Roundtable Discussion: Enzymatic debridement vs. silver products in DFUs
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Roundtable Discussion: Enzymatic debridement vs. silver products in DFUs

(upbeat music) – It’s fun to have a panel of providers of different types. And we work in different settings and all of us I’m sure have
debridement in our practices so it would be interesting to hear about the different
forms of debridement that we have and how we make that decision about which debridement method we use. – We do a little bit of everything. We do some bedside sharp, definitely. A lot of enzymatic, a little bit of autolytic occasionally. – Being in a wound care center, we do a fair amount of sharp debridement but you know these are
walking, talking patients. And because we can’t
completely anesthetize them we use mostly topicals. That’s why we need to have something in between the sharp sharp debridements to continue to do the debridement. – It kind of depends on the patient but most of the time I feel like if you’re gonna use this, and the need the sharp, use the enzymatic with it. Because if you don’t have the enzymatic then it’s harder to do the
sharp when you come back to see ’em the next time
or at their next visit. – As far as talking about
methods of debridement the first Motley Paper had a big impact on the way that we do things. Which showed that diabetic foot ulcers that receive sharp
debridement plus Santyl. Versus those that
received sharp debridement without santyl. The ones that got the
Santyl got smaller, faster. – Ah huh. – I’m kind of curious, do you start the debridement process, sharp debridement at their first visit in the outpatient setting? – Many times they’ll have some debridement to some degree that first time. – Well the first
principle in time, tissue. So if we leave the necrotic
tissue in the wound bed, we’re not gonna get ourselves
where we need to go. And we’re setting it up
for further infection. – So Jeff earlier you
brought up the Motley study and how it really educated
us about the combination of sharp debridement and Santyl with diabetic foot ulcers. The second Motley Study where they actually did it
as a comparison to Silver. – The primary end point was the mean percent reduction in ulcer area, there was a clinically relevant difference between the two groups where those that receive sharp debridement
plus Santyl decreased in size by an average of 62%. Whereas those that receive
the sharp debridement plus Silver decreased in size by only an average of about 40%. – I think this kind of
goes to wound bed prep idea though right, getting a wound smaller is really what really we’re trying to do. – Not only in comparing the
group that received the Santyl versus the group that
received the Silver did we see that those that received the Santyl had a greater decrease in the mean area but what may have been surprising to some was that the Silver group
actually had more people that developed infection
than did the Santyl group. – That, that was surprising but I think it goes to what you made such a good point about is we need to take away the nidus
for that bacterial growth, the groceries if you will of what the bacteria like to feed on. So getting it clean you
know getting it clean more efficiently faster is certainly going to reduce, take that nidus away. – What we found is a set of toxicity, it’s really lowering our healing rate because we’re delaying
things even further. – Because we now have the clinically relevant Silver resistance, which I think is important for clinicians to respect and it’s important that we keep that in mind when we make the decisions
about the use of Silver. – For us, I think looking at that paper, what has really thought
about how it affected a diabetic foot. And historically we
really haven’t used much in the way of Silver for diabetic foot. So I think it was a validation of some of our constructs in saying we’re not gonna use Silver for diabetic foot too much. And what we’re doing already is okay. – We hit them with Santyl right away. Because we’re doing a sharp debridement at that initial visit
almost every single time and we want to back that up with the enzymatic debridement that Santyl offers. And you mention the bio burden, sharp debridement’s great, right? And if we’re not working
on that necrotic tissue via enzymatic debridement
between our sharp debridements, the food source, is there to help it
maybe come back faster. – I think a lot of people
would have looked at it and said okay, I would have been fine with the paper if it had said
the area gets smaller in this group over Silver. I think the added portion of
having the large reduction in the number of actual infections kind of made you think okay this is definitely not something we need
to be doing with Silver. And the Santyl is an appropriate agent is an appropriate agent
to use in this population. – But the take home message wasn’t that it was the anitomical
microbial it was that getting wound bed prep, following that time principle but getting that wound bed prep done earlier means likely less infections because the bacteria just don’t
have anything to munch on. – This really spoke to that
concern where five people in the Santyl group developed an infection whereas 11 in the Silver group did so. Actually that should really speak to those that might be holding on despite the resistance that we now know about. – When we’re trying to educate people on the importance of getting
tissue debrided rapidly the faster we get wounds cleaned up the less potential for infection. – With Santyl it’s gonna be selective, it’s not gonna harm your good tissue. – So even with all this
discussion of Silver that we’ve had, there will be those that
still want to use it. So what about combining
different products with Santyl. Some may want to see about
maybe using them both together. – Absolutely yeah, we’ve all been talking about
the Davidovich paper for so many years and what’s exciting is they’ve done further testing to look at other compatibilities so people can go to now and get the whole laundry list of what it is that can and cannot be combined. As soon as we’re done
here I’m gonna look it up on the internet I’m excited. – [Narrator] Collagenase Santyl
Ointment 250 units per gram, is indicated for debriding
chronic dermal ulcers in severely burned areas. A slight transient erythema
has been noted occasionally in the surrounding tissue, particularly with
Collagenase Santyl Ointment was not confined to the wound. Therefore, the ointment
should be applied carefully within the area of the wound. Safety and effectiveness in Pediatric patients
have not been established. One case of sytemic hypersensitivity has been reported after one year of treatment with
Collagenase and Cortisone. Use of Santyl Ointment should be stopped when debridement is complete and granulation tissue
is well established. See complete prescribing
information for more details. This video is intended for
health care professionals practicing in the US only. It is offered for informational and educational purposes
only and is not intended as medical advice. Viewer discretion is advised.

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