Role of Debridement

16 June/July 2014 Today’s Wound Clinic® Chronic wounds clearly represent a healthcare burden of tremendous magnitude as they afflict hundreds of thousands of patients while costing on the order of billions of dollars annually in the US alone. The difficulties posed to those living with and caring for nonhealing wounds are not new; rather, they have plagued human civilizations for thousands of years. Archaeologists have found evidence through tablets unearthed from Babylonia that prove people were concerned with the proper treatment of wounds as early as 2100 B.C. These tablets spell out in the Sumerian language a sort of “primitive” wound care prescription. Recommendations included “to pound together dried wine dregs, juniper, and prunes,” adding beer to the mixture in order to create a salve that would harden over the oiled wound.1 Similarly, ancient Egyptian physicians were well known in the Near East for their unique healing skills. Acute wounds were covered with raw meat and swabs soaked with honey to prevent infection and bandaged with pads, linen, and nets.2 Burn dressings used the milk from mothers of male babies as well as moldy bread, honey, and copper salts.3 While ancient Greek physician Hippocrates advocated the “dry” treatment of wounds,4 several hundred years later Galen, the ancient Roman physician and surgeon to the gladiators, proposed and wrote prolifically on the theory of “laudable pus,” which held that suppuration of wounds should be encouraged as a part of the natural healing process. This latter theory was adopted by much of ancient civilization and became a tradition that precluded aseptic treatment of wounds up to the 19th century.5 As such, little progress was made in wound management during this time. In 2000, Vincent Falanga, MD, FACP, professor of dermatology and biochemistry at the Boston University School of Medicine, and Gary Sibbald, FRCPC, ABIM, DABD, Med, professor of public health sciences and medicine at the University of Toronto, formally introduced the concept of wound bed preparation.6,7 Separately, but similarly, their focus was initially on the management of bacterial and moisture balance as well as debridement of devitalized tissue. Three years later, at a meeting of the International Wound Bed Preparation Advisory Board, an algorithmic approach to wound bed preparation was delineated with the development of the T.I.M.E. acronym — tissue debridement, infection or inflammation control, moisture balance, and attention to edge effect.8,9 The concept was updated by Sibbald in 2006 to emphasize treatment of patient-specific factors that impair wound healing and was made more comprehensive in 2011 with links to evidence-based literature, expert opinions, and clinical practicebased strategies.10,11 Taken together, this framework encompasses globally applicable strategies for wounds of differing types that aim to aid clinicians in maximizing wound healing potential.