Abstract
Chronic, open, non‐healing wounds pose a continual challenge in medicine as the treatment is variable and there are no documented consistent responses. Although wound aetiologies vary and there are a number of factors that affect chronic wound pathogenesis, wound ischaemia and bacterial colonisation of wounds are the chief concerns among them. Conventionally, pulse lavage has been used primarily as a wound debriding device. To address both the critical factors of wound ischaemia and bacterial burden, a couple of technical points were proposed and applied in this study. The objective of our study was to evaluate pulse lavage therapy's ability to improve the healing rate of chronic wounds compared to that of the traditional saline‐wet‐to‐moist dressings. The study period was from 1 August 2010 to 31 January 2012 and was conducted in our institution. Thirty patients with 31 chronic, non‐healing wounds were enrolled in the study after obtaining proper consent. Subjects were randomised (15 patients each) to the pulse lavage group and the control group. Patients in the test group were subjected to irrigation of their wounds with pulsed lavage at 10 to 15 psi pressure. In the control group, wound was closed by applying moist betadine saline gauze dressings after cleaning with saline. Wounds treated with pulse lavage system significantly reduced in size, had better control of bacterial contamination and had overall faster healing rates. Efficacy of pulse lavage can be increased by correct method of administration of the irrigant.
Keywords: Bacteriology of chronic wounds; Chronic wounds; Irrigation pressure; Pulse lavage; Semi‐quantitative wound swab; Wound irrigation
Introduction
Chronic wound is one that is unresponsive to initial therapy or persistent in the face of appropriate care. Chronic or non‐healing wounds may develop in the setting of many diseases and are the source of considerable morbidity and health care costs (1). Studies have shown that patients with chronic wounds experience five times longer stay in hospital than those without. Chronic, open, non‐healing wounds pose a continual challenge in medicine as the treatment is variable and there are no documented consistent responses.
Although wound aetiologies vary and there are a number of factors that affect chronic wound pathogenesis, wound ischaemia and bacterial colonisation of wounds are the chief concerns among them. Many chronic wounds occur in the setting of some degree of local tissue ischaemia either from chronic fibrosis as in pressure sores and venous ulcers or from atherosclerosis as in many diabetic ulcers. Bacteria compete with healing tissue for oxygen and nutrients; create a proinflammatory environment that resists host defences and also forms a proteinaceous matrix or bio film that prevents antibiotics from acting on them. One of the mainstays of wound treatment that is used to reduce bacterial contamination of wounds is wound irrigation. Combined with debridement, irrigation is a critical step in facilitating progression from the inflammatory to proliferative phase of wound healing by removing debris that can impede the healing process. The goal of irrigation is to clean the wound while avoiding trauma to wound bed and minimising the risk of driving the bacteria further into the wound bed.
The AHCPR guideline recommends irrigation pressures ranging from 4 to 15 psi (2). It suggests that irrigation pressures <4 psi may be insufficient to remove surface pathogens and debris and that irrigation pressures >15 psi may cause wound trauma and drive bacteria into wounds. These pressure range recommendations were derived from studies conducted by Brown et al. (3), Rodeheaver et al. 4, 5, Wheeler et al. (6) and Stewart et al. 7, 8. Commonly used wound irrigation methods include the use of pour or squeeze bottles, bulb syringes, piston syringes (a 35 ml syringe attached to a 19 gauge needle or angiocatheter), pulse lavage irrigation systems, whirlpool agitation and a whirlpool hose sprayer attachment (9).
Pulsed lavage refers to an irrigating solution delivered under pressure by a powered device. The technique may be applied to acute, sub acute and chronic wounds (3). Conventionally, pulse lavage has been used primarily as a wound debriding device. To address the critical factors of wound ischaemia and bacterial burden, a couple of technical points were proposed and applied in this study. Firstly, warm irrigating fluid at 38°C was used for the lavage. This was in lieu of increasing evidence accumulating on the benefits of local tissue warming to increase blood flow 10, 11. Secondly, during delivery of the irrigant, care was taken to maintain total circumferential contact of device nozzle to the surface of the wound. This ensured that concurrent negative pressure was applied. These were the innovative aspects of this study.
