Ultrasonic Debridement Article Synergy 2007

8/14/2019 Ultrasonic Debridement Article Synergy 2007

1/13

Debridement: The Low Frequency Ultrasound Option

Vickie Driver DPM, MS, FACFAS, FAPWCA andDebashish Chakravarthy, Ph.D, FAPWCA

It is well accepted in clinical practice that a wound with necrotic tissue will notheal optimally 1. Presence of necrotic tissue is known to interfere with woundcontraction, granulation tissue deposition, and cellular migration 1. Necrotic tissueprovides an ideal medium for bacterial growth, which in turn leads to infection,endotoxin release and subsequent biofilm formation 2,3 . Increased bacterial levelsenhance the level of inflammatory molecules and destructive enzymes such asmatrix metalloproteases (MMPs) 4. Frequent and thorough debridement leads tothe removal of necrotic tissue, as well as associated bacteria and biofilm 5. Aproperly debrided wound bed extracts the maximum benefit possible from thehighly engineered advanced wound care product technologies that are

increasingly available to the clinician.

Wound debridement methods have evolved as novel technologies and havebeen introduced over the years to the clinician 6,7 . Autolysis (the use of a moistwound dressing to cause the liquefaction) of eschar, pulsed lavage, enzymetherapy, and systems like whirlpools are used with varying degrees of success.Surgical debridement 8,9 is an important method that is performed in an operatingroom environment, and can involve the removal of both necrotic as well as someviable tissue 10, 11 . In this regard, it is important to remember that the practitioneris, in essence, attempting to turn a slow healing chronic wound into an acutewound, with good reason, to produce better outcomes and faster healing rates 9.

Thus the evidence is substantial that the removal of necrotic tissue, of senescentcells 12,13 and bacteria 14 all lead to the creation of an environment conducive tohealing.

The practice of sharp debridement 9 performed outside the operating roomenvironment is another procedure of clinical benefit available to the skilledphysician, who may use a sharp scalpel or a curette to quickly remove necrotictissue such as slough and eschar as well as some quantity of fibrin clot that maybe interfering with healing. However, such practice of quick bedside proceduresis limited by the pain generally associated with effective sharp debridement, andthe patient may need several visits to cleanse a particularly large and/or painful

wound.This article describes a new technology employing low frequency ultrasound thatprovides a relatively pain free and selective debridement tool.

The Technology Low frequency ultrasound provides two largely non-thermaleffects (higher frequency ultrasound has predominantly thermal effects), whichare cavitation and acoustic streaming 15, 16 . The cavitation phenomenon consists


2/13

of the creation of microscopic gas bubbles in tissue fluid (either present in tissueor being added as saline from outside), and the oscillation in size of thesebubbles in tandem with the variation in the ultrasound field pressure levels. Atcertain amplitudes of the sound waves, the bubbles implode and are destroyed;this effect produces tiny shock waves that causes the liquefaction of tissue,

preferentially the necrotic tissue, fibrin clot, and associated biofilm17

. Evidencealso exists that the shock waves are strong enough to destroy bacterial cellwalls 18 . The acoustic streaming phenomenon consists of temporary disturbancesin the cell membranes of the chronic wounds. A number of biochemical changes,which in general are beneficial, are claimed to arise from the perturbation ofthese cell membranes. Included in the biochemical effects are increased cellmembrane permeability, increased protein synthesis, mast cell degranulation,and increased growth factor production.

Case studies A new device* based on the delivery of low frequency ultrasoundenergy to cause debridement was used on a series of patients (See Figure 1).

The clinician experience is captured in the following section. It is an efficient andfast process with pain reduction allowing a large number of wounds or a largewound area to be debrided in one sitting, so an entirely new wound bed iscreated without the need for repeat debriding visits caused by maxing out onthe pain level in a particular unit.

Figure 1. The SonicOne Ultrasonic Wound Care System Distributed by MedlineIndustries Inc., Mundelein, IL.

The following case studies were performed at the Center for Lower ExtremityAmbulatory Research (CLEAR) at the Dr. William M. Scholl College of PodiatricMedicine at Rosalind Franklin University of Medicine and Science in Chicago, IL.


3/13

Case 1A 74 year-old male presented to the clinic for 20+ multiple painful (10/10) lowerextremity ulcerations to the left leg, secondary to radiation treatment forcutaneous T-cell lymphoma. The patient had a past medical history of diabeteswith neuropathy, T-cell lymphoma, peripheral vascular disease, psoriasis,

hypercholesteremia, hypertension, and BPH. The patient related developing theulcerations immediately following radiation therapy for the t-cell lymphoma.These ulcerations were cultured positive and treated for MRSA.

The patients medications included Vancomycin , Bactrim , furosemide,Atenolol , aspirin, gabapentin, betamethasone, Zocor , and Zetia . The patientbegan ultrasound debridement treatment on 3/20/06 and received a total of 6weeks of debridement using the ultrasound process. He was not able to toleratesharp clinical debridement, even with topical anesthesia unless the ultrasoundbased debrider was used. He rated his pain at 2/10 on the numerical rating scaleusing the ultrasound debrider as compared to 10/10 with a curette or a surgical

blade.

