Methods of Wound Debridement: Best Practice for Clinicians

Methods of Wound Debridement: Best Practice for Clinicians Methods of Wound Debridement: Best Practice for Clinicians The Wound, Ostomy and Contine...
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Methods of Wound Debridement: Best Practice for Clinicians

Methods of Wound Debridement: Best Practice for Clinicians

The Wound, Ostomy and Continence Nurses Society™ suggests the following format for bibliographic citations: Wound, Ostomy and Continence Nurses Society. (2015). Methods of Wound Debridement: Best Practice for Clinicians. Mt. Laurel: NJ. Author. Copyright© 2015 by the Wound, Ostomy and Continence Nurses Society™ (WOCN®). Date of Publication: 2/3/2015. No part of this publication may be reproduced, photocopied, or republished in any form, in whole or in part, without written permission of the WOCN Society. WOCN® National Office ◊ Mount Laurel, NJ 08054 www.wocn.org 2

Acknowledgments Methods of Wound Debridement: Best Practice for Clinicians This document was developed by the WOCN Society’s Clinical Practice Wound Committee between July 2013 – August 2014. Elliott Douglass, BSN, RN, CWOCN, Chair Director WOC Nursing Department Summit Medical Center Nashville, TN

Jill Michalak, MSN, CWOCN Enterostomal Therapy Nurse Mercy St Vincent Medical Center Toledo, OH

Karen Keaney, MSN, RN, FNP-BC, CWOCN, Past Chair APN, CWOCN St. Joseph’s Regional Medical Center Paterson, NJ

Kelly Sparks, BSN, RN, CWOCN, CFCN CWOCN Mercy San Juan Medical Center Carmichael, CA

Rebekah Grigsby, DNP, MSN, RN, CWCN Dean of Professional Studies Assistant Professor Department of Nursing East Texas Baptist University Marshall, TX

Jo Ann Valent, BSN, RN, BC, CWOCN, COS-C Certified Wound, Ostomy & Continence Nurse Chilton Medical Center Pompton Plains, NJ

Sandra Lee Hartman, BSN, RN, CWOCN WOC Nurse Excela Health Westmoreland Hospital Greensburg, PA

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Table of Contents Introduction .............................................................................................................................................................................................................................................. 5 Purpose..................................................................................................................................................................................................................................................... 5 Types of Debridement.............................................................................................................................................................................................................................. 6 Definition ............................................................................................................................................................................................................................................. 6 Indications ........................................................................................................................................................................................................................................... 6 Contraindications ................................................................................................................................................................................................................................. 7 Selective versus nonselective .............................................................................................................................................................................................................. 8 Skill level required............................................................................................................................................................................................................................... 9 Method of action .................................................................................................................................................................................................................................. 9 Duration of therapy ............................................................................................................................................................................................................................ 10 Special considerations ....................................................................................................................................................................................................................... 11 Glossary ................................................................................................................................................................................................................................................. 15 References .............................................................................................................................................................................................................................................. 16 Acknowledgment about Content Validation .......................................................................................................................................................................................... 19 Appendix A - Policies & Procedures Template for Maggot Debridement Therapy (MDT) ................................................................................................................. 20 Appendix B - Template for Maggot Debridement Therapy (MDT) Consent Form .............................................................................................................................. 29

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Introduction Wound debridement may be necessary for optimal wound healing (Fleck & Chakravarthy, 2010; Harris, 2009). Wound debridement is defined as the process of removing necrotic, nonviable/dead tissue from pressure ulcers, burns, and other acute and chronic wounds to expose healthy tissue (Leak, 2012; Young, 2012). Necrotic tissue varies in appearance and form. Slough is moist, devitalized tissue that can be soft or fibrous in character. Color can be brown, yellow, green, or gray, and it can be firmly or loosely adhered to the underlying tissue (Ramundo, 2012). Eschar occurs when necrotic tissue is exposed to air, becomes desiccated, and forms a thick, leathery brown or black crust on the wound (Young, 2012). Nonviable tissue is an impediment to wound healing: It fosters inflammation and infection; causes odor; is a physical barrier to healing; prevents wound contraction and epithelialization; and prevents adequate assessment of the wound (Gray et al., 2011; Lucas & King, 2010; Ramundo, 2012; Young, 2012). Debridement of dead/necrotic tissue, senescent cells, and biofilm removes obstacles to healing; reduces the bioburden (removing a potential nutrient source for bacteria); decreases odor; and permits visualization of the wound. At the molecular level, debridement interrupts the cycle of chronic inflammation and facilitates a level of proteases and cytokines similar to an acute wound (Johnson, Collarte, Lara, & Alberto, 2012; Lucas & King, 2010; Ramundo, 2012; Sibbald et al., 2011; Widgerow, 2012; Young, 2012). Not all wounds should be debrided. In certain circumstances, dry, stable eschar should not be debrided such as in noninfected wounds or dry gangrene on ischemic limbs or heels (Ramundo, 2012; Young, 2012). In such cases, it may be better to leave hardened eschar in place rather than remove it and create an open wound which might not heal. Purpose This document was originally developed by the Wound, Ostomy and Continence Nurses Society™ (WOCN®) as a best practice guide for clinicians providing wound care (Wound, Ostomy and Continence Nurses Society [WOCN], 2005). The purpose of this updated document is to provide licensed clinicians with information to facilitate treatment according to best practices for individuals needing wound debridement. Selecting the appropriate method of debridement requires careful assessment of the patient, goals of care, characteristics of the wound, setting and skill level of the clinician, and availability of resources (Sibbald et al., 2011; Young, 2012). Before debriding wounds, clinicians must ensure that they have the necessary skills to perform the task, the skill is within their scope of practice, and there is an agency or institutional policy in place regarding debridement (Chadwick, Edmonds, McCardle, & Armstrong, 2013; Harris, 2009; Leak, 2012; Spear, 2010). This guideline provides an overview of five commonly used types of debridement: Autolytic, biologic, enzymatic, mechanical, and conservative sharp debridement (Falanga et al., 2008; Harris, 2009; Leak, 2012; Lucas & King, 2010; Moore, 2012; Sibbald et al., 2011; Spear, 2010; Young, 2012). The following information is provided for each of the debridement modalities: definition, indications, contraindications, identification of the method as selective versus nonselective, skill level required, method of action, and special considerations.

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COMPARISON OF DEBRIDEMENT METHODOLOGIES Types of Debridement Autolytic Debridement

Definition

Indications

Biologic Debridement Enzymatic Debridement Mechanical Debridement (Maggot Debridement Therapy [MDT) • Autolytic debridement is a • Biologic debridement is the • Enzymatic debridement of • Mechanical debridement is a natural and highly selective application of sterile, medical wounds can be achieved with nonselective, physical method process by which endogenous grade larvae (maggots) into the use of exogenous, of removing both viable and phagocytic cells and the wound for the purpose of proteolytic enzymes. nonviable tissue and debris proteolytic enzymes break removing devitalized tissue, • Enzymes work directly on the from a wound using a down necrotic tissue (Evans disinfection, and promotion of devitalized tissue or indirectly physical force such as wet to & Mahoney, 2013; Mayo wound healing (Bio by dissolving the collagen that dry dressings, wound Clinic Staff, 2014; Sibbald et Therapeutics, Education, & attaches the devitalized tissue irrigation, or pulsatile lavage al., 2011; Smith, Legel, & Research Foundation [BTER], to the wound bed, but have (Benbow, 2011; Cowan & Hanft, 2009; Spear, 2010; n.d.a; Jiang, Luo, Chen, Liu, Stechmiller, 2009; Spear, little to no effect on healthy Wu, Ahn, Emmons, & & Wang, 2010; Opletalová et tissue (Falanga et al., 2008; 2010; Young, 2012). Salcido, 2009; Young, 2012). al., 2012; Sherman, 2009). Lucas & King, 2010; Milne, • Debridement occurs as larvae Ciccarelli, & Lassy, 2012; introduce proteolytic enzymes Ramundo, 2012; Ramundo & to promote rapid removal of Gray, 2009; Shi & Carson, devitalized tissue. 2009; Shi, Ramsay, Ermis, & Carson, 2011; Spear, 2010). • At present, collagenase is the only enzymatic agent approved by the Food and Drug Administration in the United States (Spear, 2010).

• Autolytic debridement is • MDT is an alternative in the • Indications for enzymatic • Indications for mechanical indicated for: following situations: debridement include: debridement include: o Noninfected wounds (Mayo o Surgical debridement is o Patients who are poor o Heavily necrotic wounds Clinic Staff, 2014; Wu et al., technically difficult due to candidates for surgical with minimal viable tissue debridement; as an adjunct to and greater than 50% 2009), or as an adjunctive the close proximity of vital surgical debridement; and therapy in infected wounds. structures; nonviable tissue; o Acute wounds. o the patient refuses surgery or patients who do not have o infected, necrotic wounds; access to a healthcare o Chronic wounds. its associated procedures o acute wounds; and professional to provide sharp o chronic wounds (Cowan & (e.g., transfusion); debridement; Stechmiller, 2009; Johnson o as an adjunctive treatment et al., 2012; Ramundo, for salvaging limbs; and 2012). WOCN® National Office ◊ Mount Laurel, NJ 08054 www.wocn.org 6

Conservative Sharp Debridement (CSD) • CSD is the removal of clearly identifiable, devitalized tissue to above the level of viable tissue using sharp instruments, including but not limited to scalpels, scissors, and curettes (Gray et al., 2011; Harris, 2009; Lucas & King, 2010; Nenna, 2011; Rodd-Nielsen et al., 2013; Spear, 2010). • Minimal pain and bleeding are expected with CSD and repeated debridement is often needed (Ramundo, 2012). • CSD is differentiated from excisional or surgical debridement, which requires a surgeon, involves extensive debridement that may include viable and nonviable tissue resulting in bleeding and pain, and is best performed in an operating room with anesthesia (Gray et al., 2011; Rodd-Nielsen et al., 2013; Spear, 2010). • CSD is indicated for: o Devitalized tissue in infected and noninfected wounds. o Various types of acute and chronic wounds: pressure, neuropathic/diabetic, and venous (Werdin, Tennenhaus, Schaller, & Rennekampff, 2009).

