Dakin's solution: is there a place for it in the 21st century?

Antiseptic Irrigation Solutions Used in Total Joint Arthroplasty: A Critical Analysis Review

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There are limited data that directly compare the efficacy of antiseptic irrigation solutions used for the prevention and treatment of periprosthetic joint infections in orthopaedic procedures; there is a notable lack of prospective data.

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For prevention of periprosthetic joint infections, the strongest evidence supports the use of low-pressure povidone-iodine.

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For the treatment of periprosthetic joint infections, delivering multiple solutions sequentially may be beneficial.

Consensus on the application of negative pressure wound therapy of diabetic foot wounds

Because China is becoming an aging society, the incidence of diabetes and diabetic foot have been increasing. Diabetic foot has become one of the main health-related killers due to its high disability and mortality rates. Negative pressure wound therapy (NPWT) is one of the most effective techniques for the treatment of diabetic foot wounds and great progress, both in terms of research and its clinical application, has been made in the last 20 years of its development. However, due to the complex pathogenesis and management of diabetic foot, irregular application of NPWT often leads to complications, such as infection, bleeding and necrosis, that seriously affect its treatment outcomes. In 2020, under the leadership of Burns, Trauma and Tissue Repair Committee of the Cross-Straits Medicine Exchange Association, the writing group for ‘Consensus on the application of negative pressure wound therapy of diabetic foot wounds’ was established with the participation of scholars from the specialized areas of burns, endocrinology, vascular surgery, orthopedics and wound repair. Drawing on evidence-based practice suggested by the latest clinical research, this consensus proposes the best clinical practice guidelines for the application and prognostic evaluation of NPWT for diabetic foot. The consensus aims to support the formation of standardized treatment schemes that clinicians can refer to when treating cases of diabetic foot.

[National expert consensus on the application of negative pressure wound therapy in the treatment of diabetic foot wounds (2021 version)]

Diabetic foot has a high rate of disability and mortality. Negative pressure wound therapy (NPWT) is one of the effective techniques in treating diabetic foot wounds, but the non-standard use of it often leads to infections, bleeding, necrosis and other complications, which seriously affects the outcome. In 2020, Tissue Repair of Burns and Trauma Committee, Cross-Straits Medicine Exchange Association organized experts from department of burns, department of orthopedics, department of vascular surgery, department of endocrinology, department of wound repair, and other departments engaged in the treatment of diabetic foot to discuss and write the "expert consensus on the application of negative pressure wound therapy in the treatment of diabetic foot wounds". This consensus is based on evidence-based medicine and combined with the latest clinical research progress, aiming to form a standardized plan for the treatment of diabetic foot wounds with NPWT, which can be used as a reference for clinicians, so as to promote the improvement of clinical diagnosis and treatment of diabetic foot.

Examination of a first-in-class bis-dialkylnorspermidine-terphenyl antibiotic in topical formulation against mono and polymicrobial biofilms

Biofilm-impaired tissue is a significant factor in chronic wounds such as diabetic foot ulcers. Most, if not all, anti-biotics in clinical use have been optimized against planktonic phenotypes. In this study, an in vitro assessment was performed to determine the potential efficacy of a first-in-class series of antibiofilm antibiotics and compare outcomes to current clinical standards of care. The agent, CZ-01179, was formulated into a hydrogel and tested against mature biofilms of a clinical isolate of methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa ATCC 27853 using two separate methods. In the first method, biofilms were grown on cellulose discs on an agar surface. Topical agents were spread on gauze and placed over the biofilms for 24 h. Biofilms were quantified and imaged with confocal and scanning electron microscopy. In the second method, biofilms were grown on bioabsorbable collagen coupons in a modified CDC biofilm reactor. Coupons were immersed in treatment for 24 h. The first method was limited in its ability to assess efficacy. Efficacy profiles against biofilms grown on collagen were more definitive, with CZ-01179 gel eradicating well-established biofilms to a greater degree compared to clinical standards. In conclusion, CZ-01179 may be a promising topical agent that targets the biofilm phenotype. Pre-clinical work is currently being performed to determine the translatable potential of CZ-01179 gel.

