Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 36

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PRESSURE ULCER PREVENTION AND TREATMENT FOLLOWING SPINAL CORD INJURY

blood cells and proteolytic, fibrinolytic, and
collagenolytic enzymes that enter the wound
to digest the necrotic tissue present in the
wound. It is most active in a moist wound.
Adequate leukocyte function and number are
essential. If wound exudate is left undisturbed,
neutrophils and macrophages continue their
phagocytic work and the production of growth
factors in the wound exudate continues. If
autolytic debridement is used as a sole form
of debridement, it should be used only in
noninfected wounds. It should not be used in
the presence of neutropenia (neutrophil count
of <500 mm3) and/or wounds with advancing
cellulitis. Diminished neutrophils can result in
increased bacteria in the wound bed. In the case
of infection caused by anaerobic bacteria, the
presence of fluid in the wound bed and the use
of an occlusive dressing will increase the
growth of anaerobic bacteria.
Mechanical debridement
Mechanical debridement is most commonly
performed with the application of a wet dressing
to a wound, which is subsequently removed when
dry, thus the aptly named wet-to-dry dressing. It
can be painful for those who are sensate in the
area of their ulcers. It is a nonselective form of
debridement with the potential of removing
healthy granulation and epithelial tissue when the
dressing is removed along with necrotic tissue.
Other forms of mechanical debridement, such as
low-pressure pulsatile lavage, and intermittent
irrigation using a syringe can also be effective in
clearing the wound bed of debris.
A hydrosurgery system of debridement,
similar to high-pressure pulsatile lavage, enables
the precise removal of necrotic tissue. This
system projects a high-velocity waterjet across
the operating window into an evacuation
collector. The suction permits the surgeon to
hold and cut targeted tissue while at the same
time aspirating debris from the wound. In a case
series, (Gurunluoglu 2007) found that this type
of debridement might be a useful alternative
for soft tissue debridement in preparing wounds
for reconstructive surgery, although more
studies are needed to support its efficacy and
cost-effectiveness.
Enzymatic debridement
Enzymatic debridement works by the topical
application of commercially produced biologic
enzymatic agents that digest the components of
slough and dissolve the collagen that anchors
necrotic tissue to the wound bed, and spares the
non-necrotic tissues. Enzymatic debridement is
often helpful in wounds where the necrotic tissue

is so adherent to the wound base that it is difficult
to be safely removed by mechanical or sharp
debridement. However, the debridement would
take more time to be achieved. It is safe to use in
wounds with high bacterial loads.
Sharp debridement
Sharp debridement utilizes a scissors or
scalpel or curette to cut or scrape away necrotic
tissue and biofilm from the wound bed. Bleeding
and injury to viable tissue are the main risks. This
is the more rapid way of selectively removing
necrotic tissue and biofilm. One exception to the
recommendation for sharp debridement of
necrotic tissue and eschar is when stable eschar
is present over the heel. These stable heel ulcers
with eschar should not be debrided (Black et al.
2007). However, the presence of edema,
erythema, fluctuance or drainage would indicate
eschar debridement is necessary.
Surgical debridement
Surgical debridement is the most efficient
method of debridement for removing large
amounts of tissue in a single session. It is
performed as an operative procedure and may
involve excising the skin over the area of
undermining to allow for debridement of
underlying necrotic tissue from infected wounds
and areas of fibrosis, removal of callus from
wound edges, removal of all grossly infected
tissue, and obtaining a biopsy of the deep tissue
after debridement of all nonviable or infected
tissue for culture and pathology to determine the
presence of infection, fibrosis, and granulation
tissue. Debridement may be performed using a
scalpel, electrocautery, rongeur, or curette for
debridement of bone. Because there may be
associated pain and/or bleeding, as well as
autonomic dysreflexia, anesthesia is often used.
Bleeding, the need for anesthesia and its
associated risks, and possible injury to nervous or
other viable tissue are the main disadvantages. It
is indicated in cases of advancing cellulitis with
sepsis, immunocompromised individuals, and in
cases of life-threatening infections. Surgical
debridement of necrotic ulcers associated with
sepsis can rapidly eliminate the source of
infection (Galpin et al., 1976). Using surgical
debridement, the surgeon makes a wide excision
of the ulcer in preparation for closure. Serial
debridement is required for wounds with heavy
bioburden; maintenance debridement performed
within 24 to 72 hours of initial debridement is
recommended to control bacterial bioburden.
Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury

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