[seeker]

Does anyone know of any way (other than surgery) to debride a pressure sore? My husband has one on his perineum, and it needs debridement, but we don't want him to go to the hospital to have it done...I wouldn't be able to see him everyday...I am American, and haven't gotten accustomed to driving on the left side of the road yet, plus I have no idea where I am going. So we are hoping that there is something we can do to get the dead skin out by ourselves. We use the Manuka honey, and that is working great, but is it enough???? He is staying in bed most of the time, except when he has to get up to go somewhere (daughter's school program) or for me to change the sheets. Any help, suggestions will be appreciated.

[kewlcatkez]

hello,

I am a Registered Nurse/Staff Nurse by trade "in a previous life" ie before disability.

I suggest that you look at some of the literature regarding wound care and debridment of wounds. I was always taught that surgical removal was the only sure way to remove 'dead' or necrotic skin/tissue. However, there are agents which can be used such as dressings and the like which can assist in healing. Some people have been involved in the use of sterile medical grade maggots on the wounds. They only eat away the necrotic tissue.
Any and all decisions should be made by your husband, after he has had a chance to evaluate his choices, the facts and figures of them and the successes with that particular surgion/wound care specialist. Many wound care nurses will be happy to go through the options with your husband and yourself so that you come to a desicion based on your particular situation, general health, injury level etc.

Please see the NICE guidelines ( National Institute for Clinical Excellence). Here is a paper ( albeit from 2001) which will give you some insight inot many of the options and the evidence based success/failure rates: NICE

Here is the opening paragraphs of guidance:

Quote

1.1 There is no RCT evidence to support any particular method of
debridement for difficult to heal surgical wounds, but less robust
studies suggest modern dressings (products thought to promote
autolytic wound debridement, including hydrocolloids, hydrogels,
polysaccharide beads/paste, foam dressings, and alginate dressings) as
well as bio-surgical techniques (sterile maggots) may reduce pain and
be more acceptable to patients.

1.2 In the absence of sufficient evidence for or against any particular
method of debridement, or for one type of modern dressing over
another, the choice of debriding agent for difficult to heal surgical
wounds should be based on impact on comfort, odour control and
other aspects relevant to patient acceptability, type and location of
wound, and total costs. Costs of wound care are very sensitive to the
frequency with which dressings are changed - this applies particularly
to home wound care requiring a visit by a nurse.

SOURCE: http://www.nice.org....areguidance.pdf

( I hope that it is ok to quote this, Apparelyzed?)

Also please see:

Britich Medical Journal article

and

European Pressure Ulcer Advisory Panel, HERE


Hope this is of some help to someone,

Take care,

K

[seeker]

We had a liason nurse from one of the hospitals come in and look at it and as soon as (seriously, 2 seconds after) the district nurse took of the bandage, she said, "surgery". Not giving us any other option...if we asked about something else..."no, we need to get you on the waiting list to have it surgically repaired". No discussion what so ever. We have asked our district nurse to bring in a wound care specialist so we can get a second opinion. She has said something about dressings that will help, but she hasn't offered any of them...kind of like she doesn't want to use them. It seems like they are determined to put him in the hospital for 2 months. He definately doesn't want to do that. So anything that we could do to get this moving along would be a big help.

[NurseVic]

What have you tried, besides the honey? I'll be honest, I have seen very few patients have good results with honey. I don't like it. What is the tissue like? What colour is it? What other things have you tried? What grade is the ulcer? How deep is it? What secondary dressing are you using?

I could give you an opinion if you can post that information, based on what I would do as a DN. You should also ask for a Tissue Viability Nurse Specialist to look at it ASAP.

[seeker]

NurseVic, on Oct 20 2007, 08:29 PM, said:

What have you tried, besides the honey? I'll be honest, I have seen very few patients have good results with honey. I don't like it. What is the tissue like? What colour is it? What other things have you tried? What grade is the ulcer? How deep is it? What secondary dressing are you using?

I could give you an opinion if you can post that information, based on what I would do as a DN. You should also ask for a Tissue Viability Nurse Specialist to look at it ASAP.

Besides the honey, we have used intrasite and silvercel...they did ok, but not as good as the honey. The tissue is a mixture of dark brown, and an off white. It is softening up very well with the honey, but not so much the intrasite. We use the silvercel with the honey as well. I believe it is a grade 3, and about 1 inch deep (that is just a guess...it has never been measured). I'm not sure what you mean by secondary dressing, we put an Allevyn adhesive bandage over it, with a padding over that even when he is in bed.