Materials and methods
The objective was to study the efficacy of low pressure pulsatile lavage treatment in healing of chronic wounds. A randomised controlled study was carried out. The study period was from 1 August 2010 to 31 January 2012 and was conducted at the Christian Medical College. This study was approved by the Institutional Research Review Board of the institution. Participants were randomly assigned to a treatment group or control group after enrollment using a randomisation table. Immunocompromised patients or those with suspected malignancy and comorbid conditions like renal failure and bacterial endocarditis were excluded from our study.
Thirty patients with 31 chronic, non‐healing wounds were enrolled in the study after obtaining proper consent. Subjects were randomised (15 patients each) to the pulse lavage group and the control group. Method of randomisation used was block randomisation with block size 2:25%, block size 4:25%, block size 6:35%. Conventional treatment was considered as treatment A and power pulse irrigation was considered as treatment B. Statistical analysis was done by using the software SAS 9.1 (block randomisation). Cultures and wound measurements were obtained by independent wound evaluators blinded to the groups.
Pulse lavage protocol
Patients in the test group were subjected to irrigation of their wounds with pulsed lavage at 10–15 psi pressure using pulsatile lavage unit (Zoom™; Chennai medico‐surgicals, Chennai, Tamil Nadu, India). Normal saline at 38° was used. The procedure was done under strict aseptic precautions. The irrigation fluid used was normal saline warmed to approximately 38° by immersing unopened new bottles of normal saline into a basin containing hot water. The patient was positioned in such a way that the irrigant ran from the upper end of wound downwards. A sterile basin was kept below the wound. The bed was covered with waterproof sheet. The person administering the pulse lavage wore protective goggles, waterproof gown and sterile gloves. It was mandatory for both the patient and the health care professional to wear face masks during the procedure to prevent inhalation of the infective microdroplets that may be released during the lavage. The system consists of a battery powered device which delivers a pressurised pulsatile sterile crystalloid solution to the wound bed at a pressure no greater than 15 psi. The device administered a fluid stream to the wound surface and has a built‐in suction tube that is connected to the wall suction with a collection canister. Saline was delivered to the surface of the wound through a soft detachable spray nozzle. Total circumferential contact of this spray nozzle was maintained to the wound surface (Figure 1). This serves two purposes, one to prevent splashing back of the fluid and secondly, it maintains a negative pressure environment in the area of the wound being treated. The latter ensures immediate suctioning out of the fluid with bacteria and debris and also causes a vacuum like effect on that area of the wound. The lavage unit is then connected to the warm saline suspended from an IV stand. The unit handle was completely depressed to deliver the irrigant at 10–15 psi and at a flow rate of approximately 1025 ml/min. The volume of saline used depended on the size of wound. For wounds <5 cm2, 1·5 l was used, wounds >5 cm2 but <10cm2, 2–2·5 l of saline was used and for wounds >10 cm2, 3·5 l was used. As mentioned earlier, the outlet of the machine was connected to a wall suction which evacuated the fluid constantly preventing its accumulation at the procedure site. As the spray nozzle tip was in contact with the wound, the area of the wound under it was subjected to negative pressure which resulted in cell strain and microdeformation. Care was taken to ensure that the solution flows from the clean to the dirty area of the wound. Once an area was irrigated, the machine temporarily stopped by releasing the trigger. Then, the nozzle was kept on the adjacent area and pulse lavage device was restarted. In this manner, the entire surface of the wound was covered. After the procedure, the periwound area was cleaned with normal saline and wound was covered by conventional wet or dry dressings. The lavage was done daily. Separate disposable pulse lavage devices were allotted for each patient and used for the full course of treatment. The nozzle and the plastic shield were sterilised daily after therapy and reused on the same patient the next day.
Figure 1.
Correct technique of pulse lavage administration.
Conventional treatment in the control group consisted of debridement of non‐viable tissue followed by rinsing of the wound with saline. The wound was closed by applying moist betadine saline gauze dressings.
