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Words on Wounds

A forum to discuss the latest news and ideas in skin and wound care.

Friday, June 15, 2018

Wound Cleansing: Where Is the Evidence?
​Let's begin with a question. ​A photo of a patient's large sacral pressure injury is included below. What do you think is the best way to clean this wound? 

While wound cleansing is an integral part of wound care that is carried out with each dressing change, there is very little evidence about the best way to clean or cleanse a wound. Many best practice guidelines continue to advocate for the use of a 35 cc syringe and 19 gauge needle to generate 8 to 15 PSI of pressure to remove wound debris without traumatizing the fragile wound bed. However, there is no clinical evidence that an irrigation pressure of over 15 PSI is damaging to wound healing.  

There are other controversial areas that worth further deliberation:

1. Biofilm is ubiquitous in chronic wounds, impeding the normal healing process. Vigorous cleansing is often recommended to disturb biofilm such that antimicrobial agents can penetrate into the core of biofilm structure to prevent wound infection.

2. What if the recommended equipment (such as a 35 cc syringe) is not available?

3. Newer monofilament pads for mechanical debridement and hydrosurgery systems involve high pressure to remove nonviable tissue and unhealthy granulation. There is evidence that these modalities may promote wound healing.   

4. Wound cleansing using saline or water is not recommended for nonhealable wounds. Moisture in a nonhealing wound may promote bacterial growth, putting patients at risk for sepsis.

5. Occlusive surgical dressings are routinely used to cover surgical sites without daily wound care and cleansing. The purpose of using protective dressings is to minimize cross-contamination to prevent surgical site infection.

6. "Don't put anything in the wound that you cannot put into your eyes" is widely accepted as the best approach to wound management. However, solutions that used to be considered cytotoxic, such as providone iodine and Dakin's solution, have proven to be effective agents to address bacterial burden in chronic wounds.  

7. Irrigation into deep tunnels may leave excessive irrigants in the dead space if not expressed appropriately. Stagnated fluid creates an ideal place for bacterial growth.

Needless to say, further study on wound cleansing is needed. I think it is important to use our clinical judgment and best available evidence to determine the solutions and methods to cleanse a wound rather than basing our clinical decision on dogma, sacred cows, and rote practice.​

CSI photo 6-15-18.jpg