Saline Solution Or Tap Water?

PEDIATRICS/ORIGINAL RESEARCH

Wound Irrigation in Children: Saline Solution or Tap Water?

Jonathan H. Valente, MD Study objective: Irrigation, a critical component of wound management, is com- Rene J. Forti, MD monly performed with sterile normal saline solution. The purpose of this study was to Lawrence F. Freundlich, MS compare the infection rates of wounds irrigated with normal saline solution versus Stephanie O. Zandieh, MD those of wounds irrigated with running tap water. Ellen F. Crain, MD, PhD Methods: A prospective trial was conducted in an urban pediatric emergency From the Department of department. Tap water pressure and flow rates were measured, and cultures were Pediatrics (Valente, Forti, Zandieh, Crain), the Division of obtained before the study and at 5 months after study initiation. Patients 1 to 17 years Emergency Medicine (Valente, of age presenting to the pediatric ED with a simple laceration were eligible. Exclusion Forti, Crain), and the Depart- criteria included immunocompromise, complicated lacerations, or current use of or ment of Pathology (Freundlich), need for antibiotics. Patients were allocated to the running tap water group or the Jacobi Medical Center, Albert Einstein College of Medicine, standard normal saline solution irrigation group. Wounds were closed in standard Bronx, NY. fashion. Patients returned to the pediatric ED in 48 to 72 hours for evaluation. Results: Two hundred seventy-one patients were enrolled in the normal saline solution group and 259 in the tap water group. Tap water and normal saline solution pressures and flow rates differed. The groups did not differ in terms of patient demographic characteristics or wound characteristics. However, more wounds were located on the hand in the tap water group (21.3%; 95% confidence interval [CI] 16.3% to 27.1%) compared with those in the normal saline solution group (9.2%; 95% CI 5.9% to 13.4%). The wound infection rates were similar in the 2 groups (normal saline solution group: 2.8% [95% CI 1.1% to 5.7%] versus running tap water group: 2.9% [95% CI 1.2% to 5.9%]). Conclusion: There were no clinically important differences in infection rates between wounds irrigated with tap water or normal saline solution. Tap water might be an effective alternative to normal saline solution for wound irrigation in children. [Ann Emerg Med. 2003;41:609-616.]

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INTRODUCTION staff. In addition, 1-L samples of tap water were collected directly from each faucet, with the handle turned Wound repair is a common procedure in the pediatric to predetermined flow positions after the water had emergency department. In 1996, approximately 11 mil- been running for approximately 30 seconds. Each 1-L lion wounds were evaluated and treated in EDs across sample of tap water was passed through a 0.2-µm dis- the United States.1,2 Most of these traumatic wounds posable filter. Cultures of these filters were performed occur in children and represent approximately 30% to by using a tripticase soy broth and blood agar plates. 40% of all pediatric injuries.2,3 Wound infection is asso- Tap water cultures were obtained before the study and ciated with a variety of factors, such as timing of wound at 5 months into the study. closure, presence of foreign bodies, mechanism of This study used a prospective design over a 14-month injury, host immune response, bacterial inoculum, and period. The treating physician enrolled patients pre- presence of devitalized tissue.4 senting to an urban pediatric ED with simple wounds Wound irrigation is a critical component of wound requiring repair. Patients were allocated to one of the management. Wound infections have been shown to irrigation methods on the basis of the day of the month. correlate with tissue bacterial counts of more than 105 On odd days, wounds were irrigated with tap water. On per gram of tissue.5,6 However, bacterial counts cannot even days, wounds were irrigated with normal saline be assessed in the ED, and therefore, all wounds are irri- solution. gated copiously for decontamination. Patients were included if they were 1 to 17 years old Most authors recommend wound irrigation pres- and had simple wounds 8 hours old or less located on sures of at least 0.35 to 0.56 kilogram-force per square the face, scalp, trunk, or extremities that required repair centimeter (kgf/cm2) generated by using a syringe with by means of sutures, staples, or skin glue. Exclusion cri- a minimum of 100 to 300 mL of continuous irrigation.7,8 teria included immunocompromise, complicated lacer- Standard water faucet pressures are typically 3.16 kgf/ ations, or the current use of or need for antibiotics for cm2.9 The higher pressure associated with tap water wound prophylaxis. Complicated lacerations were irrigation might improve the efficiency of bacterial re- defined as lacerations involving or potentially involv- moval and decrease the incidence of infection.4,5,10-13 ing tendons, joints, viscous cavities, cartilage, fascia, For patients of all ages, the standard of care in the ED muscle, bites, neurovascular deficits, the oropharynx, has been to use sterile normal saline solution with a genitourinary areas, the tongue, the lips (through and syringe for pressure irrigation of wounds. Evidence through), and the eyelids. In addition, lacerations asso- suggests that tap water might also be adequate for wound ciated with fractures and foreign bodies requiring surgi- irrigation; however, this has not been adequately stud- cal removal were also considered complicated. ied in children.6,14,15 This study was approved by the institutional review The purpose of our study was to compare, in chil- board of the institution. Written informed consent was dren, the infection rate in simple wounds irrigated with obtained from the parent or guardian of each patient en- sterile normal saline solution by means of standard rolled, and assent was obtained from all children aged 7 techniques with that in wounds irrigated with running years and older. tap water. Local, topical, or regional block anesthesia was used as warranted by the treating physician for patients in MATERIALS AND METHODS both irrigation groups. The wounds of patients assigned to the normal saline solution group were irrigated with In the immediate pre-enrollment period, the water a minimum of 100 mL of normal saline solution with a pressures and flow rates from each faucet in the pedi- 30- to 60-mL syringe and an 18-gauge angiocatheter or atric ED were measured by engineering department splash guard. Additional irrigation was performed as