Autolytic Debridement

Biologic Debridement Enzymatic Debridement (Maggot Debridement Therapy [MDT) o when the extent of the injury o various types of dermal is not defined (Ruiz et al., wounds (e.g., pressure 2010). wounds, leg wounds); and • MDT can be used in various o thermal burn injuries (Ramundo & Gray, 2009; types of acute and chronic Shi & Carson, 2009; Shi et wounds: al., 2011; Smith & Nephew, o Abscesses. Inc., 2014). o Burns. • Refer to the manufacturer’s o Infected wounds. guidelines for specific o Leg wounds: venous, indications, uses, and product ischemic, neuropathic information. (BTER n.d.b). o As an alternative to treat osteomyelitis if surgical and medical treatments are not an option or have failed (BTER, n.d.b; Ruiz et al., 2010). o Pressure wounds (BTER, n.d.b; Davydov, 2011; Marineau, Herrington, Swenor, & Eron, 2011; Ruiz et al., 2010; Sherman, 2009). o Surgical wounds and traumatic wounds (BTER, n.d.b; Jiang et al., 2010; Marineau et al., 2011). Contraindications • Contraindications for • MDT is contraindicated in the • Enzymatic debridement is not autolytic debridement include: following situations (Benbow, recommended for advancing o Patients with poor perfusion 2011; BTER, n.d.b; Ruiz et necrosis (Falanga et al., and stable, dry, and intact al., 2010; Sherman, 2009): 2008). o Presence of active eschar (Ramundo, 2012). • Enzymatic debridement o As the sole method of hemorrhage, or bleeding should not be used for debridement for actively disorders with a high risk of patients with known infected wounds or wounds bleeding. sensitivities to any of the with extensive necrotic tissue o Copious wound exudate that product’s ingredients (Smith or significant tunneling and may flush maggots out of the & Nephew, Inc., 2014). wound. undermining (European • Use enzymatic debridement o Wounds in deep body Pressure Ulcer Advisory with caution in infected cavities, fistulae or sinus Panel & National Pressure wounds (Ramundo, 2012; tracts of unknown origin. Ulcer Advisory Panel, 2009; Ramundo & Gray, 2009). Ramundo, 2012). WOCN® National Office ◊ Mount Laurel, NJ 08054 www.wocn.org 7

Mechanical Debridement

Conservative Sharp Debridement (CSD)

• Contraindications for • CSD is contraindicated in the mechanical debridement following situations: o Unable to determine the include: o Presence of significant interface between viable and granulation tissue. nonviable tissue; extensive o Patients with poor perfusion undermining or tunneling. and an intact eschar without o Use caution with exposed signs of infection. bones, ligaments or tendons. o Uncontrolled pain. o Excessive or unexpected bleeding.

Autolytic Debridement

o Patients at risk of severe infection or sepsis. o Immunocompromised patients or patients with severe neutropenia— absolute neutrophil count less than 500 mm3 (Ramundo, 2012). o Third-degree burns.

Selective versus nonselective

• Selective.

Biologic Debridement Enzymatic Debridement Mechanical Debridement (Maggot Debridement Therapy [MDT) o Wounds in close proximity • If infection is present, an to large blood vessels or appropriate topical antibiotic organs. powder can be applied to the o Presence of life-threatening, wound prior to the enzyme, acute infection. and if the infection does not o Acute wounds that require respond, collagenase should frequent inspection. be discontinued until the o Devitalized bone or tendon. infection is resolved o Inadequate circulation for (Ramundo, 2012; Ramundo & healing. Gray, 2009; Smith & Nephew o Acute or rapidly advancing Inc., 2014). tissue necrosis. • Refer to the manufacturer’s o Patient is allergic or sensitive guidelines for specific to larval proteins or the contraindications and nutrient media used to ship precautions. the maggots, which might include brewer’s yeast, soy, chicken egg, or other ingredients. o A non-consenting patient or patient’s representative. o Use of non-sterile, nonmedical grade maggots.

• Selective.

• Selective.

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• Nonselective.

Conservative Sharp Debridement (CSD) o Patient at high risk of bleeding such as unstable clotting, coagulopathy disorder, and taking anticoagulants (Ramundo, 2012; Rodd-Nielsen et al., 2013; Young, 2012). o Fascial plane penetration. o Abscess. o Dry, stable heel ulcers. o Stable, ischemic wounds (Rodd-Nielsen et al., 2013). o Dry gangrene. o Non-consenting patient or patient’s representative. o Patient unable to cooperate or maintain position for the procedure (Rodd-Nielsen, 2013). o Extreme pain (Harris, 2009). o Advancing cellulitis or sepsis, in which case surgical debridement is preferred (Rodd-Nielsen et al., 2013). o Malignant cutaneous wounds such as fungating tumors (Harris, 2009; Rodd-Nielsen, 2013; Spear, 2010; Young, 2012). o Pyoderma gangrenosum or vasculitic ulcers, in which case debridement may exacerbate the condition. o Wounds on face, hands, and feet near nerves, vascular structures, grafts, prosthesis, dialysis fistulae, or joints (Rodd-Nielsen, 2013; Young, 2012). • Selective.

Autolytic Debridement

Biologic Debridement Enzymatic Debridement Mechanical Debridement Conservative Sharp (Maggot Debridement Debridement (CSD) Therapy [MDT) Skill level • Licensed healthcare providers • Licensed healthcare providers • Licensed healthcare providers • Licensed healthcare providers • Licensed healthcare providers required who have been specifically who have been specifically who have been specifically or caregivers who have been who have been specifically trained in the trained in the application and trained in the specifically trained in the educated, trained and application/procedure. removal of larvae. application/procedure. application/procedure. demonstrated competency in CSD in accordance with licensure and facility policies and procedures (Harris, 2009; Leak 2012; Ramundo, 2012; Rodd-Nielsen et al., 2013; Young, 2012). • Individuals performing CSD must be able to distinguish tissue types and understand the anatomy of the area to be debrided to prevent damage to blood vessels, organs, nerves, or tendons in the area (Chadwick et al., 2013; Gray et al., 2011; Young, 2012). Method of action • Autolysis is the body’s own • Four primary modes of action • Collagenase works by • Mechanical debridement uses • CSD is the most selective and natural process of removing of medical grade maggots on dissolving the collagen that physical force to remove efficient method to remove devitalized tissue by the wounds have been identified: attaches the devitalized tissue. thick, adherent eschar and release of endogenous cleaning/debridement of devitalized/necrotic tissue to • Wet to dry dressings: devitalized tissue causing proteolytic, fibrinolytic, and dead/necrotic tissue; the underlying wound bed little or no damage to healthy Moistened gauze (i.e., opencollagenolytic enzymes disinfection by killing (Lucas & King, 2010; tissue. weave cotton fabric for best (Ramundo, 2012). bacteria; stimulation of Ramundo, 2012; Shi & results) is lightly packed into wound healing; removal of Carson, 2009; Smith & • Autolytic debridement the wound bed and allowed to Nephew Inc., 2014; Spear, completely dry, trapping requires a moist environment, existing biofilm; and inhibition of the formation of 2010). debris (Ramundo, 2012). adequate perfusion, and a new biofilm (BTER, n.d.a; • Dakin’s solution denatures When the dressing is removed functioning immune system; in a dry state, debris and and is enhanced by the use of Jiang et al., 2010; Opletalová protein, which loosens the et al., 2012; Sherman, 2009). slough. Collagen degradation tissue are removed from the moisture-retentive dressings • Larvae may combat wound is affected by the wound bed. (Benbow, 2011; Ramundo, infection by ingesting concentration of the Dakin’s • Pressurized wound 2012). microorganisms that are then solution (Ramundo, 2012). • Autolysis can be used alone irrigation/pulsatile lavage: destroyed in their digestive • Wound surface must be kept or in combination with other Delivers a high pressure tracts (Ruiz et al., 2010). moist; enzymes can be used in stream of fluid (i.e., 4 to15 debridement techniques combination with moist (Ramundo, 2012). pounds per square inch [psi]) dressings (Ramundo, 2012; directed at the wound bed to Ramundo & Gray, 2009; Shi remove debris (Ramundo, & Carson, 2009; Shi, Ermis, 2012). Kiedaisch, & Carson, 2010). WOCN® National Office ◊ Mount Laurel, NJ 08054 www.wocn.org 9

Autolytic Debridement

Duration of therapy

• The time frame for autolysis varies according to the size of the wound and the type and amount of necrotic tissue. • Softening and separation of necrotic tissue commonly occurs within a few days, and if significant autolysis is not observed within 1 to 2 weeks, another method of debridement should be considered (Ramundo, 2012).

Biologic Debridement (Maggot Debridement Therapy [MDT) • Larvae secrete chemicals and other substances (i.e., allantoin, urea, ammonia, calcium carbonate, etc.) that favor granulation tissue and cell migration, and promote wound healing (Ruiz et al., 2010). • Micromassage of the wound by maggot movement is thought to stimulate granulation tissue formation and wound exudate (Ruiz et al., 2010). • While biologic therapy is well tolerated and cost-effective, it is not applicable for every wound (Davydov, 2011; Gray et al., 2011; Jiang et al., 2010). Use with caution in wounds with pseudomonas or wounds with necrosis extending to, and involving, blood vessel walls (Ruiz et al., 2010).

