Warmed versus room temperature saline solution for ocular irrigation: a randomized clinical trial

Effect of Heated Saline Solution on Pain Intensity, Wound Bed Temperature, and Comfort during Chronic Wound Dressing Changes: Crossover Randomized Clinical Trial

OBJECTIVE

To evaluate the use of heated saline solution during wound cleaning on the intensity of pain related to the procedure, the temperature of the wound bed, and the comfort of patients with chronic wounds. Further, to investigate patient preference in relation to the temperature of the solution used for cleaning.

METHODS

Crossover, single-blind, clinical trial with 32 people with chronic wounds. Providers cleaned the wounds with room temperature and heated saline solution. Participants were randomized into group 1 A/B (heated solution first, room temperature second) or group 2 B/A (room temperature solution first, heated solution second), with a 10-minute washout period. Investigators evaluated pain intensity, wound bed temperature, and patient-reported comfort and preference.

RESULTS

The heated solution was preferred (P = .04) and more often referred to as comfortable (P = .04) by the participants. There was no difference in pain intensity before and after cleaning with room temperature (2.03; P = .155) and heated saline (2.25; P = .44). The heated solution increased the temperature of the wound bed by 0.5 °C.

CONCLUSIONS

Although heating saline solution could be an important comfort measure during dressing changes, quantitatively, the temperature of the solution did not significantly change the temperature of the wound bed nor the intensity of pain patients experienced.

A systematic review of methods of eye irrigation for adults and children with ocular chemical burns

AIM

To present the best available research evidence on eye irrigation methods for ocular chemical burns to facilitate better-informed clinical decisions.

METHODS

Randomized, quasi-randomized controlled trials and observational studies comparing the effectiveness of eye irrigation methods among adults or children as an active form of emergency treatment for ocular chemical burns were reviewed. Electronic databases in English and Chinese were searched from inception to June 2010. Two reviewers made independent decisions on whether to include each publication in the review and critically appraised the study quality independently. Given the clinical and methodological diversity among the studies, the review findings are presented in a narrative form.

RESULTS AND DISCUSSION

Four studies involving 302 adults and children were identified. The results of this review indicate that patients who underwent irrigation with tap water immediately following alkali burns at the scene of injury had significantly better clinical and ocular outcomes. The evidence also suggests that in hospital settings, more patients preferred balanced saline solution (BSS) plus than other irrigation fluids. Irrigation with diphoterine was found in one study that resulted in better ocular outcomes following grade 1 and 2 ocular burns. With regard to duration of eye irrigation, patients with ocular chemical burns treated with prolonged irrigation reported shorter duration of treatment at hospital and absence from work. The results should be treated with caution, as there were significant differences between the comparison groups in some studies.

IMPLICATIONS AND CONCLUSIONS

As prompt eye irrigation with tap water immediately after alkali burns had better outcomes, it would be important to commence eye irrigation immediately after burns are sustained. In this review, irrigating fluids including normal saline, lactated Ringer's, normal saline with sodium bicarbonate added, BSS Plus, and diphoterine solutions all yielded positive ocular outcomes suggesting for its use in hospital settings.

Eye irrigation for patients with ocular chemical burns: a systematic review

AIM

The aim of this systematic review is to present the best available research evidence on eye irrigation methods for ocular chemical burns.

INCLUSION CRITERIA

Randomized, quasi-randomized controlled trials and observational studies comparing the effectiveness of methods of eye irrigation among adults or children as an active form of emergency treatment for ocular chemical burns were considered for review. Studies were eligible for inclusion if methods of eye irrigation were examined within the following comparison categories: time to commence first eye irrigation; types, volumes, durations, flow rates and temperature of eye irrigating fluids; and comfort measures during eye irrigation. The types of outcome measures include immediate ocular outcomes and complications, clinical outcomes, self-reported outcomes, length of hospital stay and working days lost.

SEARCH STRATEGY

Electronic bibliographic databases in English and Chinese were searched from inception to June 2010 and yield 8,999 citations. Other sources were searched by hand to identify studies or additional relevant source materials. The reference lists and bibliographies of all articles retrieved were scrutinized to identify further studies and added a further 22 articles. A forward search on the authors of the studies identified was also performed.

METHODOLOGICAL QUALITY

A study eligibility verification form was developed for the assessment and two reviewers made independent decisions on whether to include each publication in the systematic review. Critical appraisals of study quality were undertaken independently by two reviewers using the Joanna Briggs Institute critical appraisal tools. Any disagreement that arose between the two reviewers was resolved by discussion.

DATA EXTRACTION

Data extraction was performed by one reviewer using a data extraction form developed for the systematic review. Another reviewer checked for accuracy.

DATA SYNTHESIS

Given the clinical and methodological diversity among the studies included in this review, the review findings are presented in a narrative form and no meta-analysis has been performed.

RESULTS AND DISCUSSION

A total of four studies involving 302 adults and children with ocular chemical burns met the inclusion criteria for the systematic review. One study determined the effects of prompt irrigation of the eyes with tap water immediately after alkali burns had been suffered at the scene of injury. The authors report that patients who underwent immediate irrigation had significantly better clinical and ocular outcomes. One study compared four ocular irrigation fluids administered in an emergency department and found more patients preferred a modified saline (balanced saline solution plus) than other type of irrigation fluids. Another study compare the effectiveness of two ocular irrigation fluids in hospital setting reported that for patients with grade 1 and 2 burns, the time elapsed to re-epithelialization was shorter in the group rinsing with diphoterine when compared with the group rinsing with normal saline. The results in another study demonstrated that patients with ocular chemical burns treated with prolonged irrigation reported shorter duration of treatment at the hospital and absence from work. However, the results should be treated with caution, as there were significant differences between the comparison groups in some studies, and incomplete details on methods of random assignment and a small sample size were issues of concern.

