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Abstract & Commentary
Synopsis: Clarification of misconceptions that exist regarding the quality and quantity of fluid to be used for irrigating musculoskeletal wounds is needed.
Source: Anglen JO. Wound irrigation in musculoskeletal injury. J Am Acad Orthop Surg. 2001;9(4):219-226.
This journal article summarizes the available literature on the effects on musculoskeletal wounds of the quantity of fluids used for irrigation, the method of fluid delivery (low- or high-pressure, pulsatile or nonpulsatile), and the influence of fluid additives such as antiseptics, detergents, and antibiotics. Regarding the quantity of fluid needed for proper irrigation of open fractures, Anglen recommends 3 L of fluids for irrigation of grade I fractures, 6 L for grade II fractures, and 9 L for grade III fractures. However, he admits that there are no reported human clinical trials on the effect of the volume of irrigant on outcome.
Several years ago, high-pressure, pulsatile irrigation was felt advantageous. Anglen states that although high-pressure irrigation has been shown to be more effective then low-pressure irrigation in removing particulate matter, necrotic tissue, and bacteria, it may cause gross damage and microscopic fissure formation in cortical bone. Moreover, in 1 animal study, wounds irrigated with either low- or high-pressure irrigation showed a higher infection rate when the wound was inoculated after irrigation, indicting that irrigation with low- or high-pressure lavage results in some compromise of the infection-fighting ability of tissues.1 Evidence is cited in this review indicating that pulsatile lavage can increase the rate of infection several centimeters from the pulsed site. Presently under investigation is a system that would decrease the negative effects of high-pressure flow on tissues by delivering higher fluid flow rates parallel rather than perpendicular to the surface of the wound. Anglen summarizes the information on the delivery of the irrigating fluid by stating that one should "utilize higher pressure settings in severely contaminated wounds and delayed treatment situations when bacterial removal is the most important issue, and lower pressure settings when the level of contamination is less and treatment is prompt."
With regard to additives to the irrigating fluid, Anglen’s review found that although many antiseptics have been used in the past to kill bacteria in wounds following musculoskeletal injury (eg, hydrogen peroxide, providone-iodine solution or scrub, chlorhexidine gluconate, hexachlorophene, sodium hypoclorite, and benzalkonium chloride), antiseptics also have concentration-dependent toxicity to host cells. For this reason, even though studies are contradictory, Anglen recommends not adding antiseptics to irrigating fluids for musculoskeletal wounds. Moreover, because the clinical efficacy of antibiotic irrigating solutions in preventing infection is not proven, he recommends not using bacitracin, polymyxin, or neomycin solution routinely for wound irrigation. He suggests that surfactants such as castile soap, green soap, and benzalkonium chloride be used only in highly contaminated wounds to increase the efficiency of bacterial removal from the wound, ie, for cleansing the wound. Although surfactants carry a low risk of causing harm to host tissues, some in vitro studies have shown surfactants, in certain concentrations, can cause host-cell death.
Comment by Letha Y. Griffin, MD, PhD
This article is an "eye-opener" for many of us who routinely use antiseptics or antibiotic irrigating solutions not only for irrigating highly contaminated, open wounds secondary to trauma, but also in less contaminated wound situations including irrigation of operative wounds in clean, noncontaminated cases. This review makes one reconsider such practices in light of the information presented.
1. Wheeler CB, et al. Side-effects of high pressure irrigation. Surg Gynecol Obstet. 1976;143:775-778.
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