Wound Cleansing: Water or Saline? (2006)

Reference: Fernandez R, Griffiths R, Ussia C. Water for wound cleansing. Cochrane Database Syst Rev.20022CD003861. Available at: http://www.cochrane.org/reviews/en/ ab003861.html. Clinical Question: Do rates of infection and healing differ depending on whether tap water or normal sterile saline is used to cleanse acute and chronic wounds? Data Sources: Studies were identified by electronic searches of the following databases: Cochrane Wounds Group Specialized Register (June 2004), MEDLINE (1966–2004), CINAHL (1982–2004), Nursing Collection (1995–2000), Health STAR (1975–2000), EMBASE (1980–2004), and the Cochrane Controlled Trials Register (Issue 2, 2004). Additional searches were conducted with reference lists of included studies. Contact with investigators, company representatives, and content experts was initiated to identify additional eligible studies. The search terms included water, saline, solution or solutions, tap and water, cleansing, irrigation, wound or wounds, and healing. Study Selection: Studies in any language were eligible for inclusion if they were randomized or quasirandomized controlled trials of human subjects that compared the use of water (tap, cooled, boiled, or distilled) with normal sterile saline or any other solution specifically for wound cleansing in subjects of all ages with any wound in any setting. Wound cleansing was defined as “the use of fluids to remove loosely adherent debris and necrotic tissue from the wound surface.” Data Extraction: The characteristics of the subjects, interventions, follow-up, outcomes, and findings were extracted from each study by 2 authors and verified by the third. The primary outcome measure was objective and/or subjective wound infection. Secondary measures were proportion of healed wounds, rate of healing, pain and discomfort, and patient and staff satisfaction. All studies were graded independently by 2 authors and verified by a third author to determine methodologic quality. Where appropriate, the data were pooled and analyzed with a fixed-effects model. RevMan software (version 4.2; Cochrane Centre, Oxford, UK) was used for statistical analysis. Main Results: Specific search criteria identified 24 studies for review, of which 9 met inclusion and exclusion criteria. Baseline data for each treatment group were provided in 6 studies. Details of randomization procedures were not fully explained in 2 studies, and the procedures in 6 were subject to selection bias. The sample sizes ranged between 35 and 770 patients, and patient ages ranged between 2 and 95 years. Surgical wounds were involved in 4 studies, lacerations in 3, and open fractures and chronic wounds in 1 each. Eight studies were conducted in hospital emergency departments and wards and 1 in the community. The medical or nursing staff performed the cleansing in 5 studies and the subjects themselves in 4, using irrigation and showering techniques. Primary and secondary outcome variables were recorded between 1 and 6 weeks postinjury. Wound infection was subjectively measured (redness, purulent discharge, pain, or smell) in all 9 studies, and 1 used blinded outcome assessment (cleansing solution used was unknown to assessors). Among patients with surgical wounds in 3 studies, no significant difference was noted in infection rates between cleansing (bathing or showering with and without shower gel) with tap water and no cleansing (relative risks [RR] = 1.06, 95% confidence interval [CI] = 0.07–16.50). In 1 study, tap water reduced the relative risk of infection by 45% compared with normal sterile saline for cleansing (irrigation) of acute soft tissue wounds that were sutured (RR = 0.55, 95% CI = 0.31–0.97). Two studies revealed that in children with acute wounds, cleansing (irrigation) with tap water or normal sterile saline demonstrated no significant differences in infection rates (RR = 1.07, 95% CI = 0.43–2.64). In another study, cleansing (irrigation) of nonsutured chronic wounds with tap water or normal sterile saline showed no significant differences in the rate of infection (RR = 0.16, 95% CI = 0.01–2.96). Water was also compared with isotonic saline for cleansing (irrigation) of open fractures. The author reported no significant difference in wound infection rates between distilled water and cooled, boiled water (RR = 1.69, 95% CI = 0.68–4.22), distilled water and isotonic saline (RR = 0.49, 95% CI = 0.19–1.26), or cooled, boiled water and isotonic saline (RR = 0.83, 95% CI = 0.37– 1.87). Additionally, no significant differences in the rate of infection were found when the distilled and cooled, boiled water results were pooled and compared with isotonic saline (RR = 0.65, 95% CI = 0.31–1.37). Among patients with postoperative wounds, 1 group found no significant differences in the infection and healing rates after cleansing (washing) with tap water or procaine spirit. An analysis of secondary outcomes revealed no significant differences in wound healing rates between cleansing (bathing or showering with and without shower gel) of surgical wounds with tap water and no cleansing (RR = 1.26, 95% CI = 0.18–8.66), nonsutured chronic wounds with tap water and normal sterile saline (irrigation) (RR = 0.57, 95% CI = 0.30–1.07), and postoperative wounds with tap water and procaine spirit (washing; neither RR nor CI was reported). Patients felt better when allowed to shower their wounds and preferred showering to irrigating their wounds from a bottle. Tap water ($1.16) was also shown in 1 study to be cost-effective compared with normal sterile saline ($1.43). Two groups reported that the quality of tap water met the national health requirements of the country in which the data were collected and that bacteria counts were low. Conclusions: No differences were noted in the rates of infection and healing between the use of tap water and normal sterile saline in the cleansing of acute and chronic wounds. However, 1 group suggested that tap water was effective in reducing infection rates for cleansing of acute soft tissue wounds that were sutured. The methodologic quality of the studies should be considered in the interpretation of the findings. Additional randomized controlled trials are needed to determine the effectiveness of tap water used for wound cleansing among various populations and settings.