Medical providers legally licensed by state statutes to perform low pressure jet lavage include physicians, residents, interns, physicians assistants, nurse practioners, physical therapists. Registered nurses and advanced practice nurses are allowed to perform the wound treatments but under direct supervision of a physician. We assume this means the physician must have availability in the treatment facility. Jet lavage irrigators are state of the art treatment to remove inflammatory products of chronic infection, and more importantly is powerful system to remove biofilm bacteria. Experience shows that treatment must be done 2-3 days per week and in difficult cases such as diabetes or severe vascular disease, 5 days per week. Peristaltic pumps create 2000 ccs/minute irrigation flow providing an efficient and optimal treatment and the pressure is at or below 15 PSI. The basic jet lavage treatment requires applying a custom fluid collection bag over the wound and then sealing the wound site with double film ostomy tape provided on the bag. A small hole is made over the wound allowing the irrigation to be done with the irrigator and the irrigator tubing to be spiked into a saline IV bag. The jet lavage irrigator comes with a Yankar type of irrigation tip that creates a 65 to 90 degree jet spray for optimal bioburden removal. Successful treatment requires surgical mechanical debridement which includes frequent sharp debridement, high pressure surgical tools such as the Versajet or the Misonix low frequency derider, low pressure irrigation (below 15 PSI) such as the Perilav system (Stiehl Tech), adjunct antiseptics/surfactants, and appropriate wound dressings. There are a variety of state of the art wound regenerative products, but these treatments are not necessarily focused on removing the biofilm bacteria of chronic infection. However, wound bed preparation is critical for advanced products to be successful. Providers must consider all treatments, 'throwing the kitchen at it' which means multifaceted treatment. Nutritional support, pressure control in debilitated, and modification of comorbidities are also essential for 'early wound bed preparation'. The specific benefit of the Perilav system is to move most patients out of the inflammatory phase and this is done by heavy flows of saline (or clean water) under low pressure. Biofilm and bacteria can be removed after several treatments, and the high volumes of proteases produced by neutrophils and bacteria are quickly diminished. It must be considered that normal patients can easily move into the regenerative phases of healing with a clean wound, but patients with compromised tissues cannot. Recurrence of the chronic phase is fragile in some cases, and just losing irrigation of 2-3 days results in tissue ischemia and necrosis. Again, this does not occur in normal patients with clean dressings. The ability for jet lavage irrigators to promote early wound healing is extraordinary and easily shown by the Ho study performed at the Cleveland VA hospital in 2012. (Ho CH, Bensitel T, Wang X, Bogie KM. Pulsatile lavage for enhancement of pressure ulcer healing: a randomized controlled trial. Physical Therapy 2012; 92: 39-48.)
