Debridement of wounds
Figure 1 Debriding a diabetic ulcer on the base of the great toe
One of the biggest challenges in wound care is the lack of understanding of how important debridment is, or a lack of knowledge about how to do this in a safe manner. There is also a lot of uncertainty as to how much debridement can be carried out by a nurse or medical assistant, and what should be done by a medical doctor.
A chronic wound will first start to heal properly once necrotic tissue has been removed. The most effective way to remove this is by sharp debridement. Many caregivers have a high threshold to take a sharp instrument and start scraping in a wound. This is mostly due to lack of training, sometimes for fear of causing the patient discomfort or even a complication.
Learning how to debride a wound is one of the most important skills we have to teach those dealing with chronic ( and acute) wounds. This is not something you can just read about and do - it is a practical skill where you should have a mentor by your side as you learn the procedure. There are some good videos online to show how a debridement is done, but the best is of course, if you practice this under guidance on a patient.
So - how aggressive debridement can be carried out by a nurse or a medical assistant? This question is difficult to answer in one sentence as it depends on a number of factors. What level of experience does the person have with debridement? Is there a doctor available in the area who can do a deeper debridement? Do you have local anesthesia available and have you been trained on how to use it?
Also in western countries, there is a grey zone between what a nurse/medical assistant can do and what should be done by a doctor who may have a more profound understanding of the anatomical structures closeby. At the tissue viability clinic where we work, the nurses do most of the debridements at the outpatient clinic, while deeper debridements which are performed in the operation theatre, are done by surgeons.
Usually, debridement is a fairly safe procedure, as long as you only remove dead tissue. It is normal that it will bleed a little when we debride and on occasion it may bleed more, but usually this can be stopped by compressing the bleeding site with a cotton swab for at least three minutes. Do not be tempted to look underneath the swab before a full three minutes have passed- otherwise you may end up starting all over again. It is very useful to have a general understanding of the antomic structures closeby. For example when debriding deep wounds in the groin area there are large vascular structures there which can bleed profusely if damaged. When debriding a presure ulcer in the sacral area be aware of the ischias nerve which can lie close to the wound bed. Damaging this nerve can cause sever loss of motoric and sensoric function in the limb. When debriding a wound which lies over a joint you will have to know what the joint capsule looks like. You have to avoid at all costs opening this capsule as this can lead to a devastating infection of the joint.
Remember that it is often painful for the patient to get his/her wound debrided. The exception to this are for example patients with severe sensory neuropathy due to diabetes or syphilis- here we can usually debride without the patients having any discomfort. Before we take a look at debridement methods, we first have to adress how we should deal with pain during debridement procedures. It can be useful to give the patient oral pain medication about 45-60 minutes before the procedure. Paracetmaol + Codeine is usually sufficient in most cases. Please refer also to our chapter on "pain treatment"
Dealing with pain during debridement
Paradoxically many caregivers do not take decisive measures to make the debridement as "comfortable" as possible for the patient. Not seldomly, patients are asked to bite their teeth together and tolerate the procedure a little longer- " I am soon finished" is something we hear are lot as caregivers scrape away in the wound. Not all patients are good at giving us feedback about their pain. Especially elder men often believe that they must tolerate the pain we bring upon them. We have made a short list of measures you can use to make the procedure as comfortable as possible.
1. Create a calm atmosphere in the treatment area. The patient will sense it straight away if you are nervous. Even if you have had a very busy schedule that day it is important that you take some time here. Get rid of curious bystanders- but it may of course help to have a hand to hold from a loved one or a friend during the procedure. Some patients feel safer if they are in control and can follow the entire procedure. Other patients feel very uncomfortable if they see someone scraping in their wound and in this case you will need a cloth barrier. Patients are very different in this way and you should ask them for their preferences before you start. In our experience, most patients actually prefer not to have a visual barrier but that they relax with their eyes closed and that they can take a peek whenever they feel like it. In this maner most patients feel they stay in control of what is going on.
2. Try to have all the necessary equipment close by and that everything is prepared beforehand. It will only add to the patients nervousness if you are constantly jumping up to get a new instrument, or even more so, if you are constantly leaving the room to get something.