3/20/06


4/13

3/20/06


5/13


6/13

4/25/06


7/13

4/25/06

Case 2A 54 year-old male presented to clinic with a history of acute onset left drop foot,pitting edema and 27 full thickness painful skin lesions along with blisters on both

legs. The patient was consulted to neurology, rheumatology limb preservation,and vascular surgery. He had no known drug allergies. The patients medicationswere Mobic , Lisinopril , hydrocodone/APAP, Lyrica , 60 milligrams ofprednisone daily and cyclophosphamide. The patient was diagnosed withpolyarteritis nodosum and ulcerations secondary to vasculitis which were infectedwith MRSA. The wounds were covered with bacteria and necrosis, but could notbe debrided in the clinic due to the patients report of 10/10 pain level on thenumerical rating scale even with emla cream.


8/13

The patient began his first ultrasound treatment on 1/17/06. The patientunderwent a total of 16 treatments and had closed all but one small wound on5/30/06 despite some level of infection persisting on and large doses ofprednisone.

2/2/06


9/13

2/2/06


10/13

4/4/06


11/13

4/4/06


12/13

5/30/06

In summary, perhaps we have truly found an option for the patients that havepainful wounds that limits many debridement options. This new treatment may

allow us to achieve maintenance debridement on these patients in the clinicalsetting. In the past, we could only take them to the operating room or use anenzymatic or autolytic debrider. The device is easy to adjust during the therapysession. It allows the clinician the ability to offer pulse or continuousdebridement, which directly correlates to a reduction in pain to the patient.Although this device does not take the place of surgical debridement in the faceof infection, abscess and the like, ultrasounic debridement may kill bacteria aswell as cleaning up the wound bed, creating an acute wound out of a chronic


13/13

wound, stimulating the healing process, while controlling pain, then we may wellsee mutliple benefits with these devices.

References1

Falanga V. Classifications for wound bed preparation and stimulation of chronic wounds.Wound Rep and Regen 2000;8: 347-352).2 Robson MC. Wound infection: a failure of wound healing caused by an imbalance of bacteria.Surg Clin North Am 1997:77:637-650.3Clark R, Cutaneous tissue repair:basic biologic considerations. J Am Acad Dermatol 1985;13:701-725).4 Kawaguchi H, Hizuta A, Tanaka N, Orita K. Role of endotoxin in wound healing impairment.Res Com Mol Path and Pharm 1995; 89: 317-327.)5 Haury B, Rodeheaver G, Vensko J, Edgerton MT, Edlich RF. Debridement: an essentialcomponent of traumatic wound care. American Journal of Surgery. 1978;135:238-242).6 Bradley M, Cullum N, Sheldon T. The debridement of chronic wounds: a systematic review.Health Technology Assessment 1999; 3 (17 Pt 1): iii-iv, 1-78.7 Lewis R, Whiting P, ter Riet G, OMeara S, Glanville J. A rapid and systematic review of theclinical and cost effectiveness of debriding agents in treating surgical wound healing bysecondary intention. Health Technology Assessment, 2001; 5: 1-131).8 (Steed DL, Donohoe D, Webster MW, Lindsey L. Effect of extensive debridement andtreatment on the healing of diabetic foot ulcers. Diab Ulcer Study Group. J Am Col Surg 1996;183: 61-4.9 Granick M, Boykin J, Gamelli R, Schultz G, Tenenhaus M. Toward a common language:surgical wound bed preparation and debridement. Wound Rep Regen, 2006; 14 S1-S10.)10 (Schultz G, Sibbald R, Falanga V, Ayello E, Dowsett C, Harding K, Romanelli U, Stacey M,Teot L, Vanscheidt W. Wound bed preparation: a systemic approach to wound management.Wound Rep Reg 2003; 11: S18. Elek S. Experimental staphylococcal infections in the skin ofman. Ann NY Acad Sci 1997; 16: 59-66).11 Elek S. Experimental staphylococcal infections in the skin of man. Ann NY Acad Sci 1997; 16:59-66.12 Hasan A, Murata H, Falabella A, Ochoa S, Zhou L, Badivas E, Falanga V. Dermal fibroblastsfrom venous ulcers are unresponsive to the action of transforming growth factor-beta 1. JDermatol Sci 1997: 16: 59-66.13 Vande Berg J, Rudolph R, Hollan C, Haywood-Reid P. Fibroblast senescence in pressureulcers. Wound Rep Reg 1998; 6: 38-4914 Rennekampff H, Schaller S, Wisser D. Tenenhaus M. Debridement of burn wounds with awater jet surgical tool. Burns, 2006; 32: 64-915 Stanisic M, Provo B, Larson D, Kloth L. Wound debridement with 25 kHz Ultrasound.Advances in Skin and Woundcare; 18: 9, 484-490,16 Young S. Ultrasound therapy. In: Kitchen S. ed. Electrotherapy: Evidence-Based Practice.11 th ed. New York, NY: Churchill Livingstone; 2002:211-3017 McDiarmid T, Ziskin MC, Michlovitz SL. Therapeutic ultrasound. In Michlovitz SL, ed. Thermalagents in Rehabilitation. 3 rd Ed. Philadelphia, PA: F.A. Davis Company; 2002: 203-31.).18 Scherba G, Weigel R, OBrien W Jr., Quantitative assessment of the germicidal efficacy of

ultrasound energy. Appl Environ Microbiol 1991; 57:2079-84.

* SonicOne Ultrasonic Wound Care System Distributed by Medline IndustriesInc., Mundelein, IL.

Documents

Ultrasonic Debridement Article Synergy 2007