Optimal Pressures PDF - Veterinary Nursing Journal - Wound Management

Veterinary Nursing Journal ISSN: 1741-5349 (Print) 2045-0648 (Online) Journal homepage: https://www.tandfonline.com/loi/tvnj20 Optimal pressures and irrigation techniques used in small-animal wound management Stephanie-Rose Ball To cite this article: Stephanie-Rose Ball (2017) Optimal pres...

Veterinary Nursing Journal ISSN: 1741-5349 (Print) 2045-0648 (Online) Journal homepage: https://www.tandfonline.com/loi/tvnj20 Optimal pressures and irrigation techniques used in small-animal wound management Stephanie-Rose Ball To cite this article: Stephanie-Rose Ball (2017) Optimal pressures and irrigation techniques used in small-animal wound management, Veterinary Nursing Journal, 32:11, 325-328, DOI: 10.1080/17415349.2017.1327833 To link to this article: https://doi.org/10.1080/17415349.2017.1327833 Published online: 20 Oct 2017. Submit your article to this journal Article views: 245 View Crossmark data Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=tvnj20  CLINICAL Optimal pressures and irrigation techniques used in small-animal wound management Stephanie-Rose Ball FdSc RVN Stephanie-Rose Ball FdSc RVN Works in a small animal practice in Reading, England Stephanie qualified as an RVN in 2016 after completing her degree at the Royal ABSTRACT: Wound management is a vital aspect of veterinary nursing. This Veterinary College. She has since been article reflects on common wound management techniques and when they working in a first-opinion small-animal should be applied in practice. Owners are the first to identify when their pet has a practice, where she gains experience wound so when they bring them into the practice for treatment is crucial; wound in a variety of areas around the clinic, management should occur in the first 6 hours post-injury to encourage optimal including wound management. healing. This article will discuss cleansing techniques, as well as ideal irrigating Email: [email protected] pressures and the appropriate solutions to be used when presented with a wound. Introduction (Chivers, 2010). Recognising these phases will help VNs to determine abnormalities Many studies have sought to determine if they occur. optimal wound management. In the reviewed literature, three topics of wound Wound complications can arise through any management are discussed frequently. phase of the healing process, so VNs should This literature review will focus upon be familiar with the risk factors of wound these three topics, which are: wound complications. Khalil, Cullen, Chambers, cleansing techniques, optimal pressures, Carroll and Walker (2015) acknowledged and appropriate irrigating solutions. the following factors affecting wound Although the literature conveys these top- healing in humans and animals alike: the ics in a range of contexts, this review will presence of comorbidities, age, malnutrition focus on their application to successful and certain medications. Canines have been wound healing. reported as being more vulnerable to wound complications than felines (Elliston, Heayns, & Fish, 2012). However, this statement is Wound healing limited in that the study was undertaken on It is important for veterinary nurses (VNs) ovariohysterectomy procedures, which typi- to understand the wound healing-process cally take longer in bitches than queens and to successfully manage wounds and take duration is a high-risk factor for post-surgi- the correct course of action. Wound heal- cal site infections. Wound healing in patients ing has three main stages. The inflamma- that fall into the categories discussed should tory phase is the formation of a blood clot be monitored closely for complications. immediately after an injury occurs, which is activated by the presence of platelets Client compliance is a crucial factor that and fibrin (Chivers, 2010). The release ultimately affects wound healing. By pro- of growth factor triggers the cell prolif- viding clients with literature explaining the eration phase, and fibroblasts produce a choice of dressing and the healing process, new medium where endothelial cells can the client can become more educated and transfer across, creating new capillaries, have a better understanding of the impor- and epithelialisation occurs, the result tance of wound management (Calder, of which is the formation of granulation 2012). Alternatively, forming a plan with tissue (Hosgood, 2006). Finally, in the the