DEBRIDING AGENTS FOR SURGICAL WOUNDS

A rapid and systematic review of the clinical effectiveness and cost-effectiveness of debriding agents in treating surgical wounds healing by secondary intention

Background

Most surgically sutured wounds heal without any complication. However, in some cases wound healing can be delayed due to the presence of infection or wound breakdown. This can result in the wounds becoming cavity wounds and thus necessitate healing by secondary intention. Other surgical wounds that are not sutured but left to heal by secondary intention include abscess cavities such as perianal abscesses or breast abscesses.

Surgical wounds healing by secondary intention are thought to heal more slowly than wounds healing by primary intention, especially if infection is present or healing is compromised by factors such as decreased blood supply, poor nutritional status or a general suppression of the immune response. Such wounds may contain dead tissue and have a moderate or high level of exudate.

Debridement involves the removal of devitalised, necrotic tissue or fibrin from a wound. There are many different methods that can be used to debride a wound, which are broadly classified as surgical/sharp, biosurgical, mechanical, chemical, enzymatic and autolytic. Although it is generally agreed that the management of surgical wounds which contain devitalised tissue and are healing by secondary intention requires debridement, it is not always clear as to what is the best method or agent to use. There is currently a large selection of products with debriding properties available on the market, which vary considerably in cost. It is important that the choice of both debriding method and product is based on the best scientific evidence available, taking into account both cost and effectiveness data.

This review had two main objectives: to determine the clinical effectiveness and cost-effectiveness of debriding agents in treating surgical wounds healing by secondary intention; and to evaluate the clinical effectiveness and cost-effectiveness of treating patients with surgical wounds healing by secondary intention at specialised wound care clinics as compared to conventional care.

The review incorporated all debriding methods and any agent that is considered to have a debriding property.

Findings

Clinical effectiveness: In summary, there is a suggestion that modern dressings have a beneficial effect on healing compared to traditional gauze dressings, especially for toenail avulsions, where significant benefits of modern dressings were found. However, these results should be interpreted with caution due to the poor quality of the studies, the fact that the direction of bias is unclear and the unknown effects of potential publication bias.

There is some evidence to suggest a beneficial effect of modern dressings for surgical wounds on other outcomes, such as pain, dressing performance and resource use, although a beneficial effect for these outcomes was not found for studies of toenail avulsions. However, in addition to the methodological problems highlighted above, these outcome measures are very difficult to assess and are particularly subject to bias, especially in unblinded studies.

In view of the lack of data and the poor methodological quality of the trials, there is no evidence to support the superiority of one type of modern dressing over another.

Cost-effectiveness: Four economic evaluations met the inclusion criteria. All four studies included a cost-effectiveness analysis of an autolytic debriding method compared with traditional gauze dressings soaked in various antiseptic solutions. The dressings investigated were silicone elastomer foam dressings, polyurethane foam dressings and calcium alginate dressings. No economic evaluations that compared the cost-effectiveness of two different types of modern dressings were found. No economic evaluations investigating specialised wound care clinics were found.

Conducted by: Lewis R1, Whiting P1, ter Riet G1,2, O’Meara S1, Glanville J1

1. NHS Centre for Reviews and Dissemination; 2. Department of Epidemiology, Maastricht University, The Netherlands

Further details

Project page on HTA Programme website

Related guidance

Commissioned to inform NICE Technology Appraisal 24: Wound care - debriding agents. London: National Institute for Clinical Excellence; 2001

Publications

Lewis R, Whiting P, ter Riet G, O'Meara S, Glanville J. A rapid and systematic review of the clinical effectiveness and cost-effectiveness of debriding agents in treating surgical wounds healing by secondary intention. Health Technol Assess. 2001;5(14):1-131

Funding

Commissioned by the HTA Programme on behalf of NICE's Technology Assessment Report (TAR) process