Enzymatic Debridement

Mechanical Debridement

Conservative Sharp Debridement (CSD)

• Enzymes can be used in • Noncontact low-frequency conjunction with autolytic, ultrasound therapy uses mechanical, and sharp acoustic energy to remove debridement (Ramundo & necrotic tissue by mechanical Gray, 2009). debridement (Ramundo, 2012). • Manufacturers’ guidelines should be followed to achieve • Hydrotherapy may be used to optimal efficacy. remove bacteria and debris and promotes softening and loosening of adherent necrotic tissue (Ramundo, 2012). • Negative pressure wound therapy (NPWT) promotes autolytic debridement via a moisture retentive dressing and mechanical nonselective debridement with the removal of the open cell foam or gauze dressing (Loree, Dompmartin, Penven, Harel, & Leroy, 2004). • For high pressure irrigation, the pressure should not exceed 15 psi to avoid damaging or forcing bacteria into healthy tissue (Ramundo, 2012). • Progress with MDT should be • The length of time for • Mechanical debridement • The length of time for CSD observed in 2 days to 2 enzymatic debridement ranges should be discontinued when varies according to the size of from days to weeks weeks. significant granulation tissue the wound and the amount of (Ramundo, 2012). is present, or if significant necrotic tissue and may take • In an RCT, most of the pain or bleeding occurs. days to weeks, and often debridement occurred in the • Enzymes should be requires serial debridements discontinued when the wound first week of MDT (Ramundo, 2012). is free of devitalized tissue (Opletalová et al., 2012). • CSD is repeated as often as and granulation tissue is needed to remove devitalized visible, or according to the tissue from the wound bed. manufacturer’s recommendation (Ramundo & Gray, 2009).

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Autolytic Debridement

Special considerations

• Autolysis is the most conservative form of debridement. • Autolysis may not take place fast enough to encourage rapid wound healing (Young, 2012). • Autolysis is a simple/easy form of debridement that is slower than other methods, but causes minimal pain and discomfort for the patient (Ramundo, 2012; Spear, 2010; Young, 2012). • Using a moisture-retentive dressing such as an occlusive or semi-occlusive dressing can enhance the process while maintaining a moist wound environment (Ramundo, 2012). • During the autolytic process: o The wound may increase in length, width, and depth because the full wound is exposed and the true extent of the wound is revealed as the autolytic process continues (Ramundo, 2012). o Odor may increase as devitalized tissue is liquefied (Ramundo, 2012; Young, 2012). o Exudate may increase, which can cause maceration of the periwound skin (Ramundo, 2012; Young, 2012). o The specific autolytic dressing or secondary dressing may need to be reconsidered throughout the treatment.

Biologic Debridement Enzymatic Debridement Mechanical Debridement Conservative Sharp (Maggot Debridement Debridement (CSD) Therapy [MDT) • Maggots are medical-grade • Enzymatic debridement is • Mechanical debridement may • Caution should be used with larvae and should be ordered considered a conservative cause pain, bleeding, and CSD for patients who are only from an approved method. damage to healthy, exposed taking anticoagulant supplier (Ruiz et al., 2010). • The decision to use an granulation and epithelial medications. tissue (Cowan & Stechmiller, • Caution is advised if using • Maggot larvae are considered enzyme is based on the 2009; Ramundo, 2012; Spear, CSD in infected wounds a “perishable item” and following: 2010). o Availability. should be used as soon as (Ramundo, 2012; Young; • Consider a pain management 2012). o Cost. possible after delivery— program. o Ease of dressing changes. ideally within 24 hours • If surgery is not an option, o Frequency of dressing (Sherman, 2009). • Note: Wet to dry dressings are appropriate antibiotic changes. • If maggots are not used upon not generally an acceptable coverage is needed along with • An enzyme requires a CSD on infected wounds delivery, check the form of moist wound care or prescription. (Ramundo, 2012). manufacturer’s debridement. recommendations for • Well-adhered eschar should • Wet to dry gauze dressings • CSD often requires additional refrigeration and storage. be crosshatched with a No.10 are not appropriate for debridements (Gray et al., • Maggots are contained in a blade by a debridement in most cases 2011; Ramundo, 2012; Rodd“cage-like” dressing applied licensed/credentialed because they do not support Nielsen et al., 2013). over the wound (BTER, n.d.a, healthcare provider to allow optimal granulation and moist • The wound may increase in b; Ruiz et al., 2010; Sherman, penetration of the enzyme wound healing; are costly, length, width, and depth 2009). using care not to damage time consuming and labor because the full wound is intensive; can cause pain, • The maggots may be allowed underlying viable tissue. exposed and the true extent of to move freely within the cage Consider softening the eschar bleeding and trauma to the wound is revealed as via autolytic debridement first healthy tissue; do not provide necrotic tissue is removed. dressing, with the wound (Ramundo, 2012; Ramundo & a bacterial barrier; and are less • Prior to performing CSD, the floor acting as the bottom of effective than other methods the cage, or the maggots may Gray, 2009; Smith & clinician should determine if Nephew, Inc., 2014). (Cowan & Stechmiller, 2009; the setting and environment be contained within a sealed pouch that is placed on top of • Collagenase should be applied Gray et al., 2011; Harris, are clean and safe with at least once daily or twice per 2009; Leak, 2012; Lucas & the wound (BTER, n.d.a). adequate lighting to perform King, 2010; Nenna, 2011; • The dressing must be kept air day with a cover dressing. CSD; if there is a stable Sibbald et al., 2011). The cover dressing can be surface to position the patient; permeable because maggots and if assistance is available require oxygen to live (BTER, moist or dry (Ramundo, 2012; • The wound may increase in Ramundo & Gray, 2009; length, width, and depth n.d.b). (if needed) during the Smith & Nephew, Inc., 2014). because the full wound is procedure (Rodd-Nielsen et • When maggots are satiated, exposed and the true extent of al., 2013). • The enzyme may cause mild they become substantially and transient burning or pain, the wound is revealed as the larger and seek to leave the process continues. or slight erythema if the site of a wound. • Superficial wounds or wounds ointment contacts the • Dressings should be changed periwound skin (Ramundo & with small amounts of every 24 to 48 hours and no necrotic tissue can be more longer than 72 hours (BTER, Gray, 2009; Smith & effectively treated with other Nephew, Inc., 2014). n.d.b; Ruiz et al., 2010; debridement methods. Sherman, 2009). WOCN® National Office ◊ Mount Laurel, NJ 08054 www.wocn.org 11

Autolytic Debridement

Biologic Debridement Enzymatic Debridement Mechanical Debridement (Maggot Debridement Therapy [MDT) o Protection for the periwound • Multiple courses of maggot • Enzymes are sensitive to pH skin should be included to therapy may be administered range: Acidic or highly prevent maceration, depending on the severity of alkaline solutions can denudation, and further skin the non-healing wound. Most decrease the effectiveness of damage during treatment patients require 2 to 3 collagenase and should be (Young, 2012). applications of MDT avoided (Ramundo, 2012; (Davydov, 2011). Ramundo & Gray, 2009). • Maggots do not reproduce in • Collagenase is effective over the wound because they are a wide pH range, but the still in the larval stage and too optimal pH for collagenase immature to replicate activity is 8.5 (Shi et al., (Davydov, 2011). 2011). Reproduction only occurs • Normal saline and Dakin’s when they become adult flies solution are compatible with and mate (Ruiz et al., 2010). collagenase (Smith & • The wound may increase in Nephew, Inc., 2014). length, width, and depth • Do not use cleansers or because the full wound is dressings containing heavy exposed and the true extent of metals (e.g., silver, iodine), or the wound is revealed as the acidic or hyperchlorite process continues. solutions with collagenase • Odor is controlled by maggots because they can deactivate ingesting devitalized tissue the active ingredients in the and bacteria (Benbow, 2011). enzyme (Ramundo & Gray, 2009; Shi & Carson, 2009; • Maggots can be removed from the wound using gloved Shi et al., 2010). fingers, forceps, or moistened • Include protection for the periwound skin to prevent gauze pads followed by maceration, denudation, or flushing the wound with further skin damage during saline. • Care should be taken to avoid treatment. • Exudate may increase during killing/bursting maggots in the debridement process and the wound because some patients can have anaphylactic cover dressings may need to reactions to larval protein, and be reconsidered throughout the maggots contain the the treatment. bacteria and necrotic tissue they ingested in the wound (BTER, n.d.b).

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Conservative Sharp Debridement (CSD) • Use sterile instruments such as forceps, scissors, and #10 blade scalpels for CSD (Rodd-Nielsen et al., 2013). Use aseptic technique. Nonsterile gloves are appropriate (Perelman et al., 2004; Ramundo, 2012; Rowley, Clare, Macqueen, & Molyneux, 2010; WOCN, 2012). • Policies and procedures should be in place and supplies should be available to manage complications such as minor bleeding (Ramundo, 2012; Rodd-Nilsen et al., 2013). • The need for analgesia during the procedure should be assessed, and adequate pain control provided (Ramundo, 2012; Rodd-Nielsen et al., 2013). • CSD poses a risk for transient bacteremia (Ramundo, 2012; Rodd-Nielsen et al., 2013). • CSD should be discontinued if the following occurs: o Severe or uncontrolled bleeding. o The pain tolerance of the patient has been reached. o Fatigue of the person performing the debridement.

