Debrideme nt for surgical wounds (Review)
Smith F, Dryburgh N, Donaldson J, Mitchell M
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2013, Issue 9
http://www.thecochranelibrary.com
Debridement for surgical wounds (Review)
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
T A B L E O F C O N T E N T S
1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
8RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
16CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
30DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
30WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
30HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
30CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
31DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
31SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
32INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
iDebridement for surgical wounds (Review)
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]
Debrideme nt for surgical wounds
Fiona Smith
1
, Nancy Dryburgh
2
, Jayne Donaldson
3
, Melloney Mitchell
4
1
School of Nursing, Midwifery and Social Care, Faculty of Health, Life & Social Sciences, Edinburgh Napier University, Edinburgh,
UK.
2
Edinburgh, UK .
3
School of Nursing, Midwifery and Social Care, Edinburgh Napier University, Edinburgh, UK.
4
The Royal
Infirmar y, Edinburgh, UK
Contact address: Fiona Smith, School of Nursing, Midwifery and Social Care, Faculty of Health, Life & Social Sciences, Edinburgh
Napier University, Sighthill Campus, Edinburgh, EH11 4BN, UK.
f.smith@napier.ac.uk.
Editorial group: Cochrane Wounds Group.
Publication status and date: New search for studies and content updated (no change to conclusions), published in Issue 9, 2013.
Review content assessed as up-to-date: 13 June 2013.
Citation: Smith F, Dryburgh N, Donaldson J , Mitchell M. Debridement for surgical wounds. Cochrane Database of Systematic Reviews
2013, Issue 9. Art. No.: CD006214. DOI: 10.1002/14651858.CD006214.pub4.
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
A B S T R A C T
Background
Surgical wounds that become infected are often debrided because clinicians believe that removal of this necrotic or infected tissue will
expedite wound healing. There are numerous methods available but no consensus on which one is most effective for surgical wounds.
Objectives
To determine the effect of different methods of debridement on the rate of debridement and healing of surgical wounds.
Search methods
In March 2013, for this third update, we searched the Cochrane Wounds Group Specialised Register; the Cochrane Central Register
of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed
Citations); Ovid EMBASE; and E BSCO CINAHL.
Selection criteria
We included randomised controlled trials (RCTs) with outcomes including at least one of the following: time to complete debridement
or time to complete healing.
Data collection and analysis
Two review authors independently reviewed the abstracts and titles obtained from the search, extracted data independently using a
standardised extraction sheet and independently assessed methodological quality. One review author was involved in all stages of the
data collection and extraction process, thus ensuring continuity.
Main results
Five RCTs (159 participants) were eligible for inclusion; all compared treatments f or infected surgical wounds and reported time
required to achieve a clean wound bed (comple te debridement). One trial compared an enzymatic agent (streptokinase/streptodornase)
with saline-soaked dressings. Four trials compared the effectiveness of dextranomer beads or paste with other products (diff erent
comparator in each trial) to achieve complete debridement. Meta-analysis was not possible due to the unique comparisons within each
trial. One trial reported that dextranomer achieved a clean wound bed significantly more quickly than Eusol, and one trial comparing
enzymatic debridement with saline-soaked dressings reported th at the enzyme-treated wounds were cleaned more quickly. However,
methodological quality was poor in these two trials.
1Debridement for surgical wounds (Review)
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Authors’ conclusions
There is a lack of large, high-quality published RCTs evaluating debridement per se, or comparing different me thods of debridement
for surgical wounds, to guide clinical decision-making.
P L A I N L A N G U A G E S U M M A R Y
Debridement for surgical wounds
Following surgery most surgical wounds heal naturally with no complications. However, complications such as infection and wound
dehiscence (opening) can occur which may result in delayed healing or wound breakdown. Infected surgical wounds may contain
dead (devitalised) tissue. Removal of this dead tissue (debridement) from surgical wounds is believed to enable wound healing. Many
methods are available to clinicians to debride surgical wounds. This review showed that there is insufficient valid research evidence to
recommend any one particular method.
