Empirical evidences of pin site care practices

http://doi.org/10.33698/NRF0049

Suresh K. Sharma, Jogindra Vati, Indarjit walia,Ramesh K. Sen.

Abstract : pin site infection is a most common complication with external skeletal fixation .infection rates are repoeted to be as high as 85 per cent, which can be minimized with meticulous pin site care.however ,literature shows that there is high variability and inconsistency in current pin site care practices .in present study all the pin sites were cared with sterile technique and more than 50% of them were cared only one to three times a week .pin sites were cleansed with providonne iodine (88.47%),normal

saline  (6.23%) ,hydrogen peroxide (5.30%) ,crust was removed (90.65%) and pin sities were covered with povidone iodine soaked gauze (88.16%) ,dry gauze (7.17%) ,bulky dressing (4.67%) without appling  any ointment .the pin sites cared more frequently had less infection ,which was statistically significant (p<0.001) statistically significant (p<0.05) lower pin site infection was found in pin sites where crust was removed and dry gauze was applied. Pin sites cleansed with povidone iodine had higher pin site infection rate (36.97%) than normal saline (30%) and hydrogen peroxide (11.77%) but that was not found statistically significant (p.0.05).

key words:   empirical evidences ,pin site care ,practices orthopedic pins and wires have been used to apply skeletal traction from many  years ,and there has been an increase in the use of external fixators.1 multiple pins are frequently used and as such ,create potential portals for infection .pin site infection is most common complication with external skeletal fixation .infection rates are reported to be as high as 85 per cent,which can be minimized with meticulous pin site care.2 however ,Literature shows that there is high variability   And inconsistency in current pin site care  Practices.  five areas of controversy related  to pin,as    pin  site care were identified : (a) the Frequency of care ,(b) the use of solutions(c) Care given  to  pin –site crusts (d) the use of Ointments  e) the use of dressings .frequency Of care:    Trigueiro3 asserted that: the more a Pin site   is handled ,manipulated or prodded ,the greater the possibility of irritation .celeste et al4 and Behrens  have advocated daily treatment ,while others have advocated twice daily6-8. 8 williams And fundenburg 9.emphasized that excessive manipulation Of pin need to be avoided .use of solutions : the most Commonly recommended solution  is hydrogen peroxide, either in half (3%) or full strength (6%) ,and in some cases followed  by arinse of either saline solution or by a rinse of either saline solution or water4,6,8,10-12. Povidine has also been recommended .6,13 its antibiotic effect is, however, reduced by contact with exudates,perhaps reducing its cost –effectiveness .14 povidine is also believed to have a corrosive affect on skeletal pins15. alcohol ,particularly  chlorhexidine  in spirit ,has been recommended 8,13,10Sproles8 recommended only alcohol for cleaning the pine ,not the skin,arguing that dirty pins can lead to bacteria tracking down into the tissue. several authors have also recommended normal saline .17-19this is a safe ,nonirritant and non-toxic solution and although it has no antiseptic properties ,it does dilute the concentration of bacteria14.soap and water is another favored solution by green7 and trigueiro3. Removal of crusts :  by leaving crusts intact, a natural barrier to the outside environment is formed   if crusts are allowed to accumulate around. in external fixation where there is greater tissue involvement ,a buildup of fluid  under the crusts occurs ,which may cause a  secondary bacterial infection .20 the only (statement found consistently in the literature   is that in external fixation ,crusts should be removed to allow free drainage.4,6-8.use of ointment:  antibiotic creams were recommended .5,6,10 the use of antibiotic cream is counterproductive and ,as a general rule, antibiotics should not be applied topically ,but given  systemically .the use of ointment of any sort could clog  up  the pins and result in the same effect as wound crusts are removed.20 use of dressings: According to green21 the dressing needs to be bulky to try and reduce movement around the pin. a bulky dressing may, however ,result in the dressing staying untouched for skin surface ,which is not recommended .gauze has been recommended by a number of authors.11,22 if gauze is used it should not be cut ,as this can result in filaments migrating into the pin tract; keyhole dressing are preferred .23 lodine soaked gauze has also Been recommended ,4,11 but ,as shown in the criteria for  the use of solutions ,this is not cost effective .there are a number of authors who have recommended leaving the pin sites uncovered.5,6,11,22  sisk6 qualified his recommendation by saying the pin sites should be left open unless there is soft tissue damage, or excessive tissue movement is expected aroud the pin. There are great variations in recommendations for pin care regime from clinician to clinician .the nursing and medical literature were reviewed in an attempt to identify a pin site care standard based upon scientific findings .unfortunately, the research on prophylactic treatment of pin sites is limited .there is no evidence-based practice for the care of pin site to prevent pin site infection in patients receiving external fixation devices ,however the literature would appear to indicate that pin sites practices are often ritualistic with no research basis.24 there is very little evidence to say that which pin site Care regimen best reduces infection rates .so an attempt is made to see that which existing practices are better for prophylactic treatment of pin sites is limited .there is no evidence –based practice for the care of pin Site to prevent pin site infection in patients receiving external fixation devices; however the literature would appear to indicate that pin sites practices are often ritualistic with no research basis.24 there is very little evidence to say that which pin site care regimen best reduces infection rates .so an attempt is made to see that which existing practices are better for prophylaxis of pin site infection in our scenario with the following objectives.

