Clinical Mythbusters: Common Misconceptions About Dakin's Solution
Dr Jonathan Johnson and clinical nurse specialist Alex Khan discuss common myths and misconceptions about Dakin’s solution, from pH and cytotoxicity to concentration, formulation, and amount used. They share perspectives on matching the concentration and application to the wound’s condition and the treatment objective.
Transcript
Dr Jonathan Johnson: Welcome, wound care family. We're going to talk a little bit today about a wound-based video series specifically focusing on a very common product that we use called Dakin's. Now, there's some myths and some misconceptions specifically from a clinical standpoint about how we use this specific wound care treatment. So we're going to talk about a couple concepts, specifically four. Number one, common misconceptions about showing how concentration, formulation, exposure, wound condition, and the treatment objective of specific clinical aspects of Dakin’s, which basically means we're going to look at the everyday use of Dakin’s and try to make sure we're on the right clinical path as far as management is concerned and talk a little bit about some of the myths or misconceptions that we hear about Dakin’s out in the wound care world.
So, I'm Dr Jonathan Johnson, Head of Comprehensive Wound Care Services. We focus on complex surgical wound care management, specifically debridement, wound bed preparation, reconstruction, and making sure the wound has advanced wound care treatments. I'm here today with Alex Kahn, and Alex is a superstar in his own right, and I'm happy to have him on the show today. Alex, go ahead and introduce yourself.
Alex Khan: Oh, thank you. My name is Alex Kahn. I am an advanced practice nurse, clinical nurse specialist in wound care and have over 25 years of experience in wound care. Let's get to it, Dr Johnson.
Dr Jonathan Johnson: Sounds good. Sounds good. So this is going to be a little bit different, team. We're going to focus on a first myth or misconception. And then Alex and I are going to talk a little bit about the clinical relevance and some of our day-to-day interactions with Dakin’s and how we specifically would use it on the patients. So let's look at our first myth and/or misconception:
Myth #1: Skin pH products are inherently more biocompatible and more effective at treating infection.
Dr Jonathan Johnson: Alex, tell us a little bit about your thoughts on this and tell us a little bit about how you use Dakin’s from a clinical standpoint.
Alex Khan: So this is one of the most important aspects that every wound care professional should know, that when skin is intact, the external pH level is between 4.5 and 5.5. It’s roughly about that, but remember, we're talking about intact skin. But whenever we have a skin breakdown, and when we're dealing with wounds, you're not on the external level, because there's 4.5 and a 5.5 pH level, it's slightly on acidic side. It is not neutral. Now to understand that when the skin breakdown has occurred, and now you're within a human body or a tissue, the pH level within the human body is different. And looking deep dive into arterial, I mean, I came across arterial blood. We're looking at pH level of 7.35 to 7.45. And the venous blood is 7.31 to 7.41. And intracellular fluid we came about the 7.0 to 7.2 percent of pH levels. As you see, internal pH level in the body is different than the externally intact skin. And you also need to know that the neutral pH, when we talk about, we're talking about 7.0 to 7.4. That is a neutral pH that we're approximately, we're talking about. So it's very important to understand pH level.
And of course, if the wound is more acidic in nature, it behaves differently, and if it's more alkaline, then it behaves differently. So it's very important to know that whatever the product you're using, what kind of pH level it is going to produce within the wound, because that is going to make a change based on the pH level.
Dr Jonathan Johnson: Right. Great point. So it seems, based on what you're saying, Alex, and I think we can all agree, is that a open wound will have a different pH value or level, etc, than a closed wound, right?
Alex Khan: That’s correct.
Dr Jonathan Johnson: So normal intact skin is that 4.5 to 5.5. It's acidic. And the point of that is to make sure that it has that initial barrier to make sure that specific microorganisms aren't automatically infecting the skin. So you want a little acidic aspect of your intact skin there. But when the wound gets open, or when it opens from chronic issues, etc, we're looking at a more alkaline base, right?
Alex Khan: Correct.
Dr Jonathan Johnson: So we're going to have a basic skew on the pH scale. So we're looking at 7.5, 8, etc. So I think the most important concept here is that intact skin and open wounds/open skin have different pH levels. So really understanding how product selection focuses on that is really important.
