Wound bed preparation: an overview.

Wound bed preparation is the management of a wound in order to optimise healing and/or facilitate other therapeutic measures. It is the most pivotal step in healing wounds. Early referral to a specialist wound clinic can markedly improve the wound healing process. This overview will discuss the techniques involved in the preparation of the wound bed that will effectively accelerate the healing process. The process begins with a correct diagnosis of the wound and optimising the patient's medical condition. The TIMERS framework is discussed. Wound dressings, including the use of negative-pressure wound therapy, are discussed, along with debridement techniques and agents. The timing of wound intervention and evaluating progress will also be discussed, and wound bed preparation strategies will be included. There has been an added challenge of wound care in the community as a result of the COVID-19 pandemic. The present article provides an overview of how to prepare a wound bed in the community.

Wound Healing and Wound Care in Neonates: Current Therapies and Novel Options.

GENERAL PURPOSE: To provide wound care information that considers the specific physiology of neonates. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Differentiate the use of hydrocolloids, hydrogels, foam dressings, and barrier creams in the neonatal population.2. Identify issues related to the use of solvents, alginates, collagen dressings, and negative-pressure wound therapy in neonates. ABSTRACT: OBJECTIVETo discuss what is known about the wound milieu in premature and full-term neonates, including the unique challenges pediatric clinicians face, the therapies that have proven effective, and the therapies contraindicated for use in neonatal wound healing to guide treatment that accounts for the specific physiological characteristics of this often overlooked population. DATA SOURCES: Data were collected on neonatal wound healing from a wide variety of sources, including PubMed, Google Scholar, journals, and textbooks. STUDY SELECTION: Selection criteria included publications focused on the differences and nuances of wound healing in neonates in comparison with all other age groups. DATA EXTRACTION: Data were extracted based on articles covering wound healing therapies with proven effectiveness in neonates. Terms for neonatal wound care were compiled, and then a comprehensive literature search was performed by the authors. DATA SYNTHESIS: Although many therapies are safe for treatment of older children and adolescents, most have not been explicitly tested for neonatal use. This article reviews therapies with proven effectiveness and/or specific concerns in the neonatal population. CONCLUSION: This review sheds light on the advantages and disadvantages of current standards of care regarding wound healing for neonates to direct researchers and clinicians toward developing treatments specifically for this delicate population.

To discuss what is known about the wound milieu in premature and full-term neonates, including the unique challenges pediatric clinicians face, the therapies that have proven effective, and the therapies contraindicated for use in neonatal wound healing to guide treatment that accounts for the specific physiological characteristics of this often overlooked population. Data were collected on neonatal wound healing from a wide variety of sources, including PubMed, Google Scholar, journals, and textbooks. Selection criteria included publications focused on the differences and nuances of wound healing in neonates in comparison with all other age groups. Data were extracted based on articles covering wound healing therapies with proven effectiveness in neonates. Terms for neonatal wound care were compiled, and then a comprehensive literature search was performed by the authors. Although many therapies are safe for treatment of older children and adolescents, most have not been explicitly tested for neonatal use. This article reviews therapies with proven effectiveness and/or specific concerns in the neonatal population. This review sheds light on the advantages and disadvantages of current standards of care regarding wound healing for neonates to direct researchers and clinicians toward developing treatments specifically for this delicate population.

Active debridement of venous leg ulcers: a literature review to inform clinical practice.

Community nurses often care for patients with sloughy venous leg ulcers. Slough is viewed as a potential infection source and an impediment to healing, but it is unclear if active debridement of slough promotes healing. Using a clinical scenario as a contextual basis, this literature review sought research evidence to answer this clinical question. A strategy based on the '4S' approach was used to identify research evidence. The retrieved evidence included one systematic review, three clinical guidelines and six qualitative and quantitative studies. The analysis suggested that there is no robust evidence to support the routine practice of active debridement of venous leg ulcers to promote healing, and that debridement is associated with increased pain. Since autolytic debridement can be achieved through the application of graduated compression therapy, active debridement may offer no additional benefit.

Wound bed preparation: a survey of general nurses' understanding.

This article will discuss the clinician's knowledge of wound assessment based on electronic voting responses gathered at the Journal of Wound Care conference, ''Wound Expo', held in September 2015. Data were gathered on aspects such as demographic data, experience and opinions. Each workshop lasted 45 minutes and they were designed purposely to be interactive and inclusive. The session was repeated ten times over the 2-day period. A total number of 196 delegates participated in the voting and amongst the questions posed they were asked to consider which term most suited their skill set and understanding, that of 'debridement' or 'desloughing'. Of the respondents, 91% stated that they felt most confident in desloughing.

Slough and biofilm: removal of barriers to wound healing by desloughing.

