Micro waterjet technology for gentle debridement
Application for a pressure ulcer category IV ~ Sebastian Kruschwitz
Chronic wounds cause a high level of suffering and severely restrict the quality of life of affected patients. Treatment is often difficult. An important problem here is often the presence of bacterial colonization in the form of biofilms on the wounds. This is because bacteria embedded in a biofilm have a high tolerance to the otherwise highly effective and proven wound disinfectants. This makes it all the more important to remove the biofilm - preferably gently and without damaging the tissue. Here, microjet technology can provide very gentle yet highly effective debridement and a well-prepared wound bed (see box).
In addition to treating the root causes, a clean wound bed is a basic prerequisite for the undisturbed course of the complex wound healing processes. Thus, the international consensus document1 describes the strategic approach to wound hygiene in four steps1:
1st step: irrigation and cleansing,
2nd step: debridement,
3.step: the wound edge and surrounding treatment,
4th step: the wound dressing.
When a wound is difficult to heal, the interruption of the healing process is largely due to the presence of a persistent biofilm (tough, thin layer of mucus or matrix with various microorganisms embedded in it) contained in the wound. Although other patient-related factors can also delay healing, it is increasingly recognized that the majority of chronic wounds contain biofilm, which is a major barrier to healing. Biofilm, as an enabler of critical colonization, increases the risk of infection in any tissue. An increased risk for biofilm formation exists in chronic wounds based on underlying conditions such as diabetes mellitus, chronic venous insufficiency (CVI), or peripheral arterial disease (PAVD). Increased microbial virulence, antibiotic resistance and/or immunodeficiency or immunosuppression of patients further multiplies the risk of biofilm formation. However, nursing-related factors can also be responsible for impaired wound healing, as can be seen from the subsequent case report.
A bedridden 61-year-old female patient suffered from a grade IV decubitus ulcer that could no longer be managed purely as an outpatient in accordance with best practice wound care, but required hospitalization for surgical management. This patient had the following diagnoses:
- Waking coma with truncal ganglion hemorrhage on the right side, with
- ventricular collapse in arteriovenous malformation (AVM)
- diabetes mellitus type 2
- severe dysphagia
- Arterial hypertension
- nursing relevant components: Incontinence Urinary and fecal severe cognitive dysfunction.
In summary, the following aggravating care-related and wound healing-influencing factors were observed in the patient:
- weakened immune status
- consumptive underlying disease
- Cognitive impairment
- completely immobile
- urinary and fecal incontinence
- Causal therapy:
- in bed a repositioning system
- Mobilization to wheelchair (with AD cushion).
The patient was admitted to a Berlin hospital for surgical debridement of the pressure ulcer because multiple necroses and avital tissue had formed at the wound bed.
Successful use of a focused microwater jet
However, the wound bed was still clearly covered after surgical debridement (Fig. 1). In order to cleanse the wound as gently as possible and to remove the remaining or re-forming tough biofilm, we used the so-called microjet technology (debritom+, Medaxis). A controlled, multicenter study has already demonstrated the advantages of debridement using microjet technology over standard surgical debridement.2 The gentle removal of infected, damaged or dead tissue with the debritom also produced excellent healing results in our application. After application of the debritome, significantly fewer coatings are visible on the wound bed (Fig. 2).
The wound was treated with the debritome a total of 4 times. After each treatment, it could already be seen that the wound bed could be cleaned significantly more and the wound healing processes progressed further (Fig. 2-6).
Wound care was performed with an alginate as wound filler. A superabsorber was used as a cover for so long,
until the granulation tissue completely filled the wound. In the later course, a PU foam was then used. The intervals between dressing changes were three days. Overall, wound healing took up to 10 months, which was, however, also attributable to the reduced general condition and the other accompanying healing-inhibiting factors described above.
Sebastian Kruschwitz, Head of Wound Management Department, Wound Care Therapist ICW, Nursing Specialist for Out-of-Hospital Ventilation, Deputy Case Manager, ZBI Group, Franz-Jacob-Strasse 4D, 10369 Berlin, Germany.
1 International Consensus Document: Defying hard-toheal wounds with an early antibiofilm intervention strategy: wound hygiene. JWC 2020; 29(3): S2-S26
2 Armstrong DG, Zelen C: Multicenter, Randomized Controlled Clinical Investigation Evaluating a Unique Micro Water Jet Technology Device Versus Standard Débridement in the Treatment of Diabetic Foot. Diabetes 2022; 71(Supp_1). DOI: 10.2337/db22-30-LB.
Here you can find the full report:
Study Sebastian Kruschwitz