client will help them feel more involved remodelling phase, a layer of collagen is and encourage them to comply to reach the formed and a scar can be seen. Over time, common goal (Wiggins, 2016). In effect, this DOI: 10.1080/17415349.2017.1327833 this scar will remodel and strengthen will also provide good client and patient care © 2017 British Veterinary Nursing Association (BVNA) Veterinary Nursing Journal VOL 32 November 2017 Page 325 CLINICAL Cleansing techniques Irrigation assists in the removal of for- eign material and bacteria and should be performed as soon as possible (Aldridge, 2013). The initial six hours following injury is known as the “golden period”; if irrigation is not carried out in this period, the risks of infection are considerably more (Hussey & Bagg, 2011). Wounds retaining more than 105 bacteria per gram of tissue will become infected (Moscati, Mayrose, Reardon, Janicke, & Jehle, 2007). In one investigation, the study group had wounds irrigated and in 9 days the wounds were healed; meanwhile, the control group had wounds swabbed and these healed in 12 days (Mak et al., 2015). Furthermore, the investigation revealed Figure 1. The bulb syringe, a recognised irrigation technique that the study group experienced less pain than did the control group, who had swabs taken during wound cleansing, in addition and build a relationship between VN and made based on evidence and both patient to reduced healing time (Mak et al., 2015). client (Calder, 2012). Decisions should be and client circumstances (Brölmann et al., Applicants were chosen at a general out- made between the veterinary surgeon and 2012). By effective communication and fol- patient clinic where patients’ wounds were VN to provide the best wound management low-ups, VNs can maintain and encourage presented and advised to heal by secondary for individuals, these decisions should be client compliance. intention, and then the study started for the individual (Mak et al., 2015). It is clear that irrigation is capable of reducing healing times, and is additionally less painful than other therapies. It is important to exert optimal pressure onto wounds to gain maximum benefit with few contraindications. Moscati, Mayrose, Fincher and Jehle (1998) found that pressures of seven pounds per square inch (psi) or less were inadequate in wound cleansing due to the adhesiveness of contaminants on tissue; higher pres- sures were considered more suitable and effective. More recently, Gall and Monnet (2010) found pressures of 8 psi or more were damaging to surrounding tissue. High-pressure irrigation can spread fluid into surrounding tissues, exposing risks of oedema and leaving the wound more sus- ceptible to infection, so its use should be limited to heavily contaminated wounds where the contraindications are out- weighed by the need to remove the more adhesive bacteria (Edlich et al., 2008). A suitable pressure for clean wounds is 0.5 psi; the bulb syringe exerts pressures of 0.5 psi only, making this an appropriate technique to use (Atiyeh, Dibo, & Hayek, 2009). Different irrigation techniques are capable of different pressures, so it is important to be aware of the advantages and disadvantages of alternative practices. Open wounds should be treated to ensure a healthy and ideal environment that will encourage successful healing. A study was performed where goats had Pseudomonas Figure 2. Sterile saline, a popular irrigation solution aeruginosa injected into wounds. Page 326 VOL 32 November 2017 Veterinary Nursing Journal © 2017 British Veterinary Nursing Association (BVNA)  CLINICAL Table 1. A comparison of irrigation techniques. Technique Benefits Disadvantages Bulb syringe  Ideal for clean wounds due to its 0.5 psi (Atiyeh et al., 2009)  Not ideal for contaminated wounds (Brown et al., 1978)  Little or no risk of damage to surrounding tissues Gall & Monnet (2010) Pulsatile jet lavage  Has been recognised to reduce bacterial counts (Brown  Risk of damage to surrounding bone structure and soft tis- et al., 1978) sue, and delaying wound healing due to its high pressures (Crowley, Kanakaris, & Giannoudis, 2007)  Exerts pressures of around 50 psi (Brown et al., 1978) 19-gauge needle and 20-ml syringe  Exerts pressures of 8 psi which is considered strong enough to dislodge adhesive contaminants (Aldridge, 2013)  Pressure is significantly less likely to cause wound trauma (Aldridge, 2013) Irrigation methods were then employed time (Aldridge, 