Wound antisepsis and sterile technique

Unquestionably, efforts taken to properly prepare the wound and the surrounding skin surfaces will influence the likelihood of infection and will directly impact on the process of wound repair. Under normal circumstances, the skin surface surrounding a wound about to be sutured should be washed and disinfected with a solution that is rapidly acting, with a broad spectrum of antimicrobial activity.

Prior to cleansing, the area around a wound may have to be anaesthetized to reduce the discomfort to the patient.

Most Emergency Departments will stock a range of antiseptic solutions, including 1% Profidone Iodine (Proviodine), Hydrogen Peroxide and Chlorhexidine-based solutions (Savlodil, Savlon). Although excellent skin cleansers, these solutions are potentially toxic to the local wound defenses and may increase the rate of subsequent wound infection if they are spilled into a wound in large quantities. These solutions should be irrigated from the wound with a sterile normal saline solution as the final step in wound cleansing.

It is rarely necessary to remove significant quantities of body hair prior to repair of a simple laceration. In fact, razor removal of hair has been shown to damage surface skin follicles and lead to increased rates of wound infection. Occasionally, for repair of scalp lacerations, for example, scissor trimming will allow for easier identification of wound margins and will facilitate later wound care. Due to inconsistent regrowth of eyebrow hair, it should never be shaved when repairing lacerations in that area.

Actual preparation of the wound involves cleansing and debridement. The ideal wound cleanser should have broad antimicrobial activity, but should not delay healing or reduce tissue resistance to infection. There is controversy about the potentially adverse effects of the readily available skin cleansing antiseptic solutions when introduced directly into the wound. What is certain, however, is that 0.9% normal saline is a very effective and non-toxic irrigating solution. Therefore, 0.9% normal saline should be used as the final solution when cleaning a wound and one should minimize spillage of other solutions into the wound during preparation.

Wound irrigation is a form of mechanical wound cleansing that is known to effectively remove bacteria and other debris. A 10 c.c. or 20 c.c. syringe can be fitted with a commercially available splash cover, and the wound can then be irrigated with either normal saline or Ringer's lactate. These solutions are used because they do not irritate body tissues. Following irrigation, remaining debris and devitalized tissue can be removed with fine forceps or with a scalpel.

Ensuring sterile technique while repairing a wound is, perhaps, the most difficult concept for the inexperienced person to grasp. A break in sterile technique, with contamination of the field, is a common procedural error. It leads to an increased incidence of wound infection and breakdown.

Sterile technique requires that the physician:

  • is able to open and don gloves without contamination to the sterile surface of the gloves
  • is able to clean and drape the wound and surrounding area
  • is able to control the instruments and suture, such that they are not contaminated by non-sterile surfaces