The presence of non-viable tissue in a chronic wound presents a barrier against effective wound healing, hence removal facilitates healing and reduces areas where microorganisms can attach and form biofilms, effectively reducing the risk of infection. Wound debridement is a necessary process in those wounds that have evidence of cellular debris and non-viable tissue. As slough is a form of non-viable tissue we hypothesise that it will support the attachment and development of biofilms. Biofilms are entities that have serious implications in raising the risk of infection and delaying wound healing. In those wounds that contain only slough, high-risk debridement methods are not considered necessary for its removal. The use of mechanical techniques for removing the slough is regarded as posing a much lower risk to the patient and the wound bed. The process of removing slough from a wound is referred to as 'desloughing'. We propose that mechanical desloughing is a low-risk method of debridement to aid the specific removal of slough. Slough in a wound is a recurrent issue for a large majority of patients. Consequently, desloughing should not be deemed a one-off process but an on-going procedure referred to as 'maintenance desloughing'. Maintenance desloughing will help to achieve and maintain a healthy wound bed and aid the removal of wound biofilms, facilitating wound healing.

Are community nurses prepared for wound debridement?

Debridement is an essential component of wound care. However, autolysis remains a frequently used method of debridement, despite recent recommendations from the European Wound Management Association and the National Institute for Health and Care Excellence. Community nurses are recognised as front-line clinicians participating in debridement interventions. It is essential that community nurses are able to deliver the most appropriate debridement method regardless of their current skill set. This will require community nurses to revisit the evidence base for debridement, reflect on their current methods of debridement and expand their skill set when required. Guidance exists to ensure community nurses are able to offer appropriate and safe debridement to clients with non-viable tissue which is delaying the wound healing process.

Understanding methods of wound debridement.

Autolytic debridement describes the body's natural method of wound-bed cleansing, helping it to prepare the wound bed for healing. In acute wounds, autolytic debridement occurs automatically and often does not require intervention, as during the inflammatory stage of a wound, neutrophils and macrophages digest and removes devitalised tissue, cell debris and contaminants, clearing the wound of any cellular barriers to healing. In chronic wounds, by contrast, healing is often delayed, frequently because of inadequate debridement. The autolytic process becomes overwhelmed by high levels of endotoxins released from damaged tissue (Broadus, 2013). Therefore wound debridement becomes an integral part of chronic-wound management and practitioners involved in wound care must be fully competent at wound-bed assessment and have an awareness of the options available for debridement. This article will review wound-bed assessment, highlighting variations in devitalised tissue, and explore options available for wound debridement, taking into consideration patients' pain and quality of life.

A special case: treatment of a patient with necrotising fasciitis.

The case study in this article describes the rapid and accurate diagnosis of a critically ill patient with necrotising fasciitis (NF). Full-thickness patchy skin necrosis of the right thigh, buttock and flank was detected on admission. Prompt radical debridement together with aggressive fluid resuscitation and broad-spectrum antibiotic administration was initiated. Case ascertainment was used to evaluate the effectiveness of a debridement and wound treatment regime,using a monofilament debridement product, negative wound pressure treatment and, after the critical period had ended, a bio-cellulose+ polyhexamethylene biguanide (PHMB) dressing, followed by a collagen dressing. NF after open haemorrhoidectomy represents a life-threatening complication to otherwise healthy patients. Accurate diagnosis, prompt critical care and surgical treatment, together with debridement using the monofilament product and effective wound bed preparation, lead to a successful outcome.

[Debridement- crucial procedure in the treatment of chronic wounds]. / Debridement- krucijalni postupak u lijecenju kronicnih rana.

Debridement is the process of removing dead tissue from the wound bed. Devitalized tissue can obstruct or completely stop healing of the wound. The aim of debridement is to transform a chronic wound into an acute wound and to initiate the process of healing. Debridement is the basis of each wound treatment and it has to be repeated, depending on the necrotic tissue formation. There are several types of debridement, as follows: mechanical, autolytic, chemical, enzymatic, biological, and new debridement techniques. With advances in technology, new types of debridement have been introduced. Besides standard methods, methods of pulsed lavage debridement (hydro-surgery, water-jet) and ultrasound-assisted wound treatment are ever more frequently introduced. The method of debridement the clinician will choose depends on the amount of necrotic (devitalized) tissue in the wound bed, size and depth of the wound, underlying disease, possible comorbidity, and the patient general condition. Frequently, the methods of debridement are combined in order to achieve better removal of devitalized tissue. In addition, debridement significantly reduces bacterial burden.

Debridement--is it time to revisit clinical practice?

