Clean It Like You Mean It!

According to basic training and nursing school methodology, we are taught: Using a sterile basin and sterile technique, clean the wound from top to bottom and from the center to the outside. Following this pattern, use new gauze for each wipe, placing the used gauze in the waste receptacle.¹ Unquestionably, students need to learn sterile technique and the textbook methodology for common procedures. In the world of chronic wound management, we deal with residuals and exudates from dressings that are left in place for days at a time, gelatinous and proteinaceous coagulum containing bacteria and biofilms, and necrotic material that harbors all of the above. With that visual in mind, how we clean wounds takes on new meaning. This month’s Back to Basics provides general points to consider as we approach wound cleaning.

Solution. The choice of the solution to be used to clean a wound should be based on the perceived need — that is, do you want to cleanse the wound or do you feel you need to disinfect? If addressing bioburden is a primary factor, the use of an antimicrobial or antiseptic solution should be considered. For general cleansing of a clean wound, isotonic saline is a reasonable choice if delivered effectively. Another option is to use cleansers and antimicrobial solutions in commercially prepared dispensers.

Delivery. Have you witnessed or used a pink, twist-top bullet with 3, 5, or 10 cc of normal saline (NS), dribbled it over a wound, and called it clean? My friend and colleague, Terry Swanson, a wound care Nurse Practitioner from Australia, calls that “anointing,” not cleansing. Although we should never say never, this delivery is useless in disengaging most exudates, previous treatment residues, or tenacious debris. The goal of delivering the up to 15 psi often recommended warrants the use of a commercially available irrigation device or a syringe and angiocath to put more force behind the stream.^2,3 The literature abounds with mention of the use of a 35-cc syringe and a 19-gauge angiocath to deliver solution at 8 psi. The sources of that recommendation date from 1976⁴; good luck finding a 35-cc syringe and 19-gauge angiocath to deliver 8 psi in your facility. However, a 2012 article⁵ describes the use of a 20-cc syringe and 18-gauge angiocath to deliver 12 psi, sizes much more readily available. Rodeheaver and Ratliff³ provide additional information on wound irrigation pressures.

Commercial products in pourable containers may be delivered as described above. Such products, available in spray dispensers and many with adjustable spray/stream options, combine a cleanser with surface-acting and wetting agents that can reduce the wound surface tension of debris, allowing for improved cleansing.

When the wound needs more. Effective cleansing may require physically touching the wound to remove visible/nonvisible debris. In a multinational survey examining dressing practices among wound clinicians,⁶ avoiding pain and trauma was an important concern. The context of trauma is 2-fold: trauma that damages tissue and trauma that causes pain. The potential for injuring tissue must be balanced with the potential negative effects of debris and bioburden, the latter being the larger threat. Once the wound is granulating and healing, less traumatic methods can be employed. From the pain perspective, if wound cleansing cannot be performed because the patient cannot tolerate the discomfort, the clinician may consider using topical anesthetics (eg, lidocaine gel, solution, or ointment) to mitigate the pain. The wound bed can be cleansed using woven gauze or monofilament pads⁷; however, the use of gauze for scrubbing has been shown to be less effective than the use of a monofilament pad for reducing bacteria and biofilms in vitro; in practical experience the monofilament pad is generally better tolerated for painful wounds.⁸ The net result: either will usually result in a visibly cleaner wound than just flushing or irrigation alone.

Case study. As an illustration, a 37-year-old man presented with history of chronic venous insufficiency and an ulcer present for almost 5 years that was exquisitely painful and unable to be cleansed easily (see Figure 1). After using lidocaine jelly to reduce wound bed pain, we began cleansing with NS saturated onto a monofilament device (see Figure 2). The patient continued in this manner at home, using collagenase to clean the wound and after a few weeks a self-adjusting foam dressing, with continuous use of compression stockings until closed; Figure 3, Figure 4, and Figure 5, taken at 15, 29, and 49 days of treatment, show progression toward healing.

The takeaway lesson is this: cleansing a wound involves the appropriate solution and application. How would you grade yourself on your knowledge and practice?

Next month: Exudate management.