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Pressure Irrigation

- See:
    - topical antimicrobials
    - skin prep agents

- High Pressure Irrigation:
    - irrigation can remove enough wound bacteria to cross the threshold to non-infected states, but only if the irrigant is delivered with sufficiently high pressure to mechanically disrupt bacterial adherance to the wound surface; 
    - to be clinically effective wounds should be delivered by a fluid jet impacting on the wound with 7 pounds of pressure per sq inch;
    - this level of fluid can be generated by forcefully expressing saline from a 35 cc syringe irrigation thru an 18 gauge needle, but it can not be generated by bulb syringe or by gravity flow;
    - thus the notion that that large volume, low pressure wound flooding provides effective irrigation is erroneous and should be disgarded;

- Low Pressure Irrigation:
    - motivation for this technique is based on the idea that high-pressure irrigation may have adverse effects on bone.
    - in the study by Bhandari M, et al (2001), the authors compared the effects of various irrigating solutions on the number and function of osteoblasts and osteoclasts and we examined the effectiveness of these solutions in removing adherent bacteria from bone;
           - in an experimental study, the authors isolated calvarial cells from newborn mice and exposed the cells to equivalent concentrations of ethanol, povidone-iodine, liquid soap, antimicrobial wash (50 U/L of bacitracin), or chlorhexidine gluconate, for two, ten, or twenty minutes;
           - each solution resulted in a time-dependent decrease in the number of calvarial osteoblasts and osteoclasts compared with that in the controls.
           - 1% soap solution resulted in greater preservation of both alkaline-phosphatase activity and bone-nodule formation than did the other solutions;
                  - soap solution preserved the number of osteoclasts to the greatest extent;
                  - povidone-iodine and chlorhexidine-gluconate solutions resulted in the largest decline in bone-nodule formation, alkaline-phosphatase activity, and number of osteoclasts;
                  - low-pressure pulsatile lavage with the soap solution removed the most bacteria from the  contaminated tibia when compared with  either the soap solution alone or low-pressure irrigation with saline solution
           - The efficacy of low-pressure lavage with different irrigating solutions to remove adherent bacteria from bone.

Wound cleansing by high pressure irrigation.

The biomechanical effect of high-pressure irrigation on diaphyseal fracture healing in vivo.

High and low pressure irrigation in contaminated wounds with exposed bone.

Traumatic wound debridement: a comparison of irrigation methods.

Intramuscular air as a complication of pulse-lavage irrigation. A case report.