There is a clear need for more research into which method is most effective in removing dead tissue from surgical wounds that have
become infected.
B A C K G R O U N D
Surgical wounds, by definition, are initially acute and most heal
naturally without delay or complications (Bale 1997; Baxter
2003
). However, complications such as infection and wound de-
hiscence (opening) may occur, and may result in either delayed
wound healing or wound breakdown, or both. Wounds with sur-
gical site infections may contain devitalised (dead) tissue. The ap-
pearance, colour and texture of this tissue may vary from hard,
black tissue (necrotic or eschar) to a soft fibrous yellow or green
tissue (slough) (
Thomas 1999; Vowden 1999a; Ramundo 2000;
Stotts 2000; O’Brien 2003a). This may be accompanied by in-
creased production of fluid (exudate) and the presence of an odour
(
Dealey 1994; O’Brien 2003a).
There is a widely held belief that wound healing is impeded by
the presence of devitalised, necrotic tissue and wounds containing
such material do not heal successfully (
Baharestani 1999; Lewis
2000; Stotts 2000; NICE 2001; O’Brien 2002). Non-viable tissue
not only inhibits the growth of epithelial tissue, but also increases
the production of exudate, impairs assessment of the wound bed,
and makes it more difficult to achieve wound closure, thus having
an adverse effect on quality of life (Baharestani 1999). Although
Baharestani 1999 details a number of reasons for the removal of
the dead tissue (as detailed above), these reasons do not appear to
be supported by robust, scientific evidence.
Debridement is the process whereby foreign material and dead or
damaged tissue and debris are removed from a wound (
Vowden
1999a
; O’Brien 2002; O’Brien 2003c). Debridement of wounds
includes any method that removes infected or contaminated tis-
sue, cell debris or dead, devitalised, fibrous material (frequently
classified as eschar or slough) to create a clean wound bed (
Vowden
1999a
; NICE 2001; O’Brien 2002 ). Debridement is thought
to provide a foundation for the subsequent healing of wounds
(
O’Brien 2003b).
Debridement may be achieved by a variety of methods including:
surgery; biosurgical (larvae) debridement; autolytic debridement;
mechanical debridement; chemical debridement and enzymatic
debridement.
Surgical or sharp d ebridement
Surgical debridement may be achieved by the aggressive excision
of all devitalised tissue using surgical techniques (
Thomas 1999;
Vowden 1999b; Sibbald 2000; Schultz 2003). Disadvantages as-
sociated with this method are the requirement for hospital admis-
sion, the administration of an anaesthetic with associated compli-
cations, and time in the operating theatre. It is also associated with
pain, bleeding and excision of healthy tissue and, as such, is not
suitable or desirable for all patients (Baharestani 1999; Thomas
1999
; Vowden 1999b; Sibbald 2000; Schultz 2003). On the other
hand, sharp debridement involves the excision of small quantities
of dead tissue by a clinician using scissors or a scalpel (
O’Brien
2003a; O’Brien 2003c). This procedure may be performed in a
community or hospital setting (
Poston 1996). However, for both
surgical and sharp procedures, issues of patient consent, training
and skill of the clinician must be considered (
Ashworth 2002).
2Debridement for surgical wounds (Review)
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Biosurgical/biological debridement
In biosurgical or biological debridement, sterile larvae (maggots)
of the Lucilia sericata species of greenbottle fly are applied to a
sloughy wound. There, the larvae are capable of producing pow-
erful proteolytic enzymes that destroy the dead tissue by lique-
fying and ingesting it. Healthy tissue in the wound bed is not
damaged and, although there are aesthetic considerations, larvae
are increasingly being used for wound debridement (
Baharestani
1999
; Lewis 2000; O’Brien 2003a).
