body's own defense mechanisms to clean the wound of
necrotic debris.
Effective, versatile and easy to perform
Little to no pain for the patient
Disadvantages:
Not as rapid as surgical debridement
Wound must be monitored closely for signs of infection
May promote anaerobic growth if an occlusive hydrocolloid is used

Enzymatic Debridement:
Description:
Chemical enzymes are fast acting products that produce slough of necrotic tissue.
Some enzymatic debriders are selective, while some are not.
Best Uses:
On any wound with a large amount of necrotic debris.
Eschar formation
Advantages:
Fast acting
Minimal or no damage to healthy tissue with proper application.
Disadvantages:
Expensive
Requires a prescription
Application must be performed carefully only to the necrotic tissue.
May require a specific secondary dressing
Inflammation or discomfort may occur

Mechanical Debridement:
Description:
This technique has been used for decades in wound care. Allowing a dressing to
proceed from moist to wet, then manually removing the dressing causes a form of
non-selective debridement.
Hydrotherapy is also a type of mechanical debridement. It's benefits vs. risks are of
issue.
Best Uses:
Wounds with moderate amounts of necrotic debris
Advantages:
Cost of the actual material (ie. gauze) is low
Disadvantages:
Non-selective and may traumatize healthy or healing tissue
Time consuming
Can be painful to patient
Hydrotherapy can cause tissue maceration. Also, waterborne pathogens may cause
contamination or infection. Disinfecting additives may be cytotoxic.

Surgical Debridement:
Description:
Sharp surgical debridement and laser debridement under anesthesia are the fastest
methods of debridement.
They are very selective, meaning that the person performing the debridement has
complete control over which tissue is removed and which is left behind
Surgical debridement can be performed in the operating room or at bedside,
depending on the extent of the necrotic material.
Best Uses:
Wounds with a large amount of necrotic tissue.
In conjunction with infected tissue.
Advantages:
Fast and Selective
Can be extremely effective
Disadvantages:
Painful to patient
Costly, especially if an operating room is required
Requires transport of patient if operating room is required.

Knowledge base
Practitioners undertaking sharp/surgical debridement must have the knowledge and skills to
complete the task safely and effectively and be confident in their ability to deal with any
complications that may arise. They will need to have a good knowledge of the anatomy in
the region of the wound; there are clear areas of risk when arteries, veins or nerves are
near the surface. Figure 1 shows an example of where good anatomical knowledge is
required for sharp debridement to be achieved safely.


Figure 1 - Area of skin necrosis after extravasation of intravenous fluid.

When not to debride
Careful assessment is essential before taking the decision to debride a wound, particularly
as there are some instances when necrotic tissue should be left in situ. For example, when
there is underlying vascular disease with associated gangrene it is conventional to wait for a
line of demarcation. The degree of underlying ischaemia should be assessed and corrective
vascular surgery considered. It is also possible that necrotic material may auto-amputate
itself (Figure 2). Early intervention can precipitate wet infected gangrene which spreads
proximally and may need an urgent higher amputation.


Figure 2 - Mummified toe.

Full thickness dry pressure sores usually need excision after softening with appropriate
dressings (Figure 3). However if the patient has a terminal illness, it may be beneficial to
leave the necrotic 'caps' in place, especially if they are not causing discomfort and there is
no wound malodour or exudate. Although the wound will not heal with the necrotic tissue in
situ, any potential benefits should be balanced against the need for increased intervention
and possible disruption to the patient if the 'caps' are removed. Where there is a
combination of dry cap and cellulitis, exudate or odour, antimicrobial therapy should be
considered to control the symptoms and alleviate the physical and psychological suffering of
a patient with a malodorous wound. Care should be taken if a wound is showing clinical
signs of infection.


Figure 3 - Pressure sore on the heel with black, full thickness 'cap'.