Autolytic Debridement

Biologic Debridement Enzymatic Debridement Mechanical Debridement (Maggot Debridement Therapy [MDT) • Pain and minor bleeding have • The wound may increase in occurred with MDT length, width, and depth (Davydov, 2011; Ramundo, because the full wound is 2012; Sherman, 2009). exposed and the true extent of the wound is revealed as • Pain is usually a result of the enzymatic debridement caustic exudate that denudes continues. the periwound skin. • The periwound skin should be • Refer to the manufacturer’s protected with a hydrocolloid, guidelines for specific information about the zinc oxide based moisture administration and application barrier ointment, and the manufacturer's system should of the enzyme. be utilized to help prevent skin breakdown. • Therapy may need to be stopped to address the pain. • Some patients report a tickling sensation from the movement of the larvae in the wound. • Exposure to hydrogel with polyethylene glycol may negate the action of the larvae (Young, 2012). • MDT is not recommended as the sole method for debridement of neuropathic/diabetic foot wounds because larvae cannot remove callus (Chadwick et al., 2013). • Disposal of larvae should be according to facility policy, and used larvae should be considered biohazardous waste. • Refer to the manufacturer’s guidelines for other specific/special considerations regarding MDT. WOCN® National Office ◊ Mount Laurel, NJ 08054 www.wocn.org 13

Conservative Sharp Debridement (CSD)

Autolytic Debridement

Biologic Debridement Enzymatic Debridement (Maggot Debridement Therapy [MDT) • See Appendix A for a sample template for policies and procedures for MDT, and Appendix B for a sample template for an MDT consent form (BTER, n.d.b, c).

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Mechanical Debridement

Conservative Sharp Debridement (CSD)

Glossary Acute wound: Disruption in the integrity of the skin and underlying tissue that progresses through the healing process in a timely and uneventful manner. Biofilm: Bacteria that forms microbial communities which demonstrate increased resistance to antibiotics and interferes with wound healing. Must be removed with debridement. Chronic wound: Wound that is unresponsive to initial therapy despite appropriate care. A chronic wound fails to respond to treatment and heal in the normally expected time frame (i.e., approximately 4 weeks), and becomes “stuck” in the inflammatory phase. Wound chronicity is attributed to the presence of intrinsic and extrinsic factors including medications, poor nutrition, co-morbidities, or use of inappropriate dressings. Denudation: Loss of the epidermis, caused by prolonged exposure to urine, feces, body fluids, wound exudate, or friction. Infected wound: Wound typically has at least one or more of the following symptoms: foul odor, purulent drainage (pus), debris (yellowish to greenish) or dead tissue, and ongoing symptoms of inflammation (i.e., fever, pain, redness, swelling, warmth). The infection can also affect the surrounding tissues and may cause a bacterial skin infection (cellulitis) or an acute or chronic bacterial bone infection (osteomyelitis). If the infection spreads to the blood vessels, the bacteria may spread and cause infection in other areas of the body (sepsis or systemic infection). Maceration: Softening and breakdown of skin from prolonged exposure to moisture. Often presents as white rim around the immediate periwound edge. Noninfected wound: Wound that is free from bacteria, odor, purulent drainage (pus), or dead tissue and shows no signs of inflammation (i.e., fever, pain, redness, swelling, warmth). Mild erythema can be present and is a part of the initial inflammatory phase.

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References Benbow, M. (2011). Debridement: Wound bed preparation. Journal of Community Nursing, 25(3), 18, 20, 22-23. BioTherapeutics, Education, & Research (BTER) Foundation. (n.d.a). Maggot therapy. Retrieved April 2014 from http://www.bterfoundation.org/node/19 BioTherapeutics, Education, & Research (BTER) Foundation. (n.d.b). Policies & procedures template for maggot debridement therapy (MDT). Retrieved April 2014 from http://www.bterfoundation.org/node/19 BioTherapeutics, Education, & Research (BTER) Foundation. (n.d.c). Template for maggot debridement therapy (MDT) consent form. Retrieved April 2014 from http://www.bterfoundation.org/node/19 Chadwick, P., Edmonds, M., McCardle, J., & Armstrong, D. (2013). Best practice guidelines: Wound management in diabetic foot ulcers. Wounds International, 1-23. Retrieved April 2014 from http://www.woundsinternational.com/pdf/content_10803.pdf Cowan, L. J., & Stechmiller, J. (2009). Prevalence of wet-to-dry dressings in wound care. Advances in Skin & Wound Care, 22(12), 567-573. doi:10.1097/01.ASW.0000363469.25740.74 Davydov, L. (2011). Maggot therapy in wound management in modern era and a review of published literature. Journal of Pharmacy Practice, 24(1), 89-93. doi:10.1177/0897190010366938 European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. (2009). Pressure Ulcer Prevention, Quick Reference Guide. Retrieved October 2014 from http://www.npuap.org/wp-content/uploads/2012/02/Final_Quick_Prevention_for_web_2010.pdf Evans, J., & Mahoney, K. (2013). Efficacy of medical-grade honey as an autolytic debridement agent. Wounds UK, 9(1), 30-36. Retrieved April 2014 from http://www.advancis.co.uk/themes/advancis/images/media/all_wales_article_(web).pdf Falanga, V., Brem, H., Ennis, W. J., Wolcott, R., Gould, L. J., & Ayello, E. A. (2008). Maintenance debridement in the treatment of difficult-to-heal wounds. Recommendations of an expert panel. Ostomy Wound Management, June (Suppl), 2-13. Fleck, C. A., & Chakravarthy, D. (2010). Newer debridement methods for wound bed preparation. Advances in Skin & Wound Care, 23(7), 313-315. doi:10.1097/01.ASW.0000383755.62091.1e Gray, D., Acton, C., Chadwick, P., Fumarola, S., Leaper, D., Morris, C.,…Young, T. (2011). Consensus guidance for the use of debridement techniques in the UK. Wounds UK, 7(1), 77-84. Retrieved April 2014 from http://www.wounds-uk.com/pdf/content_9821.pdf Harris, R. J. (2009). The nursing practice of conservative sharp wound debridement: Promotion, education and proficiency. Wound Care Canada, 7(1), 22-30. Retrieved April 2014 from http://cawc.net/images/uploads/wcc/harris.pdf

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Jiang, K. C., Luo, N., Chen, Y. C., Liu, L., & Wang, A. P. (2013). Use of maggot debridement therapy for tropical diabetic hand syndrome. Journal of Wound Care, 22(5), 244-247. doi:10.12968/jowc.2013.22.5.244 Johnson, S., Collarte, A., Lara, L., & Alberto, A. (2012). A multi-centre observational study examining the effects of a mechanical debridement system. Journal of Community Nursing, 26(6), 43-46. Retrieved April 2014 from http:www.//video.molehost2.net/wounds-uk/harrogate-2013/activa/microsite/pdfs/JCNObservational-study-of-effects-of-Debrisoft.pdf Leak, K. (2012). How to… Ten top tips for wound debridement. Wounds International, 3(1). Retrieved April 2014 from http://www.woundsinternational.com/practice-development/how-to-ten-top-tips-for-wound-debridement&print Loree, S., Dompmartin, A., Penven, K., Harel, D., & Leroy, D. (2004). Is vacuum assisted closure a valid technique for debriding chronic leg ulcers? Journal of Wound Care, 13(6), 249-252. Lucas,V. S., & King, A. W. (2010). Wound care for the plastic surgery nurse. Plastic Surgical Nursing, 30(3), 158-169. doi:10.1097/PSN.0b013e3181ee1760 Marineau, M. L., Herrington, M. T., Swenor, K. M., & Eron, L. J. (2011). Maggot debridement therapy in the treatment of complex diabetic wounds. Hawaii Medical Journal, 70(6), 121-124. Mayo Clinic Staff. (2014). Bedsores (pressure sores). Retrieved April 2014 from http://www.mayoclinic.org/diseases-conditions/bedsores/basics/treatment/con20030848 Milne, C. T., Ciccarelli, A., & Lassy, M. (2012). A comparison of collagenase to hydrogel dressings in maintenance debridement and wound closure. Wounds, 24(11), 317-322. Retrieved April 2014 from http://www.woundsresearch.com/files/wounds/WOUNDS_November2012_Milne.pdf Moore, Z. (2012). Technology update: The important role of debridement in wound bed preparation. Wounds International, 3(2), 1-4. Retrieved April 2014 from http://www.woundsinternational.com/pdf/content_10389.pdf Nenna, M. (2011). Pressure ulcers at end of life: An overview for home care and hospice clinicians. Home Healthcare Nurse, 29(6), 350-365. doi:10.1097/NHH.0b013e3182173ac1 Opletalová, K., Blaizot, X., Mourgeon, B., Chêne, Y., Creveuil, C., Combermale, P.,…Dompmartin, A. (2012). Maggot therapy for wound debridement. A randomized multicenter trial. Archives of Dermatology, 148(4), 432-438. doi:10.1001/archdermatol.2011.1895 Perelman, V. S., Francis, G. J, Rutledge, T., Foote, J., Martino, F., & Dranitsaris, G. (2004). Sterile versus nonsterile gloves for repair of uncomplicated lacerations in the emergency department: A randomized controlled trial. Annals of Emergency Medicine, 43 (3), 362-370. Ramundo, J. (2012). Wound debridement. In R. A. Bryant & D. P. Nix (Eds.), Acute & chronic wounds. Current management concepts (4th ed., pp. 279-288). St. Louis, MO: Elsevier-Mosby.