[NurseVic]

If you've tried intrasite and honey, and you're still not getting adequate autolytic debridement then I would probably agree that surgical debridement might be the best option.

Have you tried granugel with tegaderm hydrocolloid/sacrum? It might make the wound exude more, but the dressing can be changed every 1-3 days. You definitely need to see a Tissue Viability specialist nurse to look at it, but the thing is, if you don't get the sloughy/necrotic tissue off, it won't heal. If you get it off, you have a real chance. I would go for the method that you know will work, at this point.

[seeker]

NurseVic, on Oct 22 2007, 08:40 PM, said:

If you've tried intrasite and honey, and you're still not getting adequate autolytic debridement then I would probably agree that surgical debridement might be the best option.

Have you tried granugel with tegaderm hydrocolloid/sacrum? It might make the wound exude more, but the dressing can be changed every 1-3 days. You definitely need to see a Tissue Viability specialist nurse to look at it, but the thing is, if you don't get the sloughy/necrotic tissue off, it won't heal. If you get it off, you have a real chance. I would go for the method that you know will work, at this point.

No we haven't tried that. I'll mention that next time the nurse comes. The district nurse has been trying to get ahold of a tissue viability specialist, but she has been on holiday...should be hearing sometime soon when she can come see us. It is looking a lot better now, I am real encouraged. Thanks for your opinions...I'll let you know what happens.

[kewlcatkez]

Hi again,

I just wanted to throw one more thing into the mix here re: pressure sores.

Has your husband had a wound swab taken and sent to the lab to see what it grows? Pressure ulcers are inevitably infected with and anaerobic bacteria and either gram negative, gram positive bacteria.

If the swab culture does grow something ( as above) it can be treated with oral antibiotics, such as penicillin or cephalosporins. As you state that your husband wishes to avoid hospitalization, it may be useful to know that research has shown that Clarythromycin ( if indictated) and many other antibiotics are actually just as useful given orally as they are given IV. The exception being if dealing with a septacaemia etc. Of course there is always benefit to IV boost initially.
The use of antibiotic ointments, such as silver sulfadiazine or triple antibiotic ointment is contraversial, but some wound care practitioners and physicians will opt for it as a stop gap before surgery, or as a last chance before debriding the wound surgically.

I trust that whoever is performing the dressing changes is not pulling the dressing if it has started to adhere to the wound edges ( or centre, but this is less likely if necrosis is present there). As this will cause damage to any/the granulating new tissue. The dressing should be moistened with sterile saline before removal if adhereing is taking place.

Also, ( sorry to go on, but I was a wound care link nurse on my unit until recently) I have taken the liberty to copy and paste the stages of pressure sores ( decubiti). I noticed that you had not been informed of your husband's stage of sore and hope this helps. Please see below:

The below extract is taken from MAYOCLINIC.COM

Quote

Stage I. Initially, a pressure sore appears as a persistent area of red skin that may itch or hurt and feel warm and spongy or firm to the touch. In blacks, Hispanics and other people with darker skin, the mark may appear to have a blue or purple cast, or look flaky or ashen. Stage I wounds are superficial and go away shortly after the pressure is relieved.

Stage II. At this point, some skin loss has already occurred — either in the epidermis, the outermost layer of skin, in the dermis, the skin's deeper layer, or in both. The wound is now an open sore that looks like a blister or an abrasion, and the surrounding tissues may show red or purple discoloration. If treated promptly, stage II sores usually heal fairly quickly.

Stage III. By the time a pressure ulcer reaches this stage, the damage has extended to the tissue below the skin, creating a deep, crater-like wound.

Stage IV. In the most serious and advanced stage, a large-scale loss of skin occurs, along with damage to muscle, bone, and even supporting structures such as tendons and joints. Stage IV wounds are extremely difficult to heal and can lead to lethal infections.
If you use a wheelchair, you're most likely to develop a pressure sore on:

Your tailbone or buttocks
Your shoulder blades and spine
The backs of your arms and legs where they rest against the chair

**links to detaailed information here at apparelyzed (including illustrations), can be found HERE**


I hope this helps and let us know how your hubby gets on!

take care,

k


(trained RN ( Cardiology) early 'retired' jan 07)

[seeker]

kewlcatkez, on Oct 23 2007, 04:51 PM, said:

Hi again,

I just wanted to throw one more thing into the mix here re: pressure sores.