Evaluation of Necrotic, Edematous and Inflammatory Changes in Bone Marrow and Soft Tissue After Irrigation with Different Concentrations of NaOCl Solution: An Experimental Study in Rat Tibia

Objective

We aimed to investigate effects of different concentrations (0.5-5%) of Sodium Hypochlorite (NaOCl) solution on healthy tissues, and determine the optimal concentration that does not harm to tissue.

Materials and Methods

30 tibias of 15 male Wistar albino rats were used. The tibias were randomly divided into 5 groups (Salin, 0.5%, 1%, 2.5%, and 5% NaOCl). Tibias were reamed intramedullary, and irrigated with 20 ml of saline or increasing concentrations of (0.5-5%) NaOCl. The tibias were embedded in paraffin and the sections were stained with hematoxylin-eosin. All sections were assessed for edema, acute inflammation, or necrosis according to their density, in bone marrow and soft tissues.

Results

Pairwise comparisons revealed that irrigation of tibia with saline or 0.5% NaOCl solutions was not statistically significant in terms of necrosis in the bone marrows (p=0.320). However, irrigation of rat tibia with saline caused less necrosis in the bone marrows compared to high concentrations (1%, 2.5%, and 5%) of NaOCl (saline and 1% NaOCl, p=0.017; saline and 2.5% NaOCl, p=0.0007; saline and 5% NaOCl, p=0.001).

Conclusion

As an irrigation solution, the effects of 0.5% NaOCl are similar to those of saline in terms of edema, inflammation, and necrosis. There is a need for evaluation of necrosis for extended periods such as one week or one month by immunohistochemical methods and flow cytometry.

The Continued Utility and Viability of Dakin's Solution in Both High- and Low-resource Settings

Healthcare is expensive and often inaccessible to many. As a result, surgeons must consider simple, less expensive interventions when possible. For wound care, an older but quite effective cleaning agent is Dakin's solution (0.5% sodium hypochlorite), an easily made mixture of 100 milliliters (ml) bleach with 8 teaspoons (tsp) baking soda into a gallon of clean water or 25 ml bleach and 2 tsp baking soda into a liter of water. Gauze is then wet with this solution, placed on the wound, and replaced every 24 hours as needed. Our team of surgeons in Haiti and the United States is currently using Dakin's solution for wound care following orthopedic surgery and finds it to be a low-cost, safe, and effective treatment for post-surgical wound care for both resource-limited and non-resource strained environments. This report aims to update the current literature and encourage the consideration of Dakin's solution for modern wound care.

Fusarium spp.—An Emerging Pathogen in Chronic Diabetic Ulcer: Case Report and Review of the Literature

The genus Fusarium is ubiquitous in the environment and has been emerging as an opportunistic human pathogen. We report the case of a 65-year-old man with a history of neuroischemic, otherwise unamenable to revascularization, diabetic foot, who was admitted due to an infected deep foot ulcer. Despite conventional antibiotic and wound care treatment, no improvement was initially observed. A reappraisal of the diagnosis, with microbiological and histological analyses, documented infection of the foot ulcer with Fusarium oxysporum. Clinical improvement was noted under prolonged oral voriconazole therapy. The present case broadens the differential diagnosis of diabetic foot infection. Subcutaneous fusariosis should be considered in recalcitrant infected diabetic ulcers, as early diagnosis and management may help prevent amputation and life-threatening disease.

Dakin's solution in the treatment of severe diabetic foot infections

Acute necrotising diabetic foot (DF) infections are common, costly, and do not infrequently result in debilitating major lower-extremity amputations. Dakin's solution is a long-standing topical antiseptic that has shown benefit in this clinical setting, but its use is undermined by a presumed risk of cytotoxicity. In this single-centre case series, we retrospectively evaluated 24 patients with severe necrotising DF infections treated with a cyclical instillation of Dakin's solution at a referral multidisciplinary DF unit. Most patients achieved favourable outcomes in infection control and limb salvage, with only one patient (4.2%) requiring a major (at or above-the-ankle) amputation. The mean time to complete or near-complete wound granulation was 5.4 weeks. Of the 12 patients who completed 12 or more months of longitudinal follow up, only 2 (12.2%) had a wound recurrence. In this severe DF infection patient cohort, Dakin's solution led to a clinically meaningful improvement. No remarkable impairment in the wound-healing process was observed.