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Ramundo, J., & Gray, M. (2009). Collagenase for enzymatic debridement: A systematic review. Journal of Wound, Ostomy and Continence Nursing, 36(6S), S4S11. doi:10.1097/WON.0b013e3181bfdf83 Rodd-Nielsen, E., Brown, J., Brooke, J., Fatum, H., Hill, M., Morin, J., & St-Cyr, L. (2013). Canadian Association for Enterostomal Therapy evidence-based recommendations for conservative sharp wound debridement: An executive summary. Journal of Wound, Ostomy and Continence Nursing, 40(3), 246-253. doi:10.1097/WON.0b013e31828fd3fc Rowley, S., Clare, S., Macqueen, S., & Molyneux, R. (2010). ANTT v 2: An updated practice framework for aseptic technique. British Journal of Nursing, 19 (5), S5-S11. Ruiz, J. C., Muñoz, A., F., Jiménez, H. E., Platonoff, A. L., Castañeda, O. C., Giadans, H. E.,…Aguilar, R. (2010). Clinical practice guideline for the treatment of acute and chronic wounds with maggot debridement therapy. Mexican Association for Wound Care and Healing. Retrieved April 2014 from http://www.aawconline.org/wp-content/uploads/2011/09/GPC_larvatherapy.pdf Sherman, R. A. (2009). Maggot therapy takes us back to the future of wound care: New and improved maggot therapy for the 21st century. Journal of Diabetes Science and Technology, 3(2), 336-344. Retrieved April 2014 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2771513/ Shi, L., & Carson, D. (2009). Collagenase Santyl ointment: A selective agent for wound debridement. Journal of Wound, Ostomy and Continence Nursing, 36(6S), S12-S16. doi:10.1097/WON.0b013e3181bfdd1a Shi, L., Ermis, R., Kiedaisch, B., & Carson, D. (2010). The effect of various wound dressings on the activity of debriding enzymes. Advances in Skin & Wound Care, 23(10), 456-462. doi:10.1097/01.ASW.0000383224.64524.ae Shi, L., Ramsay, S., Ermis, R., & Carson, D. (2011). pH in the bacteria-contaminated wound and its impact on clostridium histolyticum collagenase activity: Implications for the use of collagenase wound debridement agents. Journal of Wound, Ostomy and Continence Nursing, 38(5), 514-521. doi:10.1097/WON.0b013e31822ad034 Sibbald, R. G., Goodman, L., Woo, K. Y., Krasner, D. L., Smart, H., Tariq, G.,…Salcido, R. S. (2011). Special considerations in wound bed preparation 2011: An update. Advances in Skin & Wound Care, 24(9), 415-436. doi:10.1097/01.ASW.0000405216.27050.97 Smith & Nephew, Inc. (2014). What is collagenase Santyl® ointment? Retrieved April 2014 from http://www.santyl.com/ Smith, T., Legel, K., & Hanft, J. R. (2009). Topical Leptospermum honey (Medihoney) in recalcitrant venous leg wounds: A preliminary case series. Advances in Skin & Wound Care, 22(2), 68-71. doi:10.1097/01.ASW.0000345283.05532.9a Spear, M. (2010). The necessity of wound debridement. Plastic Surgical Nursing, 30(1), 54-56. doi:10.1097/PSN.0b013e3181cfe684 Werdin, F., Tennenhaus, M., Schaller, H. E., & Rennekampff, H. O. (2009). Evidence-based management strategies for treatment of chronic wounds. Eplasty, 9:e19. Retrieved April 2014 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2691645/#__ffn_sectitle WOCN® National Office ◊ Mount Laurel, NJ 08054 www.wocn.org 18

Widgerow, A. D. (2012). Deconstructing the stalled wound. Wounds, 24(3), 58-66. Retrieved April 2014 from http://www.woundsresearch.com/article/deconstructing-stalled-wound?page=0,4 Wound, Ostomy and Continence Nurses Society. (2005). Conservative sharp wound debridement: Best practice for clinicians. Mt. Laurel, NJ: Author. Wound, Ostomy and Continence Nurses Society. (2012). Clean vs. sterile dressing techniques for management of chronic wounds: A fact sheet. Journal of Wound, Ostomy and Continence Nursing, 39(2S), S30-S34. Wu, S. S., Ahn, C., Emmons, K. R., & Salcido, R. S. (2009). Pressure ulcers in pediatric patients with spinal cord injury: A review of assessment, prevention, and topical management. Advances in Skin & Wound Care, 22(6), 273-284. doi:10.1097/01.ASW.0000305474.37745.55 Young, T. (2012). Safe debridement in the community setting. Wound Essentials, 2, 82-89. Retrieved April 2014 from http://www.activahealthcare.co.uk/casestudies-files/DS024-Safe_debridement_in.pdf

Acknowledgment about Content Validation This document was reviewed in the consensus-building process of the Wound, Ostomy and Continence Nurses Society known as Content Validation, which is managed by the Center for Clinical Investigation.

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Appendix A Policies & Procedures Template for Maggot Debridement Therapy (MDT) Source: Bio-Therapeutics Education and Research Foundation. Used with permission. These sample policy/procedure and consent forms are not intended to be adopted and used as a substitute for a particular organization’s specific forms. The documents are to be used only as guides to developing policies/procedures and consent forms. Each organization must develop individualized forms in accordance with guidance and approval of appropriate administrative, legal, and risk management departments.

36 Urey Court, Irvine, CA 92617 ~ Fax: 949-679-3001 ~ [email protected] ~ www.BTERFoundation.org Advancing Healthcare through Education & Research in BioTherapy

Policies & Procedures Template for Maggot Debridement Therapy (MDT) DISCLAIMERS AND LEGAL NOTICES This template for maggot debridement therapy policies and procedures is provided by the BioTherapeutics, Education and Research Foundation, without warranties concerning the applicability of this draft at any specific facility. Please modify the document as needed to fit the specific policy, procedure, formulary, or logistic demands of your institution. Be sure to read and follow all warnings and labeling information associated with products used in the application and removal of maggot therapy dressings. Copyrights are owned by the BTER Foundation. This protocol is provided freely for personal and single institutional use. For such use, this item may be reproduced and amended, as needed. However, this protocol may not be distributed, in any format, for commercial benefit, without specific review and permission by the BTER Foundation. The BioTherapeutics, Education and Research (BTER) Foundation is a public charity whose mission is to support patient care, education, and research in maggot therapy, leech therapy, and the other diagnostic and treatment modalities that use live animals. More information about our services can be found at the address below, or on the internet at: www.BTERFoundaiton.org Disclosure: Ronald Sherman, one of the co-authors of this template and Board Member of the BTER Foundation is also the Co-Founder and Laboratory Director of Monarch Labs, which produces and distributes Medical Maggots™ and other biotherapy products.

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Draft Policies & Procedures for Maggot Debridement Therapy (MDT)

POLICY NAME Maggot Debridement Therapy Policy and Procedure POLICY NUMBER XXXXX PURPOSE The purpose of this policy is to provide guidelines for the use of Maggot Debridement Therapy (MDT) in wound management. PERSONNEL ET and/or Wound Care Specialist MD, DO, DPM, PA, NP RN, LPN, LVN, CCA, CNA, NA Physical therapists Pharmacy and/or Supply & Receiving staff Social Worker/Case Manager Infection Control INDICATIONS Non-healing wounds that contain slough or necrotic tissue (neuropathic and/or ischemic foot ulcers, pressure ulcers, venous stasis ulcers, traumatic wounds, and problematic post-surgical wounds). Some therapists also use MDT for maintenance debridement, or to determine the level of viability by debriding the necrotic tissue until reaching the viable tissue underneath. Some therapists use MDT for palliation of odor, drainage or pain. Be sure to document the indication(s) for treatment. WARNINGS, CONTRAINDICATIONS and RELATIVE CONTRAINDICATIONS 1. Persons allergic to fly larvae or materials used in their manufacture (brewer’s yeast; soy) may manifest allergic reactions to maggots prepared in such media. Check manufacturer’s labeling. 2. Rapidly advancing infection that needs frequent inspection and possibly surgical intervention. MDT dressings could impair direct visualization of the wound. 3. As an alternative to surgical resection for osteomyelitis, when surgery itself is not contraindicated. Surgical resection, when feasible, is the preferred method of debriding dead bone. 4. Necrosis extending to, and involving, blood vessel walls may be dissolved by the maggots’ digestive secretions, along with the other necrotic tissue, leading to serious bleeding. If such wounds are to be treated with maggot therapy, then treatment should be rendered under close or intensive observation. 5. Unable to obtain informed consent from patient or power of attorney for healthcare. 6. Patients with natural or pharmacologically induced coagulopathy are at increased risk of bleeding; if they are treated with MDT they must be observed closely and frequently. 7. Disinfected maggots should never be transferred from one patient to another. 8. Vials of medicinal maggots should never be used more than once. They are not intended nor approved for multi-dosing. 9. Pseudomonas infections may not always respond to maggot therapy; they may need specific antimicrobial therapy before and/or during MDT.

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10. Medicinal maggots should not be used if the sterile seal is broken, if the container is damaged, if the maggots have a strong offensive odor, or if they are known or suspected of being contaminated. PERSONAL PROTECTION Personal protective equipment (PPE) will be used at all times, as appropriate. Clean gloves will be used when handling maggots or wound dressings. Mask, eye protection, and gown, when performing treatment where exposure to blood/body fluids is likely. COMPETENCIES Only licensed personnel who have been trained in the procedure will apply MDT dressings. Any licensed personnel may remove MDT dressings. Outer dressings may be changed by any personnel allowed to change simple dry dressings by current hospital policy. Patients, family members and caregivers may remove MDT and/or change outer dressings as a part of teaching prior to discharge. PROCEDURES – Dressing Application The specific procedures and supplies for applying maggot therapy dressings depend on the location and dimensions of the wound. Several methods will be described here, but the successful therapist will often have to improvise. All of these dressings have in common the fact that they are designed to create a ‘cage’ over the wound floor, providing the maggots with free access to the wound bed (and undermined areas), but preventing them from leaving the proximity of the wound. An absorbent dressing (i.e., gauze) on the outside of the cage-dressing collects the liquified necrotic tissue drainage, and gets replaced as frequently as necessary (as frequently as it gets soiled). It is crucial that adequate air reaches the maggots through the dressing, and that the maggots do not drown in the liquid exudate that they create. Wound documentation supplies – Camera, wound tracing device, marker, Skin Ulcer Flow Sheet, Nursing records. Miscellaneous supplies – Consent form, PPE (see below), rubbish collection supplies. 1) Planar Wounds (Examples: ischial or sacral pressure wounds, plantar foot wounds, anterior tibial wounds, etc.) A) Pre-assembled MDT dressings (i.e., LeFlap [Monarch Labs]) 1. Assess wound for appropriateness (see Clinical Indications, above). 2. Obtain MD order. 3. Obtain patient and/or family informed consent, and consent for photography, if applicable. 4. Gather and inspect all supplies. Read and understand product literature (preferably before reaching the bedside). 5. Photograph the wound before the first treatment (recommended), and periodically thereafter to measure and document progress. 6. Gently cleanse the wound and peripheral skin (never use povidone iodine or other skin irritants), cut hair, if extensive, and protect the skin with a skin protectant, if possible. 7. When using a dressing like LeFlap, it will be necessary to cut out from the hydrocolloid layer a hole that matches the dimensions of the wounds. If the dressing itself needs to be trimmed to fit the anatomy, then LeFlap DuJour is the better choice, because it can be trimmed without losing adhesiveness. If the dressing already has a hole cut out in the foundation (hydrocolloid) layer, then it will not be necessary to cut the hole. Using the wound tracing device and marker, outline the wound, and cut out the pattern. Trace the pattern onto the hydrocolloid pad, and cut out the shape of the wound from these dressings.