Objectives

  1. To  identify the practices of pin site care for patients with external skeletal fixation.
  2. To determine the association between different practices of pin site care and pin site infection.

 

Materials and methods :This prospective study was conducted in selected wards of Nehru hospital ,PGIMER, Chandigarh during months of January-February 2005.it is a tertiary care hospital which is well known for its trauma and emergency care facilities where annually about more than 400 patients are treated with external fixation .in months of January-February ,total 62 patients treated with external skeletal fixation .out of them 50 consecutively purposively selected patients with 54 Fixators and 321 pin sites were studied .all age group patients with history of preoperative infection ,immune suppression and local cutaneous infection were excluded from sample population .an identification data sheet and observation proforma was prepared to collect data. Validity was established by seeking the opinion of 5 experts who were  from  fields of research ,nursing ,orthopaedics and microbiology .an inter-rater reliability was also calculated and found to be significant for research tools. Selected patients’ pin sites care was observed every day for a week postoperatively and pin sites were also observed on 3rd ,5th and 7th postoperative day to determine the presence of pin site infection .if any pin site had increased coloured discharge ,it was send for culture and sensitivity test to confirm pin site infection and to know causative organism .the data were analyzed and presented by using descriptive and inferential statistics.

Results

Findings revealed that 92% males and 8% females with mean age of 31.38-+13.41 years (6-70years) belonged to rural (68%) ,urban (30%) and slum (2%) areas.in fifty patients and 54 fixators ,total 321 pin sites’ care and occurrence of infection was observed for a week postoperatively .it revealed that all the pin sites’ care was done Under sterile technique and more than half of them i.e.189 (58.88%) were cared for about one to three times a week ,followed by 79 (24.61%) pin sites cared about 4to 6 times a week.whereas only 53 (16.51%) pin sites received care once daily .as per cleansing solution ,majority i.e .284 (88.47%) pin sites were cleaned with providone iodine (betadine) followed by 20 (6.23%) pin sites with normal saline and 17 (5.35) pin sites with normal saline and 17(5.3%) pin sites with hydrogen peroxide .in majority of (90.65%) pin sites crust was removed during pin site care ,whereas in 30 (9.35%)  pin sites this was not practiced .none of pin site had application of any ointnment and majority of them i.e.283(88.16%) were wrapped with povidone iodine soake Gauze. Whereas 23 (7.17%) pin sites were wrapped with dry gauze and 15 (4.67 %) pin sites were dressed with povidone iodine soaked gauze with bulky dressing (table1)

Table 1: practices of pin site care.