So from a Dakin’s standpoint, how are you utilizing Dakin's, Alex, if you have an open wound? Are you using more or less? Tell me a little bit about how you're utilizing it specifically.
Alex Khan: Okay, so once you have an open wound and you're managing, as you know, that wounds are not sterile. Every wound is contaminated. And my focus, or our focus, should be focused on that bioburden tends to increase with time, which is when you do a dressing change today and after 24 hours, the bioburden will continue to increase. And then, of course, then you do a dressing change again. So for the maintenance of bioburden, and remember, we're not killing everything. It's not going to be a sterile situation in the wound. We still need the bioburden, but at the par level. So we are going to use wound cleanser aspect, which is a concentration of 0.0125% of sodium hypochlorite solution instead of something that is more stronger. So any product you're using, you want to make sure that, because this particular concentration makes sodium hypochlorite non-toxic, non-corrosive, and non-irritation, it doesn't cause any irritation to the skin or the internal structures of the wound.
Dr Jonathan Johnson: Right.
Alex Khan: So we can clearly say that it is a safe bet to utilize such a small concentration and have an antimicrobial effect. With that antimicrobial, you can still see maintaining the bioburden and that because if the bioburden level increases to now we're getting colonization, that means that the number of bacteria within the wound or microbes in the wound are increasing. And as you know, that it's from contamination to colonization, then critical colonization, it turns into an infection. So our target maintenance of healthy wounds, we are using wound cleanser with a sodium hypochlorite concentration of 0.0125%, which has shown to be very effective in addressing the bioburden and keep the bacteria at par, allowing the granulation tissue to continue to granulate and all the healing properties of the wound will continue to happen. And it would not cause any cytotoxic effect or corrosive effect or any irritation or damage to the healthy tissue.
Dr Jonathan Johnson: Great point. Great point. So I think the most important concept from a surgical standpoint as well is utilizing Dakin's prior to aggressive surgical debridement in my specific practice is key, because I can really help the tissue that I feel is devitalized or is 100% eschar or has a lot of necrotic tissue—not necessarily 100% eschar, but necrotic tissue—I can really use Dakin's and use that as a soaked primary dressing so that it's easier to remove some of that necrotic tissue and it's not as dry and not as adherent. So having an important pre-debridement resource is 100% key.
So, Alex, I really like the concept of what you said as far as cytotoxicity. So, that leads us to our second myth or misconception, and that is:
Myth #2: Dakin’s is too cytotoxic to use on a healing wound.
Dr Jonathan Johnson: All right, so: too cytotoxic to use on a healing wound. So we've already talked about the normal pH of the skin. We know it's more acidic. We talked about the fact that there are varying pHs when a wound is open. Most of the time when it's chronic, it is more of a basic or alkaline-based pH. But what does too cytotoxic mean, right? Do we want to make sure we're utilizing Dakin's effectively on normal, healthy, great granulation tissue? Tell us a little bit, Alex, about the too-cytotoxic myth and how Dakin's can actually be effective when we've eradicated a lot of that necrotic and dead tissue, and now we're actually utilizing it to prep the wound for advanced surgical debridement, for biologics, for full-thickness or split-thickness skin grafts, etc. What's your clinical experience utilizing it on clean and healthy tissue?
Alex Khan: Okay, so this is another great question. And so I look at this as a medical provider. We have a great opportunity dealing with sodium hypochlorite solution because it is available in the market under different, I would say, concentrations. So full-strength sodium hypochlorite solution is 0.50%, and then we have half, which is 0.25%, and then we have a quarter is 0.125%, and then we have a cleanser, which is 0.0125%. So why I'm telling you this is just like any other pharmacology, like earlier I saw a patient, and as a medical provider, when you have a medicine with a different strength, you would use the strength differently with the different patients and based on your objectives. If somebody's A1C is not being optimal utilizing metformin 500 milligram once daily, you would automatically will do twice daily and then you can go up to 750 milligram versus 850 and then bump up to 1000 milligram, right? Based on your objectives. So, this is the way we look at sodium hypochlorite solution, that if my focus is to maintain a therapeutic environment, which is neutral pH or which is, when we're talking about neutral pH, I want to remind our audience here that we are talking about 7.0 pH level. We're not talking about 5.5 and we're not talking about 4.5. We are talking about roughly 7.0 to 7.3 or 7.4, which is slightly alkaline in nature. That's what we're looking at. And for that, you would be using sodium hypochlorite 0.0125%.
