استشارى
minia university hospital
Total years of experience :31 years, 6 Months
تشخيص وعلاج المرضى واحراء الجراحات اللازمه
Medline\].
•Bernstein BH, Tam H. Combination of subatmospheric pressure dressing and gravity feed antibiotic instillation in the treatment of post-surgical diabetic foot wounds: A case series. Wounds. 2005. 17(2):37-48.
•Gabriel A, Shores J, Heinrich C, et al. Negative pressure wound therapy with instillation: a pilot study describing a new method for treating infected wounds. Int Wound J. 2008 Jun. 5(3):399-413. \[Medline\].
•Scimeca CL
. 2004. 23(1):51-7. \[Medline\].
•Anglen JO. Wound irrigation in musculoskeletal injury. J Am Acad Orthop Surg
. 1987 Jun. 24
irrigation is the steady flow of a solution across an open wound surface to achieve wound hydration, to remove deeper debris, and to assist with the visual examination. The irrigation solution is meant to remove cellular debris and surface pathogens contained in wound exudates or residue from topically applied wound care products. Compared to swabbing or bathing, wound irrigation is considered to be the most consistently effective method of wound cleansing.\[1\]
Normal wound healing is characterized by 3 interrelated phases: inflammatory, proliferative or fibroplastic, and remodeling. In normal wound healing, infectious microorganisms, foreign debris, and necrotic tissue are removed from the wound during the inflammatory phase due to vascular and cellular responses to trauma. However, weaknesses in the body’s inflammatory response can cause deficits in its ability to overpower surface microorganisms. This can lead to delayed angiogenesis and granulation tissue formation, as well as infection. Contaminating microorganisms can upset collagen synthesis and modify matrix metalloproteinases, leading to anoxia and impeding neutrophil and macrophage function.
Combined with debridement, irrigation is a critical step in facilitating progression from the inflammatory to proliferative phase of wound healing by removing debris that can impede the healing process. When performed properly, wound irrigation can aid in wound healing from the inside tissue layers outward to the skin surface. It may also help prevent premature surface healing over an abscess pocket or infected tract.\[2\] The goal of irrigation is to clean the wound while avoiding trauma to wound bed and minimizing risk of driving bacteria further into the wound bed.
Key considerations - Selecting an irrigation solution
Choosing an appropriate solution is a critical step in wound irrigation. Solutions intended for topical use include topical cleansers, antibiotics, antifungals, antiseptics and anesthetics. Ideally, an irrigant should be isotonic, nonhemolytic, nontoxic, transparent, easy to sterilize, and inexpensive. Unfortunately, such a solution does not yet exist. Current literature generally favors use of normal saline. Many antiseptics and antibiotics have been employed, but the ideal additive is the subject of debate. Cytotoxicity of the solution should certainly be considered. In particular, antiseptic solutions, such as povidone-iodine, chlorhexidine, and hydrogen peroxide, may be toxic to tissues and may negatively influence acute wound healing. Some conventional topical irrigants are discussed below.
Normal saline
Normal saline is isotonic and the most commonly used wound irrigation solution due to safety(lowest toxicity) and physiologic factors. A disadvantage is that it does not cleanse dirty, necrotic wounds as effectively as other solutions. Similar wound infection rates have been reported with potable tap water versus saline in adult and pediatric populations.\[3, 4\] It is important to note the date of opening a saline container, as bacterial growth in saline may be present within 24 hours of opening the container.
Sterile water
Prepared by distillation, sterile water is nonpyrogenic and contains no antimicrobial or bacteriostatic agents or added buffers. It is often used in irrigation, particularly in developing countries, as a less expensive alternative to isotonic saline. Sterile water is hypotonic and may cause hemolysis and will be readily absorbed by the tissues during surgical procedures; therefore, its use under such conditions is not recommended. Water toxicity may result when excess volumes are used.
Potable water
Potable water is recommended in the event that normal saline or sterile water are not available. Its use is particularly attractive in austere environments. In fact, a few studies have shown potable water to be as effective at reducing bacterial counts as normal saline.
Commercial wound cleansers
Commercial wound cleansers are increasingly used in irrigation. Detergent irrigation is meant to remove, rather than kill, bacteria and has seen promising results in animal models of the complex contaminated musculoskeletal wound.\[5\] Due to the surfactant content in cleansers, less force is required to remove bacteria and cellular debris. Thus, cleansers may be best suited for wounds with adherent cellular debris or in dirty, necrotic wounds. Trigger sprays can help direct the cleanser more effectively and safely. Cleansers typically contain preservatives to slow growth of bacteria, molds, and fungi, and extend product shelf life.
Povidone iodine
Povidone iodine is a broad spectrum antimicrobial solution effective against a variety of pathogens including Staphylococcus aureus. However, similar wound infection rates have been reported in adult and pediatric populations with saline irrigation versus 1% povidone-iodine.\[3, 4\] A disadvantage is its cytotoxicity to healthy cells and granulating tissues. The solution dries and tends to discolor skin. It may also cause local irritation to the periwound skin.