3. Explain to the patient what you are going to do before you remove the old dressing. Something that would calm the patient would be to say: " Now we shall carefully remove the old dressing and take a look, before we do anything else". Once you have removed the old dressing and see that the ulcer has deteriorated and is full of sloghy necrotic material, do not roll your eyes and exclaim: " Oh my goodness, this looks terrible, this is the worst I have seen". Instead, keep your calm and say. " Now let us give this wound of yours a good rinse and then see how we can clean it up". Obviously we are exaggerating a little here to get our point across, but such scenarios actually exist in the world of wound care.
4. As we are removing the old dressing you will already get some indication of how sensitive the patient is. If the patient is very afraid, then even a careful loosening of the dressing can cause visible discomfort. It is therefore essential that we do everything to make the patient feel safe in our care. If the patient feels a lot of discomfort while removing the old dressing, you can be very sure that a sharp debridement is difficult to do without local anesthesia.
5. Before you touch any sharp instruments, give the wound a thorough rinse with body temperated water - you can usually used boiled tap water for this or of course saline solution. Pat the woundbed gently dry with a cotton gauze.
6. If the patient at this stage has shown no discomfort during removal of the dressing and the rinse of the wound it may be possible to gently debride without any use of local anesthesia. Inform the patient what you are about to do and that they can take a " time-out" at any point.
7. In the world of wound debridement it is very common to apply local anestetics directly to the wound bed.
There are several different formulations for this use. Remember that all local anesthetics are toxic at high doses. This is something which is surprisingly often overseen by some caregivers! Even though applying it topically rather than injecting it into the tissue allows for higher dosages, we normally use the same dosage restrictions for topical use as we would for injections to be on the safe side. There are reports of lethal toxic reactions that have occured when large amounts of topical anesthetics were applied to open wound surfaces ( for example burn patients)! Another important thing to rememeber: numbing creams like Emla and tapin have strict dose restrictions because they are absorbed more readily. They should be used with extreme caution in children under three years of age because of toxic reactions and they are infact contraindicated in children under the age of 12 months!
a) Dripping lidocaine into the wound
The simplest method is to drip lidocaine solution ( the same type as we use to inject) onto the woundbed. If you have the 2% solution available to you this will work better then the 1% or even weaker formulations. It usually works quite fast - within about 5 minutes the nerve endings in the woundbed will be somewhat numbed. It doesnt work very deep, however. Once you have debrided superficially it is usually wise to drip some more lidocaine into the wound before debriding more. Because these local anesthetics have a low pH, sometimes patients will feel a burning sensation as this is applied. Usually this side-effect quickly goes away as the numbing effect sets in. Note: there are also lidocaine sprays available - these are often used by ear-nose-throat specialists or before endoscopic procedures like gastrocopies. Some of these sprays are not ideal for use in open wounds as they contain other substances like flavourings. We have experienced that one type of lidocaine spray with banana flavour caused a severe burning sensation to the patient when applied. We therfore recommend you to avoid these sprays unless they only contain lidocaine or an equivalent.
b) Applying lidocaine gel into the wound
It is very common to apply for lidocaine (xylocaine) gel on the wound bed and let it work for about 30 minutes before trying the debridement. This penetrates slightly deeper then method a) and if you do a gentle debridement, this method is usally adequate for the majority of your patients. Lidocaine gel is fairly cheap.
c) Applying numbing cream into the wound
Even more effective are local anesthetic creams like Emla or Tapin cream. These type of numbing creams are often used for example for numbing the skin on childrens hands/arms before setting a iv cannula. When used to numb a woundbed they should also be left in place for about 30-45 minutes before the procedure. The advantage of these numbing creams is that they penetrate deeper into the woundbed than lidocaine gel. This often allows us to debride somewhat more "aggressively". However, you have to be aware that these numbing creams are not approved by the manufacturers for use in open wounds! A huge global community of wound care professionals worldwide, use this product in open wounds nonetheless, for lack of better alternatives. We have also used this method for over 20 years and have never experienced any adverse effects. But the bottom line here is: if you apply these products to an open wound this is considered " off-label" use of the product and you are doing so on your own responsibility. These type of numbing creams are usually a lot more expensive than regular lidocaine and a re usually not availabe in clinics with low resources. As we mentioned earlier, because these numbing creams are absorbed through the skin there are strict dosage restrictions and you have to be especially careful when using them on children under the age of 3 years. These products are contraindicated in children under 12 months!