Debridement is the removal of non-viable tissue from a wound bed. It is an essential procedure in order to achieve wound healing and symptom control. The clinical presentation of non-viable tissue varies in content, appearance, depth and level of hydration. There may be a risk of systemic infection if non-viable tissue is not removed in a timely fashion. There are various methods of debridement each with its own advantages and limitations. The competence of the practitioner undertaking the debridement is crucial and is a key consideration along with availability of the necessary equipment and the provision of the optimal environment. Client choice and involvement are vital to the debridement process. There should be no hierarchy of debridement methods and the chosen method should achieve timely optimal pain-free removal of non-viable tissue. There is a need to question the current situation in which the specialist nurse is highly skilled in the debridement process while the generalist nurse potentially carries a higher caseload of patients who require this procedure.

The wound debrider: a new monofilament fibre technology.

Debridement is a basic necessity to induce the functional process of tissue repair, especially in chronic wounds. In this pilot study the authors used a new debrider technology with specific monofilament fibres in a unique texture to evaluate its efficacy, safety and tolerability. In eleven patients, exhibiting all types of wound-associated debris (biofilms, slough, necrotic crusts and hyperkeratotic plaques), the debrider, wetted with physiological solution, was wiped without specific force over the wound for about 2-4 minutes. This led to removal of almost all debris leaving healthy granulation tissue intact, including small epithelialized islands of vital tissue. The procedure was without pain and adverse events. Scanning electron microscopic analyses identified the majority of the removed debris tightly packed within the monofilament texture. A surgeon who blindly assessed pictures taken before and after the debridement categorized all except one wound without the need for surgical debridement and ranked all the debridement results with the new debrider as 'very good' (best category). This formulates the basic concept that the new debrider-based technology is easy, fast, highly efficient, well tolerated and cost effective.

Understanding wound bed preparation and wound debridement.

Wound bed assessment and optimum local wound care are essential to facilitate the wound healing process. The presence of devitalized tissue, for instance necrotic tissue or slough, is common in hard-to-heal wounds and acts as a barrier to healing. There are several debridement options available to the practitioner with the choice of wound debridement technique being made following a holistic assessment of the patient and the wound. The method of debridement should be discussed with the patient and family where appropriate and consent to treatment obtained prior to the procedure being undertaken.

Preliminary Experience with Conservative Sharp Wound Debridement by Nurses in the Outpatient Management of Diabetic Foot Ulcers: Safety, Efficacy, and Economic Analysis.

Background: Treatment of diabetes costs the United States an estimated $245 billion annually; one-third of which is related to the treatment of diabetic foot ulcers (DFUs). We present a safe, efficacious, and economically prudent model for the outpatient treatment of uncomplicated DFUs. Methods: 77 patients (mean age = 54 years, range 31 to 83) with uncomplicated DFUs prospectively enrolled from September 2008 through February 2012. All patients received an initial sharp debridement by one of two orthopaedic foot and ankle fellowship trained surgeons. Ulcer dressings, offloading devices, and debridement procedures were standardized. Patients were evaluated every two weeks by research nurses who utilized a clinical management algorithm and performed conservative sharp wound debridement (CSWD). Results: Average time to clinical healing was 6.0 weeks. There were no complications of CSWD performed by nurses. The sensitivity for the timely identification of wound deterioration was 100%, specificity = 86.49%, PPV = 68.75% and NPV = 100% with an overall accuracy of 89.58%. The estimated cost savings in this model by having nurses perform CSWD was $223.26 per encounter, which, when extrapolated to national estimates, amounts to $1.56 billion to $2.49 billion in potential annual savings across six to ten-week treatment periods, respectively. Conclusion: CSWD of DFUs by nurses in a vertically integrated multidisciplinary team is a safe, effective, and fiscally responsible clinical practice. This clinical model on a national scale could result in significant healthcare savings. Surgeons and other licensed independent practitioners would have more time for evaluating and treating more complex and operative patients; nurses would be practicing closer to the full extent of their education and training as allowed in most states.Level of Evidence: III.

Clinical experience with wound biofilm and management: a case series.

Biofilm is a relatively new concept in the fields of infectious disease, wound infection, and healing. Although scientific research and "noise" regarding wound biofilm is increasing, little is known about the presentation, diagnosis, potential implications, and management strategies regarding wound biofilms. A series of four clinical cases is utilized to demonstrate the existence of wound biofilm. All patients presented with or developed a film on the wound bed that appeared to be distinct from slough; wounds also were failing to progress. Although the slough in some of the wounds was easily removed with traditional debridement methods, removal of the film required physical disruption with a curette or dry gauze. All wounds eventually progressed to healing. Considering the biofilm concept and available preclinical research, it is evident from this small case series that the appearance of biofilm in wounds is quite different from slough and requires different management strategies for its control. The evolving biofilm paradigm could profoundly change approaches to wound management. Additional research is needed in this evolving aspect of wound management.

Development of abdominal wound dehiscence after a colectomy: a nursing challenge.