    N=321

 

                           Variables                                                                                    f (%)

              Frequency of pin site care 

1-3 times a day                                                                                   189(58.88)

4-6 times a day                                                                                     79(24.61)

Once a day                                                                                             53(16.51)

              Type of cleansing solution used

                      Povidone iodine                                                                                   284 (88.47)

Normal saline                                                                                        20 (06.23)

Hydrogen peroxide                                                                                17 (05.30)

Care to pin site crust

                          Crust removed                                                                                  291 (90.65)

Crust not removed                                                                               30(09.35)

Type of dressing used

Povidone soaked gauze                                                                    283(88.16)

Dry gauze                                                                                          23(07.17)

Bulky dressing                                                                                   15(04.67)

 

 

Note :- all pin sites were cleansed with sterile technique & no ointment was applied.

Table 2 depicts association between frequency of pin site care and prevalence of pin site infection .data reveals

That about half (46.3%) of the pin sites developed infection which were cared for only one to three times a week.whereas infection was less in pin sites which were cared four to six times a week (29.11%)  or once a day (5.66%) chisquare test was used to see the statistical significance .here the calculated value of chi-square (29.62) was more than the tabulated value (13.82) at 0.001 level of significance and two degree of freedom. This difference in infection rate between one to three ,four to six and once a day was statistically significant (p<0.001

Table 2: frequency of pin site care and pin site infection

 

        Pin site care

 

 

Pin site infection

  

1-3 times a week

F(%)

 4-6 times a week

f(%)

 Once a day Total Chi-square

Test
Present

Absent

 87 (46.03)

102 (53.97)

  23 (29.11)

56 (70.89)

 03 (05.66)

50 (94.34)

 113

208

         X2=29.62

d.f.=2

p< 0.001
              Total 189 79 53 321

Table 3show that 36.97% pin sites developed infection ,which were cleansed with povidone iodine followed by 30% indfection in pin sites which were cleansed with normal saline and 11.77% infection in pin sites which were cleansed with hydrogen peroxide .this difference in pin site infection with use of these different cleansing solutions was not statistically significant (p>0.05).

Table 3: type of cleaning solution used and pin site infection.

          Cleansing solution used

 

Pin site infection

 Hydrogen

Peroxide

F(%)

 Povidone –

Iodine

F(%)

 Normal saline

           f(%)

 Total

f

 Chi-square test
Present

Absent

 02(11.77)

15(88.23)

 105 (36.97)

179 (63.02)

 06 (30.00)

14(70.00)

 113

208

 X2 = 4.72

d.f.= 2

p> 0.05
TOTAL 17         284 20 321

 Observation revealed that  60% pin sites developed infection where pin site crust was not removed during pin site care, whereas only 32.65% pin sites where found to be infected where pin site crust removal was practiced .there was significant (p<0.05) difference in pin site infection where pin site crust removal was practiced.(table4)

Table 4: care to pin site crust and pin site infection.

        Care to crust

 

Pin site infection

 Pin site crust

Not removed

 Pin site crust removed Total Chi-square test
f(%) f(%)            f  
Present

Absent

 18(60.00)

12(40.00)

 95(32.65)

196(67.35)

 113

208  

 X2 =7.74

d. f.=2

p< 0.005

Table 5 depicts that 37.46% pin sites were found infected which were wrapped with povidone iodine soaked gauze followed by 33.33% in pin sites which were dressed with povidone iodine soaked gauze with bulky dressing .whereas only 8.70% infection were observed in pin sites which were wrapped in a dry gauze after cleansing .a statistical significant difference  was found in pin site infection where pin sit dressing was done with three different techniques        (p<0.05)

Table 5: Type of dressing used and pin site infection .

