A Trial of Wound Irrigation in the Initial Management of Open Fracture Wounds

,

doi:10.1056/nejmoa1508502

Cited by 250 publications

(105 citation statements)

References 35 publications

Supporting

Mentioning

102

Contrasting

Unclassified

Order By: Relevance

“…However, a review by Anglen et al gives the following suggestion: 3 liters for Grade I fractures, 6 liters for Grade II fractures, and 9 liters for Grade III fractures [13]. Alternatively, the FLOW investigators suggest 3 liters for Grade I fractures and 6 liters for Grade II and III fractures [10]. Thus, our results are listed in irrigation time per 3-liter quantities of fluid.…”

Section: Discussionmentioning

confidence: 94%

“…Furthermore, soap has frequently been shown to have worse outcomes in comparison to normal saline in some studies, especially noted in the recent FLOW trial [10]. …”

Section: Discussionmentioning

confidence: 99%

“…These techniques differ in two main ways: the presence of pulsation and the maximum force applied to the tissues. Pulse irrigation can generate low (5–10 pounds per square inch (psi)) or high (20+ psi) pressure pulsations, whereas gravity irrigation results in very low continuous pressures (1–2 psi) [10]. …”

Section: Introductionmentioning

confidence: 99%

“…However, it has also been associated with a greater degree of damage to bone and soft tissue and thought to potentially drive bacteria deeper into tissues [11, 13–18]. Recently, results of the Fluid Lavage in Open Wounds (FLOW) trial have helped to establish that there are no significant differences in the need for reoperation or wound infection treatments between high or low-pressure pulse irrigation or gravity irrigation [10]. However, it is unclear which method is fastest, resulting in the most expeditious irrigation.…”

Section: Introductionmentioning

confidence: 99%

See 3 more Smart Citations

Comparing the speed of irrigation between pulsatile lavage versus gravity irrigation: an Ex-vivo experimental investigation

et al. 2017

View full text Add to dashboard Cite

BackgroundThe need for reoperation or wound infection treatments between pulsatile and gravity irrigation are statistically equivalent, however, it is unclear which method maximizes operative efficiency and expeditious irrigation. In this study we set out to determine the differences in irrigation rate between these various treatment methods.MethodsThis was an ex-vivo experimental laboratory study not involving human subjects. Irrigation rates were tested based on the time in seconds required to empty a three-liter bag of normal saline hanging at either 6 or 9 ft. Three forms of irrigation were tested: gravity irrigation (GI6, GI9), low-pressure pulsatile irrigation (LP6, LP9) and high-pressure pulsatile irrigation. One-way ANOVA and Student’s t-test were used to compare rates based on height and form of irrigation.ResultsSignificant differences in irrigation rates were noted at 6 ft between all three forms of irrigation with gravity irrigation the fastest followed by high-pressure and low-pressure pulsatile irrigation (GI6, mean 142 s ± 3.2; HP6, mean 189 s ± 10.2; LP6, mean 323 s ± 22.5; p < 0.001). This difference was also found at 9 ft (GI9, mean 114 s ± 1.5; HP9, mean 186 s ± 10.5; LP9, mean 347 s ± 3.5; p < 0.001). Gravity irrigation was significantly faster (p < 0.001) at an increased height, whereas the high and low-pressure irrigation rates were unaffected by height. List price comparison found pulsatile irrigation to cost approximately 3.3 times more than gravity lavage.ConclusionsGravity irrigation provided the most rapid rate of irrigation tested, regardless of the height. With existing literature demonstrating equivalent clinical outcomes between methods, gravity lavage offers a faster and potentially more cost-effective form of irrigation.

show abstract

Section: Discussionmentioning

confidence: 94%

“…Furthermore, soap has frequently been shown to have worse outcomes in comparison to normal saline in some studies, especially noted in the recent FLOW trial [10]. …”

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Comparing the speed of irrigation between pulsatile lavage versus gravity irrigation: an Ex-vivo experimental investigation

et al. 2017

View full text Add to dashboard Cite

show abstract

“…Although no differences were found regarding type of pressure, surgical irrigation with highpressure lavage might anticipate bacterial seeding into the intramedullary canal, increasing wound bacterial counts at 48 hours after irrigation and compromising the bone-healing process [91,103,[112][113][114]. Furthermore, the FLOW trial showed that irrigation with normal saline obtained better results than irrigation with a soap solution [114]. Therefore, based on literature data, we suggest rinsing the open fracture wound at low to very low pressures with normal saline (irrespective of the degree of contamination).…”

Section: Surgical Debridement and Irrigationmentioning

confidence: 99%

Prevention of fracture-related infection: a multidisciplinary care package

Metsemakers

Onsea

Neutjens

et al. 2017

International Orthopaedics (SICOT)