Figur 2 An overview over some of local anesthetic products that can be use to make debridement less painful. On the left we have the injectable form of local ansthetics ( here Lidocaine and Marcaine) which can be repetadely dripped onto the woundbed as we debride. In the middle we have numbing jellys like Lidocaine2% or Lignocaine 2%. On the right we have numbing creams which are more efficient as they penetrate somewhat deeper into the tissue. These are usally a mixture of lidocaine and prilocaine. Be aware that all local anesthetic products are toxic when applied at too high dosages. Read the package insert carefully and never exceed the dosage recommendations! Also, the products on the right are not approved by the manufacturers for use in open wounds. When using these in woundcare, we do this as " off-label-use at our own risk! Emla and Tapin should be used with caution in children under 3 years and never in children under 12 months!
8. When we do a deeper debridement, topically applied numbing products are often not sufficient. In these cases we usually use injectable forms of local anesthetics. This should ideally only be done by medical doctor or a nurse with a medical doctor closeby. Obviously, in very low resource areas a doctor may not be available and trained medical officers or equivalent may have to do this on their own. Remember that some patients may have severe allergic reactions to this substance, although that occurs rarely. Always ask the patient beforehand if they have received injections with local anesthetics earlier and how they reacted to this. A very good tip is to inject the local anesthetic through the necrotic tissue - ideally you want to numb the area which is just behind or below the necrotic layer. This requires multiple injections, maybe up to ten or more injections for an ulcer of about 10 cm2. If you do this gently, advancing the needle ever so carefully this is hardly painful for the patient. If you, however, set the injections the traditional way, through healthy tissue around the ulcer this will usually be very painful to the patient. On occasion we have to use this method but in most cases the " through the neccrotic layer" method of injections is applicable and more gentle! We try to use the thinnes needles we have although this makes it hard to push the solution through the syringe and puts a strain on our fingers.
9. Sometimes there will be a need for a more thorough debridement at hospital level, especially when there are signs of serious infection or bone/joint involvement. This will have to be done in either sedation, a nerve block, spinal anesthesia, epidural anesthesia or general anesthesia ( narcosis). Rememeber that even if the patient is elderly and frail, there may be a need to get the patient hospitalized for a few days, to be able to do a proper debridement.
10. As we mentioned earlier: if we know beforehand that the patient is very anxious and scared it is very useful to give the patient some sort of painkillers about 45-60 minutes before the debridement procedure. A combination of paracetamol and codeine is a good choice here. Alternatively you can give Tramadol ( Ultram). In some instances you may even have to give the patient opiods. 5- 10 mg Morphine orally can be used for adults 30-60 minutes before the procedure and lower doses for children.
Methods of debriding
Autolysis
Autolysis means to " dissolve by itself". In wound care this refers to the body`s own mechanisms of dissolving dead ( necrotic tissue). In normal wound exudate which the body produces there are a number of powerful enzymes ( proteinases) which gradually dissolve the necrotic tissue. These enzymes need a moist wound environment to work which is also one of the reasons moist wound care is generally recommended. If the wound is to dry- most of the healing processes in a wound come to a halt and the wound may even deteriorate. Gels, honey and foam dressings are usually good choices to keep the wound environment at an adequately moist level. Remember, most of these products do not contain any active substances that actually dissolve the necrotic tissue. The way these dressings actually work is that they provide a perfcet environment for the enzymes and other cellular functions to heal the wound. There are however a few handful of dressings that speed up the autolytic process signifcantly - Polymem is an example of such a dressing. It contains glycerol and a surfactant and when applied to necrotic wounds the activation of theautolytic cleaning process is visible after just a few days use.
A special variant of speeding up the autolytic processes is by using occlusive dressings. With occlusive dressings we mean dressings which do not " breathe" very well. They are not completly airtight but have very little permeability. Usually, selv-adhesive hydrocolloid plates are used for this ( for example DuoDerm). They create a wam and moist wound environment which the proteinase enzymes love and which really can speed up the autolytic process manifold. However, most types of bacteria really love this environment aswell and with such an " airtight" dressing you are creating an anaerobic environments which many of the most pathogenic bacteria love even more! So please, do not use this method in Africa! And never, ever, use it on a patient with diabetic foot ulcers - that would be risking the patients limb and life. We consider this not a safe method at all. Yes, we know that it can be used with success but we have also seen catastrophies leading to septicemia and ultimately death of the patient. That being said, hydrocolloids absolutely deserve their place in woundcare. they can for example be used to protect areas of skin from shear and friction. They can also be used for very superfiscial, clean wounds.