2013). Some practices saline solution proved longer-lasting as (Owens,White, & Wenke, 2009). The have combined the use of a 3-way tap and bacterial regrowth was significantly less study concluded that the bulb syringe a giving set attached to a bag of saline to when compared to the other solutions in technique removed significantly more reduce the time taken during irrigation; 48 hours. Surfactants such as castile soap bacteria than did pulsatile lavage systems this also enables better control over the function by reducing surface tensions and (Owens et al., 2009). However, there exists exertion pressure (Aldridge, 2013). High inhibit bacterial adhesion, allowing easier a disagreement between Owens et al. pressures should be limited to a maxi- removal (Anglen, 2001). Like antiseptics, (2009) and Brown, Shelton, Bornside and mum of 15 psi to avoid tissue trauma, or castile soap solutions have been found to Cohn (1978). Pulsatile jet lavage elimi- used with caution (Aldridge, 2013). In damage the host’s cells; therefore, their use nated more Escherichia coli than did the summary of the previous points, based should be restricted to highly contaminated bulb syringe in the study of Brown et al. on the degree of wound contamination, wounds and followed by saline irrigation (1978). While this is true, these wounds the most suitable wound irrigation tech- (Anglen, 2001). VNs should be aware of the were heavily contaminated which, as dis- nique should be employed, with heavily risks of using these solutions, and their use cussed earlier, require higher pressures of contaminated wounds needing higher should be justified (see Table 2). irrigation which the bulb syringe cannot pressures between 8 and 15 psi to remove perform. Furthermore, in this study, the adhesive bacteria, and less contaminated Alternative solutions have been studied pulsatile lavage technique exerted pres- wounds requiring pressures of 7 psi or against more traditional solutions in irrigat- sures of 50 psi (Brown et al., 1978). This below (see Table 1). ing wounds to find the most beneficial. Tap investigation proves the need for different water was used to irrigate in-vitro canine pressures on individual wounds; however, fibroblasts; however, distinct degenerative it must be remembered that the study by Irrigation solutions changes occurred, causing disturbances to Brown et al. (1978) is significantly older Wound irrigation solutions should be the cells (Buffa, Lubbe, Verstraete, & Swain, than that of Owens et al. (2009). non-irritant to tissues and reduce bacterial 1997). Ringer’s lactate solution, on the counts with no adverse reactions (Atiyeh other hand, proved physiologically suita- A syringe with a needle attached is a et al., 2009). Antiseptic solutions are likely ble because of its neutral pH and osmotic commonly recognised technique. An to cause tissue damage and impair wound nature, making it like plasma (Buffa et al., 18-gauge needle attached to a 20-ml healing (Moscati et al., 2007). They can 1997). It must be remembered that this syringe releases pressures of 7 psi destroy bacteria, and research has shown investigation was carried out in vitro and onto the wound, so it is considered a they are also detrimental to many of the normal healing physiology would make the low-pressure technique (Atiyeh et al., host’s cells including erythrocytes, leu- results potentially less valid. Sterile saline 2009). On the other hand, a 19-gauge kocytes and osteocytes (Anglen, 2001). has been the preferential solution for two needle attached to a 20- or 35-ml syringe Evidently, their use in irrigation is coun- reasons: it does not disturb normal wound will exert pressures of 8 psi, making it teractive due to these effects on tissues. healing physiology and it is an isotonic a high-pressure technique (Quinn & A study discussed earlier, carried out by solution and therefore does not disturb Macias, 2006). Needles and syringes are Owens et al. (2009), found that castile osmotic balance among the tissues (Atiyeh readily available in practice, making soap solution was most effective initially et al., 2009). In a study, tap water was more them the technique of choice most of the with reduced bacteria levels, although cost-effective and efficacious in irrigating Table 2. A comparison of common irrigation solutions used in practice. Solution Benefits Disadvantages Antiseptic solutions  Capable of destroying bacteria (Anglen, 2001)  Research suggests