Now, if you think your wound is critically colonized, now what does that mean? It means you have purulent drainage, you have foul odors, you have friable tissue. In that situation, 0.0125% may not be enough, because this is just the maintenance dose that you're doing. So you would you can bump it up to a quarter or a half strength. But if you're looking into, like you have said Dr Johnson, you're looking at some slough, there is scattered slough in the wound and you want some debridement to occur, for that you'll be using a full strength. And remember, the objective is not antimicrobial activity; our focus is to, now, proteolytic activity, which is to start to debride or dislodge this non-viable tissue from the wound and make it nicer and cleaner. But if that is the objective, then you should be focusing on the higher-strength sodium hypochlorite solution.
Dr Jonathan Johnson: I love the breakdown of strengths because I think from a, not necessarily a misconception standpoint, but maybe a misunderstood standpoint, everyone focuses on the quarter strength of Dakin’s. “Oh, just put quarter strength.” “Oh, just put quarter strength.” “Oh, just put quarter strength.” But you have to remember that you want to titrate the concentration based on what the wound is telling you. So for instance, if I'm seeing a patient in a home care setting, and the patient has extensive necrotic tissue, I know I need to increase the concentration after surgical debridement because I need to maintain that wound bed from a proteolytic standpoint and also from a microbiologic standpoint, because I don't want that reaccumulation of necrotic and dead tissue to increase before I see the patient the next visit, whether that's in a couple days, whether that's in one week, etc. The same thing in long-term care and also the same thing if you're seeing the patient in an ambulatory surgery center. If you're seeing the patient and you know you're going to see them one or two times and that specific patient encounter is surgical, you need to maintain the wound bed. So understanding the correct titration is key, but also understand concentration. And again, it's okay to utilize a specific strength, see how the wound actually reacts to that, see how the patient reacts to it, and then move on to titrate either up or down based on what the wound is telling you. So it's very important to really understand that cytotoxicity doesn't automatically mean that great granulation buds and the good healthy tissue is going to automatically regress if you're utilizing Dakin's, because I think that's one of the major myths that are out there.
So, as we continue to move to our next myth and misconception, we're going to look at our third concept, and I'll read this one: Hypochloric acid is always gentler and more effective than sodium hyperchlorite. Let me repeat that:
Myth #3: Hypochlorous acid is always gentler and more effective than sodium hypochlorite.
Dr Jonathan Johnson: Alex, tell us a little bit about that myth and misconception. And it also ties into a little bit about what we said in the previous video. Help us understand a little bit more about those two differences.
Alex Khan: Yeah. So sodium hypochlorous acid is also considered a weak acid. And I also want to tell you that it's more into the acidic side versus sodium hypochlorite solution, which is more on alkaline side. So if you're going to compare, the question is, yes, the molecular formulation it makes, it is called a weak acid. But the fact is, if the focus is to the proteolytic activity or debridement aspect, then hypochlorous acid would not be the solution for your objective if that's what you're trying to do. So for debridement of a tissue, hypochlorous acid would not be appropriate. Antimicrobial activity, of course, when you look at the biograms with the PCR testing and we, I have not done comparative testing with, but I have done some other chemicals like EDTA, and I have done those PCRs and I'll tell you that hypochlorous acid, and when we talk about sodium hypochlorite acid, you can't just say based on their formulation the effect on the wound will be visible. So making a comparison like that would not be an appropriate thing to do.
But how, what the measurements or the formulation of each acid is, and their stability, because there's so many factors, because these, both acids have chlorine as an oxidizer, in hypochlorous acid and also in sodium hypochlorite solution, but you're talking about antimicrobial activity effect, so also people have used a hydrogen peroxide as well.
