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Surgical wound irrigation: A call for evidence-based standardization of practice

      Surgical wound irrigation has long been debated as a potentially critical intraoperative measure taken to prevent the development of surgical site infection (SSI). Unlike many other SSI prevention efforts, there are no official practice guidelines or recommendations from any major medical group for the practice of surgical irrigation. As a result, practitioner implementation of the 3 major irrigation variables (delivery method, volume, and solution additives) can differ significantly. A focus group of key thought leaders in infection prevention and epidemiology convened recently to address the implications of different surgical irrigation practices. They identified an urgent need for well-designed clinical trials investigating surgical irrigation practices, improved collaboration between surgical personnel and infection preventionists, and examination of existing evidence to standardize irrigation practices. The group agreed that current published data are sufficient to support the elimination of antibiotic solutions for surgical irrigation; the avoidance of surfactants for surgical irrigation; and the use of sterile normal saline, sterile water, and 1 medical device containing a sterile 0.05% chlorhexidine gluconate solution followed by sterile saline. Given the current lack of sufficient evidence identifying ideal delivery method and volume choices, expert opinion must be relied on to guide best practice.

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      References

        • Anderson D.J.
        • Kaye K.S.
        • Classen D.
        • Arias K.M.
        • Podgorny K.
        • Burstin H.
        • et al.
        Strategies to prevent surgical site infections in acute care hospitals.
        Infect Control Hosp Epidemiol. 2008; 29: 551-561
        • Stone P.W.
        Economic burden of healthcare-associated infections: an American perspective.
        Expert Rev Pharmacoeconomics Outcomes Res. 2009; 9: 417-422
        • Dohmen P.M.
        Economic burden of surgical site infections in cardiac surgery.
        J Med Microb Diagn. 2013; 2: e120
        • Fry D.
        Fifty ways to cause surgical site infections.
        Surg Infect. 2011; 12: 497-500
        • Burke J.F.
        The effective period of preventive antibiotic action in experimental incisions and dermal lesions.
        Surgery. 1961; 50: 161-168
        • DiPiro J.T.
        • Cheung R.
        • Bowden T.A.
        • Mansberger J.A.
        Single dose systemic antibiotic prophylaxis of surgical wound infections.
        Am J Surg. 1986; 152: 552-559
        • Edmiston C.E.
        • Bruden B.
        • Rucinski M.C.
        • Henen C.
        • Graham M.B.
        • Lewis B.L.
        Reducing the risk of surgical site infections: does chlorhexidine gluconate provide a risk reduction benefit?.
        Am J Infect Control. 2013; 41: 549-555
        • Tubaki V.R.
        • Rajasekaran S.
        • Shetty A.P.
        Effects of using intravenous antibiotic only versus local intrawound vancomycin antibiotic powder application in addition to intravenous antibiotics on postoperative infection in spine surgery in 907 patients.
        Spine. 2013; 38: 2149-2155
      1. Greco G, Shi W, Michler R, Blackstone E, Kron I, Moquete E, et al. The economic impact of healthcare associated infections in cardiac surgery. 2013. Available from: http://www.abstractsonline.com/Plan/ViewAbstract.aspx?sKey=b9193dbe-c752-450f-9b49-f41fdf2be1c0&cKey=8fc06889-f397-4701-b7df-b7ae743b307f&mKey=951e351e-429c-4b2e-84d0-8da73b00de45. Accessed December 30, 2013.

