Cleansing the Wound

It is recommended that pressure injuries, as well as the skin around the wound (i.e., the peri-wound) be cleansed at every dressing change in order to facilitate wound healing:

• Use normal saline, potable or sterile water, or non-cytotoxic wound cleansers for wound cleansing. Normal saline is recommended for all types of wounds because it does not damage human tissue. Potable water is also recommended for most wounds. Wound cleansing solutions with surfactants or antimicrobials (e.g., povidone iodine) are recommended for wounds with debris, high bacterial colonization, and suspected or confirmed infection.
• Before cleansing, warm fluids to room temperature. The expert panel recommends this in order to facilitate the person’s comfort during wound cleansing.
• Use sufficient irrigation pressure while ensuring that no trauma is caused to the wound bed. Pressure should be sufficient to remove slough or necrotic tissue, thus ensuring proper cleansing, but should not cause trauma to the wound bed; traumatized wound tissue is more susceptible to infection and delayed wound healing. The expert panel does not recommend irrigating pressure injuries with extensive tunneling—that is, when the irrigating solution does not drain out or return from the wound. Instead, consider compressing pressure injuries (including any tunnels or sinus tracts within the wound). This is achieved by gently applying warm, saline-soaked gauze compresses into the pressure injury for 30 seconds before replacing it with another saline-soaked gauze.
• Gently irrigate the wound with at least 100 to 150 millilitres of solution. Irrigation of the wound reduces surface bacteria and tissue trauma. A sufficient amount of wound cleanser is required to completely irrigate the entire wound surface. Large wounds may require larger volumes of cleansing solution to completely clean the open wound. Safe and effective ulcer irrigation pressures range from 4 to 15 psi. Pressures of 4 to 15 psi are achieved using (a) a 35-millilitre syringe with a 19-gauge angiocath to create 8 psi of pressure, or (b) a single-use 100-millilitre saline squeeze bottle. As an acceptable alternative to 35-millilitre syringes, which are not available in Canada, the expert panel recommends the use of 30-millilitre syringes. Although 100-millilitre squeeze bottles are available, bottles containing 118 millilitres of normal saline are also acceptable to use for wound irrigation.
• Consider person-centred goals. Irrigation for healable pressure injuries may differ from irrigation for wounds that are non-healable or maintenance. For example, non-healable and maintenance pressure injuries may not require the same amount and force of irrigation. Moreover, if a person has a non-healable or maintenance wound and the goals of care are focused on comfort (e.g., as in palliative care), extensive irrigation will be unnecessary.