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Dr R Fernandez, Centre for Applied Nursing Research, Liverpool, New South Wales, Australia;
How does water compare with other solutions for cleansing wounds?
Included studies compared water with other solutions for cleansing acute or chronic wounds or with no cleansing and reported objective outcome measures. Studies assessing cleansing solutions as part of dental procedures, prophylaxis, preoperative or operative procedures, and those of patients with burns or ulcers were excluded. Outcomes included wound infection and healing.
Medline, CINAHL, and EMBASE/Excerpta Medica (all to 2007); Cochrane Wounds Group Specialised Register; Cochrane Controlled Trials Register (Issue 3, 2007); 2 other databases; and reference lists were searched for randomised controlled trials (RCTs) or quasi-RCTs. Authors, experts, and companies were contacted. 5 RCTs and 6 quasi-RCTs (age range 2–95 y) met the selection criteria; duration of follow-up ranged from 1 to 6 weeks.
Meta-analysis showed that tap water reduced infections compared with saline for cleansing acute wounds (table). Individual studies showed that tap water and saline did not differ for infections or healing of chronic wounds (table); distilled water and saline, cool boiled water and saline, and distilled and cool boiled water did not differ for infections (table). No RCTs compared water with no cleansing or tap water with cool boiled water.
Infection rates do not differ for wounds cleansed with water or saline.
Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev 2008;(1):CD003861.
Clinical impact ratings: Surgery/General 7/7; Paediatrics 6/7; Surgery/Plastic 6/7; Paediatric emergency medicine 6/7; Surgery/Orthopaedics 5/7; Emergency medicine 5/7
The meta-analysis by Fernandez and Griffiths compared water with other fluids for wound cleansing and found that tap water caused fewer infections than saline. Infection rates in acute lacerations were low (3–5%), and cost savings of switching to tap water were estimated to be >$65 000 000 in the USA.
Type of delivery system was not addressed. Most studies recommend high pressure (25–35 psi) syringe irrigation. Standard water faucets deliver about 45 psi.1 Patients who self-irrigate in a sink would not need expensive delivery devices, and fewer personnel would be exposed to open wounds. Other studies show that pulsatile lavage may harm tissues and recommend low pressure systems, such as bulb syringes or suction irrigation.2 Further study of optimum pressures and delivery devices for irrigation is needed.
In the review by Fernandez and Griffiths, solution temperature was addressed in a comparison of distilled water with cooled boiled water in open fracture wounds. As expected, infection rates were high for open fractures but did not differ between groups. In a small study, patients with lacerations preferred warm saline irrigation for comfort3; however, too few patients were included to measure infection rates.
Non-sterile water irrigation may be necessary for wilderness injuries, including lacerations, which are common.4 Those participating in wilderness activities need to be prepared to care for wounds in the field. Knowing that irrigation does not require sterile saline or instruments can ease wound care until definitive medical care is available.
The review by Fernandez and Griffiths helps dispel the myth that washing with sterile solutions is required. Multicentre RCTs evaluating type of irrigation fluid, temperature, and pressure are needed.
Source of funding: no external funding.