Pulse Lavage

Literature Review of Pulse Lavage – Katie B, Michael D, Amanda Y, Adam M

Evidence for Pulse Lavage:

Pulsed lavage in wound cleansing

In a review done by Ludedtke-Hoffman and Schafer (2000), they discussed various studies concerning pulsed lavage and the effectiveness of various levels pressure (psi) on bacterial contamination in wounds.  Pressures of 1 psi or less are shown to be ineffective for wound cleansing, resulting in significant bacterial counts.  Pressures of 5 to 10 psi are most effective for debridement of loose necrotic tissue.  Pressures above 10 psi are most effective for bacterial infections 

In the review, they also discussed potential hazards associated with pulsed lavage in wound care.  One concern was the development of bacteremia in a wounds following pulsed lavage. In the study, a water-pik at 50 psi was used by participants with their regular tooth brushing routine.  Blood samples were taken at 15, 45, and 60 days after use and had no evidence of periodontal disease or bacteremia. 

Another study cited in the review looked at potential damage and particle penetration as a result of pulsed lavage in animals. Irrigation was applied at 8 psi with a piston syringe, 70 psi with pulsed irrigation, and then had a control group that didn’t receive irrigation.  While both irrigation groups had similar infection rates, they were still higher than that of the control group leading researchers to believe that high pressure irrigation does result in some tissue damage making infection a high likelihood.  As stated in the article: “ Wheeler et al cautioned that high-pressure irrigation should not be used indiscriminately.  Rather, its use should be reserved for heavily contaminated wounds” (Ludedtke-Hoffmann & Schafer, 2000).        

Ludedtke-Hoffmann, K. A., & Schafer, D. S. (2000). Pulsed lavage in wound cleansing. Journal of the American Physical Therapy Association, 80(3), 292-300.

Comparison of Bulb Syringe and Pulsed Lavage Irrigation with Use of a Bioluminescent Muskuloskeletal Wound Model

 Major Steven J. Svoboda, MD1; Terry G. Bice, MS1; Heather A. Gooden, BS1; Daniel E. Brooks, BS1; Darryl B. Thomas, MD1; Joseph C. Wenke, PhD1

There are many variables to wound irrigation. The purpose of this study was to compare the efficacy of pulse lavage and bulb syringe irrigation in reducing wound bacterial counts. This study used a contaminated musculoskeletal wound that was developed using  a bioluminescent strain of Pseudomonas aeruginosa that can be quantified. Goats were the patients in this study and were randomly assigned either pulse lavage or bulb syringe irrigation. Each wound was irrigated with normal saline solution in 3-L increments for a total of 9 L and was imaged after each 3-L increment. In addition, culture samples were taken from different tissues in the wound before and after irrigation. Pulsed lavage decreased the amount of luminescent units by 52%, 64%, and 70% at 3, 6, and 9 L, respectively. The bulb syringe irrigation only reduced the  luminescent units by 33%, 44%, and 51% at the same volumes. Significant differences were noted between the two groups after both 6 and 9 L. The conclusion of this study is that pulse lavage is more effective than bulb syringe irrigation.

Comparison of Wound Irrigation and Tangential Hydodissection in Bacterial Clearance of Contaminated Wounds: Results of a Randomized, Controlled Clinical Study

This randomized controlled trial compared the use of pulse lavage (PL) to a high-pressure parallel waterjet (HPPWJ), in their abilities to reduce bacterial counts on infected wounds.  The study consisted of 23 participants with 12 receiving the HPPWJ and 9 receiving PL.  Each participant was randomly assigned to which group they would be in and bacterial counts were taken pre-test and post-test (from a central location). PL was completed at a pressure of 40 psi; while the parameters for HPPWJ were set at a power setting of 4-6, or about 5,025-7,360 psi. 

After treatment, the bacterial count in the PL group was reduced by 86.9%.  And, the HPPWJ bacterial count was reduced by 90.8%.  This article was looking more towards the effectiveness of HPPWJ, but at the same time, concluded that PL is still very effective at reducing the bacterial count in contaminated wounds.

Granick, M. S., Tenenhaus, M., Knox, K. R., & Ulm, J. P. (2007). Comparison of Wound Irrigation Bacterial Clearance of Contaminated Wounds : Results of a Randomized, Controlled Clinical Study. Ostomy/Wound Management, 53(4), 64-72.

