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Irrigation of simple lacerations with tap water or sterile saline in the emergency department did not differ for wound infections
  1. Marcia Edmonds, MD
  1. University of Western Ontario, London, Ontario, Canada

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    In patients presenting to the emergency department (ED) with simple lacerations, is wound irrigation with tap water equivalent to irrigation with sterile saline for wound infections?

    Moscati RM, Mayrose J, Reardon RF, et al. A multicenter comparison of tap water versus sterile saline for wound irrigation. Acad Emerg Med 2007;14:404–9.

    Clinical impact ratings GP/FP/Primary care ★★★★★★⋆ IM/Ambulatory care ★★★★★★★ Cardiology ★★★★★★⋆ Endocrine ★★★★★★⋆

    METHODS

    Embedded ImageDesign:

    randomised controlled trial.

    Embedded ImageAllocation:

    unclear.

    Embedded ImageBlinding:

    blinded (outcome assessors).

    Embedded ImageFollow-up period:

    5–14 days after wound closure.

    Embedded ImageSetting:

    2 urban trauma centres and 1 suburban community hospital in the US.

    Embedded ImagePatients:

    713 patients >17 years of age who presented to the ED with acute uncomplicated skin lacerations requiring staples or sutures. Exclusion criteria were puncture or bite wounds; self-inflicted wounds; grossly contaminated wounds; wounds >8 hours old; wounds involving tendon, joint, or bone; diabetes; significant peripheral vascular disease; HIV or immunocompromised conditions; use of antibiotics or corticosteroids; or pregnancy.

    Embedded ImageIntervention:

    339 patients were allocated to tap water irrigation. Patients with upper extremity wounds were instructed to irrigate their wounds for ⩾2 minutes under tap water from an unmodified tap in a steel sink. Patients with wounds in other locations used a non-sterile, single use, approximately 1-metre length of clear plastic tubing connected to the tap to facilitate irrigation. 374 patients were allocated to sterile saline irrigation. Wounds were irrigated by providers, using ⩾200 ml sterile saline administered with a sterile 35 ml syringe. Wound care after irrigation, including method of closure, was at the provider’s discretion in both groups. All patients were instructed to return to the ED in 5–14 days for suture or staple removal and wound evaluation.

    Embedded ImageOutcomes:

    wound infection (wounds that required a significant change in treatment course after closure, specifically, debridement, antibiotics, or early suture or staple removal). Equivalence between groups would be accepted if the tap water group had a wound infection rate <10%. A sample size of 1000 was calculated to provide 80% power to detect a 5% absolute difference in wound infection rates with α = 0.05 and 15% attrition.

    Embedded ImagePatient follow-up:

    89% were included in the analysis (64% with upper extremity wounds).

    MAIN RESULTS

    The tap water and sterile saline groups did not differ for wound infection rates (table); the trial was underpowered to detect a difference between groups.

    Tap water v sterile saline for irrigation of simple lacerations in the emergency department*

    CONCLUSION

    In patients presenting to the emergency department with simple lacerations, wound irrigation with tap water did not differ from irrigation with sterile saline for wound infections.

    A modified version of the abstract also appears in Evidence-Based Nursing.

    Commentary

    Standard care of uncomplicated traumatic lacerations in the ED has traditionally involved use of “sterile technique,” including wound disinfectants, sterile gloves, and irrigation with sterile saline. However, the role of skin disinfectants is unclear, and some may impair wound healing.1 More recently, the use of sterile gloves has also been suggested to be unnecessary.2 Now, use of sterile saline for irrigation is under question.

    Previous smaller trials did not find a difference in infection rates between tap water and sterile saline irrigation. Although the trial by Moscati et al was appropriately designed to demonstrate equivalence between tap water and sterile saline, it failed to reach the necessary sample size to meet the predetermined criteria for equivalence. This was due, in part, to difficulties in recruiting patients. However, the overall infection rate was also lower than anticipated, and so a larger sample size would have been required. Despite this, the infection rates were similar in both groups, which makes it less likely that we would miss a large difference in infection rates.

    Although the study doesn’t prove equivalence between the treatments, it seems unlikely that irrigation with sterile saline provides a large benefit over tap water. As the authors point out, tap water is easy to use, decreases the amount of equipment needed, may decrease exposure of healthcare providers to bodily fluids, and may decrease costs. The authors also suggest that a meta-analysis including the other existing trials, which also failed to show any benefit of sterile saline irrigation, might further clarify the issue.

    References

    View Abstract

    Footnotes

    • Sources of funding: in part, Federal Highway Administration through the Center for Transportation Injury Research and Calspan University at Buffalo Research Center.