Serial Surgical Debridement of Common Pressure Injuries in the Nursing Home Setting

Outcomes and Findings

Bardia Anvar, MD; Henry Okonkwo, PA-C

Disclosures

Wounds. 2017;29(7):215-221. 

In This Article

Discussion

The action of surgical debridement of wounds can produce rapid removal of severely infected tissue, gross slough, necrosis, and devitalized tissue.[12] Currently, practitioners base the decision to debride upon the physical appearance of the wound tissue. It has been elucidated through many previous studies[3–14] that the presence of devitalized tissue can impede wound healing and cause wounds to worsen. To the best of the authors' knowledge, the exact timing and periodicity of debridement has not been examined in the nursing home population.

Although many protocols and policies exist to prevent PI formation, PIs have not gone away, and the question of how to best care for these wounds with significant tissue compromise remains.[13] In the present study, the majority of patients responded to bedside surgical debridement in the nursing home setting; 73% of wounds showed a 25% reduction in size within the first month of debridement, while the minority exhibited either no response or worsened. The investigators found that on the whole the wounds that did not reduce in surface area as a result of surgical debridement began with a smaller surface area and less depth. It may be that the nonresponder group had wounds that were worsening and the debridement only managed the degree of necrotic tissue. Since the nonresponding wounds were smaller, they may have not yet manifested the underlying PI at the bony prominence, and they increased in size as the debridement of the underlying necrotic tissue progressed. Overall, the age characteristics of the 2 patient populations were similar. The starting percentage of granulation tissue was nearly equivalent in both groups; therefore, 1 group did not have a better appearance than the other.

This study also demonstrates that each pressure site responded to treatment, though the coccyx sites demonstrating the greatest difficulty to heal. The difficulty of healing coccyx sites may be due to a variety of factors including the greater proximity of the coccyx to the anus, the protrusion of the coccyx bone, the challenge of offloading this area, or other possible factors.

Pressure injuries are chronic wounds, which are defined by the inability to follow an orderly wound-healing pathway.[14] Chronic wounds are stalled in the inflammatory phase of wound healing, making the process of achieving wound healing difficult. This stalled phase is characterized by an increase in matrix metalloproteinases, a decrease in tissue inhibitor metalloproteinases, and abnormal cellular senescence.[15] The biological characteristics of PIs make wound healing challenging.

The present study demonstrates that despite multiple weekly surgical debridements, the vast majority of the wounds did not heal. Providing surgical wound debridement of PIs without consideration of the overall patient condition and the after care of the patient by nursing staff will most likely not lead to optimal wound healing outcomes. This study did not examine important related factors such as daily nursing care, dressing selection, risk wound healing factors, and patient medical history. Wound healing is a multifactorial process based on both biology and care. As patients age and develop medical problems, their ability to properly heal wounds diminishes. Skin aging causes cellular senescence, a process where the skin cells no longer divide and multiply. The inability of senescent cells to proliferate can impair tissue regeneration after injury, causing prolonged or permanent tissue damage with age. With respect to wound healing, an excessive number of senescent cells may restrict cell proliferation and disrupt paracrine signaling cascades, thereby retarding the ability of wounds to resolve after injury.[16]

Wound care providers must work in concert with ancillary staff to provide optimal wound care on a daily basis to provide wound healing to these patients. Proper selection of wound dressings and appropriate care of periwound skin are also important factors of wound healing. Moisture-associated skin damage from both wound drainage and surrounding urinary and fecal contamination may be contributing factors in the impairment of wound healing.[17] In this study, the investigators only examined outcomes of surgical debridement and did not examine other important factors such as nursing care, wound dressing selection, and periwound skin care. Although the aim of this study was to establish baseline healing characteristics in patients who received serial debridement based on visual assessment, further studies must be done to delineate other options to reduce the repetition of tissue breakdown.

In order to heal wounds long term, it is important for wound care practitioners to go beyond the process of surgical debridement in order to provide wound healing. Although surgical wound debridement has been shown to be beneficial in removing necrotic tissue, slough, and infection, it has not demonstrated optimal wound healing in this study.

The results of this study can serve as a guideline for practitioners in the field treating chronic PIs located in the SSCIT region. Practitioners should monitor wound sizes closely for response and efficacy. If practitioners are performing a debridement, they should assess for size reductions at each visit and monitor strategy accordingly.

Further studies may be performed to clarify debridement numbers needed to heal a wound. In addition, studies should examine why certain wounds or patients are harder to heal than others. Takahashi et al[18] found a number of important factors that make wound healing more challenging: number of ulcers per resident, hemoglobin levels, and others. Other results have suggested debridement may induce more immediate wound healing week-to-week, and a "more is better" approach to surgical debridement may be correlated to improved wound healing rates and more frequent wound closure.[19] It is important to reduce wound rates on patients, as this can improve patient morbidity and mortality.

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