Evidence against Pulse Lavage

An Outbreak of Multidrug-Resistant Acinetobacter baumannii Associated With Pulsatile Lavage Wound Treatment

Lisa L. Maragakis, MD, Sara E. Cosgrove, MD, MS, Xiaoyan Song, MD, MS, Denny Kim, MD, MPH, Patricia Rosenbaum, RN, CIC, Nancy Ciesla, PT, BS, Arjun Srinivasan, MD, Tracy Ross, BS, Karen Carroll, MD, Trish M. Perl, MD, MSc

Pulse lavage is a high pressure irrigation method used in many health care settings for wound debridement. The objective of this study is to investigate an outbreak of the multi-drug resistant Acinetobacter baumannii and test the hypothesis that pulse lavage was the mode of transmission. The investigation  included case identification, review of medical records, environmental cultures, and pulsed-field gel electrophoresis. Patients included 11 patients infected or colonized with multidrug resistant A baumannii. 10 of these patients were health care associated cases and 8 of the 10 had received pulse lavage. These results of this investigation  confirm that pulse lavage was a risk factor for acquing multidrug-resistant A baumannii. Infection control precautions should be used during pulse lavage therapy and should be included in pulse lavage equipment labeling.

An Outbreak of Multidrug-Resistant Acinetobacter baumannii Associated With Pulsatile Lavage Wound Treatment

            In a study by Maragakis et al., researchers determined that the implementation of pulsed lavavage treatment of wounds attributed to an outbreak of a multidrug-resistant bacteria in a group of patients.  Ten patients from the same hospital acquired the bacteria, 8 of which received pulsed lavage treatment to a wound.  The researchers established that the risk of patients acquiring the bacteria who received pulsed lavage was 12% when compared to a control from the same hospital.  Acquisition of this infection was very serious, as 3 of the patients were admitted to the ICU for sepsis and 2 died.  The researchers also decided that other aquaphilic organisms could be spread through pulsed lavage.  Around the time of the outbreak, the wound care specialists changed their pulsed lavage procedure.  Instead of emptying the suction canister inserts following each treatment, they allowed the canisters to fill before replacing them.  It is hypothesized that this played a role in the epidemic.  To prevent episodes such as the latter, pulsed lavage treatment must be performed according to the manufacturers’ protocol, with the necessary infection control measures in place.

An Outbreak of Multidrug-Resistant Acinetobacter baumannii Associated With Pulsatile Lavage Wound Treatment Lisa L. Maragakis et al. JAMA.  2004; 292(24):3006-3011.doi:10.1001/jama.292.24.3006

Evidence with mixed results pertaining to Pulse Lavage

Irrigation of wounds in open fractures

“Irrigation of wounds in open fractures” is a review discussing the outcomes of using antiseptics, antibiotics, and irrigation on open fracture wounds. (Crowly, Kanakaris & Giannoudis, 2007).  The most common used antiseptics were Betadine and chlorhexidine gluconate which are used for a variety of bacteria, fungi and viruses.   Disadvantages of these were delayed wound healing from toxicity of healthy cells and destruction of fibroblasts. In animal studies it was also shown that there was a negative effect on microvascular flow and tissue integrity. Antibiotics that are commonly used are neomycin, bacitracin, and polymyxin.  Studies have shown that antibiotics have been effective in keeping bacteria levels low in wounds, however there are a few possible complications.   Reports of anaphylaxis or allergic reaction to the antibiotic of choice is a risk with using these medications  with irrigation of a wound. 

When comparing pulsed lavage with a bulb syringe, they found that pulsed lavage was more effective in bacteria clearance and wound irrigation However, there is evidence that it causes more tissue damage whereas the suction and bulb syringe do not.  The authors also discussed an animal study the showed that high pressure pulsed lavage could cause microscopic damage to bone allowing bacteria to enter into the medullary canal. Another animal study evaluated the possibility of increased fluid penetration, would resistance to infection, and transient bacteraemia caused by high pressure pulsed lavage.

Based on the current evidence, the authors recommend normal saline should be used for irrigation of fractures instead of antibiotics and antiseptics due to the possible adverse effects.  They also recommend the use of low pressure irrigation versus high pressure pulsed lavage.  If high pressure is used, the pressure limit should be 50 psi. 

Crowly, D.J., Kanakaris, N.K., & Giannoudis, P.V.(2007). Irrigation of wounds in open fractures. Journal of Bone & Joint Surgery, 89-B(5), 580-585.