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Wound Cleansing With a Hypochlorous Acid–Preserved Wound Cleanser in Pediatric Patients With Burns
Wound cleansing and wound bed preparation is an important step toward healing of any wound etiology. A hypochlorous acid–preserved wound cleanser (HAPWOC; Vashe, Urgo Medical) is used widely across the continuum of care in the author’s large hospital system, which includes a pediatric burn unit. HAPWOC is used widely in inpatients and outpatients for acute and chronic wounds, including burns. Its use is of particular importance when wound bioburden is a consideration.
METHODS
A literature survey was done to examine the published evidence on HAPWOC and wound cleansing, so that the guidelines and chemistry behind HAPWOC and its known noncytotoxicity could be presented in summary. A survey of the burn unit was done to report on clinical application protocols. Case studies from the pediatric burn unit were collected, and 2 illustrative cases are presented here.
RESULTS OF CLINICIAN AND LITERATURE SURVEYS
The clinician survey showed that the use of HAPWOC in pediatric patients with burns is driven by clinical satisfaction based on many years of use. The literature survey identified a significant clinical evidence base,1-9 including in pediatric situations, of HAPWOC and hypochlorous acid–based solutions being safe and efficient in wound cleansing. It was noted as being safe and effective in graft management in burns as an alternative to resistance-inducing antibiotic solutions.4 Several guidelines mention or recommend the use of hypochlorous acid–preserved solutions in wound cleansing.10-13 Hypochlorous acid is effective as a powerful antimicrobial preservative but still, HAPWOC is noncytotoxic to human cells compared with other cleansers.14 Likely due to HOCl-specific protective mechanisms that exist with human tissues, there is evidence that it removes planktonic and biofilm-based bacteria.15-17 Also, the acidic pH in the product is associated with healing.18-20
The survey of burn care providers showed that protocols have been standardized over a long period of use and consisted of soaking gauze with HAPWOC and then applying it to the burn site, allografts, or autografts for 5 to 10 minutes during wound cleansing. Although soap and water can be used in smaller wounds for cleansing purposes, the clinical team preferred to use HAPWOC when there was a clinical concern for bacterial burden either existing or being potentially emergent. Additionally, HAPWOC is used for wound bed preparation in the operating room (OR) for allografting or autografting procedures. Although chlorhexidine gluconate is typically used in the OR as a skin preparation, it is not used in open wounds due to concerns of tissue toxicity. Due to the concerns of cytotoxicity with other solutions, as a standard, HAPWOC is used to prepare open wounds prior to grafting to address bacterial burden while not compromising wound bed preparation.14
In both cases presented, patients had 20% total body surface area deep partial-thickness burns. Positive cultures were identified before HAPWOC treatment in these cases. After treatment, the wounds proceeded to healing or closure. In case 1, culturing was done after HAPWOC treatment to ensure elimination of the bacteria identified, and the posttreatment culture results were negative. Clinicians reported that HAPWOC was not painful when applied and opined that it was easy to use repeatedly during regular cleansing without causing trauma.
CASE REPORTS
Case 1 (Figure 1). A 3-year-old child had a 20% second-degree deep partial-thickness grease burn. The patient’s length of stay was 20 days, with 2 OR visits for treatment/grafting. Gram-positive cocci were present before HAPWOC treatment. There was no culturable growth 2 days after HAPWOC soaks. The patient was draped, and the skin around the burn area was prepared with chlorhexidine gluconate (Chloraprep, Becton, Dickinson and Company) and HAPWOC (for the wound) before placement of allograft in the OR. The patient underwent a 2-stage procedure. The first was debridement with immediate allograft placement on admission day 2. The patient underwent a split-thickness skin graft for final closure 5 days later. The patient was discharged 1 week later, and the wound ultimately went on to full epithelialization. The patient is now receiving physical therapy for scar management.
Case 2 (Figure 2). A 2-year-old child had a 20% second-degree deep partial-thickness flame burn. The length of stay was 28 days, with 3 OR visits for treatment/grafting. Methicillin-resistant Staphylococcus aureus/Psuedomonas were cultured. HAPWOC was used in preparation for allografting and after autografting. The patient was admitted to the intensive care unit and underwent tangential excision in the OR on days 1 and 5 with allograft placement. She underwent split-thickness skin graft for final closure on day 20 and was discharged on day 27.
DISCUSSION
Based on the evidence examined,1-21 HAPWOC addresses the bacterial burden in burn wounds in patients, including pediatric patients, with minimal and no trauma, while also allowing the preservation of cells because of its noncytotoxic nature.14 For reasons that are still being researched, HAPWOC seems to be able to penetrate biofilms (in vitro)15-17 and is able to help remove, mechanically, necrotic tissue, particularly when used with NPWT.1,2 The acidic pH of the product is conducive to wound healing.18-20
When burn wounds have delayed healing in a pediatric patient, it is less likely, in the author’s experience, that blood flow or nutrition is the culprit. Bacteria colonization is often the etiology; thus, cultures are performed. On culture-positive wounds, after identification, the protocol in the author’s institution is to use HAPWOC soaks during major procedures and wound cleansing. Generally, improvement of wound status is visible using this global regimen, over time, and is generally without complications.
Discussions with the burn team led to the conclusion that HAPWOC is particularly useful in the following situations: 1) delayed healing in outpatients, 2) preparing for allografting/autografting, 3) complicated wounds (suspected biofilm/colonization, necrotic tissue, known Pseudomonas), and 4) concerns about wound hygiene/cleansing in the home setting; families are more receptive to soaking a wound and gently wiping it than vigorously scrubbing it. This practice is consistent with existing guidelines for burn care.21
In some cases, based on clinician discretion, a culture test is done after HAPWOC exposure. In such cases, a lack of culturable organisms after HAPWOC treatment is usual, commensurate with the healing progress of the wound.
Wide use of the above protocols is reported in the author’s burn unit, particularly with “problem” wounds, with a largely standardized protocol that has been developed through years of safe, evidence-based experience. HAPWOC requires more research, but this report shows positive experiences treating pediatric patients with burns.
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 and is based on a poster presented at John A Boswick Wound and Burn Care Symposium, Maui, HI, January 22–27, 2022.
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