Has your husband had a wound swab taken and sent to the lab to see what it grows? Pressure ulcers are inevitably infected with and anaerobic bacteria and either gram negative, gram positive bacteria.

If the swab culture does grow something ( as above) it can be treated with oral antibiotics, such as penicillin or cephalosporins. As you state that your husband wishes to avoid hospitalization, it may be useful to know that research has shown that Clarythromycin ( if indictated) and many other antibiotics are actually just as useful given orally as they are given IV. The exception being if dealing with a septacaemia etc. Of course there is always benefit to IV boost initially.
The use of antibiotic ointments, such as silver sulfadiazine or triple antibiotic ointment is contraversial, but some wound care practitioners and physicians will opt for it as a stop gap before surgery, or as a last chance before debriding the wound surgically.

I trust that whoever is performing the dressing changes is not pulling the dressing if it has started to adhere to the wound edges ( or centre, but this is less likely if necrosis is present there). As this will cause damage to any/the granulating new tissue. The dressing should be moistened with sterile saline before removal if adhereing is taking place.

Also, ( sorry to go on, but I was a wound care link nurse on my unit until recently) I have taken the liberty to copy and paste the stages of pressure sores ( decubiti). I noticed that you had not been informed of your husband's stage of sore and hope this helps. Please see below:

The below extract is taken from MAYOCLINIC.COM

Quote

Stage I. Initially, a pressure sore appears as a persistent area of red skin that may itch or hurt and feel warm and spongy or firm to the touch. In blacks, Hispanics and other people with darker skin, the mark may appear to have a blue or purple cast, or look flaky or ashen. Stage I wounds are superficial and go away shortly after the pressure is relieved.

Stage II. At this point, some skin loss has already occurred — either in the epidermis, the outermost layer of skin, in the dermis, the skin's deeper layer, or in both. The wound is now an open sore that looks like a blister or an abrasion, and the surrounding tissues may show red or purple discoloration. If treated promptly, stage II sores usually heal fairly quickly.

Stage III. By the time a pressure ulcer reaches this stage, the damage has extended to the tissue below the skin, creating a deep, crater-like wound.

Stage IV. In the most serious and advanced stage, a large-scale loss of skin occurs, along with damage to muscle, bone, and even supporting structures such as tendons and joints. Stage IV wounds are extremely difficult to heal and can lead to lethal infections.
If you use a wheelchair, you're most likely to develop a pressure sore on:

Your tailbone or buttocks
Your shoulder blades and spine
The backs of your arms and legs where they rest against the chair

**links to detaailed information here at apparelyzed (including illustrations), can be found HERE**


I hope this helps and let us know how your hubby gets on!

take care,

k


(trained RN ( Cardiology) early 'retired' jan 07)

Yes a swab was taken, but I don't remember what it showed, but they weren't concerned. We also asked them about antibiotics and they said that they weren't needed, and won't prescribe them. I believe it is a stage 3 but we haven't been officially told. It is looking a lot better now...for some reason, when he gets up for a few hours during the day...3 to 4 hours...it seems to do better. If it weren't for needing to get up, he would stay in bed, but he has to get up...prior commitments...so don't lecture on staying in bed...we know he needs to, but there are times when you just can't.

[kdhat]

seeker, on Oct 19 2007, 05:07 AM, said:

Does anyone know of any way (other than surgery) to debride a pressure sore? My husband has one on his perineum, and it needs debridement, but we don't want him to go to the hospital to have it done...I wouldn't be able to see him everyday...I am American, and haven't gotten accustomed to driving on the left side of the road yet, plus I have no idea where I am going. So we are hoping that there is something we can do to get the dead skin out by ourselves. We use the Manuka honey, and that is working great, but is it enough???? He is staying in bed most of the time, except when he has to get up to go somewhere (daughter's school program) or for me to change the sheets. Any help, suggestions will be appreciated.

I am not a professional wound care nurse, but I have a "bed sore" and have tried a number of the conventional treatments for debridement. One that worked for me was a couple of different ointments that were algae derivatives, and actually green. They had to be careful because it would digest healthy tissue as well.