The first experience of the use of hydro-surgical technologies in the treatment of children with pulmatic-pleural complications of destructive pneumonia

Drainage and endoscopic methods of sanitation of the pleural cavity do not always allow to achieve effective debridement of pathological contents.

AIM

To development and introduction into clinical practice of hydrosurgical technologies for debridement of the pleural cavity.

MATERIAL AND METHODS

From 423 children with acute community-acquired pneumonia 88 (20.80%) children destructive pneumonia were diagnosed. Of the 88 patients with destructive pneumonia, 28 patients did not have pleural complications and were excluded from the study. 60 patients were divided into 2 groups depending on the method of surgical treatment. In the first group (n=30), two additional subgroups were formed: IA group (main n=15) - they carried out drainage and washing the pleural cavity with saline; IB group (control n=15) - only drainage of the pleural cavity. The second group (n=30) were also divided into 2 subgroups; Group IIA (main n=15) children operated according to the method of video-assisted thoracoscopic sanitations of the pleural cavity developed by us using hydrosurgical technologies; Group IIB (control n=15) - children are operated on by the method of traditional video-assisted thoracoscopic sanitations of the pleural cavity. A prospective, non-randomized, single-center study was conducted to evaluate the effectiveness of various treatments. The treatment plan was determined on the basis of a combination of anamnesis, clinical and instrumental studies and laboratory parameters.

RESULTS

All studied in the comparison groups were homogeneous by sex, weight and height. The results of applying the Kruskal-Wallis test revealed statistically significant differences between the groups for the periods of relief of the intoxication syndrome (p<0.001) and the periods of relief of the pain syndrome (p=0.012) in favor of the main group. Summarizing all analyzing the parameters in the comparison groups allowed us to prove the advantage of the proposed treatment methods over the treatment methods used in the control groups.

CONCLUSION

Hydrosurgical methods of treatment demonstrate obvious clinical and economic efficacy, which leads to the rapid reexpantion of the affected lung.

Dakin's Solution: "One of the most important and far-reaching contributions to the armamentarium of the surgeons"

Henry Drysdale Dakin is a notable person in the history of surgery, wound care, military medicine and infectious disease control. Dakin is an exemplar scientist who in the midst of war forged an international collaboration with scientists in multiple fields to create and universalize an antiseptic utopia, which saved thousands lives during World War I, remarkably diminished functional disabilities from wounds and continues to be a "far-reaching armamentarium" of the surgeons and wound care specialists around the globe. Dakin investigated over 200 different antiseptic substances to finally conclude that a 0.5% buffered sodium hypochlorite solution satisfies his criteria for an ideal antiseptic. The only potential limitation was that the germicidal property of the solution was short lived, which meant the solution had to be used continuously or repeatedly delivered into wounds. Dakin's solution, still in use by modern wound care specialists around the globe, has laid the foundation for wound care management as we know it today. Nevertheless, Dakin contributed more to science than just his solution. In this article, Dakin's life story, his unique scientific career and his contributions to surgical literature are explored. The article also illustrates how a wartime necessity resulted in a medical discovery that is still in use to date.

Rapid degradation and non-selectivity of Dakin's solution prevents effectiveness in contaminated musculoskeletal wound models

BACKGROUND

Dakin's solution (buffered sodium hypochlorite) has been used as a topical adjunct for the treatment of invasive fungal infections in trauma patients. Prudent use of Dakin's solution (DS) for complex musculoskeletal wound management implies balancing antimicrobial efficacy and human tissue toxicity, but little empirical evidence exists to inform clinical practice. To identify potentially efficacious DS concentrations and application methods, we conducted two animal studies to evaluate the ability of DS to reduce bacterial burden in small and large animal models of contaminated musculoskeletal wounds.

