Pulsed lavage offers significant advantages that make it first choice
Suction device allows isolation of irrigant
While using pressurized water to clean wounds has become standard in several areas of practice, a new system of pulsed lavage has significant advantages over water jets and whirlpools that make it the first choice for many wounds. Principal among these is the ability to isolate the irrigant, thus decreasing the likelihood of cross contamination. The system’s versatility also means that the treatment can be taken to the patient, and not vice versa, which reduces stress on the patient and additional trauma to the wound.
The idea of using jets of water to stimulate or cleanse tissue dates back decades. Dentists and oral surgeons commonly use water under pressure to clean gums, and pulsating water jets have been used in wartime to treat some combat wounds. In the 1980s, orthopedists began using pressurized water to irrigate and debride traumatic wounds and to prepare bone surfaces for joint arthroplasty. In chronic wound care, whirlpool therapy has been a mainstay for cleaning and debriding wounds.
Water jets reduce bacterial burden of wound
A somewhat more recent variation on this theme is pulsed lavage (sometimes referred to as pulsatile lavage) with suction. The idea of this modality is the same as other hydrotherapy methods: to direct pressurized jets of water at and around wounds to remove and soften debris and necrotic tissue, and to reduce the bacterial burden of the wound (thus decreasing the risk of infection). There is some sentiment that water jets also stimulate the formation of granulation tissue.
The pulsed lavage systems on the market today were designed specifically for use on a variety of wounds. The suction device distinguishes pulsed lavage from other forms of direct irrigation because the irrigant is removed from the field into a dedicated container rather than drained into a basin. This feature bestows a certain degree of flexibility that is not present with other hydrotherapy treatments, according to clinicians experienced in the use of pulsed lavage. Two companies, Davol Inc. in Cranston, RI, and Stryker Corp. in Kalamazoo, MI, actively market pulsed lavage with suction.
Clinicians who favor pulsed lavage over whirlpool cite a number of reasons for their preference. "It provides treatment right at the wound instead of having to put the whole patient from the waist down in the whirlpool," says Ofelia Gonzales, PT, GCS, PAC, rehabilitation manager on the skilled nursing unit at Presbyterian Hospital of Dallas. "That means we can provide lavage at the patients bedside, which saves on transport, time, and effort. It’s a more efficient way to provide therapy." Gonzales notes that most patients who are candidates for whirlpool treatment can also receive pulsed lavage.
Among the features associated with pulsed lavage:
• The system allows the user to control the irrigation pressure delivered to the wound, which is difficult with whirlpool treatment.
And because pulsed lavage can be set to deliver pressures higher than modalities such as bulb syringes, it is more effective for eliminating bacteria from wounds. Pressure variability also means that different pressures can be used on different parts of a wound; some areas may need more aggressive treatment than others.
• The pulsing of the irrigation fluid may increase the amount of debris that is removed because the tissue is alternately compressed and decompressed.
This effect has not been proven definitively, but there is some supporting evidence as well as anecdotal reports. One researcher reported that pulsed lavage was 18 to 40 times more effective for removing tissue debris in crush wounds. The effectiveness varied according to the water pressure. If pulsed lavage does enhance the loosening and softening of tissue debris, sharp debridement, if necessary, would be made easier.
• The suction feature of pulsed lavage may have a beneficial effect on wound healing.
Suction applied to chronic wounds is thought by some to increase the rate of granulation tissue production, reduce edema, increase blood supply, and decrease bacterial colonization. Concurrent suction also means that irrigation fluid, which has been contaminated by contact with the wound, is immediately removed from the field. Therefore, the device is mobile and can be used in patient rooms and even in home care.
"You don’t need a basin to collect [the fluid], which reduces risk of cross contamination," says Carrie Sussman, PT, president of Sussman Physical Therapy Inc. in Torrance, CA. "The benefit of suction is that it cleans up the wound and sucks out debris and exudate that may have accumulated in the wound. At the same time, suction puts stress on tissue, and that may stimulate additional cell growth. Tissues that are stressed tend to lay down more collagen." She adds that the when using pulsed lavage, universal precautions should be practiced, and the suctioned fluid should be treated as infectious waste.
Integral suction also makes it easier for clinicians to use greater amounts of irrigation fluid.
• Pulsed lavage offers several advantages over whirlpool therapy. Whirlpool treatment has many limitations.