Regardless of which dressings we use - autolysis is a fairly slow process and it may sometimes require weeks - months before a wound is clean of necrotic tissues. Only when most of the necrotic tissue is gone, can the wound start to heal. That is why, in addition to autolysis, we sometimes need faster debridement methods.
"Dry to wet" debridement
This is a very commonly used method. When we for example use polyurethane foam dressings, we use this principle. We apply the dry dressing onto the woundbed and the dressing gradually absorbs the moisture while at the same time providing a moist environment. This is often a perfect environment for autolysis. It works well when there are low-moderate amounts of dead tissue. If there is a lot of necrosis however, this process is usually slow and as the dead tisssue slowly dissolves, foul smell can be a problem. In these cases we have to change our tactics.
"Wet to dry" debridement
Simply explained this method involves placing a slightly moist gauze into the wound and letting it dry out in the course of a few days. At this point in time it will usually have adhered to the woundbed and when we remove the dressing we tear with us some of the necrotic tissue. There are several obvious disadvantages with this method. Understandably, the removal of the dressing can be very painful for the patient. Secondly, the drying out of the wound halt the autolytic enzymatic activity and may even desiccate ( dry out) and kill healthy tissue. Thirdly, this method is not very effective at removing larger amounts of necrotic tissue. Fourthly, in wounds with moderate- high secretion it will not work anyway beacuse the dressing will be moist all the time.
The " wet- to dry" method goes against modern wound care principles and it has been abandoned by most caregivers at least 10-15 years ago. Strangely enough it still has some followers here and there, who are not willing to give up on this method. Some of the followers who adhere to the method of wet-dry debridement are highly regarded professionals in the field of wound care. To be on the fair side, many years ago we also used this method, and not seldomly with success. So it would be wrong to say that this method does not work. In the right wounds, at the right time, in the right hands, it may give excellent results with respect to wound healing when there is little necrosis. With respect to how effective it is for debriding wounds we are more doubtful. The problem is that sometimes it can do the opposite, and delay wound healing. It may be difficult to foresay which wounds respond best to this and which not. Using a more modern, moist wound healing approach will work better in the majority of cases.
Dale et al. published an excellent article in 2011: "Say Goodbye to Wet-to-Dry Wound Care Dressings: Changing the Culture of Wound Care". If you are interested in this topic we strongly recommend you to read the article, which highlights several key points of why this method should be abandoned.
Incidentally, there are times where we certainly try to turn a very wet wound into a more dry wound. Infact, whenever we have a wound with high exudate, we instinctively aim at drying out the wound more. This is not the same as wet to dry debridement! Trying to get control over the exudate by placing dry products into the woundbed and changing them frequently, is simply trying to reduce the exudate to more normal levels.
Other situations where we want to keep the wound dry are vascular ulcers with dru eschar, especially on the feet. If we have a patient with poor arterial circulation and dry necrosis on the feet and no signs of infection present, we want to keep the necrosis dry! If we start to moisten these dry necroses, they will turn into a moist slough, start to smell and can easily lead to infection. Again, this has nothing to do with wet-to dry debridement. We just mention it here to make a point of that sometimes, just sometimes, we want to dry out a wound or keep it dry.
Figure 3 Dale et al. published an excellent article in 2011: "Say Goodbye to Wet-to-Dry Wound Care Dressings: Changing the Culture of Wound Care". If you are interested in this topic we strongly recommend you to read the article, which highlights several key points of why this method should be abandoned. Click on the image above to get to this link. image copyright: homehealthcarenow
Although we see this method as outdated, we will briefly explain how it is usually carried out. Normally cotton gauze is used for this purpose. A pieze of cotton gauze or an appropriately sized cotton swab is formed so that it fills the ulcer well. It is slightly moisturized with 0,9%saline solution, or 0,9%saline gel is applied on the side towards the wound bed. The cotton should be moist but not dripping wet. Important: whilst we generally recommend using clean tap water or boiled water for rinsing wounds, we do not recommend using this to moisten dresings which are to stay in the wound for a period of days.
