Enzymatic debridement: No perfect solution yet
The search appears far from over
A recently published study on procedures for determining the effectiveness of various enzymatic wound debriding agents illustrates the continuing need for a reliable, cost-effective enzymatic debrider for use in wound care.1
Researchers concluded that the automated in vitro procedure used in the study can produce useful information for evaluating the effects topical antimicrobials, wound cleansers, wound dressings, and drug infiltrates have on the effectiveness of debriding agents. The study used porcine skin and muscle tissue as substrates in an automated Franz-type in vitro diffusion cell system.
Enzymatic debriding remains a part — albeit often a small one — of most wound care practices. Ronald G. Scott, MD, medical director of the Wound Care Clinic of North Texas at Presbyterian Hospital of Dallas, says, "If I were breaking it down, I do probably about 80% sharps debridement, 15% autolytic or some combination of autolytic and enzymatic, and 5% straight enzymatic." Scott says he often uses a hypertonic saline gel called Hypergel. "It works a lot like an enzymatic debrider at about half the cost."
Drawbacks of surgical debridement
Cost is an important factor in debridement no matter how it’s done.2 Surgical debridement is expensive because in most places a surgeon has to do it. In states where nurses are permitted to perform sharps debridement, they face significantly higher liability but don’t receive pay equivalent to what surgeons receive for doing the same job.
Patients in nursing homes and in home health care frequently have physical difficulty getting to a hospital or clinic. Surgeons sometimes practice surgical debridement aggressively, going well beyond the outer edges of a wound, which creates a larger wound and an opportunity to spread infection through a bleeding site. Autolytic and enzymatic debridement are less expensive than surgical debridement, and therefore more financially accessible to many patients, but they also are lengthier processes.
Barry Constantine, director of product development for Integra LifeSciences Corporation of Island Heights, NJ, has interviewed numerous wound care nurses in the course of his work. "What they want in an enzymatic debridement agent is one that is fast-acting, that works within 24 hours, and one that will not damage the surrounding viable tissue." He points out that enzymes may not discriminate between the non-living tissue they are being used to debride and the adjacent living tissue. Enzymes also may degrade themselves, making a truly accurate measure of their efficacy in debriding necrotic tissue impossible. Constantine points out that both enzymatics and hydrogels require multiple applications and usually require between four and eight days before appreciable degradation of the necrotic tissue is seen. "My concern is that during that four- to eight-day interval, that necrotic tissue acts as a substrate for bacteria that have the potential to form an infection, especially if the patient is immunocompromised."
A good idea whose time has not come
Herbert Meites, MD, FACS, medical director of the wound care center and hyperbaric medicine department and associate medical director of the burn center at Integris Baptist Medical Center in Oklahoma City, also has a low opinion of enzymatics currently available. "The idea is fine," Meites says, "but we don’t have a good enzymatic debridement agent now. We really need a good model to be able to say, OK, we’re going to treat all the wounds the same.’ We now have only one variable, which is enzyme vs. none."
Meites also points out that many of the chronic wounds he sees have had very poor wound care and improve very quickly once the level of wound care rises. He says he thinks the positive outcomes that result from using enzymes to debride wounds come more from the attention given the wound than the ability of the agents themselves. When a patient receives enzymatic debridement, the wound caregiver attends to the wound almost every day, and may sharply debride the wound during the same visits. "The real question is," Meites says, "is the wound getting better faster because of the enzyme, or because there’s a lot more attention being paid to the wound? I think it’s probably the increased attention and not necessarily the product. It may well be that good wound care with no agent will do better than poor wound care with an agent."
References
1. Hobson D, et al. Development and use of a quantitative method to evaluate the action of enzymatic wound debriding agents in vitro. Wounds 1998; 10:105-110.
2. Sieggreen MY, Maklebust J. Debridement: Choices and challenges. Advances in Wound Care 1997; 10:32-37.
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