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deemed necessary by the treating physician. The total skin glue. Information was collected regarding patient volume of irrigation solution used was recorded. demographic characteristics, wound characteristics, For children who received tap water irrigation, the wound irrigation, and repair method. Wound care in- tap water was run for approximately 30 seconds before structions were provided to all patients, and wound irrigation. Wounds were irrigated with running tap check and suture removal appointments were provided water directly from the faucet, with the handles turned before discharge home according to a standard proce- to a predetermined position to standardize pressure and dure. flow rate. Irrigation was performed by having the patient Patients returned in 48 to 72 hours for a wound check place accessible wounds under the faucet. Wounds by clinicians blinded to the method of irrigation or the unable to be placed under the faucet were irrigated by study purpose. Wounds were assessed for evidence of the treating physician using a 2-foot section of dispos- infection. The wound was considered infected if there able, clean, corrugated, segmented, flexible polyethy- was any tenderness, warmth, discharge, adenopathy, lene and ethyl vinyl acetate tubing (Airlife, McGaw lymphangitis, fever, erythema, edema, or indura- Park, IL) attached to the faucet (Figure 1). The injured tion.16,17 Patients who did not return for a wound body part was placed over a basin to catch the excess check were evaluated at the time of suture removal or water. All wounds were irrigated for a minimum of 10 were contacted by means of telephone to document out- seconds with the tap water (approximately 1.5 L), and come. this was timed by the treating physician using a watch. The primary outcome was the development of Additional irrigation was performed as deemed neces- wound infection. Assuming a 3% wound infection rate sary by the treating physician. The total time of irriga- after standard wound care, application of the method tion was recorded on the data sheet so that the total vol- proposed by Blackwelder18 for sample size estimation ume of irrigation used could be calculated. for an equivalence study resulted in a sample size of 259 After irrigation, all wounds were repaired by using 1 patients required in each group. of 3 standard surgical techniques: sutures, staples, or In patients with multiple wounds, the largest wound was selected for inclusion in the final sample to ensure independence of the observations. Epi info version 6.04 (Centers for Disease Control and Prevention, Atlanta, Figure 1. Tap water setup with corrugated tubing. GA) was used to calculate frequency distributions and confidence intervals (CIs) around proportions.

RESULTS

The measured tap water pressure from the faucets in the pediatric ED was approximately 3.52 to 4.22 kgf/cm2. The measured average flow rate of the tap water was 238 mL/s. On average, there was less than 1 colony-forming unit of bacteria per milliliter of water cultured. The organisms identified were Bacillus megaterium, an aerobic gram-positive spore forming bacillus and saprophytic organism widely distributed in nature, and Staphylococcus hominis, a nonvirulent gram-positive coccus considered to be rarely pathogenic.

