wound bed preparation Cleansing and debridement

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Wound bed preparation is defined as ‘the management of the wound to accelerate endogenous healing or to facilitate the effectiveness of other therapeutic measures’.31 The principles of wound bed preparation that will be discussed in this section are the entrenched concepts of TIME (Tissue; Infection/Inflammation; Moisture; Edge)72, 157 and biofilm-based wound care (BBWC)158 that guide best practice in wound assessment and management. Application of these principles promotes maintenance of a healthy wound bed and involves therapeutic wound cleansing and debridement, which aims to disrupt biofilm, prevent its reformation, and facilitate removal of necrotic, non-viable or infected tissue.

Therapeutic Wound Cleansing

Wound cleansing is a fundamental component of wound bed preparation.159, 160 Wound cleansing is defined as actively removing surface contaminants, loose debris, non-attached non-viable tissue, microorganisms and/or remnants of previous dressings from the wound surface and its surrounding skin.20 Therapeutic cleansing is rigorous cleansing of chronic or hard-to-heal wounds and is performed:

  • To remove excessive wound exudate or debris from the wound bed in order to optimise visualisation and reliable assessment
  • Prior to collection of a wound sample (swab or biopsy)
  • To assist in hydrating a desiccated wound bed.155, 161

Wound hygiene technique was referred to in the 2016 edition of this document and has been expanded by an expert panel as a term to remind clinicians that wound hygiene practices should be ‘repetitive, regular, frequent and necessary’.162 Wound hygiene involves cleansing, debridement of the wound bed and edge, and prevention of biofilm reformation.148

Selecting And Using Wound Cleansing Solutions 

The ideal wound cleansing solution has not been established conclusively. Selection of a solution is based on:171, 172

  •  Assessment of the wound (e.g. aetiology, anatomical location and visible structures)
  •  The person’s risk of wound infection
  •  Signs and symptoms indicative of local wound infection or spreading infection
  •  Colonisation with multi-drug-resistant organisms
  •  Efficacy and organism sensitivities of solution
  •  Goals of care
  •  Local policies and resources. 

Wound cleansing solution options are outlined in Table 9. Inert substances are appropriate for cleansing most non-infected wounds.159, 161 Sterile normal saline or sterile water are inert solutions that are used in clinical situations requiring a sterile solution. Evidence from systematic reviews163, 173-176 and randomised controlled trials177-179 has demonstrated that potable water178 is a safe alternative to other wound cleansing solutions for both chronic and acute wounds. Potable water might be chosen in low-resource settings, community settings or for wounds with high levels of exudate or fistula effluent.166 There is a role for judicious wound irrigation with an antiseptic solution, for example:

  • To prevent surgical site infection when there is a high risk of infection (e.g. traumatic and contaminated wounds
  •  In the presence of clinical signs and symptoms of local or spreading wound infection
  •  In conjunction with surgical, sharp or conservative-sharp debridement as a component of biofilm-based wound care.166, 171

Surfactants (surface active agents) are cleansing agents that contain a substance that lowers the surface tension between the wound bed and the fluid or between two liquids. The lowered surface tension facilitates the spread of the fluid across the wound bed. Surfactants assist separation of loose, non-viable tissue72, 168, 180 by breaking bonds between non-viable tissue/debris and the wound bed.161 These products might be chosen for cleansing wounds that require greater mechanical action when cleansing: for example, wounds with suspected biofilm.180 Some topical antiseptic agents are manufactured in combination with a surfactant to capitalise on these properties and increase penetration of the antimicrobial agents across the wound bed.72 The manufacturers’ instructions for wound cleansing surfactants and antiseptic agents should be adhered to in regard to efficacy, recommended duration of each application and duration of consecutive treatments.172

Prontosan® How It Works?

 Table 9. Wound cleansing solution options

Fluid typeSafety profileCommentsKey model features
Potable tap waterHypotonic

■ No cytotoxicity

■ Not sterile

■ Generally inert solution that varies in content169

■ Effect achieved through mechanical detachment of contaminants181

■ Safe alternative when sterile solutions are not available or feasible (e.g. low resource settings or community settings)177

■ In low resource settings with non-potable water, boiled and cooled water is an alternative165

■ When using potable tap water, run the tap to remove contaminates before using the water166

