The Solution to Pollution is Dilution

A Standard of Practice Without a Standard

Dr. Charles Edmiston, Emeritus Professor of Surgery, Medical College of Wisconsin, Milwaukee, WI, shares key insights from his recent review article from Surgical Infections on the significance of intraoperative wound irrigation, its role in surgical practice, and why it must become a standardized practice in surgery.

Historically, the primary role of intraoperative wound irrigation (IOWI) was to remove tissue debris, metabolic waste and tissue exudate from the surgical field prior to wound closure. Unfortunately, the technique of wound irrigation is highly variable in relation to the volume of fluid used to irrigate the surgical wound or operative site and the type of supplemental components added to traditional saline lavage. While a recent systematic review and meta-analysis suggests that IOWI has a significant beneficial effect in reducing the risk of postoperative surgical site infection in selected surgical disciplines, the process clearly lacks standardization.1,2

Choice of irrigation fluids - What do the guidelines say?

While intraoperative irrigation is common surgical practice, the 2016 recommendations from both the World Health Organization, WHO Global Guidelines for the Prevention of Surgical Site Infections and the American College of Surgeon/Surgical Infection Society Surgical Site Infection Guidelines offer little insight or recommendations on the practice. However, the 2017 Centers for Disease Control and Prevention Guidelines for the Prevention of Surgical Site Infection and the online publication of the Wisconsin Division of Public Health Supplemental Guidance for the Prevention of Surgical Site Infection published online in January 2017 both recommend the use of an antiseptic agent as an additive to intraoperative lavage (irrigation). The concept of using an antiseptic for intraoperative wound irrigation is not a new concept but harkens back to the Listerian concept of antiseptic surgical practice.

Intraoperative irrigation within the realm of device-related surgical procedures

Laboratory and animal investigations suggest that adding an antiseptic agent, often with surfactant properties, to intraoperative irrigation fluid may assist in preventing the adherence of biofilm-forming bacteria to the surface of a biomedical device. Antiseptic (biocidal) activity with an agent such as chlorhexidine gluconate (CHG) is rapid, occurring within 30-60 seconds of contact with the bacterial cell. While the historic irrigation fluid has been normal saline, it offers no residual activity, an antibiotic lavage solution is fraught with the same criticism, contact time is too limited to have any residual activity. Use of an antiseptic agent which has a high tissue binding potential such as afforded by chlorhexidine gluconate would provide a measure of residual activity sufficient for a wide range of Gram-positive or Gram-negative wound pathogens.  Povidone iodine is less likely to afford any sufficient residual activity due to its potential to be inactivated by blood or tissue protein.

Melding irrigation with innovative wound protection

Integrating wound protection with continuous intraoperative wound irrigation (IOWI) is an innovative approach to consider in our strategic focus of reducing the risk of postoperative surgical site infection.  A recent pilot study was conducted in 86 eligible patients undergoing elective colorectal procedures, utilizing a novel wound retractor-protector sleeve that combines continuous irrigation with barrier protection. This innovative technology was associated with a 66% reduction in overall bacterial contamination at the protected incision edge compared to the exposed incision edge, documenting a significant reduction in bacterial contamination in patients undergoing colorectal surgery.3

Pursuing an evidence-based pathway

While more and more well-designed clinical studies are published embracing the concept of an evidence-based (and standardized) surgical care bundle, the science of intraoperative irrigation (lavage) remains, “the odd man out”, trapped within the hallow halls of tradition and dogma, lacking a clear evidence-based pathway.

For more details on this topic, please reference my review article recently published in Surgical Infections.

References

1 Mueller TC, Loos M, Haller B, et al. Intra-operative wound irrigation to reduce surgical site infections after abdominal surgery: a systematic review and meta-analysis. Langenbecks Arch Surg. 2015;400(2):167-181.

2 Barnes S, Spencer M, Graham D, Johnson HB. Surgical wound irrigation: a call for evidence-based standardization of practice. Am J Infect Control. 2014;42(5):525-529.

3 Papaconstantinou HT, Ricciardi R, Margolin DA, et al. A Novel Wound Retractor Combining Continuous Irrigation and Barrier Protection Reduces Incisional Contamination in Colorectal Surgery. World Journal of Surgery. 2018.