Once the moistened gauze is placed in the wound it is covered with a dry dressing, often also gauze. A roll of gauze is used to hold the dressings in place. During the course of a few days the inner dressing will have dried out ( unless the wound has a lot of exudate). Dressing changes are usually done every 3-4 days. The inner gauze will adhere to the wound bed and upon removal will tear with it some of the necrotic tissue.
Figure 4 "Wet to dry" debridement. A slightly moistened cotton gauze piece is placed into the ulcer and covered with dry cotton gauze. A roll of cotton gauze holds the dressing in place. This type of debridement, although sometimes successful, is today rarely used. copyrights ( all images): Dr. Ido Weinberg (angiologist.com)
Debridement using abrasive pads/cloths
In the past years a number of debridement pads or cloths have come on the market. These products have in common that they have a slightly abrasive surface. When the product is rubbed over a woundbed some superfiscial debridement is achieved. The technology is similar to microfibre cloths which many of us have in the household today for cleaning purposes. The material consists of many small monofilament nooses which greatly increase the surface area of the material. Most pads have a core made of some type of absorbant foam. Necrotic debris and microorganisms adhere to the material.
Pads/cloths for debridement are single use- they cannot be washed or sterilized and need to be disposed off after use. Also, if a patient has multiple wounds at different anatomical sites - please use a new pad/cloth at each site to avoid cross contamination of bacteria from one wound to another in the same patient. As an example: a bedridden patient was unfortunate enough to sustain a pressure ulcer in the sacral area and the heel. We would expect more intestinal bacteria like enterococcal species to be present in the sacral area than in the heal ulcer. It would therefore be unwise to use the same pad in both wounds. If you have two ulcers within close vicinity to each other, you may use the same pad in both, as long as they are both similar in appaerance.
Even though we are rubbing the woundbed with these products they are surprisingly gentle and very often the patient has no or only little discomfort during the procedure, as long as we dont use unnecessary pressure. We generally moisten the pads/cloth with a suitable rinsing agent upon use. This could be anything from boiled water (clean tap water), 0,9% saline or antimicrobial solutions like super-oxidized water, a 2% vinegar solution or a polyhexanide solution just to name a few. Note that some cloths are premoistened - usually with some sort of solution containing a mild surfactant ( a soap-like substance).
Obviously these pads/cloth are not as effective as sharp debridement with a curette or scalpel. They are however a safe alternative for caregivers who do not feel themselves competent enough to do a sharp debridement. Do not expect miracles - you cannot simply rub away thick necrotic tissue. However, these products do work very well when there is some superfiscial slough and we believe it is an effective tool for removing biofilm. If there is a lot of necrotic tissue you always have to consider a sharp debridement first, especially if there are also signs of infection.
To be honest, when these pads/cloths first came on the market, we were sceptical. Infact, we ignored the first products that appeared and though
Debriderings pads/kluter er også veldig praktiske for å fjerne tørr flassende hud. Dessuten egner pads/klutene seg veldig godt til rensing av akutte sår.
De fleste leverandører av debridement pads/kluter reklamerer for effektiviteten av å kunne fjerne biofilm og det finnes klinisk dokumentasjon for dette. Vi minner imidlertid om at biofilm ikke er hovedutfordringen ved behandling av kroniske sår. Mens biofilm absolutt kan være et problem for enkelte sår, er dårlig blodsirkulasjon, dårlig kompresjonsbandasjering og manglende avlastning en mye større utfordring. Poenget er at det er bra at en kan redusere forekomsten av biofilm med pads og kluter men det må ikke stjele oppmerksomheten fra andre viktige aspekter av sårbehandlingen.
Om en pasient har flere sår bør man bruke en pad/klut til hvert sår for å unngå krysskontaminering, unntaket er dersom sårene er mer eller mindre sammenhengende. Dette er et engangsprodukt.
