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Water for wound cleansing

  1. Ritin Fernandez1,2,*,
  2. Rhonda Griffiths3

Editorial Group: Cochrane Wounds Group

Published Online: 15 FEB 2012

Assessed as up-to-date: 14 DEC 2011

DOI: 10.1002/14651858.CD003861.pub3


How to Cite

Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database of Systematic Reviews 2012, Issue 2. Art. No.: CD003861. DOI: 10.1002/14651858.CD003861.pub3.

Author Information

  1. 1

    University of Wollongong, School of Nursing, Midwifery and Indigenous Health, Kogarah, New South Wales, Australia

  2. 2

    St George/Sutherland Hospitals and Health Services, Kogarah, Australia

  3. 3

    University of Western Sydney, School of Nursing and Midwifery, Penrith South DC, NSW, Australia

*Ritin Fernandez, ritin.fernandez@sesiahs.health.nsw.gov.au. ritin@uow.edu.au.

Publication History

  1. Publication Status: Edited (no change to conclusions), comment added to review
  2. Published Online: 15 FEB 2012

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Characteristics of included studies [ordered by study ID]
Angeras 1992

MethodsQuasi-randomised controlled trial (allocation by alternation).
Baseline characteristics comparable.


Participants705 patients with soft tissue wounds less than 6 hours old, requiring sutures.
Exclusion criteria:
wounds that had connection with the thoracic cavity, abdominal cavity or the joints.


Interventions1) Wounds irrigated with tap water (n = 295).
2) Wounds irrigated with sterile normal saline (n = 322).


Outcomes1) Wound infection (defined as pus visible in the wound and prolonged healing time as judged by the nurse).


Notes88 patients evenly distributed between the two groups were lost to follow up. Follow up was undertaken 1 to 2 weeks after wound closure. Bacterial cultures taken every week from the tap water. Temperature of the tap water was 37 degrees C while the saline was delivered at room temperature.


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)High riskInadequate

Bansal 2002

MethodsRandomised controlled trial.
Allocation using randomisation schedule.
Baseline characteristics comparable.


Participants46 children with simple lacerations.


Interventions1) Cleansing with tap water (n = 21).
2) Cleansing with saline (n = 24).


OutcomesWound infection - criteria for wound complications (one or more of the following).
1. Cellulitis or erythema of the wound margin of more than 4 mm with tenderness.
2. Purulent discharge from the wound.
3. Ascending lymphangitis.
4. Dehiscence of the wound with wound separation of > 2mm.


NotesPerson performing the wound irrigation was blinded to the solution used. Wound irrigated with 35 ml syringe attached to an irrigation shield ( 25-40 psi).


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Low riskAdequate, allocation using randomisation schedule.

Godinez 2002

MethodsRandomised controlled trial.
Method of allocation not stated.
Baseline comparability not stated.


Participants94 participants with minor extremity lacerations.


Interventions1) Irrigation with tap water (n = 36).
2) Irrigation with saline (n = 41).


Outcomes1) Wound infection.


NotesWounds were irrigated with tap water at a flow rate of 7 litres/minute. Saline was poured in a basin and aspirated using a syringe and irrigation was done using a pulsatile motion.


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskUnclear

Goldberg 1981

MethodsQuasi randomised controlled trial.
Method of allocation by alternation. Consecutive patients allocated to each group.
Does not state if the assessor was blinded.


Participants200 patients with lacerations or incisions who were operated.


Interventions1) Patients allowed to rinse all over with soap and water after 24 hours (n = 100).
2) Patients kept their wounds dry (n = 100).


Outcomes1) Wound infection.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)High riskMethod of allocation by alternation. Consecutive patients allocated to each group.

Griffiths 2001

MethodsRandomised controlled trial.
Allocation was by a list of random numbers nominated by person not entering patients into the trial (closed list).
Both patients and outcome assessors were blinded to the treatment.
Baseline characteristics comparable.