After each lavage treatment, the subjects completed a visual analogue scale that determined the level of discomfort that they experienced during the study. A culture was done before starting treatment and after 3 days. The culture was obtained by ‘Levines Technique’(12) to ensure uniformity and consistency and prevent erroneous results. First, the wound was cleaned with a non‐antimicrobial solution to remove surface contaminants. The swab was depressed over a 1 cm2 area of the wound using enough pressure to obtain fluid. This swab was processed as a semiquantative and qualitative culture and the number of organisms was indicated as light (L), moderate (M) and heavy (H) growth based on the number of organisms in each high power field. This technique has been shown to be reasonably accurate and was comparable to quantitative measurements in sensitivity 13, 14. Wound size was measured using a planimetry (graph) method as this was considered the most accurate method of measuring size of wounds at this time. In this method, a tracing of the wound was done on an OHP sheet using felt pen. Then, it was placed on a graph paper and the area was measured by counting the squares which fell within the tracing. This was done on day 1 and after 7 days. The percentage decrease in size of wound in the 7 days was calculated.
The end point of the treatment was when healthy granulation tissue filled the area and wound was ready for primary closure or for skin grafting.
All clinical records were reviewed retrospectively. Data obtained included patient demographics, procedures, measured wound size, infecting organism, hospital stay, treatment time and time of presentation. Variables from both groups were analysed. Statistical significance was accepted for P values of <0·05. Outcome between the two groups was evaluated by an independent observer.
Results and analysis
This 18‐month study included 30 patients with varying sizes of chronic wounds. The patients' age ranged between 30 and 83 years (median 56 years). Gender distribution was 20 males and 10 females. Seventeen patients had diabetes, six were smokers and eight were overweight. All but one patient had positive microbiology cultures from their wound specimens, including Staphylococcus (n = 9), Pseudomonas (n = 10), Enterococcus (n = 4), Streptococcus (n = 5), Escherichia coli (n = 3) and Klebsiella (n = 1) (1, 2).
Table 1.
Characteristics of control group
| S. No. | Culture | Density of growth | Culture | Density of growth in 3 days | Size of wound on admission (cm2) | Size of wound × 1 week in cm2 | % Decrease in size | Pain score before treatment | Pain score after treatment | Time taken for healing/grafting in days |
|---|---|---|---|---|---|---|---|---|---|---|
| Control group | ||||||||||
| 2.1 | 1 | 1 | 1·2 | 1·2 | 30 | 28 | 6·66 | 4 | 4 | 14 days |
| 2.2 | 4 | 1 | 4 | 1 | 18 | 15·6 | 13·30 | 4 | 4 | 16 days |
| 2.3 | 2 | 1 | 1 | 2 | 26 | 24·2 | 6·93 | 6 | 4 | 13 days |
| 2.4 | 2 | 1 | 2 | 1 | 46 | 43 | 6·50 | 6 | 6 | 18 days |
| 2.5 | 1 | 1 | 1 | 1 | 6 | 5·6 | 6·66 | 4 | 6 | 10 days |
| 2.6 | 2 | 1 | 2 | 1 | 26 | 23·2 | 11·80 | 6 | 4 | 12 days |
| 2.7 | 3 | 1 | 3 | 1 | 16 | 14·2 | 11·24 | 6 | 4 | 13 days |
| 2.8 | 2 | 1 | 2 | 1 | 23 | 22·2 | 3·50 | 4 | 4 | 9 days |
| 2.9 | 1 | 2 | 1 | 2 | 8 | 7·6 | 5 | 6 | 4 | 9 days |
| 2.10 | 4 | 1 | 4 | 2 | 32 | 30 | 6·25 | 6 | 4 | 14 days |
| 2.11 | 3 | 1 | 2 | 2 | 5 | 4·5 | 10 | 6 | 4 | 12 days |
| 2.12 | 2 | 1 | 2 | 1 | 56 | 53 | 5·40 | 4 | 4 | 14 days |
| 2.13 | 5 | 1 | 5 | 1 | 11 | 10·9 | 1 | 4 | 4 | 15 days |
| 2.14 | 1 | 1 | 1 | 1 | 7·2 | 6·9 | 4·27 | 4 | 2 | 12 days |
| 2.15 | 4 | 1 | 4 | 2 | 6 | 5·4 | 10 | 2 | 2 | 14 days |
| Note | |||||||
|---|---|---|---|---|---|---|---|
| Culture | Staph‐1 | Pseudo‐2 | Entero‐3 | Strepto‐4 | Ecoli‐5 | Klebsiella‐6 | |
| Density of growth | Heavy‐1 | Medium‐2 | Low‐3 | No growth‐0 | |||
| Pain score | None‐0 | Annoying‐2 | Uncomfortable‐4 | Dreadful‐6 | Horrible‐8 | Agonising‐10 | |
Table 2.