CONCLUSIONS

There is insufficient evidence to determine the optimal eye irrigation methods to improve ocular and clinical outcomes. Randomized trials using sample sizes with adequate power are needed to compare the clinical benefits of eye irrigation methods and further trials should take into account the potentially important factors such as the time to commence eye irrigation and cumulative effects of irrigating fluids that might affect the outcomes and adopt strategies to deal with them.

IMPLICATIONS FOR PRACTICE

Currently there is insufficient evidence to inform practice of eye irrigation among adults or children as an active form of emergency treatment for ocular chemical burns. Healthcare professionals need to continuously update themselves about the latest evidence on the optimal methods of eye irrigation in enhancing patient outcomes.

IMPLICATIONS FOR RESEARCH

More well designed randomized and quasi-experimental trials with adequate sample size are needed to further examine the effective methods of eye irrigation for ocular chemical burns. Future studies should provide sufficient information about the demographic and clinical data including the types and severity of ocular injuries, causative chemicals, first-aid management, and time elapsed to eye irrigation. Furthermore, a clear description of the eye irrigation protocol is crucial to facilitate comparisons across studies.

POTENTIAL CONFLICT OF INTERESTS

The authors of this systematic review do not have any type of conflict of interest.

Ophthalmologic procedures in the emergency department

Ophthalmologic emergencies account for up to 3% of visits to emergency departments in the United States. Although isolated ocular complaints are rarely life-threatening, they can lead to significant short- and long-term morbidity, including permanent visual loss. The role of the emergency physician in management of ocular emergencies is similar to that for other chief complaints: to recognize and diagnose emergency conditions, to provide appropriate initial therapy, and to ensure correct disposition. This article reviews several of the essential ophthalmologic procedures that are within the scope of emergency medical practice. Slit lamp examination, foreign body removal, use of ultrasound, tonometry, and other emergency ophthalmologic procedures are discussed.

Ocular irrigant alternatives in pediatric emergency medicine

Minimizing pain and discomfort is an important consideration in pediatric ocular decontamination. The pH of an irrigant solution plays a significant role in its tolerability, because a solution with a pH that is too low or too high may cause edema and discomfort to the conjunctiva. We reviewed several available ocular irrigation solutions with respect to their chemical composition, pH, and cost efficiency. Currently, the irrigation solution of first choice for most ocular decontaminations in the pediatric emergency department (ED) is 0.9 % saline solution or normal saline (NS), which has a pH range between 4.5 and 6.0. Alternative ocular irrigant solutions available include Lactated Ringers solution (LR), which has a pH range between 6.2 and 7.5, buffered NS with pH adjusted to 7.4 with sodium bicarbonate, and Balanced Salt Solution Plus (BSS Plus), which has a pH of 7.4. Of these alternative solutions, all except BSS Plus are comparable in cost efficiency to NS. The use of more pH neutral solutions such as LR, NS with bicarbonate buffer, or BSS Plus may decrease ocular pain and irritation associated with copious irrigation, and may improve tolerance of ocular decontamination by a child.

Warmed versus room temperature saline for laceration irrigation: a randomized clinical trial

BACKGROUND

Patient comfort is an important part of laceration repair.

METHODS

The study was a randomized single-blind cross-over trial in which each participant received 250 ml warmed and 250 ml room temperature saline irrigation in simple linear wounds after a local anesthetic was instilled. The solutions and the order of irrigation (warmed first versus second) were separately randomized with a washout period between. Investigators obtaining scores were blinded. Participants determined preferred solution, whether the solution was soothing, and which caused the most discomfort. Participants rated the pain of irrigation using separate Visual Analog Scale scores.

RESULTS

Thirty-eight patients were enrolled in the study. Significantly more preferred warmed to room temperature solutions (difference, 34%; 95% confidence interval, 5.7-63). A Wilcoxon signed-rank test for paired data showed no order effect (P = 0.49) or difference in pain measured according to the Visual Analog Scale (P = 0.082).

CONCLUSION

Warmed saline was more comfortable and soothing than room temperature saline as a wound irrigant among patients with linear lacerations.

Warmed versus room temperature saline solution for ear irrigation: a randomized clinical trial

STUDY OBJECTIVE

To test the hypothesis that ear irrigation with warmed normal saline solution is more comfortable and results in fewer side effects than irrigation with room temperature saline solution in normal volunteers.

METHODS

The study was a randomized, single-blind, crossover trial in which each subject received 30 mL warmed normal saline solution in 1 ear and 30 mL room temperature saline solution in the opposite ear. The solutions (warmed versus room temperature) and the order of irrigation (right versus left ear) were separately randomized. Investigators obtaining scores were blinded to solution temperature. Subjects rated the discomfort of irrigation, using separate visual analog scales, from 0 (no pain) to 100 mm (worst pain ever).

RESULTS

Forty volunteers were enrolled in the study. The mean difference in visual analog scale scores favoring warmed over room temperature saline solution was 26 mm (95% confidence interval [CI], 19 to 33 mm; P <.0001). Twenty percent more patients reported dizziness with room temperature irrigation (95% CI, 6% to 34%). There was no gender effect or order effect for the 2 solutions.

CONCLUSION

Warmed normal saline solution was both clinically and statistically more comfortable than room temperature saline solution as an ear irrigant in normal volunteers. Significantly less dizziness was reported with the warmed solution.