100

View full text Add to dashboard Cite

Fracture-related infection (FRI) remains a challenging complication. It may result in permanent functional loss or even amputation in otherwise healthy patients. For these reasons, it is important to focus attention on prevention. In treatment algorithms for FRI, antibiotic stewardship programmes have already proved their use by means of a multidisciplinary collaboration between microbiologists, surgeons, pharmacists, infectious disease physicians and nursing staff. A similar approach, however, has not been described for infection prevention. As a first step towards achieving a multidisciplinary care package for infection prevention, this review summarises the most recent guidelines published by the World Health Organization (WHO) and US National Institutes of Health Centers for Disease Control and Prevention (CDC), primarily focusing on the musculoskeletal trauma patient. The implementation of these guidelines, together with close collaboration between infection control physicians, surgeons, anaesthesiologists and nursing staff, can potentially have a beneficial effect on the rate of FRI after musculoskeletal trauma surgery. It must be stated that most evidence presented here in support of these guidelines was not obtained from musculoskeletal trauma research. Although most preventive measures described in these studies can be generalised to the musculoskeletal trauma patient, there are still important differences with nontrauma patients that require further attention. Future research should therefore focus more on this very defined patient population and more specifically on FRI prevention.

show abstract

Effectiveness of Iodophor vs Chlorhexidine Solutions for Surgical Site Infections and Unplanned Reoperations for Patients Who Underwent Fracture Repair

Slobogean

Sprague

Wells³

et al. 2020

JAMA Netw Open

View full text Add to dashboard Cite

IMPORTANCEThe risk of developing a surgical site infection after extremity fracture repair is nearly 5 times greater than in most elective orthopedic surgical procedures. For all surgical procedures, it is standard practice to prepare the operative site with an antiseptic solution; however, there is limited evidence to guide the choice of solution used for orthopedic fracture repair.OBJECTIVE To compare the effectiveness of iodophor vs chlorhexidine solutions to reduce surgical site infections and unplanned fracture-related reoperations for patients who underwent fracture repair. DESIGN, SETTING, AND PARTICIPANTSThe PREP-IT (Program of Randomized Trials to Evaluate Pre-operative Antiseptic Skin Solutions in Orthopaedic Trauma) master protocol will be followed to conduct 2 multicenter pragmatic cluster randomized crossover trials, Aqueous-PREP (Pragmatic Randomized Trial Evaluating Pre-Operative Aqueous Antiseptic Skin Solution in Open Fractures) and PREPARE (Pragmatic Randomized Trial Evaluating Pre-Operative Alcohol Skin Solutions in Fractured Extremities). The Aqueous-PREP trial will compare 4% aqueous chlorhexidine vs 10% povidoneiodine for patients with open extremity fractures. The PREPARE trial will compare 2% chlorhexidine in 70% isopropyl alcohol vs 0.7% iodine povacrylex in 74% isopropyl alcohol for patients with open extremity fractures and patients with closed lower extremity or pelvic fractures. Both trials will share key aspects of study design and trial infrastructure. The studies will follow a pragmatic cluster randomized crossover design with alternating treatment periods of approximately 2 months. The primary outcome will be surgical site infection and the secondary outcome will be unplanned fracture-related reoperations within 12 months. The Aqueous-PREP trial will enroll a minimum of 1540 patients with open extremity fractures from at least 12 hospitals; PREPARE will enroll a minimum of 1540 patients with open extremity fractures and 6280 patients with closed lower extremity and pelvic fractures from at least 18 hospitals. The primary analyses will adhere to the intention-to-treat principle and account for potential between-cluster and between-period variability. The patient-centered design, implementation, and dissemination of results are guided by a multidisciplinary team that includes 3 patients and other relevant stakeholders. DISCUSSION The PREP-IT master protocol increases efficiency through shared trial infrastructure and study design components. Because prophylactic skin antisepsis is used prior to all surgical procedures and the application, cost, and availability of all study solutions are similar, the results of the PREP-IT trials are poised to inform clinical guidelines and bring about an immediate change in clinical practice. TRIAL REGISTRATION ClinicalTrials.gov Identifiers: NCT03385304 and NCT03523962

show abstract

A Trial of Wound Irrigation in the Initial Management of Open Fracture Wounds

Cited by 250 publications

References 35 publications

Comparing the speed of irrigation between pulsatile lavage versus gravity irrigation: an Ex-vivo experimental investigation

Comparing the speed of irrigation between pulsatile lavage versus gravity irrigation: an Ex-vivo experimental investigation

Prevention of fracture-related infection: a multidisciplinary care package

Effectiveness of Iodophor vs Chlorhexidine Solutions for Surgical Site Infections and Unplanned Reoperations for Patients Who Underwent Fracture Repair

Contact Info

Product

Resources

About