Sterile normal 0.9% salineIsotonicNo cytotoxicity

■ Inert, isotonic solution with no antimicrobial properties169

■ Effect achieved through mechanical detachment of contaminants181

■ Once opened, product is no longer sterile182

Sterile waterHypotonicNo cytotoxicity

■ Inert, hypotonic solution with no antimicrobial properties169

■ Effect achieved through mechanical detachment of contaminants181

■ Once opened, product is no longer sterile182

Surfactant wound cleansers (e.g. Poloxamer 407, undecylenamidopropyl betaine and macrogolum)Surfactant Low cytotoxicity to fibroblasts and keratinocytes in vitro180

■ Categorised based on type of chemical charge168

■ Commonly combined with antimicrobial /antimicrobially-preserved agents including octenidine dihydrochloride (OCT) or polyhexamethylene biguanide (PHMB)

■ Removes bacteria without damage to healing wound tissues180

Super-oxidised solutions (hypochlorous acid and sodium hypochlorite are present as antimicrobial preservatives)HypotonicVaries (see Table 11)

■ Contain naturally occurring hypotonic, oxidising agents183

■ Antimicrobial and antibiofilm action varies (see Table 11)

Povidone iodine■ Antiseptic ■ IodophorDose dependent cytotoxic effect on osteoblasts, myoblasts and fibroblasts184, 185

■ Antiseptic solution

■ Broad spectrum antimicrobial185-189 and antibiofilm185-187 action (see Table 11)

Other agents containing antimicrobials and/or active preservativesVariesVaries (see Table 11)■ Range of antimicrobial/antimicrobially-preserved agents solutions, less commonly used solely as a cleansing agent (see Table 11) 

Key Considerations In Wound Irrigation Agents1

Saline and tap water

Although tap water and saline are not cytotoxic and do not seem to be harmful to wounds, these cleansing choices may not actively promote healing, particularly in chronic wounds with biofilm and / or increased bacterial burden indicating that nonantiseptic cleansing does not remove harmful molecules such as matrix metalloproteases and elevated proinflammatory cytokines.

Irrigation agentCharacteristics
Saline

Low toxicity

Limited ability to reduce bacterial load

Bacterial growth can occur in an open container within 24 hours

Sterile water

Limited ability to reduce bacterial load

Readily absorbed by tissues; water toxicity may result when excess volumes are used

No longer sterile after opening

Tap water

Recommended where saline and sterile water are not available

Limited ability to reduce bacterial load

Microbes, in particular P. aeuruginosa, can colonise taps and as a result may end up in wounds irrigated in this way

Prontosan® Wound Irrigation Solution

Next to PHMB, it contains betaine, a surfactant, to lift microbes and debris and suspend them in solution to prevent wound recontamination

Has an increased ability to penetrate difficult-to-remove coatings, lifting debris,bacteria and biofilm from the wound

Broad spectrum of activity against bacteria, viruses and fungi

No evidence of resistance

AdvantagesProntosan®SalineWaterAntiseptic
Removal and prevention of biofilm   
Infection prevention   
Faster wound closure   
Reduction of odour   
Reduction of pain  
Safe for long term use 
Cost effective – can be used up to 8 weeks after first opening   
No inhibition of granulation tissue   

Debridement

Necrotic, non-viable tissue provides a focus for infection, exacerbates the inflammatory response and impedes wound healing.13, 170 This includes the presence of foreign material (e.g. wound dressing remnants, sutures, biofilm or slough, exudate and debris) on the wound bed. Debridement provides a window of opportunity in which the biofilm defences are temporarily interrupted, allowing for increased efficacy of topical and systemic management strategies.14 However, the impact of the different types of debridement on biofilm may be dependent upon its stage in the biofilm development cycle. A comprehensive assessment of the individual and their wound determines the goal of care and precedes the decision to debride and selection of the debridement method to employ.190 However,  caution should be taken, or debridement avoided, in the following situations:

  • The non-infected ischaemic foot ulcer covered with dry eschar in the presence of inadequate tissue oxygenation to support infection control and wound healing97, 190
  •  In individuals when palliative management is the goal of care and necrosis covers vulnerable vascular structures
  •  In wounds with underlying, uncontrolled inflammatory causes (e.g. pyoderma gangrenosum)191
  •  When there is an increased risk of bleeding (e.g. during anti-coagulation or anti-platelet therapy)
  •  The level of pain management required to accomplish appropriate debridement necessitates anaesthetic.