Sometimes it is difficult to position a patient so that the jets are directed at a wound. The result may be a less-than-desired flushing of debris and, therefore, a wound bed that is not as clean as desired. Gonzales says this is especially true of sacral wounds. It’s also true for deep or tunneling wounds. The limited adjustability of whirlpool jets makes it difficult to create the optimal amount of flushing for these wounds, says Gonzales, while special hand-piece tips available with pulsed lavage systems allow access to the recesses. Other shortcomings attributed to whirlpool therapy include the possibility of cross-wound contamination, the lengthy setup and cleaning procedures, the need, sometimes, to place the patient in uncomfortable positions, and the potential for over-hydration of surrounding tissue, which can lead to maceration.
In some cases, a whirlpool should be used
However, there are times when a whirlpool is a better choice than pulsed lavage, says Gonzales. Patients with very large wounds are better candidates for whirlpool, as are patients who experience too much pain from the touch of the pulsed lavage tip.
In general, patients who would benefit from hydrotherapy but are contraindicated for whirlpool are candidates for pulsed lavage. This includes patients who are unresponsive, those who are cardiovascularly compromised, those with venous insufficiency, and those who are febrile or incontinent. Patients with ostomies; incisions with intact sutures; IV placements; skeletal traction; casted extremities; or those confined to an intensive care unit, burn unit, or restrained because of combativeness are also candidates for pulsed lavage.
Pulsed lavage is suitable for use on many types of chronic wounds, including pressure sores, diabetic ulcers, venous ulcers, deep or tunneling wounds, infected surgical sites, heavily contaminated or dirty wounds, and chemical burns or injuries.
Pulsed lavage systems allow clinicians to control water pressure, which must be closely monitored. Bulb syringes produce pressure levels in this range. An accepted safe range for irrigation pressure is 4 to 15 psi. Bulb syringes typically produce pressures around 4 psi. Pressures below 4 psi are considered ineffective for cleansing and flushing. Some research has demonstrated that a pressure of 13 psi reduced inflammation in traumatic wounds, while other work showed that a pressure of 8 psi was effective for removing bacteria and reducing infection. The trouble may begin above 15 psi, at which point bacteria may be pushed downward into the wound. "If the pressure used is too high, it may drive bacteria into the wound," says Sussman.
Pulsed lavage can be painful
Pulsed lavage is not without its disadvantages. Like any technique that directly impacts the wound, it can cause pain. Analgesics are often administered prior to the procedure. However, one nurse told Wound Care that the pain caused by pulsed lavage is often less than that caused by moving patients into and out of a whirlpool and the force of the jet stream on the wound and surrounding tissue. Treatment should be stopped if any of the following occur: the patient experiences increased or severe pain or excessive bleeding, an abscess other than the one being treated opens up, or a joint becomes disarticulated.
Reimbursement for pulsed lavage in wound care is sporadic, but users advise billing the treatment with a debridement code, not as hydrotherapy.
When judged by direct costs, pulsed lavage is also relatively expensive. For instance, use of Davol’s disposable Simpulse kit averages about $45 per case. But one clinician noted that the cost is offset by a number of factors, such as quicker setup and shorter procedure times. Pulsed lavage treatment often takes 15 to 30 minutes, while whirlpool treatment usually takes an hour or more. And because most pulsed lavage systems are labeled as single-use disposable items (or have reusable bodies and disposable tips), cleanup is quick, users told Wound Care. In some cases, pulsed lavage can eliminate the need for debridement in an OR suite, which results in cost savings, according to one physical therapist.
She adds that pulsed lavage is cost-effective because it requires "less time to clean up and reduced staffing compared to whirlpool. It’s nice to have a modality that requires very little ancillary help and that you can use for many conditions where whirlpool is contraindicated.
"It’s probably more extensive in terms of hard costs, such as the actual cost of the device vs. filling a whirlpool tank," says Gonzales. "Where you save is with staff costs. Setup time is shorter and more efficient. I’m in a skilled nursing unit. If we were to transport all our patients to hydrotherapy, we’d have to do it one at a time. With pulsed lavage, we can wheel a cart from room to room."
[Editor’s note: For more information on pulsed lavage with suction contact these manufacturers: Davol Inc., Cranston, RI. Telephone: (800) 556-6275. Stryker Corp., Kalamazoo, MI. Telephone: (800) 787-9537.]
Suggested reading
1. Loehne H. Pulsed lavage with suction. In: Sussman C, Bates JB, Eds. Wound Care: A Collaborative Practice Manual for Physical Therapists and Nurses. Gaithersburg, MD: Aspen Publishers Inc.; 1998.
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