Autolytic debrid ement
Over time, naturally occurringenzymes will eventually break down
and dissolve dead or sloughy tissue in wounds. This natural process
is promoted by the maintenance of a moist environment through
judicious use of dressings and topical agents (e.g. hydrogels, semi-
occlusive and occlusive wound dressings). Many of these dressings
hydrate and remove black, necrotic tissue and slough (
Baharestani
1999
; Vowden 1999a; Lewis 2000). Dextranomer is an example
of a hydroscopic dressing which has a high absorptive capacity and
is capable of removing bacteria, debris and absorbing wound exu-
date, thereby facilitating autolytic debridement. However world-
wide production of dextranomer beads and paste was discontin-
ued in 2007, with the exception of the paste which is still available
in South A frica.
Mechanical debridement
Mechanical methods of debridement are non-selective and may
result in damage to healthy tissue (Baharestani 1999). These
methods include: wet to dry debridement, wound cleansing de-
bridement and whirlpool debridement (
Vowden 1999a; Ramundo
2000
; O’Brien 2003a; Stotts 2004; Falabell a 2006).
Wet to dry debridement
The wet to dry me thod of debridement involves the application
of a saline-soaked gauze dressing to a wound. The moist dress-
ing induces separation of the devitalised tissue and, once dry, the
dressing is removed, together with the slough and necrotic tissue.
This process is continued until all the devitalised tissue is removed.
This is reported to be a painful procedure and may damage healthy
tissue; fibres may be left in the wound and the dressing does not
provide a barrier to bacterial contamination (
Baharestani 1999;
Ramundo 2000; O’Brien 2003a; Stotts 2004).
Wound cleansing debridement
Wound cleansing debridement involves irrigating a wound with
a continuous or intermittent flow of fluid delivered under high
pressure. The force of the fluid is between 8 and 12 pounds pe r
square inch (psi), and is sufficient to remove devitalised tissue
and wound bacteria (
Baharestani 1999; Ramundo 2000). Newer
wound cleansing systems use pressurised saline delivered via a noz-
zle at between 12,800 and 15,000 psi (
Granick 2006).
Whirlpool debridement
Whirlpool debridement is used for large wounds on the trunk or
extremities. The affected person is immersed in a whirlpool bath,
where the vigorous action of the water and its hydrating effect
loosen the surface bacteria and devitalised tissue, and allow them
to be washed away (
Baharestani 1999; Ramundo 2000).
Chemical debridement
A range of chemical agents, including hypochlorites such as EU-
SOL (Edinburgh University Solution of Lime) and Dakin’s Solu-
tion (sodium hypochlorite), hydrogen peroxide and iodine, h ave
been used to promote debridement of wounds. The use of chemical
agents remains a controversial area, in which any benefits need to
be judged against any detrimental effects on the process of healing
(
Brennan 1985; Baharestani 1999; Hofman 2002; Ayello 2004).
Enzymatic debridement
Topical enzymatic preparations are applied to moist (or moist-
ened) devitalised tissue. Such preparations include: streptoki-
nase/streptodornase (Lewis 2000; O’Brien 2003a), collagenase
(
Ramundo 2000; Stotts 2004), papain/urea, and a combination of
fibrinolysinand deoxyribonuclease (
Ramundo 2000; Stotts 2004).
This method has a number of disadvantages, including a require-
ment for frequent dressing changes and a slow rate of debridement.
Worldwide production of the enzymatic preparation of streptok-
inase/streptodornase has now been discontinued.
Overview
There is considerable de bate about the appropriateness and efficacy
of debridement methods (
Ashworth 2002). A systematic review
published in 1999 indicated that there were no studies comparing
non debridement with debridement and therefore the benefits of
debridement on wound healing were unclear (
Bradley 1999). A
guidance document on the use of de briding agents for difficult-
to-heal surgical wounds highlighted the lack of sufficient evidence
(and the corresponding absence of randomised controlled trials
(RCTs)) to support any particular method of debridement (
NICE
2001
). However a Cochrane Review on the debridement of dia-
betic foot ulcers found evidence suggesting that the rate of healing
increased when a hydrogel dressing was used in comparison to
a gauze dressing (
Edwards 2010). The choice of debriding agent
and method is usually made on the basis of the clinician’s e xpertise
3Debridement for surgical wounds (Review)
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