Characteristics of test group
| S. no. | Culture | Density of growth | Culture | Density of growth in 3 days | Size of wound on admission (cm2) | Size of wound × 1 week | % Decrease in size | Pain score before treatment | Pain score after treatment | Time taken for healing/grafting (days) |
|---|---|---|---|---|---|---|---|---|---|---|
| Test group | ||||||||||
| 1.1 | 1 | 1 | – | 0 | 25 | 18 cm2 5 days | 18% | 4 | 2 | 5 |
| 1.2 | 1·5 | 1·1 | – | 0 | 51 | 44 cm2 | 13·72% | 4 | 0 | 8 |
| 1.3 | 5 | – | 0 | 15 | 12 cm2 | 20% | 6 | 2 | 7 | |
| 1.4 | 4 | 1 | 4 | 3 | 49 | 37 cm2 | 14·50% | 4 | 2 | 5 |
| 1.5 | 1 | 1 | – | 0 | R‐501; L‐702 | R‐356 cm2; L‐589 cm2 | R‐18·9%; L‐702 cm2 | 6 | 2 | 6 |
| 1.6 | 6·2 | 1·1 | – | 0 | 67 | 53 cm2 6 days | 11·90% | 4 | 0 | 6 |
| 1.7 | 2·3 | 1·2 | 2 | 3 | 6·2 | 5 cm2 | 12% | 2 | 0 | 7 |
| 1.8 | 3 | 1 | – | 0 | 16 | 13·2 cm2 | 17·50% | 2 | 0 | 6 |
| 1.9 | 2 | 1 | 2 | 3 | 6·7 | 4·9 cm2 | 16·70% | 2 | 0 | 5 |
| 1.10 | 2 | 1 | – | 0 | 76 | 59 cm2 | 12·40% | 6 | 2 | 6 |
| 1.11 | 1 | 1 | – | 0 | 30 | 23 cm2 | 13·33% | 6 | 0 | 6 |
| 1.12 | 0 | 0 | – | 0 | 28 | 20 cm2 | 18·58% | 4 | 0 | 6 |
| 1.13 | 1 | 1 | 1 | 1 | 150 | 138 cm2 | 8% | 6 | 2 | 9 |
| 1.14 | 4 | 2 | – | 0 | 205 | 180 cm2 | 12·20% | 6 | 2 | 7 |
| 1.15 | 2 | 1 | 2 | 2 | 195 | 165 cm2 | 15·40% | 6 | 2 | 6 |
| Note | |||||||
|---|---|---|---|---|---|---|---|
| Culture | Staph‐1 | Pseudo‐2 | Entero‐3 | Strepto‐4 | Ecoli‐5 | Klebsiella‐6 | |
| Density of growth | Heavy‐1 | Medium‐2 | Low‐3 | No growth‐0 | |||
| Pain score | None‐0 | Annoying‐2 | Uncomfortable‐4 | Dreadful‐6 | Horrible‐8 | Agonising‐10 | |
The outcome measures were analysed under different headings as noted below.
Percentage decrease in size of wound
T‐test for the variable group versus decrease in size was done. Decrease in size of the wound is a reliable predictor of the efficacy of wound treatment measures. The percentage decrease in size between the control group and test group was compared and statistically evaluated (Table 3 and Figure 2). There was highly significant difference between the groups, with the P value <0·001. The wounds in test group did better than in control group.
Table 3.
Percentage decrease in size of wound among test and control group
| Groups | n | Mean (SD) | F Value | T Value | P‐Value |
|---|---|---|---|---|---|
| Test | 15 | 14·88 (3·36) | 0·024 | 6·198 | 0·000 |
| Control | 15 | 7·23 (3·39) |
There is high significance between the groups with the P value <0·001.
Figure 2.
Percentage average weekly decrease in size of wound comparison.