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8. Place the dressing on the skin, open the netted (flapped) layer, and place the maggots on the wound (easily accessible because of the hole in the hydrocolloid layer). 9. The dose of maggots is 5-10 per square cm. If the maggots come as “maggot-impregnated gauze” then simply calculate the amount of gauze necessary to contain the desired number of maggots, and place that amount of gauze over the wound. If this amount of gauze is not adequate to cover the entire wound, then an additional pad of gauze can be moistened with sterile water or saline and placed over the wound bed. For example, if the wound were 5 cm by 7 cm, then its surface area would be 5 x 7 = 35 cm. The dose wound be 175 - 350 maggots. If the vial of maggot-impregnated gauze contained 600 maggots, then the therapist would need about half that to equal 300 maggots. The therapist would take or cut half the gauze and place it over the wound. There is no need to count each maggot, or attempt repeatedly to get every single maggot out from the vial. The maggots can simply be transferred from the vial to the wound within the maggot-impregnated gauze pad. 10. Now peel back the adhesive liner and flap down the netted fabric layer. Press firmly in place, to create a good bond. 11. If the patient or wound area is likely to move a lot or become soiled, it may be desirable to reinforce the dressing with silk, cloth or pink plastic tape, or with transparent membrane dressings, in a “picture frame” pattern. The film should cover the hydrocolloid frame and peripheral skin, but must NOT cover the central porous wound covering, or else it will prevent air from reaching the maggots and prevent the necessary drainage of necrotic wound exudate. 12. Cover this “maggot cage dressing” with dry absorbent gauze and secure loosely with a short gauze wrap or two pieces of tape. Air should be able to enter the dressing and the liquefied necrotic tissue should be able to drain out. Check this outer dressing every 4-6 hours for soiling, and replace with clean dry gauze as needed. 13. Leave the maggot cage dressing in place for approximately 48 hours. B) Do-It-Yourself (DIY) dressings, custom-made at the bedside Sometimes the size or shape of a wound does not lend itself easily to being covered with a standard maggot dressing. In such cases, it is valuable to be able to create a MDT dressing from locally available products. The procedure is similar to that described above, except that the netted fabric layer must be adhered to the hydrocolloid layer with glue, tape, and other bonding materials. 1. Assess wound for appropriateness (see Clinical Indications, above). 2. Obtain MD order. 3. Obtain patient and/or family informed consent, and consent for photography, if applicable. 4. Gather and inspect all supplies. Read and understand product literature (preferably before reaching the bedside). 5. Photograph the wound before the first treatment (recommended), and periodically thereafter to measure and document progress. 6. Gently cleanse the wound and peripheral skin (never use povidone iodine or other skin irritants), cut hair, if extensive, and protect the skin with a skin protectant, if possible. 7. Using the wound tracing device and marker, outline the wound, and cut out the pattern. Trace the pattern onto a hydrocolloid pad, and cut out the shape of the wound from the pad. 8. Place the cut-out hydrocolloid pad over the wound, to expose the wound but cover the periwound skin. Apply securely to the skin, such that it frames the wound. 9. Coat the hydrocolloid ring with a layer of liquid adhesive, such as NuHope Adhesive or Skin Bond (Smith & Nephew). The adhesive will become tacky while the maggots are placed within the wound bed.

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10. The dose of maggots is 5-10 per square cm. If the maggots come as “maggot-impregnated gauze” then simply calculate the amount of gauze necessary to contain the desired number of maggots, and place that amount of gauze over the wound. If this amount of gauze is not adequate to cover the entire wound, then an additional pad of gauze can be moistened with sterile water or saline and placed over the wound bed. For example, if the wound were 5 cm by 7 cm, then its surface area would be 5 x 7 = 35 cm. The dose wound be 175 - 350 maggots. If the vial of maggot-impregnated gauze contained 600 maggots, then the therapist would need about half that to equal 300 maggots. The therapist would take or cut half the gauze and place it over the wound. There is no need to count each maggot, or attempt repeatedly to get every single maggot out from the vial. The maggots can simply be transferred from the vial to the wound within the maggot-impregnated gauze pad. 11. Place a porous cover (i.e., polyester net, such as Creature Comforts™ by Monarch Labs or Tegapore by 3M) over the maggots in the wound, making sure to extend it well past the wound edges, and affix it securely to the hydrocolloid pad with another layer of glue. The layers of glue above and below the porous net will bond will with each other, through the pores. Then add a layer of cloth or silk tape to sandwich the bond (hydrocolloid - glue - net glue -tape). 12. If the patient or wound area is likely to move a lot or become soiled, it may be desirable to reinforce the dressing with silk, cloth or pink plastic tape, or with transparent membrane dressings, in a “picture frame” pattern. The film should cover the hydrocolloid frame and peripheral skin, but must NOT cover the central porous wound covering, or else it will prevent air from reaching the maggots and prevent the necessary drainage of necrotic wound exudate. 13. Cover this “maggot cage dressing” with dry absorbent gauze and secure loosely with a short gauze wrap or two pieces of tape. Air should be able to enter the dressing and the liquefied necrotic tissue should be able to drain out. Check this outer dressing every 4-6 hours for soiling, and replace with clean dry gauze as needed. 14. Leave the maggot cage dressing in place for approximately 48 hours. If maggots escape the dressing they should be disposed of in a red garbage bag. The dressing may be resealed, if possible, or may need to be removed completely and replaced with a normal saline moist to moist dressing (see below), changed every shift until new dressing orders can be written. 2) Three-dimensionally complicated wounds (Examples: stump wounds, large heel wound, anterior foot wound, which cannot easily be covered with a simple sheet of fabric without wrinkling). These wounds are usually best covered by bag-like or stocking-like dressings, which can cover the stump, foot or circumferential let wounds. For years, nylon stockings have been used for this purpose. They are simple to work with, readily available, and of low cost. The stretchable weave allows them to fit a variety of sized wounds. The major drawback, however, has been the fact that the smallest maggots, when first applied, can escape through the expandable holes. This can be quite disconcerting (seeing up to 5% of the applied larvae crawling out of the dressing), although it is of little concern, since the larvae, before finding their way to the wound bed, are germ-free and will desiccate within 30 minutes, so they will not spread to anyone else. Up until now, our only suggestion has been to use white- or ivory-colored nylon stockings, so the larvae will exit mostly unnoticed. There is now a maggot-specific, fixed-weave (non-stretchable) polyester net dressing in the shape of a stocking, which will avoid the problem of escaping larvae (LeSoc™ by Monarch Labs). Since it is not stretchable, it comes in a variety of sizes to match the needs of the patient. Both can be applied in a similar fashion, which will be described below.

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Warning - since fixed-weave fabrics do not stretch, be sure not to use them in a manner, or on patients who are susceptible to, constriction by the fabric, leading to ischemia. 1. As described previously, assess the wound for appropriateness (see Clinical Indications, above). 2. Obtain MD order. 3. Obtain patient and/or family informed consent, and consent for photography, if applicable. 4. Gather and inspect all supplies. Read and understand product literature (preferably before reaching the bedside). 5. Photograph the wound before the first treatment (recommended), and periodically thereafter, to measure and document progress. 6. Gently cleanse the wound and peripheral skin (never use povidone iodine or other skin irritants), cut hair, if extensive, and protect the skin with a skin protectant, if possible. 7. Cut a hydrocolloid pad into 1 cm wide strips, and place these strips as a fence around the wound. For example, they should be placed around the mid foot, proximal to a fore-foot wound involving the toes or toe stumps; for a circumferential leg wounds, one strip should be placed around the leg just proximal to the wound, and another just distal to the wound. For a breast wound involving the axilla, a fence could be made by laying strips down the mid-chest, laterally along the scapula and antero-lateral chest wall, and then across the proximal arm and down the flank or back. 8. Coat the hydrocolloid ring with a layer of liquid adhesive, such as NuHope Adhesive or Skin Bond (Smith & Nephew). The adhesive will become tacky while the maggots are placed within the wound bed. 9. The dose of maggots is 5-10 per square cm. If the maggots come as “maggot-impregnated gauze” then simply calculate the amount of gauze necessary to contain the desired number of maggots, and place that amount of gauze over the wound. If this amount of gauze is not adequate to cover the entire wound, then an additional pad of gauze can be moistened with sterile water or saline and placed over the wound bed. For example, if the wound were 5 cm by 7 cm, then it’s surface area would be 5 x 7 = 35 cm. The dose wound be 175 - 350 maggots. If the vial of maggotimpregnated gauze contained 600 maggots, then the therapist would need about half that to equal 300 maggots. The therapist would take or cut half the gauze and place it over the wound. There is no need to count each maggot, or attempt repeatedly to get every single maggot out from the vial. The maggots can simply be transferred from the vial to the wound within the maggotimpregnated gauze pad. 10. Now place the porous, sock-like dressing (nylon stocking, LeSoc™ dressing, etc) over the maggots in the wound, making sure to extend it at least far enough to cover the hydrocolloid strips. Affix it securely to the hydrocolloid strips with another layer of glue. The layers of glue above and below the porous net will bond will with each other, through the pores. Then add a layer of cloth or silk tape to sandwich the bond (hydrocolloid - glue - net - glue -tape). The excess netted fabric can be trimmed, carefully, with scissors. 11. If the patient or wound area is likely to move a lot or become soiled, it may be desirable to reinforce the dressing with silk, cloth or pink plastic tape, or with transparent membrane dressings, in a “picture frame” pattern. The film should cover the hydrocolloid frame and peripheral skin, but must NOT cover the central porous wound covering, or else it will prevent air from reaching the maggots and prevent the necessary drainage of necrotic wound exudate. 12. Cover this “maggot cage dressing” with dry absorbent gauze (perhaps roll gauze). Air should be able to enter the dressing and the liquefied necrotic tissue should be able to drain out. Check this outer dressing every 4-6 hours for soiling, and replace with clean dry gauze as needed. 13. Leave the maggot cage dressing in place for approximately 48 hours. If maggots escape the dressing they should be disposed of in a red garbage bag. The dressing may be resealed, if possible, or may need to be removed completely and replaced with a normal saline moist to moist dressing (see below), changed every shift until new dressing orders can be written.