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Five hundred eighty-six patients were eligible for the 65.7% (95% CI 59.5% to 71.6%) of the patients in the study. Fifty-six patients refused to participate. Five saline solution group and 63.2% (95% CI 56.7% to hundred thirty patients were enrolled: 271 patients in 69.3%) in the tap water group. Telephone follow-up the normal saline solution group and 259 patients in the was obtained in 34.3% (95% CI 28.4% to 40.5%) of the tap water group (Figure 2). normal saline solution group and 36.8% (95% CI 30.7% The 2 groups did not differ in terms of age, sex, or to 43.3%) of the tap water group. Overall, 40 patients ethnicity (Table 1) or any of the following wound char- were lost to follow-up, including 20 patients in each acteristics: mechanism of injury, wound shape or type, irrigation group. There was no difference in any wound length of wound, time from injury to presentation, use characteristic, including wound location, among the of or type of anesthesia, performance of wound debride- patients lost to follow-up in the 2 groups. ment, or method of wound repair. However, wound The median volume of saline solution irrigation was location was different in the 2 groups (Table 2). Patients 300 mL (25% to 75% interquartile range, 180 to 400 in the tap water group had a higher number of hand lac- mL). The median volume of tap water irrigation was erations (21.3%; 95% CI 16.3% to 27.1%) compared 7,140 mL (25% to 75% interquartile range, 3,570 to with those in the normal saline solution group (9.2%; 14,280 mL). 95% CI 5.9% to 13.4%) Despite this difference, the majority of wounds in both groups were located on the face and scalp. Table 1. The method of follow-up was similar in the 2 groups. Patient demographic characteristics. Follow-up was accomplished by pediatric ED visit in Irrigation Group Saline Solution Tap Water Characteristic (N=271) (N=259) Figure 2. Patient eligibility, enrollment, and follow-up. Mean age, y (±SD) 7.5 (4.5) 7.7 (4.8) Male sex, % 67.7 69.0 Ethnicity, % Hispanic 56.2 56.5 586 Patients eligible 56 Patients refused Black (non-Hispanic) 32.6 28.5 White (non-Hispanic) 5.6 7.1 Asian 1.6 2.1 Other 4.0 5.8 530 Patients enrolled

Randomization: even days saline solution, odd days Table 2. tap water Wound location.

Normal saline solution Tap water 271 patients 259 patients Irrigation Group Saline Solution Tap Water (N=251), (N=239), Complete follow-up: Complete follow-up: Location % (95% CI) % (95% CI) 251 patients 239 patients Face-scalp 72.5 (66.5–77.9) 64.0 (57.6–70.1) Trunk–upper extremity 6.7 (4.0–10.6) 3.0 (1.2–5.9) 86 88 Hand 9.2 (5.9–13.4) 21.3 (16.3–27.1) 165 Telephone 151 Telephone ED visit call ED visit call Lower extremity 7.2 (4.3–11.1) 7.5 (4.5–11.6) Foot 4.4 (2.2–7.7) 4.2 (2.0–7.6)

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There were a total of 14 wound infections in the study: tion had a blood culture performed before discharge 7 in the normal saline solution group and 7 in the tap home showing negative growth for bacteria. water group. Table 3 lists the overall wound infection rates, as well as wound infection rates stratified on the DISCUSSION basis of wound location and repair method. There were no clinically important differences in overall wound Our results suggest that tap water might be as effective infection rates between the normal saline solution as sterile normal saline solution irrigation for simple group and the running tap water group or in wounds wounds in children. The overall wound infection rate stratified by means of the repair method. However, was 2.9%, with comparable rates in both irrigation there was a relationship between wound location, irri- groups. There did appear to be an increased risk of gation method, and the likelihood of infection. Foot infection if foot wounds were irrigated with tap water, wounds were 4.4 times more likely to become infected but the number of patients with foot wounds was small, if the wound was irrigated with tap water (relative risk and this increase in relative risk might not persist with a 4.4; 95% CI 0.6 to 33.1). larger sample size. Table 4 lists the 14 wound infections and their char- Wound infection rates have been found to range from acteristics. All wound infections were treated on an out- 1.1% to 12.0%, even with meticulous debridement, patient basis with oral antibiotics. One patient in the preparation, and irrigation.19 Hollander et al3 reported tap water group who had a normal wound evaluation at wound infection rates of 2.1% in children; however, all 48 to 72 hours presented with an infection 9 days later of their patients were younger than 5 years old, and the after repeat trauma to the initial wound site. One patient majority of the lacerations were located on the head and in the normal saline solution group with a wound infec- neck. Tap water has been used successfully in wound irrigation in studies of both human beings and ani- mals.9,14,15,20 Minor lacerations are frequently treated

