Wound cleansing and disinfection
All wounds should be cleansed at each dressing change, before and after debridement, and in the event of contamination using a neutral, nonirritating, nontoxic solution, and routine cleansing should be accomplished with every effort to minimize chemical and/or mechanical trauma.(60-61) An exception to the requirement for routine cleansing may be the recent application of a skin graft or cellular tissue product, which should be left undisturbed; in this case the surrounding skin should be cleansed.
The choice of solution or agent used, as well as the method of delivery, is driven by the condition and local factors in the wound. The literature abounds with references over many years and there has been much discussion related to the solutions used on the open wound and the perceived risks of cytotoxicity. Although definitive research is lacking, data against the use of antiseptics such as hydrogen peroxide, acetic acid (dilute vinegar solution), Dakin’s solution(dilute bleach solution), and povidone iodine are based primarily on in vitro models demonstrating the toxicity of these agents to the viability of cells important to wound healing, such as fibroblasts, keratinocytes, and leukocytes. As a practical matter, the wound surface, the presence of necrotic or inflamed tissue and adherent exudates, the condition and hygiene of the patient, the location of the wound, and the potential for environmental or other contamination such as incontinence should drive the choice.
Good practice evidence suggests use of a nontoxic cleaning solution in combination with a delivery device that will create sufficient mechanical force to remove the surface debris without injury to healthy tissue.(15) Topical antiseptics are antimicrobial agents that reduce the number of microorganisms and may be seen as an adjunct to infection control. Whereas anti-biotics have a specific method of action, antiseptics utilize multiple targets to inhibit or kill organisms and have a larger spectrum of activity against bacteria, fungi, and viruses.(64) In choosing an appropriate wound cleanser, the clinician should consider the goals of cleaning based on a thorough assessment.
Further con-sideration will be given to how the solution or cleanser may be used, whether to cleanse or irrigate the wound or leave it behind in a delivery vehicle such as gauze. While long-term expo-sure to tissues may be overwhelming to the cells, short duration of contact during cleaning may be beneficial in dealing with surface debris and contaminants from previous dressings being in place. One must always consider the risks and benefits in the use of a particular agent, as well as determine whether the goal is to achieve wound disinfection or wound cleansing.
Newer antiseptic agents such as superoxide water solutions, dilute sodium hypochlorite, and hypochlorous acid can be advantageous in management of wounds with high bacterial loads because they can reduce microbes on the surface of the wound without causing injury to the host wound cells. Commercially available wound cleansers contain surface active agents (surfactants) that break the bonds attaching contaminants and debris to the wound surface, allowing them to be rinsed away mechanically when the solution is sprayed or poured over the wound. The clinician should consider use of cleansing solutions with surfactants and/or antimicrobials for wounds with debris, confirmed infection, suspected infection, or suspected high levels of bacterial colonization.(15) Any potential toxicity of these cleansers should be weighed against the need for a more thorough removal of surface debris and contaminants based on the assessment of the wound.
Normal saline is an effective agent for wound cleansing that will not interfere with wound healing when delivered with enough pressure to ensure adequate removal of surface debris. Pressures below 4 pounds per square inch (psi) are not sufficient to remove debris, and pressures exceeding 15 psi increase the risk that bacteria will be driven into the tissues.(64) The use of potable water (tap water) for cleansing chronic wounds has been questioned many times and is more commonly used in community and home-care nursing because it is easily accessible, efficient, and cost-effective.(65-66) The decision to use tap water to cleanse wounds should take into account the quality of water, nature of wounds, and the patient’s general condition, including the presence of comorbid conditions.(66) Recent guidelines suggest that most pressure ulcers can be cleansed with potable water (i.e., water suitable for drinking) or normal saline.(15) If the wound is going to be cleansed as part of the patient’s personal shower, the decision should also take into account the location of the wound, water conditions in a geographic area, the patient’s physical condition and immune system, and the overall hygienic advantage. Patients should be advised not to immerse an open wound into a tub.
The temperature of the wound cleansing solution and frequency of dressing change should also be considered. Neutrophil, fibroblast, and epithelial cell activity decreases when the wound bed temperature falls below 33°C (91.4°F).(67) Cleansing solutions should be used at body temperature, as it can take 40 minutes for a wound to return to normal temperature following cold cleansing (cleansing with room-temperature solutions), and around three hours for leukocyte activity to recover after irrigation with a cold(room-temperature) solution. The physiologic effects of hypothermia (e.g. vasoconstriction, depressed neutrophil activity, reduced ability of the cells to use oxygen free radicals to kill bacteria, and lower levels of collagen deposition)can result in impaired resistance to infection and delayed wound healing.
REFERENCES
For a quick look at the references mentioned above please refer to the attached PDF file. References.pdf
WOUND CARE EDUCATION
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