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PROCEDURES - Dressing Removal Dressing removal is essentially the same for all types of maggot therapy dressings. Remove all or nearly all maggots quickly and completely, disposing of them as wet dressing waste. 1. Maggot debridement dressings should be removed after approximately 48 hours (maximum 72 hours). 2. To remove the dressings, place an infectious waste (i.e., “red”) bag next to or under the dressing. 3. Inspect the dressing and surrounding skin carefully, noting any problems or abnormalities. 4. Remove the outer gauze dressing and gently loosen (but do not remove) the hydrocolloid pad from the skin. 5. Quickly peel back the hydrocolloid pad and the entire cage dressing from the wound with one hand, while wiping the larvae in the same direction with a moist 4x4” gauze held in the other hand, “sandwiching” the maggots between the hydrocolloid pad and the fresh moist gauze pad. The “wiping” gauze pad can be moistened with normal saline, irrigation water, or gentle antimicrobial (i.e., hydrogen peroxide). If using the latter, be sure to rinse out the antimicrobial thoroughly after removing the maggots (see #21, below). 6. Toss the MDT dressing and sandwiched larvae into the infectious waste bag. If the bag is mounted underneath the wounded limb, then the loose maggots will drop into the bag below as they attempt to escape. 7. Irrigate the wound with normal saline. 8. It may be necessary to use gloved fingers, forceps, or cotton swabs to remove a few immature larvae. Never kill the larvae within the wound if you are unable to extract them. It is better to leave live larvae in the wound, which will crawl out on their own and bury themselves in a dry gauze dressing, rather than risk leaving dead larvae within the wound. 9. Check the bedding for loose larvae, which may wander off in search of the infectious waste bag. Grasp them firmly and drop them off at that destination. 10. Secure the waste bag in the following manner: Tie a knot in the plastic bag (or drop the paper bag into a plastic bag, and tie a knot in that plastic bag). Then place this plastic bag into a second infectious waste bag and seal it securely with a knot. This technique is called “double-bagging.” Be sure that the knots are tied completely, securely, and “AIR-TIGHT.” A bow tie made from two opposing edges of the bag (“rabbit-ear bow-tie”) is not adequate to prevent maggots from escaping from the bag. Drop the double-bagged maggots and dressings into the infectious waste bin. 11. Assess the wound for another application of maggots, or another appropriate dressing. 12. Apply that dressing. 13. Document. ADDITIONAL CONSIDERATIONS 1. Maggot therapy must be performed within the context of good skin and wound care (pressure relief, cleanliness, repositioning of those with immobility, limb positions and dressings that optimize lymph and venous drainage and arterial perfusion, as per standard policies and procedures). 2. Patients with fever or changes in mental status should be evaluated for spread of infection (i.e., bacteremia, cellulitis) or elevated serum ammonia levels. Maggot dressings may need to be removed immediately to facilitate wound inspection. 3. See also package labeling and manufacturer guidelines. 4. Someone must be on-call and available at all times to answer questions and address problems with MDT patients. The name and contact number must be clearly identifiable in the patient’s chart, and should be made known to the nursing staff and to the patient and/or family. 5. Staff must notify the wound care specialist on call for MDT patients if: the maggots are escaping, if the dressing comes loose, if the patient is not tolerating the therapy; or if there are any other nonroutine problems. WOCN® National Office ◊ Mount Laurel, NJ 08054 www.wocn.org 26

6. If the patient does not tolerate the presence of the maggots (5-30% of patients experience some pain or discomfort after 30 hours, as the larvae grow larger, especially if the wounds were painful before MDT), then pain meds and anxiolytics should be readily available. If analgesics do not adequately control the pain, the dressing should be removed immediately. The pain should cease completely as soon as the dressings are removed. Replace the MDT dressing with a moist dressing, changed every shift, until new dressing orders can be written. 7. If maggots are seen to escape from the dressing, inspect the area and notify the wound care specialist on-call for MDT patients. Loose maggots should be “double-bagged” and discarded with infectious waste. If the dressing has a small defect or opening, and if the cage is not very full, then the dressing may be resealed. However, if the escape is due to the maggots being mature and leaving the wound, or due to too many larvae within the cage which is now bursting open, then the dressing should be removed and the wound inspected. The dressing can be replaced with a normal saline moist to moist dressing, changed every shift until new dressing orders can be written. 8. Contact the person on-call for MDT dressings if the patient expires. The dressings must be removed immediately if the patient expires. DOCUMENTATION 1. Consents 2. Skin Ulcer Flow Sheet 3. Dressing Change Flow Sheet 4. Wound Measurement Flow Sheet 5. Multidisciplinary Care Plan 6. Nursing Flow Sheet 7. Patient and Family Teaching Form 8. Discharge REFERENCES 1. Armstrong DG, Salas P, Short B, Martin BR, Kimbriel HR, Nixon BP, Boulton AJ. Maggot therapy in “lower-extremity hospice” wound care: fewer amputations and more antibiotic-free days. J Am Podiatr Med Assoc. 2005 May-Jun;95(3):254-7. 2. Mossel J, Short B, Nixon BP, Knowles EA, and Boulton AJM. Maggot debridement therapy - A primer. J Am Podiatr.Med Assoc. 92 (7):398-401, 2002. 3. BioTherapeutics, Education and Research Foundation – Maggot Debridement Therapy: Draft Policy and Procedure. www.BTERFoundation.org 4. Bonn D. Maggot therapy: an alternative for wound infection. Lancet 356 (9236):1174, 2000. 5. Dumville JC, Worthy G, Bland JM, Cullum N, Dowson C, et al. Larval therapy for leg ulcers (VenUS II): randomised controlled trial. BMJ. 2009 Mar 19;338:b773. 6. Felder JM 3rd, Hechenbleikner E, Jordan M, Jeng J. Increasing the options for management of large and complex chronic wounds with a scalable, closed-system dressing for maggot therapy. J Burn Care Res. 2012 May-Jun;33(3):e169-75. 7. Fitzpatrick M. Tiny "surgeons" prove surprisingly effective. JAMA 284 (18):2306-2307, 2000. 8. Gottrup F, Jørgensen B. Maggot debridement: an alternative method for debridement. Eplasty. 2011;11:e33. Epub 2011 Jul 12. 9. Marineau ML, Herrington MT, Swenor KM, Eron LJ. Maggot debridement therapy in the treatment of complex diabetic wounds. Hawaii Med J. 2011 Jun;70(6):121-4. 10. Mumcuoglu KY. Clinical applications for maggots in wound care. American Journal of Clinical Dermatology 2 (4):219-227, 2001. 11. Opletalová K, Blaizot X, Mourgeon B, Chêne Y, Creveuil C, et al. Maggot therapy for wound debridement: a randomized multicenter trial. Arch Dermatol. 2012 Apr;148(4):432-8. Epub 2011 Dec 19.

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12. Sherman RA: A new dressing design for treating pressure ulcers with maggot therapy. Plast Reconstruct Surg. 100 (2): 451-456. 1997. 13. Sherman RA: Maggot Therapy in Modern Medicine. (Invited article) Infect Med. 15(9): 651-656. 1998. 14. Sherman RA: Maggot therapy for foot and leg wounds. International Journal of Lower Extremity Wounds. 2002;1:135-42. 15. Sherman RA: Maggot vs conservative debridement therapy for the treatment of pressure ulcers. Wound Repair and Regeneration. 2002;10:208-14. 16. Sherman RA: Cohort study of maggot therapy for treating diabetic foot ulcers. Diabetes Care 2003; 26(2):446-51. 17. Sherman RA. Maggot therapy takes us back to the future of wound care: new and improved maggot therapy for the 21st century. J Diabetes Sci Technol. 2009 Mar 1;3(2):336-44. 18. Sherman RA, Sherman JMT, Gilead L, Lipo M, Mumcuoglu K: Maggot debridement therapy in outpatients. Archives of Physical Medicine and Rehabilitation. 82:1226-9. 2001. 19. Sherman RA, Shimoda KJ: Presurgical maggot debridement of soft tissue wounds is associated with decreased rates of postoperative infection. Clinical Infectious Diseases 2004; 39:1067-70. 20. Sherman RA, Tran J, Sullivan R: Maggot Therapy for Venous Stasis Ulcers. Arch Dermatol. 132 (3): 254-256. 1996. 21. Sherman RA, Wyle F, and Vulpe M: Maggot Debridement Therapy for treating pressure ulcers in spinal cord injury patients. J Spinal Cord Med, 18(2): 71-74. 1995. 22. Thomas S, Jones M, Shutler S, Jones S: Maggots in Wound Debridement – an Introduction. http://www.smtl.co.uk/WMPRC/Maggots 23. Thomas S, Jones M, Wynn K, Fowler T. The current status of maggot therapy in wound healing. Br.J.Nurs. 10 (22 Suppl):S5-8, S10, S12, 2001. 24. University of California, Irvine, Maggot Therapy Project: Information sheet for Physicians (FAQ). http://www.ucihs.uci.edu/com/pathology/sherman/mdt_info.pdf 25. Vistnes L, Lee R, and Ksander A. Proteolytic activity of blowfly larvae secretions in experimental burns. Surgery 90 (5):835-841, 1981. 26. Wayman J, Nirojogi V, Walker A, Sowinski A, and Walker MA. The cost effectiveness of larval therapy in venous ulcers. Journal of Tissue Viability 10 (3):91-94, 2001. 27. Wollina U, Karte K, Herold C, Looks A. Biosurgery in wound healing - the renaissance of maggot therapy. Journal of the European Academy of Dermatology and Venereology 14 (4):285-289, 2000.