Table 3. at home with tap water, with no adverse effects. Tap Wound infection rates. water is cheap, clean, and abundant and might be a suit-

Irrigation Group Saline Solution Group Tap Water Group Table 4. Characteristics of infected wounds. Characteristic No. % 95% CI No. % 95% CI

Overall Wound Location Method of Closure Irrigation Infection 251 2.8 1.1–5.7 239 2.9 1.2–5.9 No infection 251 97.2 94.3–98.9 239 97.1 94.1–98.8 1 Scalp Staples Normal saline solution Repair method 2 Face Sutures Normal saline solution Sutures 6 3.9 1.5–8.3 6 4.0 1.5–8.5 3 Lower extremity Sutures Normal saline solution 1-layer closure 5 3.6 1.2–8.2 4 2.9 0.8–7.2 4 Upper extremity Sutures Normal saline solution 2-layer closure 1 6.0 0.2–30.2 2 18.0 2.3–52.0 5 Foot Sutures Tap water Staples 1 2.3 0.1–12.0 0 0.0 0.0–9.7 6 Foot Sutures Normal saline solution Skin glue 0 0.0 0.0–6.7 1 2.0 0.1–10.5 7 Face Sutures Tap water Wound location 8 Upper extremity Sutures Normal saline solution Face-scalp 3 1.6 0.3–4.7 2 1.3 0.2–4.6 9 Foot Sutures Tap water Upper extremity* 2 11.8 1.5–36.0 0 0.0 0.0–4.9 10 Face Sutures Normal saline solution Hand 0 0.0 0.0–14.8 1 2.0 0.0–10.5 11 Foot Glue Tap water Lower extremity* 1 5.6 0.14–27.3 0 0.0 0.0–18.5 12 Face Suture Tap water Foot 1 9.1 0.23–41.3 4 40.0 12.2–73.8 13 Foot Suture Tap water *Upper extremity excluding hand and lower extremity excluding foot. 14 Hand Suture Tap water