What I'm using now is something unconventional I found online called DermaWound. It claims to auto debride. My sore is on my tailbone, but tissue is pink, healthy and granulating.

Best Wishes!

[john S.]

[quote name='seeker' date='Oct 19 2007, 06:07 AM' post='43414']
Does anyone know of any way (other than surgery) to debride a pressure sore? My husband has one on his perineum, and it needs debridement, but we don't want him to go to the hospital to have it done...I wouldn't be able to see him everyday...I am American, and haven't gotten accustomed to driving on the left side of the road yet, plus I have no idea where I am going. So we are hoping that there is something we can do to get the dead skin out by ourselves. We use the Manuka honey, and that is working great, but is it enough???? He is staying in bed most of the time, except when he has to get up to go somewhere (daughter's school program) or for me to change the sheets. Any help, suggestions will be appreciated.
[/quote)
I don't mean to sound glib, but now is your chance to learn about the city. You can get a taxi, I hope? You really want this done right and amatures debrieding wounds is like a great title for a really bad book about married life.
You could get medical maggots. There is a sight you may never get over! Nope, You need a pro doing it. They may send him home the same day anyway. It isn't that it takes long, it is the anesthetic they intend to use and risk of infection. I sure wish you both luck. This needs to be done right on the first try.

Best wishes for you both,
john

[paraman]

I have used a ointment named Debridace to get rid of the dead skin that I had on my bed sore. It worked well and did its job. When all the dead skin came off I used my regular ointments to heal the bedsore.

Debridace is an Indian brand name. Maybe it is sold in a different name in your country.

[kewlcatkez]

paraman, on Feb 1 2008, 06:22 AM, said:

I have used a ointment named Debridace to get rid of the dead skin that I had on my bed sore. It worked well and did its job. When all the dead skin came off I used my regular ointments to heal the bedsore.

Debridace is an Indian brand name. Maybe it is sold in a different name in your country.

Debridase is made from the Bromelain which is a protease enzyme extracted from the Bromeliaceae group of plants.
It has some success with the debridement of burns, but its use in infected wounds is something which hasn't been studied in as much depth. Research points to the Debridase being of some use in smaller wounds.


Quoted text follows

June 2005, 58:6 > Escharotomy with an Enzymatic Debridement...
< Previous | Next >
ARTICLE LINKS:
Fulltext | PDF (1.29 M)
Escharotomy with an Enzymatic Debridement Agent for Treating Experimental Burn-Induced Compartment Syndrome in an Animal Model.
Article Titles

Journal of Trauma-Injury Infection & Critical Care. 58(6):1259-1264, June 2005.
Krieger, Yuval MD; Rosenberg, Lior MD; Lapid, Oren MD; Glesinger, Ronen MD; Bogdanov-Berezovsky, Alex MD, PhD; Silberstein, Eldad MD; Sagi, Amiram MD; Judkins, Keith FRCA
Abstract:
Background: In patients with deep circumferential burns, adequate resolution of burn-induced compartment syndrome (BICS) is achieved by surgical escharotomy. Surgical escharotomy is traumatic, may cause considerable blood loss, does nothing toward debridement of the burn wound, and entails possible morbidity and complications. Debridase® is a bromelain-derived enzymatic preparation capable of lysing the burn eschar within 4 hours, obviating the need for surgical debridement. It has an affinity to burned necrotic tissue and does not damage healthy skin. In our clinical assessment of its efficacy, we found in several cases of deep burns of the limbs that the measured intracompartmental pressure subsided after 2-4 hours of Debridase® application, and none of the enzymatic escharotomy-treated patients suffering from circumferential burns developed BICS. To confirm these observations, we conducted this controlled study.

Methods: A model for BICS was developed by making circumferential burns to pig legs and monitoring the anterior compartment of the legs. BICS was induced in the legs of 5 pigs (20 legs); 10 legs were treated with Debridase® and 10 served as nontreated controls, treated by surgical escharotomy at the conclusion of the experiment.

Results: Debridase reduced BICS within 30 minutes from application. Debridase was as effective as a standard surgical escharotomy.

Conclusion: Escharectomy with an effective enzymatic debriding agent is potentially an adequate, simple, fast, effective procedure to treat BICS; it has the added benefit of burn debridement without surgical escharotomy.

© 2005 Lippincott Williams & Wilkins, Inc.

SOURCE: Journal of Trauma


HTH

Take care,

K