Dr Jonathan Johnson: Right, right.
Alex Khan: That it's used in antimicrobial activity. So I would go back to, I would tell all my clinician friends that based on your objectives, if you focus on each product, I think there's a place for each product in the area of wound care, but in direct comparison, I don't think it would be fair to say one is superior to another.
Dr Jonathan Johnson: Agreed.
Alex Khan: Because there are so many factors in between, and I have been using sodium hypochlorite solution for about over 25 years, working in the military and in the governmental medical facilities, Dakin’s solution or sodium hypochlorite solution has been out there for all this time. Now, sodium hypochlorous acid is also available in the market under different strengths, but it is again, it is more considered a weaker acid, it is more towards on the acidic side and it is also effectively used. But I would not do a comparative study, until we do comparative studies and with studies which we have not done.
Dr Jonathan Johnson: Exactly. And I 100% agree. Just to echo your clinical thoughts here, just from a complex surgical side and really prepping the wound bed. I think it's inconsistent in the way we should practice medicine to compare both. I think the point is to understand how the wound is progressing and really focus on the acid and really focus on specifically the treatment that's giving the best results. So for instance, from a complex wound standpoint, you want to focus on which specific treatment fits better into the broader wound bed preparation, and I've utilized Dakin’s for multiple clinical years, and really having that resource is key. Not only is it, again, helping to keep a necrotic and highly exudative and a wound that has a lot of microbial issues at baseline after surgical debridement, we can also utilize it once the wound bed has that 100% granulation bed to make sure that we're not regressing prior to, again, grafts and prior to skin grafts and biologic treatments, etc. So, really understanding the makeup of the two is key. And I think that there is a clinical world where both of them are effective. And I really think that it focuses on how well you feel comfortable utilizing either one of them.
So I guess the takeaway with that specific concept is: listen, you want to understand, like we said, the formulations, you want to understand how to titrate the exact strength, but you also want to look at how the wound is progressing. There's a place where you can utilize both, but I think really focusing on the Dakin’s side helps to prep the wound bed, number one, and number two, helps to really soften that necrotic tissue so that debridement, if needed, is not as difficult at the next specific clinical encounter.
We’d really like to focus on another myth and another quote-unquote non-traditional concept. And that non-traditional concept is, all Dakin solutions are created the same.
Myth #4: All Dakin’s solutions are created the same.
Dr Jonathan Johnson: Now, again, we've talked a little bit about this throughout the previous videos, Alex and I. So our audience is probably pretty well versed on understanding the titration and understanding the specific strength and how we utilize it based on the specific wound type. But Alex, help us understand a little bit about Dakin's solution, and is it interchangeable? And specifically, here's another great question. Can you utilize it with your other traditional wound care dressings? Tell us a little bit about your clinical experience there.
Alex Khan: Yes. So as I've said earlier, that we are very fortunate that we have sodium hypochlorite solution available in different strengths. And that gives you the more ability to utilize in different situations. If the wound is not infected, you just want to keep the bioburden at the minimum level, so you continue to use a cleanser, which is, again, the formulation of 0.0125% shown to be sort of neutral pH, non-cytotoxic, non-corrosive nature of sodium hypochlorite. And you can use that all along from the beginning till the end of the wound healing and continue to use it as your mainstay treatment or in a cleansing solution. And definitely is better than using 0.9% normal saline. Because sometimes the comparison is also set for people say the saline is more better than some of the other wound cleansers. So I disagree respectfully because saline does not have the ability to minimize the bacterial activity within the wound.
Dr Jonathan Johnson: Mm-hmm.
Alex Khan: And that may cause the bioburden to continuously increase and leading to colonization and critical colonization. So therefore you need, I am a big proponent of supporting antimicrobial solution to be utilized in every dressing change. Of course, with this neutral pH type of wound cleansing with a sodium hypochlorite solution, it does not interact or react with any other dressings, such as silver, AG, is being utilized in a lot of dressings.
Dr Jonathan Johnson: Yes.
