Authors

1. Queiros, Paulo RN, PhD
2. Santos, Eduardo RN
3. Apostolo, Joao RN, PhD
4. Cardoso, Daniela RN
5. Cunha, Madalena RN, PhD
6. Rodrigues, Manuel RN, PhD, Agregation

Abstract

Review question/objective: The objective of this review is to identify and synthesize the best available evidence on the effectiveness of cleansing solutions for wound treatment in clinical practice and compare the effectiveness of different cleansing solutions in infection and wound healing rates.

More specifically, the review will focus on the following questions:

* Does the effectiveness of different cleansing solutions influence the infection and wound healing rates?

* Which cleansing solution is more effective for reducing wounds infection rates?

* Which cleansing solution is more effective for increasing wounds healing rates?

* What if the effectiveness of cleansing solutions is affected by the wound etiology?

Background

The management of chronic and acute wounds has changed significantly in the last decade. The practice of wound cleansing or antiseptic management has a dichotomous history anchored in tradition and science.1 It is an integral part of the management of acute wounds as well as chronic wounds.2,3

Although there is a consensus that wound cleansing reduces infection rates2 there is, however, a debate in clinical circles about the potential advantages and disadvantages of cleansing wounds because the exudate itself may contain growth elements and chemokines which contribute to wound healing and for that reason it is not always necessary.3,4 Until further research has established its demerits, cleansing will continue to remain an integral part of the wound management process although there is an absence of strong evidence to indicate that cleansing wounds per se increases healing or reduces infection.5,6

This reality is also intensified by the lack of a diagnostic test that would allow healthcare professionals to identify the bacterial load in the wound that is capable of causing wound infections. In addition, the situation is further complicated by studies showing that bacterial colonization of the wound does not necessarily indicate infection and that there is no need to remove the bacteria in the absence of clinical signs of infection.2

Yet amongst scientific literature, several studies have recommended various cleansing agents for their supposed therapeutic value. It has also been suggested that wound cleansing helps to optimize the healing environment and decrease the potential for infection.7,8 It loosens and washes away cellular debris such as bacteria, exudate, purulent material and residual topical agents from previous dressings.9,10 However, in practice, the decisions on which cleansing solutions to use have been based on experience, service policy and personal preference.

In general, the characteristics of an ideal wound cleansing solution are: non-toxic to human tissues; remains effective in the presence of organic material; reduces the number of micro-organisms; does not cause sensitivity reactions; is widely available; is cost-effective; and is stable with a long shelf life.11

Normal saline fulfills all the criteria given above. Normal saline (0.9%) is the favored wound cleansing solution because it is an isotonic solution and does not interfere with the normal healing process, damage tissue, cause sensitization or allergies or alter the normal bacterial flora of the skin (which would possibly allow the growth of more virulent organisms).5,10,12,13,14,15

Tap water is also recommended and has the advantages of being efficient, cost effective and accessible.5,16 There is now increasing recognition of the safe use of tap water for wound irrigation, especially in chronic wounds15 and it is worth considering as an acceptable alternative to other products. Indeed, Flanagan11 argues that water has been used for centuries to treat wounds without any reported detrimental effects. Although the two most commonly cited concerns regarding tap water are possible infection risk and the fact that it is not an isotonic solution.

In this matter, several studies have found that there was no significant difference between the infection and healing rates in wounds irrigated with normal saline or tap water.8,16,17 Indeed, Angeras et al.16 found a higher rate of infection in those wounds irrigated with saline. However, clinicians have been cautioned against using tap water to cleanse wounds that have exposed bone or tendon, in which case normal saline is recommended.5,18

On the other hand, there is no agreement amongst wound care authorities on the advantages of using sterile solutions over non-sterile solutions.

Research has also established that the use of antiseptic solutions may compromise the healing process19 and, as a result, the use of normal saline as a cleansing solution is widely recommended.13

In fact and since the earliest times, preparations with antiseptic properties have also been traditionally used; however published research has suggested that antiseptic solutions may hinder the healing process. For this reason several guidelines and various studies discourage the use of antiseptic solutions such as povidone iodine, hydrogen peroxide, or sodium hypochlorite because in most instances, they do not effectively promote good wound healing; in contrast, most studies showed either impaired wound healing, reduced wound strength, or infection.14,20

The controversy surrounding the use of antiseptics prompted the development of guidelines for the use of antiseptics by wound care experts. These guidelines have also resulted in changes in hospital practice.5 Concerns are also mounting relating to the use of these products, and the development of bacterial resistance and the possible systemic absorption of antiseptics. In most cases, the selection of these products does not have a solid scientific basis.

Still, new cleansing solutions are appearing. Most recently, the new cleansing solution based on polyhexanide and betaine has recently emerged as a credible alternative to currently available products.21,22,23This particular solution is effective for treating colonized/infected wounds, providing optimal conditions for wound healing, reducing healing time, signs of inflammation and/or infection/colonization, provides greater odor control, has a painless application and is especially indicated for the treatment of chronic wounds and those which are difficult to heal.21,23,24,25

An extensive review of literature identified several systematic reviews and best practice guidelines. However despite the presence of these publications, rigorous research is still needed to support the identified recommendations.5,14,23

Remarkable advances have been made in the science of wound care and treatment. Despite this, numerous factors impact on this science, and managing wounds will continue to be a healthcare concern. Increasing life expectancy, frequency of wound development in the aged care community, increased prevalence of diabetes, and considerable monetary and lifestyle costs make the appropriate cost-effective management of wounds an international healthcare imperative. Nurses, both acute care and community-based, are in a unique position to provide evidence based education and interventions to their colleagues and consumers. Thus, the purpose of this systematic review is to investigate the effectiveness of cleansing solutions for wound treatment in clinical practice.