The first two steps in wound bed preparation are debridement of necrotic tissue and management of infection, both necessary in order for the chronic wound to advance from a stalled state to an actively healing wound. Pulsed lavage with suction (PLWS) is a biophysical technology that can assist in both debridement and infection control by 1) pulsating an irrigation solution into the wound bed and (2) suctioning out the debris, exudate, and bacteria. Wound cleansing is defined as the removal of “loosely attached cellular debris and surface pathogens contained in wound exudate or residue from topically applied wound care products” and wound debridement is defined as “the use of mechanical or chemical means to remove adherent material from a wound.”[i] While pulsed lavage with suction is not considered a debriding technology, it does cleanse and aid in debridement by softening necrotic tissue and loosening nonviable connective tissue, thereby facilitating sharp debridement. In addition PLWS has been shown to decrease up to 85% of bacteria and contaminants in wounds when using 10-15 psi.[ii] The use of PLWS has been shown to significantly reduce wound size and facilitate faster healing rates as compared to standard care with moist wound dressings.[iii]
PLWS provides pulsed irrigation of a cleansing solution (usually normal saline) along with suction of the exudate and loose debris, using a hand-held battery-operated hand-piece that has a trigger to control the psi. The concerns regarding the use of PLWS include using the proper psi, controlling cross-contamination, and managing patient discomfort. PSI selection depends upon the goals of treatment with the accepted range between 4-15 psi. Lower settings are used for painful or sensitive wound beds, as well as during initial treatment to introduce the procedure to the patient. Studies have indicated that pressures less than 4 psi are insufficient to remove pathogens on the wound bed and pressures greater than 15 psi may cause wound trauma, especially in granulating wounds.1 PLWS is the only cleansing strategy that provides controlled, measurable psi in the recommended range. Suction parameters are 60-80 mmHg for wounds that are painful or bleed easily and 80-100 for removal of exudate and necrotic debris. The suction pressure is adjusted at the site where suction pressure is initiated, either a wall or portable suction unit.
Contamination issues concerning the patient, the clinician, and the environment have been closely studied, and the Center for Disease Control has issued the following guidelines:
- Perform in a single-patient room or cubicle with non-fabric walls and doors that can be closed.
- Clinician and any other persons in the room wear personal protective equipment, consisting of water-proof gown, mask, sterile gloves, and hair cover.
- Have only essential equipment in the room.
- Cover horizontal surfaces with sheets or towels.
- Place a mask or clean cloth on the patient face, especially when treating above the waist.
- Cover all patient lines, ports, or other wounds.
- Disinfect surface areas that are touched, after the treatment.
- Do not re-use disposable, single-use items, e.g. tips and suction tubes. Store reusable hand-pieces wrapped in a sterile towel and placed in a zip-lock plastic bag.
- Discard the collection canister with contaminated fluid in a red biohazard container.
Patient pain can be managed in several ways, beginning with administering pain medications at an appropriate time and applying a topical analgesic, e.g. lidocaine 4% solution, to the sensitive wound bed prior to treatment.[iv] The author’s experience has been that the suction aspect of treatment is most likely to be painful, and the amount of pressure that the tip applies to the wound bed needs to be carefully controlled by the hand that does not hold the hand-piece (the non-dominant hand). For larger cavity wounds that are painful or where fluid tends to pool in one area of the wound, using a Yankaeur suctioning device (rather than suctioning through the wound tip) can make treatment both cleaner and more comfortable. (See photo) Again, lowering the psi will also help with pain tolerance.
Warming the bag of saline to room temperature prior to treatment can also make the treatment more comfortable for the patient, as well as preventing the cooling of the wound bed which can slow the healing process.4
Antibiotics can be added to the irrigation solution if the wound has clinical signs of infection, for example, 50,000 units of bacitracin and 500,000 units of polymyxin to 1 liter of normal saline can provide broad-spectrum antibiotic coverage.4
PLWS does take special precautions and set-up time for effective treatment; however, in the initial stages of caring for a large wound with necrotic tissue and exudate, it has been proven to assist in wound bed preparation and facilitate wound healing. PLWS is especially useful in conjunction with negative pressure wound therapy for cavity wounds. Judicious wound assessment and careful attention to details are essential in providing safe and beneficial treatment.
More detailed information on PLWS equipment and parameters for treatment can be found at the following:
Gibbs K, Hamm R. Pulsed lavage with suction. In Hamm R (Ed), Text and Atlas of Wound Diagnosis and Treatment: 2nd edition. New York: McGraw Hill Education. 2019, 475-486. Available at.
[i] Luedtke-Hoffman KA, Schafer DS. Pulsed lavage in wound cleansing. Physical Therapy. 2000;80(3):292-300.
[ii] Rodeheaver GT, Pettry D, Thacker JG, et al. Wound cleansing by high pressure irrigation. Surg Gynecol Obstet. 1976;141:357-362.
[iii] Shetty R, Barreto E, Paul KM. Suction assisted pulse lavage: randomized controlled studies comparing its efficacy with conventional dressings in healing of chronic wounds. International Wound Journal. 2014;11(1):55-63.
[iv] Bastawros DS. 5 things you need to know about pulsed lavage. Advances in Skin & Wound Care. 2003;16(6):282.