Alex Khan: And so another thing I want to focus on is the contact time, because if you just want to spray, spray and just wipe it off, the contact time is not, if this solution is not touching the tissue and coming in contact for 30 seconds or more, then you may not get that optimal effect of this, because in order, it's just like a mouthwash, if you want to use the mouthwash if you just gargle or you rinse your mouth and you spit it out. The manufacturer’s instructions are so you've got to keep it from 30 to 45 seconds and then rinse your mouth with it and then spit it out. So the contact time is important. We want to make sure that we're spraying it and cleaning it up and then allowing it to soak in because that's when you see the therapeutic effect of it. But talking about the interaction, no, I have not seen sodium hypochlorite solution interacting or adversely interacting with silver or alginate or any other types of dressings that we use. No, we have not seen that.
Dr Jonathan Johnson: Awesome. Love it. And just to also reiterate your thoughts from a clinical standpoint, when we're utilizing Dakin’s, I think the most important concept is to remember the wound is going to tell you what it needs. If you have really dry necrotic tissue that really needs to be removed, you want to increase the amount and the concentration of Dakin's, right? Because you want to soak that at the point, because you're ready to prep the wound bed in order for surgical removal of the necrotic tissue. Now, vice versa, if you have a heavily exudating, not necessarily heavy, but a moderately exudating wound, you don't want to add a lot of soaked dressing to the site, because obviously you don't want to increase moisture because moisture is just as detrimental in healing as the wound being too dry. So it's really important to understand the correct concentration, verify the preparation, and really be intentional about how you're using it.
Just from a surgical standpoint, I really enjoy and like using Dakin's after an extensive surgical debridement in an ambulatory surgery center because if the patient is going back to a long-term care facility or if they're going back to a home care setting or an assisted living, etc, I know that the dressing will be in place and I understand that Dakin's will be able to keep that wound bed as 100% granulated and as clean as possible. We don't want to regress in the amount of bioburden that we're seeing on the wound site. So, for instance, if I'm surgically debriding an infected wound, and I know that within the next week, the patient will then have a surgical complex graft, split-thickness graft, etc, but the patient needs to go home or needs to go back to a long-term care facility, like I said, the most important concept is I know that Dakin’s is there. It can be changed, it can be easily utilized, and it's very readily accessible. So, the point really is understanding that you don't want complex dressings and complex treatment regimens. When you're treating patients that have complex wounds, you want to make sure that the nurses understand. You want to make sure that if there's a home health team, they understand. You want to make sure that whoever's taking care of the patient understands how to utilize the effective treatment so that the patient has the best benefit in order to improve.
So with that being said, I want to ask one more quick question here, Alex, if I can.
Alex Khan: Sure.
Myth #5: Clinical Misconceptions About How Much Dakin’s Solution to Use
Dr Jonathan Johnson: Tell me a little bit about—or not necessarily a myth, but maybe a clinical misconception. Do you have to soak Dakin’s to the point where it's dripping as you're putting it into the wound site? Or is a light moisture on a dressing, like a four-by-four, appropriate? Do you have to dip a four-by-four or a primary dressing into the Dakin’s solution and pull it out? And then, tell us a little bit about your experience clinically and the amount of Dakin's to use. Because I think that's a question that I get a lot of times and my team gets a lot of times from clinical partners where, “Well, do I just take the bottle and put it into the wound site and then put the four-by-four in there? Do I soak it? Do I use it moderate?” Tell us a little bit about how you gauge that type of clinical response.
Alex Khan: So again, if we are discussing from the cleansing perspective, the art of wound cleansing is very specific. And what I like to tell my audience or whenever I teach, it's just like, Dr Johnson, when you go for surgery, how long do you spend time in scrubbing? Scrubbing your hands or arms all the way to the elbow, and even the direction? And you have to do for this sponge. Do you remember back in, I'm not sure if you're using sponges now or not.
Dr Jonathan Johnson: Of course, of course, of course.
Alex Khan: But back when we had those sponges, and we keep cleaning our arms and before going to the surgery.
Dr Jonathan Johnson: Well, also, Alex, the fingernails. That's the most important thing. That's what people forget.
