Adding a Hypochlorous Acid-Preserved Wound Cleanser to the Pressure Injury Management Toolbox: A Case Series

INTRODUCTION

Pressure injuries (PIs) can impair quality of life, and the goal of management is to create an optimal local wound healing environment.^1,2 PIs can be difficult to manage and are associated with significant morbidity and mortality. Wound cleansing is a routine part of managing these wounds and can aid in the removal of exudate, debris, and contaminants.³ PIs located on the sacrum or ischium are at high risk of infection due to exposure to urine and feces; for these wounds, regular cleansing is extremely important.⁴ 

This article presents 4 patients in whom a hypochlorous acid-preserved wound cleanser (HAPWOC) (Vashe; Urgo Medical North America) was used to manage stage 3 and 4 PI/Us. 

METHODS

Each patient presented with a chronic stage 3 or 4 PI to the sacrum or ischium. Each received 10-minute soaks of HAPWOC with each dressing change. Patients were then treated with a variety of topical advanced dressings. Healing progression of the wounds was tracked on a weekly basis. The protocol was followed for up to 90 days.

Case 1 (Figure 1). The patient was a 46-year-old man with a history of a stage 4 sacral PI as well as multiple sclerosis, neurogenic bladder, and obesity. He underwent surgical debridement of the area and colostomy placement. The wound was treated with negative pressure wound therapy (NPWT) for 3 weeks. At that time, NPWT was stopped due to the facility being unable to maintain the NPWT dressing integrity and peri-wound skin breakdown. A wound dressing protocol was then begun that included application of a cyanoacrylate skin protectant on the peri-wound area and daily dressing changes with gauze moistened with HAPWOC, which was further covered by dry gauze. The patient also had a gel cushion in his wheelchair and was lying on a low-air loss mattress. 

Case 2 (Figure 2). An 84-year-old man was seen with a stage 4 sacral PI. Medical history included non-ST segment elevation myocardial infarction and post coronary artery bypass grafting. The PI developed after admission to the intensive care unit due to COVID-19–related pneumonia. He underwent surgical debridement of the area and colostomy placement. The wound was treated with NPWT for 4 weeks. At that time, NPWT was stopped due to the facility being unable to maintain the dressing and the development of a wound odor. The same wound dressing protocol as described in Case 1 was then begun. 

Case 3 (Figure 3). The patient was a 69-year-old woman with a stage 4 sacral PI, non-ST segment elevation myocardial infarction, coronary artery disease, anxiety, type 2 diabetes, and a head injury. The PI developed after admission to the intensive care unit due to sepsis secondary to pneumonia. She underwent surgical debridement of the area and colostomy placement. The patient was then started on a dressing protocol that included daily dressing changes with gauze moistened with HAPWOC, which was then covered by dry gauze. Sitting was limited to 1-hour intervals 3 times a day, and the patient sat on an air cushion.

Case 4 (Figure 4). A 55-year-old man with a history of paraplegia, congestive heart failure, hypertension, type 2 diabetes, and a stage 4 left ischial PI underwent surgical debridement of the area and colostomy placement. The wound was treated with NPWT for 30 days. At that time, the NPWT was stopped due to the periwound skin breakdown and the patient returning home. The patient was then started on a wound dressing protocol that included application of a cyanoacrylate peri-wound skin protectant and daily dressing changes with gauze moistened with HAPWOC, which was covered by dry gauze. The patient also had a special gel wheelchair cushion. He was treated with this protocol for 60 days prior to undergoing a rotation flap closure. 

RESULTS

Each patient’s wounds showed improvements in the size, volume, and tissue quality (Figure 5). The wounds also remained free from odor and infection over the course of management with the described protocol.

DISCUSSION

Although the definitive, 1-step treatment of PIs is surgical closure of the wound, a large number of PIs are not manageable in this way immediately upon presentation.^1,2 The treatment of such wounds then revolves around meticulous wound bed preparation and, if possible, reduction of wound volume and size with methods such as NPWT.^5-7 Alternatively, secondary healing with the help of advanced wound care dressings also may be practiced. These wound management methods may continue until the wound closes or reduces in size and volume enough so that it is possible to consider surgical primary closure options.^5-7 

Due to their anatomic location and likely constant exposure to urine and fecal matter, sacral and ischial PIs tend to be particularly difficult to protect from colonization and possible infection.⁴ Patients in whom stage 3 or 4 PIs develop are at a particularly high risk of infection due to deep tissue exposure and the general comorbidities present in many of these patients.² 

In such cases in which the wound is likely to remain open for days, meticulous cleaning of the wound bed is required, desirably at each dressing change. Wound cleansers are conveniently used for the routine cleansing of the wound, and such products may contain antimicrobial preservatives for safe storage and use.³ Hypochlorous acid (HOCl) has been known to be a safe, effective, and powerful antimicrobial preservative for wound cleanser solutions, particularly in contrast to more cytotoxic agents such as sodium hypochlorite, which is present in bleach and Dakin’s solution.^7-9 The HOCl and hypochlorite species exist in a pH-sensitive equilibrium.^10,11 A cleanser can be preserved with the desirable preservative, HOCl, in its most uncontaminated form (ie, free from contaminating hypochlorite preservatives) only when formulated and stored between a pH of 3.5 and 5.5.^10,11 This pH also is associated with wound healing, as evidenced by several publications.^12-14

NPWT may be discontinued in wounds such as PIs due to the emerging inability of the NPWT dressing to maintain a seal on the dressing as the wound size and shape changes through the NPWT process. Loss of seal over time, despite efforts to keep the seal intact, can lead to an overgrowth of bacteria in the wound/periwound/NPWT dressing and seal interface. In clinical practice, we usually detect this from the development of odor and concurrent stalling of wound healing. In our practice, patients are given a “VAC vacation” in these cases. During this phase, HOCl can be helpful for wound cleansing, mechanical reduction of bioburden, and continued healing. The wound healing progress shown in Figure 5 indicates this effect. Other common reasons for NPWT discontinuation and transition to HAPWOC treatment may be periwound skin breakdown with NPWT or emergence of fungal infections; we have found HAPWOC treatment to be able to mechanically remove fungal bioburden. 

The cleanser used in this case series is preserved with HOCl primarily due to the superior biocompatibility associated with this  preservative and the clinical evidence available with this cleanser on wounds of all types, including PIs.^15-18 Evidence has led to recommendations by several authors and the National Pressure Injury Advisory Panel to list HOCl-preserved products as suitable for the management of PIs.^19-23 

The current case series of 4 patients showed that the routine use of a hypochlorous acid-preserved wound cleanser in the protocol described can be an effective tool to assist in the management of PIs, especially sacral PIs. Indeed, healing progression was evident in all cases. PI wounds in the sacrum are constantly introduced to germs, and the ability to keep the wound clean of microbes,¹⁵ microbial biofilms,^23,24 and associated debris via the mechanical removal with the HAPWOC was likely an important step in wound healing. Future recommendations include the development of a prospective study with a larger sample size. 

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Pearls for Practice is made possible through the support of Urgo Medical, Fort Worth, TX (www.urgomedical.com). The opinions and statements of the clinicians providing Pearls for Practice are specific to the respective authors and not necessarily those of Urgo Medical, Wound Management & Prevention, or HMP Global. This article was not subject to the Wound Management & Prevention peer-review process.