The various methods of debridement are outlined in Table 10. Clinical evidence currently does not support any one debridement method as more effective than another,192-195 and the optimal frequency of debridement is yet to be established. As noted in Table 10, some debridement methods (e.g. surgical debridement) will remove microorganisms from the wound bed rapidly. Selection of a debridement method should be based on clinical context, goals of care, the clinician’s expertise and local resources.196 When performing wound debridement, clinicians should always work within their scope of practice, and local policy and procedures.

Table 10: Types of debridement

MethodDescriptionAdvantagesConsiderations
SurgicalPerformed in the operating room or specialised clinic by qualified and competent practitioners using sterile scalpel, scissors or a hydrosurgical device97, 160, 170, 195 

■ Fast and efficient

■ Maximises asepsis190

■ Disrupts biofilm and removes foci of infection197

■ If adequate tissue is removed, deeper biofilm can be disrupted170

■ Non-selective

■ Requires a general or local anaesthetic

■ Will result in bleeding

■ Expensive

Sharp Performed by qualified and competent practitioners (e.g. medical practitioner, podiatrist, advanced practice nurse) using sterile scalpel, scissors or curette97, 160, 170

■ Fast and efficient

■ Disrupts biofilm and removes foci of infection197

■ If all non-viable tissue is removed, deeper biofilm can be disrupted170

■ May require a local anaesthetic

■ May result in bleeding

■ Limited selectivity, can reduce effectiveness if foci is not disrupted198

Conservative sharpPerformed by qualified and competent practitioners using aseptic technique with sterile curette, scalpel and scissors97, 170■ Removes and disrupts superficial biofilm170Limited selectivity as aims to remove loose avascular or infected tissue without pain or bleeding190, 199
Autolytic

Autolytic debridement occurs naturally and can be aided by using topical agents and contemporary wound dressings that promote autolysis.97, 170, 200, 201 Examples include:

■ Cadexomer iodine

■ Honey

■ Fibre gelling wound dressings (e.g. alginates, hydrofiber, polyabsorbent fibres)

■ Surfactant and antiseptic solutions/gels

■ Highly selective

■ Inexpensive

■ Varying effectiveness in controlling biofilm

■ Pain free, no bleeding

■ Antimicrobial autolytic agents aid infection control

■ Polyabsorbent fibres have a continuous cleaning action201

■ Slow

■ May cause maceration or irritation of surrounding skin

Mechanical

Debridement performed using:160, 170, 202-205 ■ Wet-to-dry dressings

■ Therapeutic irrigation

■ Monofilament /microfibre/foam debridement pads ■ Low-frequency ultrasound

■ Moistened gauze with aggressive circular contact

■ Evidence of disruption and removal of biofilm170, 205

■ Wet-to-dry dressings and irrigation is inexpensive

■ Debridement pads may improve patient comfort16

■ Non-selective ■ Wet to dry dressings are painful and can lead to wound bed trauma

■ Some mechanical debridement options are expensive

EnzymaticApplication of exogenous enzymes to the wound surface170, 206■ Selective ■ Potentially some level of biofilm disruption/ removal170

■ Slower than instrument or other mechanical methods

■ May cause maceration or irritation of surrounding skin

■ Not widely available

■ Can be used as an adjunct to surgical debridement206

Chemical/ mechanical/ surfactantUse of high or low concentration surfactant wound cleaners and gels that disrupt nonviable tissue, debris and microbials181■ Selective ■ Inexpensive ■ Some level of biofilm disruption/removal170 ■ May augment mechanical removal of debris when combined with negative pressure wound therapy207

■ Slower than other debridement methods

■ Some contain antimicrobial agents or active preservatives

■ May cause maceration of the periwound and surrounding skin (consider use of barrier products)

Biosurgical/ larval therapyMedical grade fly larvae (e.g. Lucilia sericata sp and Lucilia cuprina) produce proteolytic enzymes that liquify devitalised tissue, which is then ingested by the larvae97, 160, 208, 209

■ Selective

■ Fast and efficient

■ Lysis of organisms

■ Evidence of removal of biofilm in vitro and in clinical studies210, 211

■ Slight pyrexia may occur because of lysis of organisms by larvae

■ Skin irritation may occur if enzymes contact surrounding skin

■ May be unacceptable to the patient190

All content of this page, tables conent and references come from International Wound Infection Institute (IWII) Wound Infection in Clinical Practice. Wounds International. 2022
1. R. Wolcott, J, Fletcher. The role of wound cleansing in the management of wounds. Wounds International 2014; 1(1): 25-31.

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