METHODS

An established rat (Rattus norvegicus) contaminated femoral defect model was employed to evaluate the antimicrobial efficacy of DS as a topical adjunctive treatment for Staphylococcus aureus infection. A range of clinically-relevant DS concentrations (0.00025%-0.125%) were tested, both with and without periodic replenishment during treatment. Next, an established goat (Capra hircus) musculoskeletal wound model, consisting of a Pseudomonas aeruginosa contaminated proximal tibia cortical defect, muscle crush, and thermal injury, was utilized to evaluate the antimicrobial efficacy of dilute DS (0.0025% and 0.025%) as a surgical irrigant solution. In situ reactive chlorine concentrations were monitored throughout each treatment using an automated iodometric titration approach.

RESULTS

In a rat wound model, DS treatment did not significantly reduce S. aureus bioburden after 14 days as compared to saline control. Two treatment groups (0.01% single application and 0.025% multiple application) exhibited significantly higher bacterial burden than control. In a goat musculoskeletal wound model, neither 0.0025% nor 0.025% DS significantly altered P. aeruginosa bioburden immediately following treatment or at 48 h post-treatment. Overall, DS applied to exposed soft tissue exhibited rapid degradation, e.g., 0.125% DS degraded 32% after 5 s progressing to 86% degradation after 15 min following single application.

CONCLUSIONS

We did not observe evidence of a therapeutic benefit following Dakin's solution treatment for any tested concentration or application method in two contaminated musculoskeletal wound models. Despite confirmation of robust bactericidal activity in vitro, our findings suggest DS at current clinically-used concentrations does not kill tissue surface-attached bacteria, nor does it necessarily cause host tissue toxicity that exacerbates infection in the setting of complex musculoskeletal injury.

Primum non nocere - The effects of sodium hypochlorite on dentin as used in endodontics

The medical literature is replete with the maxim 'primum non nocere', cautioning health care providers to avoid doing any harm to human subjects in their delivery of medical care. Sodium hypochlorite (NaOCl) is a well-established irrigant for root canal treatment because of its antimicrobial and organic tissue remnant dissolution capability. However, little is known about the deleterious effect of this strong oxidizing agent on the integrity of human mineralized dentin. Iatrogenically-induced loss of dentin integrity may precipitate post-treatment root fracture and has potential medico-legal complications. In the present work, transmission electron microscopy provided evidence for collagen destruction in the surface/subsurface of dentin treated with high NaOCl concentrations and long contact times. Size exclusion chromatography showed that the hypochlorite anion, because of its small size, penetrated the water compartments of apatite-encapsulated collagen fibrils, degraded the collagen molecules and produced a 25-35µm thick, non-uniform "ghost mineral layer" with enlarged, coalesced dentinal tubules and their lateral branches. Fourier transform-infrared spectroscopy identified increases in apatite/collagen ratio in NaOCl-treated dentin. The apatite-rich, collagen-sparse dentin matrix that remained after NaOCl treatment is more brittle, as shown by the reductions in flexural strength. Understanding the deleterious effects of NaOCl on mineralized dentin enables one to balance the risks and benefits in using high NaOCl concentrations for lengthy periods in root canal debridement. Delineating the mechanism responsible for such a phenomenon enables high molecular weight, polymeric antimicrobial and tissue dissolution irrigants to be designed that abides by the maxim of 'primum non nocere' in contemporary medical practices.

STATEMENT OF SIGNIFICANCE

The antimicrobial and tissue-dissolution capacities of NaOCl render it a well-accepted agent for root canal debridement. These highly desirable properties, however, appear to be intertwined with the untoward effect of collagen matrix degradation within mineralized dentin. Because of its small size, the hypochlorite anion is capable of infiltrating mineralized collagen and destroying the collagen fibrils, producing a mineral-rich, collagen sparse ghost mineral matrix with reduced flexural strength. Findings from the present work challenge the biosafety of NaOCl when it is used in high concentrations and for lengthy time periods during root canal treatment, and laid the background work for future biomaterials design in debridement of the canal space.