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able irrigating fluid for cleaning simple wounds. In our irrigation time needed to provide the same volume of study, tap water pressures and flow rates were substan- water and increasing the distance from the irrigation tially higher than those of standard irrigation methods. source to the health care worker, tap water use might However, this did not result in differences in infection lessen biohazard risk. Pigman et al25 showed that a rates between the 2 irrigation groups. Previous studies splash guard (Zerowet, Redondo Beach, CA) with a evaluating the effects of high pressures on wounds did syringe produced less fluid splatter and biohazard risk not show a significant risk of driving bacteria into the during irrigation than an angiocatheter with a syringe. soft tissues of the wounds.2,5,21-24 This risk might be further diminished by using tap Riyat and Quinton6 showed that tap water of drink- water at the sink or through a hose because the health ing quality in England remained free of pathogenic bac- care worker does not have to be at the bedside. teria in the accident and emergency department when Finally, the anxiety that a child might experience sampled for Staphylococcus aureus, Clostridium species, with irrigation from a syringe, which looks similar to a Pseudomonas aeruginosa, Streptococcus species, and “shot,” might be decreased with the use of tap water coliform bacteria on 2 different occasions. In New York from a faucet or hose. City, water is treated with chlorine as a disinfectant. It is There are some limitations to our study. The method possible that if this study was performed in areas in of patient allocation for this study used odd and even which the water is treated differently, the outcomes days of the week. Therefore, we did not practice alloca- might be different. The tap water cultures before study tion concealment, and this might have resulted in selec- initiation and 5 months after the start of the study tion bias. However, records were kept of eligible patients showed no pathogenic organisms, and the wounds irri- who refused enrollment, and these patients did not dif- gated with tap water showed an infection rate similar to fer from those who were enrolled. that of the saline solution group. Although the tap water was cultured for bacteria, it Tap water irrigation might have several other advan- was not tested for particulate matter, such as rust, tages over standard irrigation techniques. For one, the which could act as a potential nidus for infection. use of tap water irrigation for simple wound manage- However, the lack of a demonstrable difference in infec- ment might decrease the cost of wound care in the ED. tion rates between the 2 groups suggests that even if The splash guard, syringe, and bottle of sterile saline particulate matter was present in the tap water, it did solution far outweigh the cost of tap water from the not contribute to infection. faucet. The cost to the hospital of the corrugated tubing Although the tap water pressures were measured used for some of the wounds irrigated with tap water from the faucets in the pediatric ED, the pressure of the was $0.52 per unit. Throughout the study period, tap water running through the corrugated tubing from approximately 90 of these tubes were used. In our pedi- the faucet could not be measured because of the inabil- atric ED, the cost of a 60-mL syringe, splash guard, and ity to connect the pressure gauge to the plastic tubing. 1-L bottle of normal saline solution is $2.01. If all of the However, the water pressure running through the cor- 530 patients enrolled had received tap water irrigation rugated tubing should be less than that measured directly without the corrugated disposable tubing, approxi- from the faucet opening because of the increased resist- mately $1,065.30 might have been saved. If tap water ance in the tubing. This decrease in pressure could the- was used on a national basis, millions of dollars could oretically produce less effective irrigation. However, be saved. Extrapolation of irrigation and wound care the majority of wounds irrigated with tap water were cost estimates to abrasions, which are frequently irri- irrigated without this tubing device. gated in the pediatric ED, could decrease wound care Overall, approximately 68% of the children enrolled costs even more. in our study had wounds that were located on the face The biohazard risks to the health care worker are also and scalp. These wounds typically have a lower rate of important considerations. By possibly decreasing the infection than wounds located elsewhere on the body,

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such as the hands and feet. Although more patients in the study and in drafting the manuscript. LFF developed the method- the tap water group had hand wounds, they did not have ology for culturing the tap water and oversaw the collection and processing of the tap water cultures and provided the data on those a higher rate of wound infections. We enrolled a sample cultures. SOZ input most of the data into the database, organized large enough to provide the power to show that infec- the data forms, and ensured that all steps of data collection were tion rates were low and similar in the 2 groups; how- met. EFC supervised all steps of the study, contributed substantially to revisions of the manuscript, and is responsible for the overall sci- ever, when the groups were stratified on the basis of entific quality of the study. JHV takes responsibility for the paper as wound location, the CIs around the proportions were a whole. wide. Further investigation is required to determine Received for publication May 21, 2002. Revisions received whether the difference in infection rates in foot wounds November 1, 2002; December 2, 2002; and December 26, 2002. by irrigation type persists in a larger sample. Accepted for publication January 7, 2003. Wound follow-up was performed by 2 experienced The authors report this study did not receive any outside funding or nurse practitioners. Although they were blinded to the support. method of irrigation, during the follow-up visit, the Presented at the Pediatric Academic Societies annual meeting, parent or patient could have mentioned the type of irri- Baltimore, MD, May 2001. gation performed. In an effort to reduce bias, the nurse Address for reprints: Rene J. Forti, MD, 1W20 Jacobi Hospital, 1400 practitioners were instructed not to ask about the Pelham Parkway, Bronx, NY 10461; 718-918-7986, fax 718-918-7459; E-mail [email protected]. method of irrigation and to record their wound assess- ment at the start of the follow-up visit. Also, 32.8% of REFERENCES the patients in the 2 groups were followed up by tele- 1. McCaig LF, Stussman BJ. National Hospital Ambulatory Medical Care Survey: 1996 phone. Telephone follow-up could have led to some Emergency Department Summary. Advance Data from Vital and Health Statistics, No. misclassification by parents of the status of wound heal- 293. Hyattsville, MD: National Center for Health Statistics; 1997. 2. Hollander JE, Singer AJ. Laceration management. Ann Emerg Med. 1999;34:356-367. ing and infection, but the risk of misclassification 3. Hollander JE, Singer AJ, Valentine S. Comparison of wound care practices in pedi- should have been similar in both groups. 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