Figur 4 Noen av debridement pads /kluter tilgjengelig i Norge i dag. Fra venstre: Debrisoft, Debriclean, Prontosan Debridement Pads og UCS debridement kluter
Video 1 Noen eksempler på hvordan UCS kluter kan brukes
Video 2 Bruk av Debrisoft
Enzymer som kan påføres såret for å løse opp nekrose
Hadde det ikke vært fantastisk om en kunne smøre noe på såret som løste opp all nekrose uten at pasienten kjente smerter? Dessverre finnes det ikke enda. De som har behandlet sår lenge vil huske et stoff som heter streptokinase (tidligere markedsført under navnet Varidase®), et pulver som inneholdt de samme enzymene som streptokokker bruker for å bryte ned vev. Dette blandet vi ut med vann og påførte det i sår. Det hadde muligens noe effekt. Streptokinase ble i hovedsak brukt til intravenøs behandling ved blodpropp ved hjerteinfarkt, nyere trombolytiske medikamenter har stort sett tatt over. Det er fortsatt noen som fremdeles bruker det i sårbehandling.
Det finnes en rekke forskjellige enzymer til sårbehandling, f.eks Papain fra Papaya frukt men foreløpig er det ingen preparater som virkelig kan vise til gode resultater. Diverse forskningslaboratorier rundt omkring i verden jobber iherdig med å isolere de enzymene som fluelarver bruker for å løse opp dødt vev. Larvenes enzymer er nemlig uhyre effektive til denne jobben. Utfordringen er imidlertid at larvene benytter seg av en kompleks cocktail av enzymer og det er ikke lett å fremstille disse syntetisk. Vi tenker at dette vil spille en sentral rolle i fremtidens sårbehandling. Om 10 år bruker vi sannsynligvis en syntetisk coktail av fluelarvenes enzymer til å rense mange sår.
Debridement med ringcurette eller skarp skje
Dette er den vanligste formen for debridement. Før i tiden benyttet en seg oftest av en skrap skje som kunne re-steriliseres men disse ble sløve over tid. Svært mange bruker i dag engangs curetter. Det finnes flere leverandører og det er kvalitetsforskjeller. Curettene fra Stiefel er vanlig i Norge og de er av høy kvalitet. Avhengig av hvilken side av ringen en benytter, har de en meget skarp kant på den ene siden (for å skjære vekk nekrose) og en mindre skarp kant på den andre (for å "koste" bort fibrin og løst dødt vev). Disse kan ikke resteriliseres. De må kastes i beholder for skarpe instrumenter etter bruk.
Figur 5 Curettene fra Stiefel er av god kvalitet og har en skarp og en butt side som er nyttig ved sårrevisjon.
Om en ikke har en ringcurette eller skarp skje tilgjengelig kan en bruke en skalpell til å skrape over såret med. Det er ikke like effektiv som en ringcurette men fungerer greit i de fleste tilfeller.
Ofte må en gjenta debridement ved hvert sårskift og litt etter litt får en til slutt såret rent.
Skarp revisjon med kniv
Mange vil anse dette som en lege oppgave, spesielt hvis en må skjære vekk større områder med nekrose. Det kan være behov for god bedøvelse, enten med lokalbedøvelse eller sedasjon/anestesi på sykehus. Oftest trenger en også en pinsett for å holde vevet mens en skjærer. Plastpinsetten som ligger i de fleste engangs vaskesett er dårlig egnet til å holde vev under en revisjon og vi anbefaler at en skaffer seg enten gode metall engangspinsetter eller pinsetter som kan resteriliseres.
Figur 6 Flergangs skalpell (øverst) og engangs skalpell (nederst). Vi anbefaler bruk av nr. 15 blad til debridement av mindre sår da det gir bedre kontroll. Husk at en god pinsett er viktig for å gripe tak i vev som skal skjæres bort. En kirurgisk pinsett har små tenner helt ytterst slik at den får bedre tak i vevet.
Figur 7 Definisjon av en kirurgisk pinsett i motsetning til andre medisinske pinsetter er at den har små tenner eller tagger helt ytterst som gir bedre grep i vevet.
Når pasienten er bedøvet med sedasjon eller til og med spinal bedøvelse/blokader/narkose er det ekstra viktig at en bruker sjansen til å rense såret så grundig som mulig, det kan til og med bety at en må skjære litt i friskt vev for å få med seg all nekrose.