Culture and density of growth at days 1 and 3
Any wound treatment measure must reduce bacterial counts for it to be effective. Hence, culture and the density of growth were compared between the two groups (Table 4 and 3, 4). There is a highly significant association between groups and density of growth in 3 days, with the P value <0·001. The control group had significant reduction in bacterial contamination 3 days after treatment. In the test group, 10 patients had no bacterial growth, 3 low density of growth and 1 patient each had moderate to heavy density of growth after 3 days of treatment. In the control group, nine patients had high density of bacterial growth, five patients had moderate growth and one patient had low density of growth after 3 days of treatment.
Table 4.
Culture and density of growth among test and control groups
| Groups | Density of growth in 3 days | P‐value | |||||||
|---|---|---|---|---|---|---|---|---|---|
| 0 | 1 | 2 | 3 | ||||||
| n | % | n | % | n | % | n | % | ||
| Test | 10 | 66·7 | 1 | 6·7 | 1 | 6·7 | 3 | 20·0 | 0·000 |
| Control | 0 | 0 | 9 | 60·0 | 5 | 33·3 | 1 | 6·7 | |
There is high significance in association between groups and density of growth in 3 days with the P value <0·001.
Figure 3.
Bar chart for density of growth in 3 days–control group.
Figure 4.
Bar chart for density of growth in 3 days–test group.
Difference in pain score before and after treatment
This was measured using the visual analogue scale (Table 5 and Figure 5). There is a highly significant association between groups and pain score after treatment, with the P value <0·001. After 3 days of treatment, 46·67% of the patients in the test group had no pain and 53·33% had mild pain. In comparison, nearly 80% of the patients in the control group continued to have some discomforting pain.
Table 5.
Cross tabulation between groups and pain score after treatment
| Groups | Pain score after treatment | P‐value | |||||||
|---|---|---|---|---|---|---|---|---|---|
| 0 | 2 | 4 | 6 | ||||||
| n | % | n | % | n | % | n | % | ||
| Test | 7 | 46·7 | 8 | 53·3 | 0 | 0·0 | 0 | 0·0 | 0·000 |
| Control | 0 | 0·0 | 2 | 13·3 | 11 | 73·3 | 2 | 13·3 | |
There is highly significant association between groups and pain score after treatment with the P value <0·001.
Figure 5.
Comparison of pain score after treatment.
Time taken for healing/grafting comparison between test and control groups
This is a key variable as any effective treatment method should hasten the healing process (Table 6 and 6, 7, 8). There is a highly significant difference between group and time taken for healing/grafting, with the P value <0·001. The wounds in the test group took significantly less time to heal when compared with the control group. The duration of treatment lasted from 5 to 9 days (mean 6 ± 1·8 days). In the test group, nearly 50% of wounds healed by sixth day, and almost all wounds healed by 7–8 days. The duration of treatment lasted from 9 to 18 days (mean 14·2 ± 2·8 days). In the control group, it took nearly 14 days for majority of wounds to heal which was twice the time taken in the test group. The duration of conventional treatment was significantly longer than treatment by pulse lavage (P = 0·009). The total length of hospitalisation was also significantly increased in the conventional group (P = 0·03).
Table 6.
Time taken for healing/grafting comparison between test and control group
| Groups | n | Mean (SD) | F value | T value | P‐value |
|---|---|---|---|---|---|
| Test | 15 | 6·33 (1·11) | 5·436 | 9·504 | 0·000 |
| Control | 15 | 13·00 (2·48) |
There is highly significant between the groups with the P value <0·001.
Figure 6.
Bar chart for time taken for healing/grafting–test group.
Figure 7.
Bar chart for time taken for healing/grafting–control group.
Figure 8.
Time taken for wound to heal‐comparison between test and control.
Summary of results
The mean age of patients in the study was 56 years. Twenty (66·6%) were males and 10 (33·33%) females. Most of the wounds had high density of growth with Staphylococcus aureus being the most common organism. The wounds treated with pulse lavage had a significantly faster reduction in size when compared with the conventional therapy. This also meant that the wounds took shorter time to heal (mean 6·8 days), which was half the time taken by the control group (mean 14·2 days). There was also a significant reduction in bacterial loads in the wounds treated by pulse lavage. Pain as calculated by the ‘visual analogue scale’ showed a significantly lesser score in the test group (pulse lavage). There were no major complications in our study.