they are detrimental to the host’s cells such as erythrocytes (Anglen, 2001) Castile soap  Owens et al.’s (2009) study found they could reduce initial  The study also concluded that bacterial regrowth was significantly bacterial counts higher than with saline over 48 hours (Owens et al., 2009)  Its use has been found to damage the hosts cells (Anglen, 2001) Tap water  It is cheap and efficacious (Moscati et al., 2007)  A study concluded that degenerative changes occurred to the cells after irrigation (Buffa et al., 1997) Sterile saline  Does not disturb normal physiology (Atiyeh et al., 2009)  An isotonic solution so does not disturb the tissues osmotic balance (Atiyeh et al., 2009) © 2017 British Veterinary Nursing Association (BVNA) Veterinary Nursing Journal VOL 32 November 2017 Page 327 CLINICAL wounds (Moscati et al., 2007). However, this Conclusion Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC1396479/ study focused on infection rates and did not A number of studies have investigated the look at the pathological state of the tissues Buffa, E. A., Lubbe, A. M., Verstraete, F. J. M., & Swain, S. F. effects and outcomes of different strategies (1997). The effects of wound lavage solutions on canine after using tap water. Its hypotonic nature in wound irrigation. From the research fibroblasts: An in vitro study. Veterinary Surgery, 6, 460–466. was briefly linked to potential cell lysis, undertaken the use of sterile saline is by far doi:10.1111/j.1532-950X.1997.tb00517.x although this was not discussed further. In the most efficacious and reliable. Although Calder, C. (2012). Approaches to wound management – summary, tap water is a reasonable choice tap water has similarities, its cellular effects part 1. Veterinary Nursing Journal, 8, 303–306. Retrieved for quick and effective initial wound care from www.tandfonline.com/doi/abs/10.1111/j.2045- are still not fully explored; however, it would in the emergency department, but its use 0648.2012.00200.x be a justifiable choice in an emergency situa- should not replace saline in normal circum- tion. It is clear from the above that no single Chivers, E. (2010). Wound healing and management of open stances (Moscati et al., 2007). wounds. The Veterinary Nurse, 2, 107–114. http://dx.doi. optimal pressure, solution or technique is org/10.12968/vetn.2010.1.2.106 appropriate for all wounds. High pressures Crowley, D. J., Kanakaris, N. K., and Giannoudis, P. V. have often been used, but their effects pose Ethical considerations risks in the spread of bacteria deep within (2007). Irrigation of the wounds in open fractures, The Bone and Joint Journal, 5, 580-585. Retrieved The research undertaken has made it the wound site instead of eliminating the from http://www.bjj.boneandjoint.org.uk/content/89- clear that there are ethical implications bacteria altogether, so higher pressures up B/5/580?related-urls=yes&legid=jbjsbr;89-B/5/580&cited- to be considered. When carrying out to 15 psi should be restricted to heavily by=yes&legid=jbjsbr;89-B/5/580 investigations in the UK, the researcher contaminated wounds. Edlich, R. F., Rodeheaver, G. T., Thacker, J. G., Lin, K. Y., Drake, must obtain a project licence granted by D. B., Mason, S. S., … Vissers, R. J. (2008). Revolutionary the Secretary of State. When carrying out Furthermore, wound irrigation has been advances in the management of traumatic wounds in the emergency department during the last 40 years: Part II. The investigations in the United Kingdom, reviewed widely in the human field, but to Journal of Emergency Medicine, 2, 201–207. doi:10.1016/j. the researcher must obtain a project a lesser extent in the veterinary field. While jemermed.2008.09.029 license granted by the Secretary of State, some literature from the veterinary field Elliston, R., Heayns, B., & Fish, C. (2012). A clinical audit when applying for the license they must was analysed for this review, most of it was to identify factors contributing to surgical wound specify the programme of work and the based upon research undertaken in human healing complication. The Veterinary Nurse, 3, 190–195. location and participants involved in the medicine, and this leaves a gap in this field of doi:10.12968/vetn.2012.3.3.188 study (Animals (Scientific Procedures) research. Investigations could be performed Gall, T. T., & Monnet, E. (2010). Evaluation of fluid pressures Act, s.5, p.a, 1986a). 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