Participants35 patients with 49 chronic wounds.
Exclusion criteria:
Grade 1 & 4 wounds, patients receiving antibiotics or who were immuno suppressed due to therapy, and wounds with a sinus where the base was not visible.


Interventions1) Wounds irrigated with tap water (n = 23).
2) Wounds irrigated with normal saline (n = 26).


Outcomes1) Wound infection (defined as presence of pus, discolouration, friable granulation tissue, pain tenderness, pocketing or bridging at base of the wound, abnormal smell and wound breakdown).
2) Number of wounds that healed.
3) Cost effectiveness.
4) Patient satisfaction.
5) Variance in wound size.


Notes4 patients in each group withdrew from the study.
Wounds were assessed at the end of 6 weeks. Quality of tap water reported to meet Australian National Health and Medical Research Council requirements.


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Low riskAdequate - allocation was by a list of random numbers nominated by person not entering patients into the trial (closed list).

Moscati 2007

MethodsRandomised controlled trial.
Allocation using computer based random numbers generator.
Baseline comparability between groups not stated.
Person performing the assessment was blinded to the solution used.


Participants715 subjects with uncomplicated skin lacerations requiring staple or suture repair.


Interventions1) Irrigation with tap water (n = 300).
2) Irrigation with minimum 200 mls of sterile saline (n = 334).
Irrigation with tap water undertaken by patient while irrigation with sterile saline was undertaken by the provider. Wounds were irrigated with a 35 ml syringe using a splash guard.


Outcomes1) Wound infection
(defined as wounds that required a significant change in their course of treatment such as surgical debridement, antibiotics or early removal of sutures).
2) Costs.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Low riskAdequate - allocation using computer based random numbers generator

Museru 1989

MethodsRandomised controlled trial.
No information on the method of randomisation.
Blinding not mentioned. No loss to follow up.
Baseline characteristics of patient not stated however baseline description of wounds comparable.


Participants86 patients with open fractures. No exclusion criteria stated.


Interventions1) Wounds irrigated with distilled water (n = 35).
2) Wounds irrigated with boiled water (n = 31).
3) Wounds irrigated with isotonic saline (n = 20).


Outcomes1) Wound infections (no definition for wound infection).
2) Chronic osteomyelitis.
3) Tetanus.
4) Gangrene.


NotesLength of follow up not stated.


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskUnclear

Neues 2000

MethodsQuasi-randomised controlled trial (allocation by the month).
Blinding not mentioned.
Both groups comparable for age however comparability for gender not stated.


Participants817 patients having surgery for varicose veins. Exclusion criteria not specified.


Interventions1) Wounds showered on day two (water only) (n = 274).
2) Wounds showered on day two (water + shower gel) (n = 268).
3) Wounds kept dry for 8 to 10 days (not cleansed) (n = 302).


Outcomes1) Wound infections (not defined).


Notes94 patients in the non showered group, 130 in the group that used only water and 40 patients in the group that used water and shower gel were lost to follow up.


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)High riskInadequate - allocation by the month

Riederer 1997

MethodsQuasi-randomised controlled trial (allocation by alternation).
Blinding not mentioned.
Patient demographics not stated.


Participants121 patients having surgery for inguinal hernia.
Exclusion criteria not stated.


Interventions1) Wounds showered on day one (n = 49).
2) Wounds kept dry for 14 days (not cleansed) (n = 52).


Outcomes1) Wound infection (defined as irritation, slight redness of skin and stitch abscess).
2) Patient satisfaction.


NotesWounds assessed after 14 days.


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)High riskInadequate - allocation by alternation

Tay 1999

MethodsQuasi-randomised controlled trial (allocation by the month).
Blinding of outcome assessors not mentioned.
Participants in both groups comparable for age, parity, educational level and duration of first and second stage of labour.


Participants100 women having an episiotomy for a normal vaginal delivery.
No loss to follow up.
No exclusion criteria specified.