Abdominal wound dehiscence is associated with prolonged hospitalization, high morbidity and mortality rates, an increase in health care costs, and risk of further surgery. A case of wound dehiscence in a patient following major abdominal surgery is reviewed and a framework for understanding wound complication as a challenge to nursing care is provided.

Use of a moderate-pressure irrigation system to effect debridement in the home setting.

Rapid debridement in the home setting could represent a cost-effective way of accelerating healing rates. This retrospective study offers an insight into whether a new moderate-pressure irrigation system could help achieve this objective.

A study of biofilm-based wound management in subjects with critical limb ischaemia.

OBJECTIVE: Bacterial biofilms cause or complicate numerous medical conditions, including chronic wounds. Biofilm-based wound care (BBWC) management strategies that suppress biofilm have been designed and are used extensively at the Southwest Regional Wound Care Center in Lubbock, Texas and are described in this article. This retrospective single-centre study was designed to evaluate the frequency of complete healing in subjects with a chronic wound in a limb with critical limb ischaemia (CLI) when managed using BBWC. METHOD: Of the 4500 subjects admitted with wounds between August 2002 and January 2006, 1400 subjects' TCpO2 levels were measured, and 266 included were identified as having CLI (TCpO2 < 20mmHg). Of these, 190 subjects were considered in the analysis because they received a substantial course of therapy (more than five visits). Each subject was individually managed to reinforce natural healing and suppress bacterial biofilm. Successful healing was defined as complete closure by March 2007. RESULTS: Of the 190 subjects with CLI, 146 (77%) healed completely, and 44 (23%) were categorised as non-healing. The healed group included 47% (68/146) with osteomyelitis and 69% (101/146) with diabetes mellitus. In the non-healed group, 75% (33/44) had osteomyelitis and 77% (34/44) had diabetes mellitus. Ninety-one per cent (30/33) of the subjects without osteomyelitis or diabetes mellitus healed, and 67% (53/79) of the subjects with both osteomyelitis and diabetes mellitus healed. CONCLUSION: When comparing the healing frequency in this study with a previously published study, BBWC strategies significantly improved healing frequency. These findings demonstrate that effectively managing the biofilm in chronic wounds is an important component of consistently transforming 'non-healable' wounds into healable wounds.

Maggot debridement therapy: serious bleeding can occur: report of a case.

Maggot debridement therapy is generally a safe therapy that is typically used as a last resort treatment for debriding wounds in patients with multiple comorbidities. We describe a case of serious bleeding in an 87-year-old woman treated in our wound care center for a mixed arterial-venous ulcer of the right leg. Daily home visits were completed by a wound care nurse, resulting in prompt recognition and management of the bleeding. The patient was transported to hospital via an ambulance, and rapidly stabilized with intravenous fluids and a blood transfusion. She subsequently returned to the home care setting for additional management of her lower extremity wound.

Is ultrasonic mist therapy effective for debriding chronic wounds?

BACKGROUND: Ultrasonic mist debridement uses acoustic energy to remove devitalized tissue from the wound bed and to promote wound healing. OBJECTIVES: We systematically reviewed the literature to determine whether ultrasonic mist therapy effectively removes necrotic debris from the bed of chronic wounds and promotes wound healing. SEARCH STRATEGY: A systematic review of electronic databases MEDLINE and CINAHL (from January 1996 to February 2008) was undertaken using the key words: (1) therapeutic ultrasound, (2) ultrasonic, and (3) ultrasonic mist. Prospective studies that compared ultrasonic mist therapy to a sham device, to another debridement technique, or to alternative treatments for wound healing were included. RESULTS: There is insufficient evidence to determine whether ultrasonic mist therapy effectively debrides necrotic tissue in chronic wound beds. Limited evidence suggests that noncontact, low-hertz frequency ultrasonic mist therapy promotes wound healing when used in conjunction with standard wound therapy. IMPLICATIONS FOR PRACTICE: Ultrasound treatment has been used on wounds associated with neuropathy, limb ischemia, venous insufficiency, trauma, as well as poorly healing surgical wounds. Few adverse effects have been noted. Pain, when reported, has been successfully addressed with topical analgesia.

Pulsed radio frequency energy in the treatment of complex diabetic foot wounds: two cases.

The use of radio waves (pulsed radio frequency energy) has become well accepted in the treatment of chronic wounds. We present 2 cases of complex diabetic foot wounds treated adjunctively with outpatient pulsed radio frequency energy using a solid-state, 27.12 MHz fixed power output radio frequency generator that transmits a fixed dose of nonionizing, nonthermal electromagnetic energy through an applicator pad. This therapy, in combination with offloading, debridement and advanced dressings, resulted in closure of both wounds in approximately 16 weeks.