Continuing our series on adjunctive therapies, this week we will examine the use of pulsed lavage in wound care.

Treatment Overview

Pulsed lavage (pulsatile jet lavage) is mechanical water therapy used to assist in debriding wounds of necrotic tissue. It utilizes a pressurized pulsed solution, sometimes in conjunction with suction, to help rid the wound of debris. It is thought that pulsed lavage improves the development of healthy, granulating tissue. The goal is to remove unwanted tissue without disturbing healthy tissue. The pressure of irrigation is measured in pounds per square inch (psi), and a pressure of 4 to 15 psi is considered safe and effective. Normal saline is the most commonly used irrigating solution.

Indications

• Cleansing/debriding a variety of wounds, including venous, pressure and neuropathic ulcers
• Burns
• Traumatic wounds
• Surgical wounds
• Patients who are not candidates for whirlpool therapy due to health condition (i.e. venous insufficiency, incontinence, certain cardiac conditions, patients in an ICU)
• Wounds with tunnelling (if the lavage system has the correct tips)

Contraindications

• No absolute contraindications exist when a psi of 15 or less is used
• Some wounds may be better suited for whirlpool therapy due to their nature (i.e. extensive burns, psoriasis, Kaposi’s sarcoma)

Advantages

• Greater amount of debridement can be obtained by increasing the psi
• Antibiotics can be added to the irrigation fluid to help reduce the wound’s bioburden
• Pulsed lavage is relatively cost-effective
• Pulsed lavage systems are easily mobile and can be used in a variety of patient care settings
• Decreased risk of contamination of the wound in comparison to whirlpool therapy
• Decreased risk of maceration of healthy surrounding tissue, as may occur with whirlpool therapy
• The technician can easily control the pressure applied to the wound

Disadvantages

• Pulsed lavage can be a painful procedure for some patients
• Cooling of the wound bed may occur when the irrigating solution is not sufficiently warm, resulting in a delay in wound healing
• Pulsed lavage is time consuming- treatments may take 15 to 30 minutes and may need to be done daily (twice daily if the wound has more than 50% necrosis)

For patients who experience pain during the procedure, appropriate pain medications can be administered 30 minutes prior to treatment; alternately, a topical anaesthetic, such as lidocaine, can be used to ease discomfort. In addition, the psi can be decreased if pain still persists despite use of other methods of pain relief.

For the third in our series on adjunctive therapies, we will examine the role of negative-pressure wound therapy in wound management.

Treatment Overview

Negative-pressure wound therapy (NPWT) is a topical intervention widely used to treat problematic acute and chronic wounds that do not respond to conventional moist wound healing techniques. A negative pressure, typically -125 mmHg, is applied to the wound bed, removing excess exudate and helping to establish fluid balance. In addition, NPWT is thought to stimulate granulation tissue formation, reduce interstitial edema and improve microvascular blood flow.

The negative pressure in NPWT is applied via a tube from a vacuum device, threaded through a gauze or foam dressing that has been sealed with a transparent film. The negative pressure may be applied continuously or intermittently, depending on the wound type and the treatment objectives.

Indications

• Chronic, acute, and traumatic wounds
• Partial-thickness burns
• Dehisced wounds
• Pressure ulcers
• Neuropathic ulcers
• Muscle flaps
• Skin grafts
• Wounds due to arterial or venous insufficiency
• Wounds with exposed bone or tendons
• Orthopedic and degloving injuries
• Wounds with exposed hardware

Contraindications

• Dry wounds
• Necrotic wounds
• Wounds in body cavities
• Wounds over malignancies
• Presence of exposed blood vessels or untreated osteomyelitis

In addition, caution should be used with patients on anticoagulants or wounds with active bleeding, and NWPT should not be applied immediately after an incision and drainage procedure

Advantages

• Provides a closed moist wound healing environment
• Helps reduce contamination from outside bacteria
• Removes excess fluid from the wound and surrounding tissues
• Reduces cell death caused by dehydration
• May facilitate wound contraction
• If used for more than a few days, it may be more cost effective than standard wound care

Disadvantages

• Some patients report pain on treatment
• The bulkiness of the unit makes mobility difficult
• Because of the suction effect, some patients may develop pressure ulcers in the areas treated
• Obtaining an airtight seal can be difficult to achieve in some wound locations
• Cannot be used on necrotic wounds
• Can be expensive, especially over a short time frame

Interested in becoming certified in wound care management? Woundeducators.com is your online resource for the most comprehensive wound care information available, and can help you take the next step in your career. Contact us today for more information.

References:

Ahearn C. (2009). Intermittent NPWT and Lower Negative Pressures - Exploring the Disparity between Science and Current Practice: A Review; Ostomy Wound Management; 55(6), p.22

Sibbald RG, Mahoney J, VAC Therapy Canadian Consensus Group. (2003). A Consensus Report on the Use of Vacuum-Assisted Closure in Chronic, Difficult-to-Heal Wounds; Ostomy Wound Management; 49(11), p.52

Tea Tree Oil has been used for acne treatments as well as ultraviolet - C- range light to eradicate systemic infections. Arguments have been made that since acne vulgaris was from a bacterial source, below the surface of the skin, that a topical anti-bacterial, such as Tea Tree could not kill the bacteria since it did not touch the bacteria. The same arguments made are typical of similar arguments originally made about C-range ultraviolet energy being incapable of destroying pathogens of a systemically infected patient.

What is overlooked in that simplification is that all bacteria tends to colonize, ie.forms “pockets” or comes together as a group. This is most common where we use ultraviolet energy, C- range, on bedsores (decubitus ulcers), and the patient has a systemic infection versus a local infection. Systemic simply meaning the bacteria is within the patient’s body and not centralized in the bed sore itself.

With ultraviolet one simply shines the light into the wound bed killing all known pathogens. One would then culture the wound and find there were no detectable traces of bacteria after the treatment. That area just “zapped” is also a great place for bacteria to re-colonize, as there is little competition for the bacteria to live and replicate, so several hours later the bacteria has left the safety of being “under the skin” and emerges into the treated area. It literally is attracted from inside the body, to the bed sore, and exposes so we can use ultraviolet energy to kill it.

Over the course of several treatments the bacterial load is reduced, the immune system takes over, and overwhelms the remaining bacteria and the wound now heals. It’s this migratory process of bacteria that makes systemic infections treatable by ultraviolet light. One literally entices the bacteria to do what it does naturally, which is colonize. The process of colonization is not unique to bacteria treated by c-range ( 254 nanometer) ultraviolet light but is the natural order of things with all bacteria. Tea Tree oil is simply another treatment option which can take advantage of the natural order of bacteria to colonize.

It is highly likely that when Tea Tree Oil is used it immediately kills the surface bacteria and upon killing, the bacteria under the skin’s surface, migrates to the surface. Each subsequent treatment with the Tea Tree oil reduces the bacterial load until the bacteria has been destroyed and acne is no longer a problem.

The issue is not the efficacy of the treatment but an understanding of how treatments by numerous agents can be successfully applied due to bacterial colonization.