Hydrogen peroxide
A 3% solution of hydrogen peroxide is a commonly used wound antiseptic. However, few studies report on its efficacy in wound healing and as an antiseptic, and its use remains controversial. While some studies have shown hydrogen peroxide to be cytotoxic to healthy cells and granulating tissues, other animal and human studies have shown no negative effect on wound healing.\[6, 7\] Several studies have also shown hydrogen peroxide to be ineffective in reducing bacterial count.\[7\] The American Medical Association summarized that the effervescing cleansing action of hydrogen peroxide may act as a chemical debriding agent to help lift debris and necrotic tissue from the wound surface when used at full strength\[8\] If used, irrigation with normal saline after full-strength hydrogen peroxide use is recommended. Use of hydrogen peroxide is not recommended in wounds with sinus tracts.
Sodium hypochlorite
Sodium hypochlorite (ie, Dakin’s solution) has been classically used in pressure ulcers with necrotic tissue to help control infection. Sodium hypochlorite is known to have a bactericidal effect against most organisms commonly found in open wounds. It is occasionally used over cancerous growths to control bacteria and minimize odor. However, the solution is known to be cytotoxic to healthy cells and granulating tissues, and its use is not recommended for periods longer than 7-10 days.
Key considerations - Selecting method of solution delivery to the wound
. Arch Surg. 1985 Mar. 120
considerations - Using sufficient volume
Increased volume improves wound cleansing to a point, but optimal volume in wound irrigation remains largely understudied. Volumes of 50-100 mL per centimeter of laceration length or per square centimeter of a wound are commonly reported in the literature.\[3, 20\]
Importantly, irrigation volume should be determined according to wound characteristics and degree of contamination. In the case of more contaminated wounds, the wounds should be irrigated until all visible debris is removed. Copious amounts of potable tap water or saline should be used for irrigation and decontamination of chemical burns.\[21\]
Key considerations - Precautions and protection against splashback
Irrigation, particularly high pressure, can splash and spread bacteria to surrounding areas and people. The use of a plastic shield at the end of the irrigating syringe reduces this hazard. Where needed, a face shield, mask, and protection over scrubs is advised. IV sites and other open areas should be protected from splashing.
Indications
Most wounds should be irrigated initially and at each dressing change. All wound surfaces should be irrigated, which may require opening wound edges and flaps for exposure. Wounds should be irrigated again upon re-examination.
Precautions and contraindications
Pulsed lavage should not be performed over exposed blood vessels, nerves, tendons, or bone.
Pulsed lavage should not be performed in the presence of active, profuse bleeding (precautionary measures for patients on anticoagulation medication).
Improper technique may harm the wound bed.
Patients with sensory impairment are unable to provide accurate feedback needed to guide the clinician if improper technique is used.
Hydrodebridement
Hydrodebridement is the synchronous application of an irrigant in tandem with debridement. Particularly in the presence of thick exudate, slough, or necrotic tissue, hydrodebridement may aid in cleansing and mechanical debridement. Both low-pressure and high-pressure methods of hydrodebridement have been used to optimize the effects of debridement, reduce bioburden, and manage exudate-all integral parts of wound bed preparation.
An emerging application of low-pressure hydrodebridement is in tandem with negative pressure wound therapy (NPWT). Some NPWT systems are equipped with technology that allows automatic instillation of topical solutions to be delivered and removed from the wound site during NPWT. This technology is indicated for patients who would benefit from vacuum-assisted drainage and controlled delivery of topical wound treatment solutions and suspensions over the wound bed. NPWT can be used with a range of solutions intended for topical use, including cleansers, antibiotics, antifungals, antiseptics, and anesthetics. Regular instillation of topical solutions during NPWT can assist with wound cleansing, irrigation, pain, and removal of infectious material.\[21\]
Instilling solutions with NPWT increases the viscosity of the wound fluid and allows more efficient removal through the reticulated open-cell foam dressing and into the canister. Solutions are delivered continuously or at timed intervals, and are gravity fed, or intermittently pumped into the wound, depending upon the NPWT system. Wounds with significant debris and bacterial contamination can be irrigated when needed at increased pressures (fluid delivered at 8-12 psi such as with a 35 mL syringe and a 19-gauge angiocatheter) during NPWT dressing changes.
NPWT with solution instillation has been advocated in cases of diffuse or extensively treated osteomyelitis, large areas of postdebrided exposed bone or joint, and in cases of critical bacterial colonization levels as an alternative to antibiotic-impregnated beads when appropriate.\[22\] Anecdotal evidence suggests topical solution instillation may enhance the efficacy of NPWT in cases of high levels of exudate and slough content, as well
effectiveness in reducing wound bacterial contamination and potential for air bacterial contamination. J Foot Ankle Res. 2009. 8:2:13.
•Gabriel A. Integrated negative pressure wound therapy system with volumetric automated fluid instillation in wounds at risk for compromised healing. Int Wound J. 2012 Aug. 9 Suppl 1:25-31. \[Medline\].
•Khan MN, Naqvi AH. Antiseptics, iodine, povidone iodine and traumatic wound cleansing. J Tissue Viability. 2006 Nov. 16(4):6-10. \[Medline\].
•Rodeheaver GT, Pettry D, Thacker JG, Edgerton MT, Edlich RF. Wound cleansing by high pressure
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