Preparation
The possible benefits of other methods of debridement should be considered alongside
sharp or surgical debridement. Sharp techniques can often benefit from being implemented
after preparation with non-sharp methods for the removal of devitalised tissue (Box 1). For
example enzymatic preparations such as collagenase can help free adherent necrotic tissue
from a granulating wound bed and hydrocolloids soften dried eschar and can aid surgical
removal, reducing the need for anaesthesia.
Pain control
Careful explanation of a debridement procedure together with an agreed place and time can
reduce apprehension and promote confidence in the patient and the practitioner. If
anaesthesia is required it is important that this is given appropriately. For local anaesthesia,
a topical anaesthetic cream such as EMLA or injection of a local anaesthetic using ring block
or regional techniques can be used. General anaesthesia is preferable for extensive
debridement, particularly if another procedure is being considered such as closure with a
skin flap. It is important that the general fitness of the patient is considered and some
patients may elect to have general anaesthesia. Wide debridement may not require general
anaesthesia and spinal or epidural anaesthesia can be considered.
No anaesthesia may be required if dead tissue is non-adherent, but excision of too much
tissue or the opening of a joint may carry complications. The removal of a dead tendon
usually requires anaesthesia. Patients with diabetes may have associated neuropathy which
permits surprisingly extensive debridement without causing pain. Paradoxically, however,
there may be a heightened sensitivity to stimuli so pain relief should always be considered.
Procedure
Sharp/surgical debridement should involve a team approach. Before undertaking the
procedure it is important to consider the following:
1. Assessment
the nature of the necrotic tissue and the best method of debridement
the risk of spreading infection and the possible use of antibiotics
the possibility of underlying disease processes
the extent of existing ischaemia
the location of the wound in relation to the surrounding anatomy.
2. Consent and extent of procedure
When taking consent it is important that the patient understands what is to
be achieved. To try and undertake too much at once can diminish confidence
between patient and professional.
3. Pain relief
Is it necessary and what form should it take?
4. Possible complications
The patient should be assessed for the risk of possible complications. Sharp
debridement is a surgical procedure and will involve some bleeding, although
local pressure with a finger is usually enough to stop this. The application of
successive layers of gauze can hide considerable haemorrhage and is
ineffective. Tourniquets are dangerous and should be avoided.
5. Location
Sharp debridement should take place in a controlled environment with
adequate lighting and equipment. Help should be at hand in case of
complications.
Once the extent of debridement has been decided and agreed with the patient, this should
not be exceeded. The procedure should also be stopped when:
The anatomy of the wound and surrounding area is unclear or a structure cannot be
identified
Bleeding is excessive or the source is unclear.
Sharp/surgical debridement in people with diabetes mellitus
This is a complex undertaking and should involve a team approach including the
diabetologist, vascular and general surgeon, specialist nurse, podiatrist, dietician and
others. Diabetes is associated with small and large vessel disease, an increased risk of
infection and poor healing. In foot ulcers there may be an underlying neuropathy (Charcot's
joints). Patients need careful assessment with control of their diabetes and infection.
Repeated appropriate debridement can avoid the need for proximal amputation with the
attendant huge drain on resources for rehabilitation.
Purpose
An open wound or ulcer can not be properly evaluated until the dead tissue or foreign matter is
removed. Wounds that contain necrotic and ischemic (low oxygen content) tissue take longer to
close and heal. This is because necrotic tissue provides an ideal growth medium for bacteria,
especially for Bacteroides spp. and Clostridium perfringens that causes the gas gangrene so
feared in military medical practice. Though a wound may not necessarily be infected, the
bacteria can cause inflammation and strain the body's ability to fight infection. Debridement is
also used to treat pockets of pus called abscesses. Abscesses can develop into a general infection
that may invade the bloodstream (sepsis) and lead to amputation and even death. Burned
tissue or tissue exposed to corrosive substances tends to form a hard black crust, called an
eschar, while deeper tissue remains moist and white, yellow and soft, or flimsy and inflamed.
Eschars may also require debridement to promote healing.

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Before surgical or mechanical debridement, the area may be flushed with a saline
solution, and an antalgic cream or injection may be applied. If the antalgic cream is
used, it is usually applied over the exposed area some 90 minutes before the procedure.

Aftercare
After surgical debridement, the wound is usually packed with a dry dressing for a day to
control bleeding. Afterward, moist dressings are applied to promote wound healing.
Moist dressings are also used after mechanical, chemical, and autolytic debridement.
Many factors contribute to wound healing, which frequently can take considerable time.
Debridement may need to be repeated.
Risks
It is possible that underlying tendons, blood vessels or other structures may be damaged
during the examination of the wound and during surgical debridement. Surface bacteria
may also be introduced deeper into the body, causing infection.

Normal results
Removal of dead tissue from pressure ulcers and other wounds speeds healing.
Although these procedures cause some pain, they are generally well tolerated by patients
and can be managed more aggressively. It is not uncommon to debride a wound again in
a subsequent session.

Alternatives
Adjunctive therapies include electrotherapy and low laser irradiation. However, at
present, insufficient research has been completed to recommend their general use.
Not all wounds need debridement. Sometimes it is better to leave a hardened crust of
dead tissue (eschar), than to remove it and create an open wound, particularly if the
crust is stable and the wound is not inflamed. Before performing debridement, the
physician will take a medical history with attention to factors that might complicate
healing, such as medications being taken and smoking. The physician will also note the
cause of the wound and the ways it has been treated. Some ulcers and other wounds
occur in places where blood flow is impaired, for example, the foot ulcers that can
accompany diabetes mellitus. In such cases, the physician or nurse may decide not to
debride the wound because blood flow may be insufficient for proper healing.


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Conclusions
Sharp debridement is a highly skilled procedure and junior doctors and practising nurses are
justifiably reluctant to undertake this technique without adequate teaching and support.
However this method of debridement should not be avoided simply because there is no one
prepared to perform it. Instead it must be included in the holistic care of the patient and be
dealt with by the clinical team. Change is needed in the way that debridement skills are
taught. Few courses exist and those that do largely cater for those who already do, or who
are prepared to undertake, surgical debridement.
Author(s)
David Leaper
MD, ChM, FRCS, FACS
Professor of Surgery
University of Newcastle
North Tees Hospital, Stockton on Tees, Cleveland, UK
Email: profdavidjohnleaper@doctors.net.uk