Figur 8 En liten saks som er spiss og lett bøyd kan være god til drebidement. En god pinsett er nødvendig.
Debridement med "vannkniv"
Versajet ® er et apparat som lager en sterk og ultratynn vannstråle som klarer å skjære gjennom vev. Det sies at prosedyren er mindre smertefull enn ved å bruke en curette eller kniv. Apparatet består av en base enhet hvor en kobler til selve vannstrålekniven som er engangsutstyr. Det er relativt dyrt og derfor ikke egnet for revisjon av mindre sår. Men på for eksempel brannskade avdelinger hvor en foretar revisjoner på store områder er det vanlig å ha utstyr til dette.
Figur 9 Versajet® II System fra Smith & Nephew™. Håndstykket er engangsutstyr og kan kun brukes på en pasient, det kan ikke re-steriliseres.
Figur 10 Versajet® sitt håndstykke "kostes" lett over såret og overfladisk nekrose og fibrin "smelter" bort.
Debridement med ultralyd
På samme måte som "vannkniv" (Versajet®) regnes revisjon med ultralyd som mer skånsom enn mekanisk revisjon med kniv eller curette.
Dette er ikke samme type ultralyd som en bruker på en røntgenavdeling, men ultralydbølger av en helt annen bølgelengde slik at de faktisk har en skjærende kraft. Det trengs fuktighet for at disse ultrasoniske bølgene når vevet og derfor kobles en vannflaske til apparatet.
Igjen er det et økonomisk spørsmål. Et slikt apparat står på mange avdelinger sin ønskeliste. Basestasjon koster ofte rundt 200.000 kroner i tillegg er det ofte noe engangsutstyr men det finnes også løsninger med resteriliserbare håndstykker.
Figur 11 GENERA® Ultrasonic system er en av mange ultrasoniske maskiner egnet for rengjøring av sår.
Når en bruker vakuum behandling skal såret være så rent som mulig. En kan ikke legge vakuum bandasje på urene sår, infiserte sår eller sår med mye nekrose. Om det finnes sparsom nekrose i et ellers velsirkulert sår kan en bruke en vakuum bandasje likevel. En ser da ofte at det friske granulasjonsvevet vokser over og "absorberer" nekrosen, en fremskynder på en måte autolyse prosessen. Men vakuum behandling kan ikke brukes til debridement generelt.
Se også kapittelet om vakuum behandling under "meny"-"verktøy"-"vakuum behandling".
Debridement med fluelarver
Bruk av fluelarver har lang tradisjon i sårbehandling. En kan ikke bruke hvilken som helst flueart da noen fluetyper kan skade frisk vev. Larvene til fluen Lucilia Serrata derimot «spiser» kun dødt vev og det er den fluearten som er kommersielt tilgjengelig i Europa og USA.
Figur 12 Biobag med små fluelarver fra Biomonde®
Larvebehandling brukes i Norge men kun sporadisk og kun av noen få behandlere. En av grunnene til dette har vært problemer med bestilling av larver.Vi har opplevd at bestillinger ble stoppet i tollen for eksempel.
I noen år kunne man bestille fluelarver fra Sahlgrenske Universitet i Sverige men de har sluttet med produksjonen i 2013. I Europa er det Firmaet Biomonde® som er den største produsenten av sterile fluelarver men de ville ikke selge til Norge uten at de hadde norsk distribusjonsfirma.
Det er nå offisielt at det er PartnerMed AS som har inngått samarbeid med Biomonde og fluelarvene kan bestilles via PartnerMed. Per dags dato (status 30.oktober 2017) fant vi ikke informasjon om bestilling av larver på PartnerMed sin nettside men det kommer sikkert snart.
Det er dessverre noen juridiske hinder i veien i Norge for bruk av larvene. Det er lov å bruke larvene men foreløpig må det sendes en individuelt søknad til helsemyndighetene for tillatelse for bruk av larvene for hver enkelt pasient! Dette er helt upraktisk og gjør det nesten umulig å bruke larvene i praksis, når en har behov for larvene er det ofte alvorlige sår hvor en ikke har en ukes tid for å vente på en godkjenning fra helsemyndighetene! Det går an å søke om dispensasjon for en hel avdeling. Det vi si at man kan søke om dispensasjon for bruk av larver på en hel sårpoliklinikk, en avdeling eller til og med et sykehus. Wounds AS håper at det byråkratiske hinderet blir ryddet av veien når det endelig kommer en norsk distributør for produktet.