Interventions1) Perineal toilet using water and procaine spirit (n = 50).
2) Perineal toilet using water only (n = 50).


Outcomes1) Wound infection (not defined).
2) Wound healing (assessed for the degree of edema, bruising, erythema, wound union and wound discharge with a score of 0-2 for each parameter).
3) Pain score assessed using a verbal analogue scale between 0-10.


NotesWounds assessed on day 14.


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)High riskInadequate - allocation by the month

Valente 2003

MethodsQuasi randomised controlled trial.
Method of allocation was by alternation.


Participants530 children with simple lacerations.


Interventions1) Cleansing with tap water (n = 259).
2) Cleansing with saline (n = 271).
Wounds assigned to the normal saline group were irrigated using a 30-60 ml syringe and a 18G angiocatheter or splash guard. Wounds assigned to the tap water group were irrigated under running tap water for 10 seconds.


OutcomesWound infection.
Criteria for wound infection not stated.


NotesTap water pressure and flow rates were measured prior to the study.


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)High riskInadequate - method of allocation was by alternation

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Bansal 1993This study compared the effects of topical phenytoin powder and normal saline on the healing of trophic leprosy ulcers.

Bulstrode 1988This study compared the addition of dilute and concentrated amino acids to saline on the rate of healing of chronic leg ulcers.

Burke 1998Study was excluded because the intervention was combined with saline dressings and whirlpool therapy (water). It is therefore not possible to attribute any effect to whirlpool therapy (water).

Chisholm 1992This study compared two devices used for irrigation of wounds. Irrigating solution used with both devices was normal saline.

Fraser 1976The purpose of the trial was not to assess the cleansing of the wound.

Greenway 1999Study excluded because it evaluates the effect of insulin and normal saline on the healing rate of wounds.

Johnson 1985Study excluded because it compares irrigation of perineal wounds with either 1% povidone-iodine or normal saline.

King 1984Wound cleansing in this study was part of the operative procedure.

Manhold 1976The study compared normal saline and glycoside for irrigation during dental procedures.

Medves 1997The study evaluates solution used to cleanse umbilical cord. A systematic review focusing on umbilical cord care has been undertaken.

Patterson 2005This study used antibacterial soap along with water for cleansing which could influence the findings.

Scondotto 1999This study evaluates the efficacy of sulodexide compared to cleansing with physiological solution and the application of elastic compression on the healing of venous ulcers.

Selim 2000Review.

Selim 2001No data reported.

Svedman 1983Compares two different methods of wound irrigation. Isotonic saline was the irrigant used in both groups.

Sweet 1976Not relevant to the review. This study compares two different devices for the irrigation of third molar surgical sites with high volumes of normal saline.

Voorhees 1982The purpose of the trial was not to assess the cleansing of the wound.

Weiss 2007Abstract only. The authors were contacted but did not respond, therefore there was insufficient information to include the trial in the update.

 
Comparison 1. Tap water versus no cleansing

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Infection3873Risk Ratio (M-H, Fixed, 95% CI)1.06 [0.07, 16.50]

 2 2. Wounds not healed2772Risk Ratio (M-H, Fixed, 95% CI)1.26 [0.18, 8.66]

 
Comparison 2. Tap water versus normal saline

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Infection (acute wounds only)5Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    1.1 Adults
31328Risk Ratio (M-H, Fixed, 95% CI)0.66 [0.42, 1.04]

    1.2 Children
2535Risk Ratio (M-H, Fixed, 95% CI)1.07 [0.43, 2.64]

 2 Infection (chronic wounds only)149Risk Ratio (M-H, Fixed, 95% CI)0.16 [0.01, 2.96]

 3 Healing1Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

 
Comparison 3. Water (distilled water and/or cool boiled water ) versus normal saline

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 1. Infection1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    1.1 Distilled water versus cool boiled water
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.2 Distilled water versus isotonic saline
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.3 Cool boiled water versus isotonic saline
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.4 Water (distilled and boiled ) vs isotonic saline
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]