APPROVALS:

Name

Title

Signature

Date

Name

Title

Signature

Date

Name

Title

Signature

Date

Original Date: ________

Effective Date: ___________

Expiration Date: ________

Supercedes #: ________

Originating Department: __________________________ WOCN® National Office ◊ Mount Laurel, NJ 08054 www.wocn.org 28

Appendix B Template for Maggot Debridement Therapy (MDT) Consent Form Source: Bio-Therapeutics Education and Research Foundation. Used with permission. These sample policy/procedure and consent forms are not intended to be adopted and used as a substitute for a particular organization’s specific forms. The documents are to be used only as guides to developing policies/procedures and consent forms. Each organization must develop individualized forms in accordance with guidance and approval of appropriate administrative, legal, and risk management departments.

36 Urey Court, Irvine, CA 92617 ~ Phone: 949-275-8315 ~ Fax: 949-679-3001 ~ www.BTERFoundation.org Advancing Healthcare through Education & Research in BioTherapy

Template for Maggot Debridement Therapy (MDT) Consent Form DISCLAIMERS AND LEGAL NOTICES This template for Informed Consent to maggot debridement therapy is provided by the BioTherapeutics, Education and Research Foundation, without warranties concerning the applicability of this draft at any specific facility. Please modify the document as needed to fit the specific policy, procedure, formulary, or logistic demands of your institution. Be sure to read and follow all warnings and labeling information associated with products used in the application and removal of maggot therapy dressings, and inform your patients of the true risks, benefits and options, as this is only a sample of the document that you should use. Copyrights are owned by the BTER Foundation. This draft is provided freely for personal and single institutional use. For such use, this item may be reproduced and amended, as needed. However, this protocol may not be distributed, in any format, for commercial benefit, without specific review and permission by the BTER Foundation. The BioTherapeutics, Education and Research (BTER) Foundation is a public charity whose mission is to support patient care, education, and research in maggot therapy, leech therapy, and the other diagnostic and treatment modalities that use live animals. More information about our services can be found at the address below, or on the internet at: www.BTERFoundaiton.org

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Draft / Template for Executing and Documenting Maggot Debridement Therapy (MDT) Informed Consent I, ___________________, hereby acknowledge that I have been informed about the procedure of maggot therapy, the reasons for its use, reasonable goals of therapy, likely risks, and appropriate alternatives, as outlined below. Furthermore, I acknowledge that I have had the opportunity to ask questions and have had those questions answered to my satisfaction. Description of the maggot therapy procedure (check those that apply):  Placement of live, germ-free (“medical-grade”) fly larvae (“maggots”) on the wound, within special dressings to confine them to the wound. The dressings and maggots will be removed within 24-72 hours  Photographs may be taken for the purposes of (delete all those not applicable) monitoring efficacy of the treatment, documentation in the medical record, teaching or publication.  Other aspects of treatment: _________________________________________________ Persons who will be involved in the procedure  ______________________________________________________________________  ______________________________________________________________________  ______________________________________________________________________ Indications (reasons) for using maggot therapy (check those that apply):  Debridement (removal) of dead tissue  Debridement (removal) of dead, infected tissue  Other: ________________________________________________________________ Risks, Warnings Possible Complications The following risks occur in over 10% of patients: Pain or discomfort, particularly in patients already experiencing wound pain. Maggot-associated pain or discomfort usually manifests at about 24 hours into therapy, and increases as the larvae grow larger. If pain medication does not control the pain, then the maggots can be removed early to achieve immediate relief of maggot-associated pain. The following risks occur in approximately 1-2% of patients: Because medicinal maggots are highly perishable, they should not be stored for more than 24 hours. Therefore, they are prepared and shipped overnight, immediately before their intended use. Rarely, they are delayed during transport (especially by bad weather conditions). The instinctive behavior of maggots is to leave the wound (host) once they are finished working (satiated). Therefore, they are “self-extracting.” But some are finished earlier than others. Depending on a variety of conditions, most maggots will be satiated by 48 hours; a few will not be satiated until nearly 72 hours. If the dressings are left on for the full 72 hours, then those that are already satiated will attempt to escape. If the dressing comes loose, they may be successful. If the dressing is removed at 48 hours or earlier, before all of the larvae are satiated, then some my hide in crevices if there is still necrotic tissue to be found. These will leave once they, too, are satiated, most likely within the following 24 hours, by entering the covering dressings and hiding therein. Those dressings should be removed and discarded as wound dressing (infectious) waste in a sealed container to prevent their escape from the waste container. If not properly disposed, escaped maggots or those not properly disposed of could pupate and mature to adult flies approximately two weeks later.

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The following risks occur in less than 1% of patients: Patients allergic to fly larvae, brewer's yeast, soy proteins or other ingredients may manifest allergic reactions. Although medicinal maggots are disinfected, they could become contaminated during processing, shipping, or handling by the user. This could lead to infection of the wound. Fever or changes in mental status could occur, and may or may not be due to the therapy. Sometimes they are due to the wound itself; sometimes to other medical problems in the body. Regardless of the cause, if such symptoms do occur it may be necessary to remove the maggot dressings in order to examine the wound and determine the cause of the fever or mental changes. Additionally, medicinal maggots are not guaranteed to be effective for every wound. The amount of necrotic tissue may be too extensive to be debrided within one or two treatments, and may require additional treatments with maggots or other methods. If the blood flow is inadequate to support the growth of new, healthy tissue, then the cleaner, bigger wound may not heal; it may even become infected or necrotic, again, before it has had a chance to heal, requiring additional debridement or more aggressive removal (resection or amputation). Mild bleeding is common during maggot debridement, and it is common for the wound drainage during maggot therapy to be blood-tinged. Patients with coagulopathy (“bleeding tendency”) or delicate or damaged blood vessels (“friable tissue” and vascular grafts) are at increased risk of significant bleeding during maggot therapy. Close supervision of the wound and dressing may be necessary in such situations, and you will need to inform your therapist immediately should you observe more than a small amount of blood-tinged drainage from the wound or maggot dressings. Pseudomonas aerugenosa wound infections are particularly difficult to treat by any means, and they may be more resistant to maggot therapy as well. If your wound is suspected of having Pseudomonas infection, you may be asked to use special treatments before maggot therapy in order to reduce or eliminate the Pseudomonas. Your therapist may use “extra” maggots in order to better combat he Pseudomonas. Nevertheless, cases have been reported in which Pseudomonas infections persist, or even grow bigger, during maggot therapy. Like your therapist, you will need to be vigilant about monitoring and reporting any signs of growing infection, before, during, and after maggot therapy. Alternative treatment options (check those that apply):  Surgical debridement or resection.  Amputation  Enzymatic debriding agents  Autolytic debriding agents  Mechanical debriding agents/devices Pre-procedure requirements (check those that apply):  Answer all questions completely and honestly, including all underlying medical and surgical problems, medications, allergies, etc.  Study all of the information given: reading materials, videos, etc.  Stop any medication or wound treatments so recommended by your healthcare provider, such as: _________________________________________________________________  Begin any medication or wound treatments so recommended by your healthcare provider, such as: _________________________________________________________ Requirements during therapy (check those that apply): WOCN® National Office ◊ Mount Laurel, NJ 08054 www.wocn.org 31

 Ensure that dressings are changed as frequently as recommended, and even more so if they become wet or soiled.  If the dressings being removed (or the wounds themselves) are dry, apply moist gauze, not dry gauze (i.e., irrigation water or saline).  Inform your therapist immediately if you find that the maggot dressing has become soiled or loose.  Inform your therapist immediately if you are having pain that is not adequately controlled.  Inform your therapist immediately if you or your wound develops symptoms that are unusual or problematic (bleeding, fever, confusion, etc).  Keep all required appointments.  ________________________________________________________________________ Post-therapy requirements (check those that apply):  Keep all required appointments.  Inform your therapist immediately if you or your wound develops symptoms that are unusual or problematic (fever, confusion, etc).  ________________________________________________________________________ Additional requirements (check those that apply):  ________________________________________________________________________  ________________________________________________________________________  ________________________________________________________________________ Of my own free will and without coercion, I agree to undergo maggot therapy and promise to adhere to the treatment and post-treatment activities, as stipulated above, as they are intended to make the treatment most successful. Patient: ______________________ Printed Name

______________________ Signature

____________ Date

______________________ Signature

____________ Date

______________________ Signature

____________ Date

Consent administered by: ______________________ Printed Name

Witness: ______________________ Printed Name

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