Type of dressing used

 

 

 

Pin site infection

 Dry gauze

 

 

 

f(%)

 Povidone iodine soaked gauze

 

           f(%)

 Povidone iodine soaked gauze with bulky dressing

f(%)

 Total Chi-square test
Present

Absent

 02(08.70)

21(91.30)

 106(37.46)

177(62.54)

 05(33.33)

10(66.67)

 113

208

 X2=7.74

d.f.=2

p<0.005
Total 23 283 15 321

Discussion :All the pin sites were cared with sterile technique .a total 58.88% (189/321) pin sites received the pin site care for one to three times a week,rest of them i.e.24.61% (79/321) pin site were cared about 4 to 6 times a week .whereas only 16.51% (53/321) pin sites received care once daily .celeste et al4 and Behrens 5 in their studies have advocated daily pin site care.whereas sisk6,green 7  and sproles8 have advocated twice daily pin site care.Most of pin sites (88.47%) were cleansed with povidone iodine solution ,whereas only 5.39 % and 6.23% pin sites were cleansed with hydrogen peroxide and normal saline respectively .povidone iodine as pin site cleansing solution has been recommended by Murphy et al13 ,sisk 6. the most commonly recommended solution was hydrogen peroxide ,either in half or full strength ,amd in some cases followed by a rinse of either saline solution or water.4,6,8,10,11,12. Farrell 17 ,Genge 18,Gill  and laflamme 19 has  recommended normal saline as pin site cleansing solution .chlorhexidine in spirit,has been recommended by burney16,Murphy et all13  and sproles8.results of the study revealed that majority of pin sites (90.65%) received crust removal practices whereas 9.35% pin sites were deprived from this. Crust removal recommendations were made by few authors.4,6-8 in present study none of the pin sites had application of any type of ointment some authors have recommended antibiotic.5,6,10  or antiseptic 5 cream. Some ointments at pin sites to prevent pin site infection .22,25 data  showed that most of pin sites were (88.16%) covered with povidone iodine soaled gauze .whereas 7.17% and 4.67 % pin sites were covered with dry gauze and bulky dressing respectively .povidone iodine soaked  gauze has also been recommended by celeste 4 and  davis 11. There are a number of authors who have recommended    leaving the pin sites uncovered .5,6,11,22  sisk 6 qualified his recommendation  by saying that the pin sites should be left open unless there is soft tissue damage or excessive tissue movement is expected around the pins .leaving the pin site open if it is dry is another recommendation by Sproles 8   and  Trigueiro 3 . The present study revealed that variation in pin site care practices brought difference in pin site infection .the pin sites cared more frequently had less infection rate,which found statistically significant (p<0.001) .in pin sites where crust was removed and dry gauze was applied the pin site infection was comparatively less ,which was found to be statistically significant (p<0.05) study results have found to be statistically significant (p<0.05) .study results have found that pin sites cleansed  with povidone iodine have higher pin site infection  rate (36.97%) than normal saline (30%) and hydrogen peroxide (11.77%) .this could be because povidone iodine is believed to have corrosive affect on skeletal pins and its antibiotic effect  is reduced by contact with exudates as reported by rutecki and seligson 15, but these results were not statistically significant (p>0.05) .green 7 also stated that no single antiseptic pin site cleansing soluation appears to be better than any other.

Conclusion :In practices of pin site care ,frequency of care varied from one to three times a week (58.88%) to once a day (16.51%) .pin sites were cleansed with povidone iodine (88.47%) ,normal saline (6.23%) and hydrogen peroxide (5.30%) ,crust was removed (90.65%) and pin sites were covered with povidone iodine soaked gauze (88.16%) ,dry gauze (7.17%) ,bulky dressing (4.67%) without appling any ointment .the pin sites which were cared once a day,crust was removed and dry gauze was applied ,had lower prevalence of pin site infection ,that was found statistically significant (p,0.05) .pin site infection ,that was found statistically significant (p<0.05) .pin sites cleansed with povidone iodine had higher pin site infection rate (36.97%) than normal saline (30%)And hydrogen peroxide (11.77%) ,but that was not found statistically significant (p<0.05) .it is recommended that,there is need to develop and standardize evidence –based pin site care protocol meanwhile providing daily pin site care with hydrogen peroxide ,removing pin site crust and dressing with dry gauze .it is also recommended to undertake a trial on effectiveness of different pin site cleansing solutiuons.

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