Hvordan larvene kommer til å prises i Norge er usikker. Da man kunne bestille larvene fra Sahlgrenske i Sverige betalte man rundt 2300.- NOK for ca 1000 larver, de kunne oppbevares i kjøleskap og da hadde man altså nok larver for ca 2-3 behandlinger over 7-10 dager. Med litt planlegging kunne man også behandle to eller flere pasienter samtidig, det blir imidlertid ikke mulig når larvene kun selges i biobags.
Indikasjon for larvene er sår hvor man må revidere gjentatte ganger men der det stadig tilkommer ny nekrose, sår som må revideres ofte og er smertefulle ved revisjon. De fleste pasienter rapporter at de ikke har ubehag under bruk av larver. Noen få pasienter har sterkere smerter under larvebehandling og da skal man gå over til en annen behandling.
Tidligere ble larvene solgt som enten «frittgående» eller i poser som ligner på teposer (biobags). Ifølge BioMonde® har en nå gått over til å kun levere larver i biobags. Larvene er ikke avhengig av å kunne være i kontakt med selve nekrosen. De spiser ikke vevet direkte men bruker sine enzymer i «spyttet» til å løse opp dødt vev som de så «slurper» i seg etterpå.
Larvene er forholdsvis ømfintlige og de trives ikke hvis såret er for tørt eller for vått (da drukner de rett og slett). De trenger også tilgang til oksygen så bandasjen over såret må kunne puste.Spesielt i starten vil såret sive ganske mye når en bruker larver og bandasjen må kunne fange opp en del sekret for å unngå at larvene drukner.
Fluelarvene beholdes i såret i 3-4 dager, deretter har de vokst seg 10 x i størrelse og er klare for å forvandle seg i pupa, det neste stadiet i fluenes syklus før de blir voksne fluer. Ofte kreves det 2 eller 3 behandlinger (altså 6-9 dager) før såret er blitt ordentlig rent men vi har også sett tilfeller hvor en 3 dagers behandling med larver var svært effektiv.
Som regel regner man 10 larver per cm2 av såret, dvs 50 larver for et 5 cm2 sår.
Før man legger larvene i såret skal det rengjøres så godt det lar seg gjøre mekanisk, deretter skal en skylle over såret med NaCl og tørke det med en tupfer eller kompress. Ikke bruk noe antibakterielle skyllemidler i renseprosess da disse kan skade de ømfintlige larvene.
Beskytt sårkantene godt med enten barrierefilm (Cavilon,Secura, Silesseeller sinkpaste) fordi sekresjon fra larvene er ganske sterk og fører ofte til irritasjon av sårkantene.
Legg biobag med larvene i sårbunnen, evtl legg en "fluffet" kompress over posen med larvene slik at posen har god kontakt med sårbunnen. Når man benyttet frittgående larver måtte man dekke over med en finmasket netting for å unngå rømlinger men nå når larvene selges i poser er dette ikke nødvendig. Sekundær bandasjen må være luftig. En bandasje med plastfilm puster ikke nok, også en skumbandasje kan føre til oksygenmangel. Her må en av og til være litt oppfinnsom men en hyperabsorberende bandasje uten plastfilm er ofte bra, en kan også klippe noen ekstra luftehull i disse.
Wounds AS mener at larvebehandling absolutt har en viktig rolle i sårbehandling. Det er på ingen måte en gammeldags behandling. Tvert imot, det kan betegnes som en high –tech biologisk behandling av sår. Det finnes noen sår som behandles aller best med larver men de aller fleste sår trenger selvsagt ikke larvebehandling. Når larvebehandling igjen blir tilgjengelig i Norge forventer man en økt etterspørsel etter produktet, spesielt hvis det nå kommer en norsk distributør som også kan stå for opplæring av helsearbeidere.
Du kan lese mer om larvebehandling under «meny»-«verktøy»-«larveterapi».
Nedenfor er en link til et konsensus dokument fra EWMA om debridement av sår. Klikk på linken for å komme til pdf av dokumentet.
