Optimizing Debridement In Patients On Anticoagulant Therapy Using A Chitosan-Based Hemostatic Agent

Dr. Lee has no current relationships to disclose, but states she will likely be working with Omni-Stat Medical, Inc. on a future research project. 

I'm Dr. Aliza Lee. I'm a staff podiatrist, the Director of Podiatric Medical Education and a clinical investigator at the Salem Veteran Affairs Medical Center in Salem, Virginia. Today, I'd like to talk about my poster, "The Ability to Perform Optimal Debridement in Patients on Anticoagulant Therapy with the Use of a Chitosan-based Hemostatic Agent."

This was presented at SAWC Fall 2021. Most obvious reason, debridement is challenging. It's a bloody mess, both for the wound bed and for the working area. Both become covered in blood.

This reduces your visual field. You don't discontinue your therapy for obvious reasons. There's associated risk of stent and/or bypass failure or thromboembolic events. What do we do? What happens next? We either have to use suboptimal debridement, which is not recommended.

We have to use caustic agents, which I'd rather not use those, or we have to do things that are time-consuming with compression dressings. Ideally, you want a fast-acting hemostatic agent that controls bleeding, but is not caustic to the wound bed.

Chitosan is a naturally occurring, biocompatible, biodegradable and non-toxic hemostatic agent, with antimicrobial, antifungal and wound healing promoting properties, which stops bleeding without causing tissue injury, which is often seen with chemical and electrocautery hemostatic modalities.

In my poster, I use a specific protocol. What I would do is do my adequate debridement than I normally would. Make sure it's thorough, and then I would apply the granules. It comes and goes, but I use granules here. I would fill the wound. Apply pressure and wait one to three minutes.

Then depending on the wound type, I would choose the next level of dressing based off of that. My first case that I presented, was a 65-year-old male. He was on Apixaban. He showed up to the local emergency room, not our facility for a laceration on the front of his chin. It was pretty deep.

They sutured it, and then sent him on his way to follow up with the primary care provider. Of course, within the first two weeks, he had a wound dehiscence separated that took the sutures out, and then he shows up to me to clean up the mess.

He had a very nasty wound full of fibrotic material, dividing life tissue. It obviously needed debridement, which I did do in the clinic. Of course, he was bleeding and I had to stop it. I applied the granules.

I held pressure, and because of the history with the wound dehiscence, I decided he probably needed something more than just the granules. I applied a collagen-based antimicrobial dressing, and I repeated this process once a week for four weeks. At the end of the four weeks, his wound was completely closed.

The second case that I presented was a 73-year-old male. He was on warfarin and enoxaparin. He actually was an established patient and was outside in the parking lot and hit his leg on a truck. Bad luck, right? He comes up to clinic, he's bleeding through his pants, and it's just dripping down his leg.

I was like, "Oh, come on back." [laughs] Took care of him. We definitely irrigated the wound. Took a look at it and applied pressure with the granules. This time, I wasn't afraid that he had something else in there that was dirty, infected. I left the granules in place, intact and just put a dry dressing.

The instructions here were to change the dressing as needed. If the granules got dislodged, it was okay, or if they dissolved, it was okay, and to apply a collagen-based silver product on top of it. Follow up in two weeks. He came back in two weeks, the wound was closed, it didn't have any issues.

The third case that came that I presented was a 72-year-old male. I'd actually seen it for multiple weeks prior to using the chitosan-based product. I did local wound care, adequate debridement. When that didn't work, then I switched to advanced biological products.

That actually didn't work out so well, because he bled so easily on his blood thinners. The grafts seemed to get dislodged, or maybe the mesh and the steri-strips were getting wet and they were moving, which was moving the grafts. I was putting all these expensive products on and it just wasn't doing anything.

Finally, I decided that I definitely had to do the debridement, which I did. Then I applied the granules and said, "That's it. I'm just going to leave the granules on there. Put a dry dressing on there. If you need to change it, change it. If not, I'll see you in a week." I followed this patient for the next 10 weeks doing exactly that.

No other products. He went on to close his wound. I went from this case series that chitosan-based hemostatic agents promote hemostasis. They reduce procedure time. They show good quality every epithelialization with use. They are not caustic to the wound bed, which is important, and alone, led to wound improvement.

I think the takeaway message is that you can provide adequate debridement on anticoagulated patient population in the clinic or in the OR setting without fear.