Alex Khan: That’s exactly right. This is just for everyone to understand the scrubbing, and allowing the contact time of the sodium hypochlorite solution to the wound base. So what, I usually do the spray, spray, spray, and get a wet gauze, put it inside the wound for at least 30 to 45 seconds I let it soak. And then when it's soaked, then you have to take the gauze and stimulate and massage it into the wound base, just like you scrub your arms, you have to do. And what the research has shown, the low stimulation, it stimulates the granulation tissue. Also, the biofilm, this bioburden that is resting and laying on the surface of the wound, that gets dismantled, it gets removed, or it gets bothered. Because remember, these planktonic activity of these free radicals, the biofilm that's trying to create, you're technically disrupting that biofilm from developing. So every time when a dressing is changed and if you do a thorough wound cleansing, you will notice that your granulation tissue is going to be really growing and it's going to look cleaner and you will see that slough is not, or this residue developing on the top, nothing going to happen and things will be better. And so it's just like brushing teeth.
Dr Jonathan Johnson: Mm-hmm.
Alex Khan: If you've got toothpaste, you've got these bristles against your gums. And when you're dealing with any time bioburden, remember, brushing teeth and using of the mouthwash is just like cleansing. I mean, sometimes I wonder that we need to invent a brush to cleanse the wound, just like we do over teeth and everything else.
Dr Jonathan Johnson: We have one.
Alex Khan: So coming back to the focus, really, that wound cleansing, soaking, and having a contact time of the sodium hypochlorite solution to the wound base at least 45 seconds or more, that is basics that I would want the people to do it and then really using the gauze to scrub gently, so disrupt the biofilm but not disrupting the granulation tissue.
Dr Jonathan Johnson: And I 100% agree. I think really the key is you have to massage the wound bed every single time you encounter that wound bed. Because remember, as we've discussed from a biochemical standpoint, wounds heal from blood flow, which brings oxygen. If you're not reinvigorating or removing or helping the stalled wound in the inflammatory phase progress to the proliferative side, you're not really doing anything to help the wound continue to improve and heal. And that's what we do as clinical experts. Our expertise is which clinical resources, whether it's surgical or whether it's a specific dressing, whether it's a Dakin’s solution, how do we help a stalled wound in the inflammatory phase progress to the proliferative, but also how do we clean a wound that we know may be at risk for increased bioburden? So understanding that is extremely key.
Okay, so we're about to wrap up. One quick clinical takeaway, Alex, give me yours.
Alex Khan: So one of the things focuses on that, when we are dealing with wound debridement, when there are several different types of debridement and what I have mentioned earlier, using of a gauze and the sodium hypochlorite solution and rubbing the wound, that is considered mechanical debridement. Now, remember that. That is mechanical debridement. And of course, if you're using higher concentration of sodium hypochlorite solution, that converts into chemical debridement because the ability of the sodium hypochlorite solution, the proteolytic ability on the tissue, on removal from the healthy tissue, from a non-healthy tissue, it is starting to dislodge it, and that would start to work. So it's very important, people need to know. And also, you have put out a really good point that phases of wound healing, understanding once the hemostasis has been achieved, now we are in inflammatory phase for up to seven days, so in that time you're going to have inflammation we can expect the seven days you're going to have a pulser procedure, we're going to have inflammation, and then the transition into the proliferation phase. And that is what we're looking at. And once you're in proliferation phase, that you are looking at more from the cleansing perspective, not the debridement perspective.
Dr Jonathan Johnson: Yes.
Alex Khan: So based on understanding your phases of wound healing, utilizing the right formulation of the sodium hypochlorite solution, leads to excellent outcomes.
Dr Jonathan Johnson: Love it. And I think for me, from a surgical standpoint, one practical takeaway is that you can utilize Dakin's when you see unhealthy, necrotic, and exudative tissue. And you can also utilize it when you see clean, healthy granulation tissue or granulated tissue to make sure that the wound does not regress. The key is to look at the wound, understand the concentration, and understand the amount.
So we are super excited, and we could not thank the audience any more for their joining us today on Wound Video Series. This is the Dakin's Mythbusters. I'm Dr Jonathan Johnson with Alex Kahn, and we hope we see you next time.
Alex Khan: Thank you.