        • Prucz R.B.
        • Sullivan S.R.
        • Klein M.B.
        Acute wound care. ACS surgery: principles and practice.
        Decker Intellectual Properties, Ontario, Canada2012
        • Jagger J.
        • Bentley M.
        • Tereskerz P.
        Patterns and prevention of blood exposure in operating room personnel: a multi-center study.
        Adv Exp Prev. 1998; 3: 61-71
        • Mohebati A.
        • Davis J.M.
        • Fry D.
        Current risks of occupational blood-borne viral infection.
        Surg Infect. 2010; 11: 1-7
        • Fry D.E.
        The ABC’s of hepatitis. Advances in surgery. Vol 33. Mosby, Inc, Maryland Heights [MO]1999
        • Beltrami E.M.
        • Williams I.T.
        • Shapiro C.N.
        • Chamberland M.E.
        Risk and management of blood-borne infections in health care workers.
        Clin Microbiol Rev. 2000; 13: 385-407
        • Gioannini P.
        • Sinicco A.
        • Cariti G.
        • Lucchini A.
        • Paggi G.
        • Giachino O.
        HIV infection acquired by a nurse.
        Eur J Epidemiol. 1988; 4: 119-120
        • Hosoglu S.
        • Celen M.K.
        • Akalin S.
        • Geyik M.F.
        • Soyoral Y.
        • Kara I.H.
        Transmission of hepatitis C by blood splash into conjunctiva in a nurse.
        Am J Infect Control. 2003; 31: 502-504
        • Sartorti M.
        • La Terra G.
        • Aglietta M.
        • Manzin A.
        • Navino C.
        • Verzetti G.
        Transmission of hepatitis C via blood splash into conjunctiva.
        Scand J Infect Dis. 1993; 25: 270-271
        • Anglen J.O.
        Wound irrigation in musculoskeletal injury.
        J Am Acad Orthop Surg. 2001; 9: 219-226
      2. Hays EP. Wound care: from door to discharge. Proceedings of the Boston Scientific Assembly; October 6, 2009; Boston, MA.

      3. Gabriel A, Schraga E, Windle ML. Wound irrigation. 2011. Available from: www.emedicine.medscape.com/article/1895071. Accessed July 20, 2013.

        • Madden J.
        • Edlich R.F.
        • Schauerhamer R.
        • Prusak M.
        • Borner J.
        • Wangensteen O.H.
        Application of principles of fluid dynamics to surgical wound irrigation.
        Curr Topics Surg Res. 1971; 3: 85-93
        • Rodeheaver G.T.
        • Peltry D.
        • Thacker J.G.
        • Edgarton M.T.
        • Edlich R.F.
        Wound cleansing by high pressure irrigation.
        Surg Gynecol Obstet. 1975; 141: 357-362
        • Maragakis L.L.
        • Cosgrove S.E.
        • Song X.E.
        • Kim D.
        • Rosenbaum P.
        • Ciesla N.
        • et al.
        An outbreak of multi-drug resistant Acinetobacter baumannii associated with pulsatile lavage wound treatment.
        JAMA. 2004; 292: 3006-3011
        • Kalteis T.
        • Lehn N.
        • Schroeder H.J.
        • Schubert T.
        • Zysk S.
        • Handel M.
        • et al.
        Contaminant seeding in bone by different irrigation methods: an experimental study.
        J Orthop Trauma. 2005; 19: 591-596
        • Chisholm C.D.
        • Cordell W.H.
        • Rogers K.
        • Word J.R.
        Comparison of a new pressurized saline canister versus syringe irrigation for laceration cleansing in the emergency department.
        Ann Emerg Med. 1992; 21: 1364-1367
        • Lammers R.L.
        • Hudson D.L.
        • Seaman M.E.
        Predictors of traumatic wound infection with a neural network-derived decision model.
        Am J Emerg Med. 2003; 21: 1-7
      4. Business Wire (Internet). Survey conducted at AORN congress reveals need for new and better surgical site infection prevention strategies; c2013 [updated 2013 March 11]. Available from: http://www.businesswire.com/news/home/20130311005412/en/Survey-Conducted-AORN-Congress-Reveals-Surgical-Site. Accessed September 27, 2013.

      5. CDC. Recommendations for preventing the spread of vancomycin resistance: recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC); September 22, 1995/44 (RR12); 1–13. Available from: http://www.cdc.gov/mmwr/PDF/RR/RR4412.PDF. Accessed July 10, 2013.