Discussion
Despite many recent advances in the understanding of the physiological basics of wound healing, their treatment remains a challenge. Chronic wounds are those that have failed to proceed through an orderly and timely process to produce an anatomic and functional integrity or proceed through the repair process without establishing a sustained and functional result (15). Chronic wounds may develop in the setting of many diseases and are the source of considerable morbidity and health care costs. Rapid healing of chronic wounds could result in decreased hospitalisation and an earlier return of function. Management options may be local or systemic. Local management includes dressings, topical antibiotics, debridement (mechanical or enzymatic), hyperbaric oxygen treatment, vacuum‐assisted closure device treatment and soft tissue coverage.
Most of these non‐operative management tools have certain limitations. For instance, the commonly used ‘vacuum‐assisted closure devices' are expensive. They cannot be used in places where there is necrotic or badly contaminated wounds. Mostly the patient remains immobile during the period of treatment. Hyperbaric oxygen is of no use in patients having normal transcutaneous oxygen levels. Also chronic wounds frequently have limited microcirculation due to scar barrier or mechanical barrier (pressure sores); the delivery of oxygen and associated benefits may be limited in these circumstances. Besides they are also associated with the common complication of barotrauma.
Pulse lavage does not have these disadvantages. Pulsed irrigation is the intermittent or interrupted pressurised delivery of an irrigant. The healing properties of pulsatile lavage are based on its mechanical and/or thermal effects. It acts on the inflammatory phase of healing.
Mainly it acts by mechanical debridement of the wound; it helps in wound cleansing by removing debris and topical agents. The exudates removal also helps in reduced infection.
Warm water increases vasodilatation of the superficial vessels.
Increased blood flow oxygen and nutrients to the tissues and removes metabolites.
Increased blood flow brings antibodies, leukocytes and systemic antibiotics.
Softening and loosening of necrotic tissue aids phagocytosis.
Cleansing and removal of wound exudates controls infection.
It breaks up dangerous ‘biofilms’ that block the penetration of systemic antibiotics and contribute to sensitive bacteria acquiring resistance(16).
Mechanical effects of the pulsatile water jet cause microdeformation of cells and stimulate granulation tissue formation.
Venturi effect – the oscillating stream of saline washes away the thick necrotic debris.
Sedation and analgesia are induced by the warm water.
Taking care to place the nozzle directly in contact with the wound surface increases the effectiveness of the lavage in two ways. One is by continuous evacuation of the fluid and debris. This prevents its reaccumulation on the wound and reinfection. Secondly, maintaining the circumferential contact of the nozzle on the wound surface causes a negative pressure‐like effect on that area of the wound causing cell strain and microdeformation (Figure 9). This is in addition to the shear stress of the fluid on the cell. Numerous studies have shown that this mechanical stress and strain brings about the tissue growth response and helps in early formation of healthy granulation tissue. Negative pressure also enhances blood flow (10, 11, 12, 13, 14, 15, 16, 17, 18).
Figure 9.
Schematic diagram showing effects of pulse lavage.
Figure 10.
Lavage being administered.
Figure 11.
18‐year‐old contaminated unhealthy wound.
Figure 12.
After 3 days of pulse lavage therapy.
Figure 13.
Same wound after grafting.
Figure 14.
Wound on heel of a diabetic patient with unhealthy granulation.
Figure 15.
After 4 days of therapy.
Figure 16.
(A) Traumatic contaminated wound on foot. (B) After 4 days of pulse lavage and grafting.
Figure 17.
Raw area leg (after debridement for necrotising fascitis).
Figure 18.
After lavage and grafting.
The results of our study show that pulsatile lavage irrigation is more effective than conventional methods in healing of chronic wounds. The efficacy of pulsatile lavage can be increased by following the simple techniques enumerated. Similar studies have been conducted before but very few publications provide any significant objective data 17, 18. Further research is needed to prove this hypothesis.
Conclusion
Wounds treated with pulse lavage system significantly reduced in size, had better control of bacterial contamination and had overall faster healing rates, nearly 50% earlier than that of conventionally treated wounds. This implied shorter hospital stay and a reduced burden on the patient and the hospital. The efficacy of pulse power lavage in treatment of chronic wounds as indicated by this study will help the clinician to considerably reduce the morbidity of infection, pain, humiliation and depression associated with these chronic wounds.