        • Golightly L.K.
        • Branigan T.
        Surgical antibiotic irrigations.
        Hosp Pharm. 1989; 24: 116-119
        • Roth R.M.
        • Gleckman R.A.
        • Gantz N.M.
        • Kelly N.
        Antibiotic irrigations: a plea for controlled clinical trials.
        Pharmacotherapy. 1985; 5: 222-227
        • Michels M.
        • Aggers W.A.
        Prophylactic use of topical antibiotic irrigation for clean surgical wounds.
        Gundersen Lutheran Med J. 2003; 2: 31-33
        • Crowley D.J.
        • Kanakaris N.K.
        • Giammoudis P.V.
        Irrigation of the wounds in open fractures.
        J Bone Joint Surg. 2007; 89B: 580-585
        • Koyonos L.
        • Zmistowski B.
        • Della-Valle C.J.
        • Parvizi J.
        Infection control rate of irrigation and debridement of periprosthetic joint infection.
        Clin Orthop Relat Res. 2011; 469: 3043-3048
        • Damm S.
        Intraoperative anaphylaxis associated with bacitracin irrigation.
        Am J Health-Syst Pharm. 2011; 68: 323-327
      6. US Food and Drug Administration. Silver Spring [MD]: Trial alcohol prep pads, alcohol swabs, and alcohol swabsticks: recall due to potential microbial contamination; c2011 [updated 2011 June 15]. Available from: http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm239319.htm. Accessed September 26, 2013.

      7. Centers for Disease Control and Prevention. Atlanta [GA]: Multistate fungal meningitis outbreak investigation; c2012 [updated 2013 September 6]. Available from: http://www.cdc.gov/hai/outbreaks/meningitis.html. Accessed September 26, 2013.

        • Burd T.
        • Conroy B.P.
        • Meyer S.C.
        • Allen W.C.
        The effects of chlorhexidine irrigation solution on contaminated bone-tendon allografts.
        Am J Sports Med. 2000; 28: 241-244
        • Owens B.D.
        • White D.W.
        • Wenke J.C.
        Comparison of irrigation solutions and devices in a contaminated musculoskeletal wound survival model.
        J Bone Joint Surg Am. 2009; 91: 92-98
        • Tarbox B.B.
        • Conroy B.P.
        • Malicky E.S.
        • Moussa F.W.
        • Hockman D.E.
        • Anglen J.O.
        • et al.
        Benzalkonium chloride: a potential disinfecting irrigation solution for orthopedic wounds.
        Clin Orthop. 1998; 346: 255-261
        • Conroy B.P.
        • Anglen J.O.
        • Simpson W.A.
        • et al.
        Comparison of castile soap, benzalkonium chloride, and bacitracin as irrigation solutions for complex contaminated wounds.
        J Orthop Trauma. 1999; 13: 332-337
      8. Daily Med (2011). Povidone iodine; c2011. Available from: http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=095c47d5-9fe0-45ed-93eb-a2ac3961db59. Accessed September 27, 2013.

        • Fletcher N.
        • Sofianos D.
        • Berkes M.M.
        • Obremskey W.T.
        Prevention of perioperative infection.
        J Bone Joint Surg. 2007; 89: 1605-1618
      9. Edmiston CE, Seabrook GR, Cambria RA, Brown KR, Lewis BD, Sommers JR, et al. Molecular epidemiology of microbial contamination in the operating room environment: is there a risk for infection? Presented at the 62nd Annual Meeting of the Central Surgical Association, Tucson, AZ, March 10-12, 2005.

        • Whyte W.
        • Hodgson R.
        • Tinkler J.
        The importance of airborne bacterial contamination of wounds.
        J Hosp Infect. 1982; 3: 123-135
        • Lidwell O.M.
        • Lowbury E.J.L.
        • Whyte W.
        • Blowers R.
        • Stanley S.J.
        • Lowe D.
        Airborne contamination of wounds in joint replacement operations: the relationship to sepsis rates.
        J Hosp Infect. 1983; 4: 111-131
        • Alp E.
        • Bijl D.
        • Bleichrodt R.P.
        • Hansson B.
        • Voss A.
        Surgical smoke and infection control.
        J Hosp Infect. 2006; 62: 1-5
        • Brown A.R.
        • Taylor G.J.S.
        • Gregg P.J.
        Air contamination during skin preparation and draping in joint replacement surgery.
        J Bone Joint Surg Br. 1996; 78: 92-94
        • McGovern P.D.
        • Albrecht M.
        • Belani K.G.
        • Nachtsheim C.
        • Partington P.F.
        • Carluke I.
        • Reed M.R.
        Forced-air warming and ultra-clean ventilation do not mix.
        J Bone Joint Surg Br. 2011; 93: 1537-1544
        • Tavitian J.D.
        • Ong S.M.
        • Taub N.A.
        • Taylor G.J.S.
        Body-exhaust suit versus occlusive clothing.
        J Bone Joint Surg Br. 2003; 85: 490-494