References
- 1. Branski LK, Gauglitz GG, Herndon DN, Jeschke MG. A review of gene and stem cell therapy in cutaneous wound healing. Burns 2008;35:171–180. Epub 2008 Jul 7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Bergstrom N, Benett MA, Carlson CE, Allman MR, Alvarez M, Oscar Bennet MA. Treatment of pressure ulcers: Clinical Practice Guideline No 15. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1994:6–7,47–53. AHCPR Publication No. 95‐0652. [Google Scholar]
- 3. Brown LL, Shelton HT, Bornside GH, Cohn I Jr. Evaluation of wound irrigation by pulsatile jet and conventional methods. Ann Surg 1978;187:170–3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Rodeheaver GT, Pettry D, Thacker JG, Edgerton MT, Edlich RF. Wound cleansing by high pressure irrigation. Surg Gynecol Obstet 1975;141:357–62. [PubMed] [Google Scholar]
- 5. Rodeheaver GT, Smith SL, Thacker JG, Edgerton MT, Edlich RF. Mechanical cleansing of contaminated wounds with a surfactant. Am J Surg 1975;3129:241–5. [DOI] [PubMed] [Google Scholar]
- 6. Wheeler CB, Rodeheaver GT, Thacker JG, Edgerton MT, Edlich RF. Side‐effects of high pressure irrigation. Surg Gynecol Obstet 1976;143:775–8. [PubMed] [Google Scholar]
- 7. Stewart JL, Carlson HC, Briggs RL, Green VA. The bacteria‐removal efficiency of mechanical lavage and rubber‐bulb syringe irrigation in contaminated avulsive wounds. Oral Surg Oral Med Oral Pathol 1971;31:842–8. [DOI] [PubMed] [Google Scholar]
- 8. Green VA, Carlson HC, Briggs RL, Stewart JL. A comparison of the efficacy of pulsed mechanical lavage with that of rubber‐bulb syringe irrigation in removal of debris from avulsive wounds. Oral Surg Oral Med Oral Pathol 1971;32:158–64. [DOI] [PubMed] [Google Scholar]
- 9. Weller K. In search of efficacy and efficiency: an alternative to conventional wound cleansing modalities. Ostomy Wound Manage 1991;37:23–28. [PubMed] [Google Scholar]
- 10. Ikeda T, Tayefeh F, Sessler DI, Kurz A, Plattner O, Petschnigg B, Hopf HW, West J. Local radiant heating increases subcutaneous oxygen tension Am J Surg 1998;175:33–37. [DOI] [PubMed] [Google Scholar]
- 11. Santilli SM, Valusek PA, Robinson C. Use of a noncontact radiant heat bandage for the treatment of chronic venous stasis ulcers. Adv Wound Care 1999;12:89–93. [PubMed] [Google Scholar]
- 12. Levine NS, Lindberg RB, Mason AD Jr, Pruitt BA Jr. The quantitative swab culture and smear: a simple method for determining the number of viable aerobic bacteria on open wounds. J Trauma 1976;16:89–94. [PubMed] [Google Scholar]
- 13. Ratliff CR, Rodeheaver G: Correlation of semi quantitative swab cultures to quantitative swab cultures from chronic wounds. Wounds 2002;14:329–33. [Google Scholar]
- 14. Stotts NA. Determination of bacterial burden in wounds. Adv Wound Care 1995;8 (suppl):46–52. [PubMed] [Google Scholar]
- 15. Lazarus GS, Cooper DM, Knighton DR, Margolis DJ, Percararo RE, Rodheaver G. Definitions and guidelines for assessment of wounds and evaluation of healing. Arch Dermatol 1994;130:489–93. [PubMed] [Google Scholar]
- 16. Otto M. Bacterial evasion of antimicrobial peptides by bio film formation. Curr Top Microbiol Immunol 2006;306:251–8. [DOI] [PubMed] [Google Scholar]
- 17. Diekmann JM. Use of a dental irrigating device in the treatment ofecubitus ulcers. Nurs Res 1984;33:303–5. [PubMed] [Google Scholar]
- 18. Haynes LJ, Brown MH, Handley BC. Comparison of pulsavac and sterile whirlpool regarding the promotion of tissue granulation. Phys Ther 1994;74 (suppl):S4. [Google Scholar]