Perspectives in Circulation Today
Electrolytes, Trace Elements, Fluid Compartments
Saline Inhibition of Wound Healing?
Sea Soaks Concentrate as a "Vac"
Sea Soaks-TM
Subcutaneous PO2 Levels of Patient FF
Time 1st toe 5th toe Med Instep Lat Instep
0 12% 7% 11% 18%
1 wk 45% 24% 30% 22%
2 wks 68% 54% 66% 59%
He was given Long Boot treatments first in the hospital and then in the Nursing Home.All measures of blood flow improved (note improvement in PO2 levels above) and most of his ulcers healed. The large ulcer on the dorsum of his foot was treated with saline wet-dry dressings. A moist environment is commonly recommended to enhance epithelization of the ulcer bed. Frantz in her website (www.nursing.uiowa.edu/sites/chronicwound/) recommends the use of gauze wetted with saline for this purpose. Recent textbooks make similar recommendations (Wound Healing And Ulcers Of The Skin by Avi. Shai, Howard Ira Maibach, Springer 2004) and Cutaneous Wound Healing by Vincent Falanga, Taylor & Francis 2001.). The ulcer developed a healthy red color and good granulations…. But even by six months it did not heal. In the discussion about his wound, it was pointed out that we were growing skin faster in the test tube with commercial culture media then he was across what appeared to be healthy granulation tissue. He asked if we could provide him with our culture media to replace his saline dressings. No, we replied; it was expensive and it was not approved by the FDA for application to wounds. But, we continued, the commercial media is very similar to diluted sea water and we could make such media from a clean sample of sea water. The discussion turned to the desirability of a skin graft. He agreed to a hospital admission for a skin graft. The next Friday evening, his daughter brought him to the hospital for admission and brought a fresh bottle of sea water to the office of Dr. Dillon. The sea water was boiled, filtered and diluted to 280 mOs to make "Sea Soaks". Wet-to-dry dressings with the latter were begun Friday night. Saturday morning a white scum appeared at the wound edges. Sunday morning the scum was seen to extend across one third of the ulcer and the wound edges had pearly white new epithelial cells. Monday morning, the ulcer appeared almost healed (right picture above). The graft procedure was cancelled. He had healed faster in three days on Sea Soaks than he had in 6 months on saline! Why?
The constituents of sea water, Sea Soaks-TM, commercial culture media, serum and intracellular water are tabulated on our website: http://www.circulatorboot.com/introduction/seasoaks.html Cell water is rich in potassium and magnesium and poor in sodium while serum is rich in sodium and poor in magnesium and potassium. Virtually all of the trace elements found in sea water are found in serum. Total body water constitutes about 70 percent of lean body mass. The intracellular water represents 50 percent of body weight or 35 liters in a 70-kg man. The extracellular water compartment represents 20 percent of body weight or 14 liters. The latter is subdivided into plasma volume (5 percent body weight) and interstitial fluid volume (15 percent body weight). The trace elements are involved in cellular metabolic and enzymatic processes and may differ in concentration in different cell types. There are seven essential trace elements in humans: chromium, copper, cobalt, iodine, iron, selenium, and zinc. None are generally measured in the clinical practice of medicine. Indeed the composition or the largest fluid compartment, the intracellular water, is rarely measured in clinical practice. When it is measured the results can be striking. For example, as sick patients with HIV lose weight, their intracellular potassium decreases in a linear fashion and when it decreases to 54% of normal, death ensues (Kotler DP, Wang J, Pierson Jr RN: Studies of body composition in patients with the acquired immunodeficiency syndrome. Food and nutrition bulletin 11(1) March 1989). As patients age or are sickened by chronic illness, their intake of essential elements suffers. Further, if their tissues are deprived of an adequate blood supply, the delivery of essential nutrients to the wounds is especially compromised. The application of saline dressings may overwhelm the capacity of the tissue adjacent to the wound to deliver the components needed for formation of new cells.
Trade in sodium chloride has been most important through the ages. It has been necessary for food preservation. Today, the FDA still provides guidelines for curing meats and poultry (http://www.cfsan.fda.gov/~dms/fcannex6.html ). The living cell expends most of its energy in establishing electrolyte gradients much like a storage battery. Nerve conduction and muscle contraction are associated with ion movements across cell membranes and energy, largely provided by the sodium-potassium ATPase pump, is expended in re-establishing the ion gradients. Immersion in pure saline can overwhelm the pump and kill the cell. Saline 0.9% is physiological in tonicity but nothing else. As a wound soak, it has demonstrated no advantages over tap water (Beam JW: Wound cleansing: water or saline? J Athl Train 41:196-7, 2006 ).The use of saline as a placebo or a control in wound healing experiments is a significant methodological error. The error may not be apparent as some studies compare the application of a new therapeutic substance against "best clinical practice". Compared to Sea Soaks, Dillon found saline to significantly impede wound healing in experimental wounds bathed in solution in cups superglued to the surrounding tissue (Dillon, R.S.: Role of cholinergic nervous system in healing neuropathic lesions; Preliminary studies and prospective, double-blinded placebo-controlled studies. Angiology 42:767-778, 1991).
Can saline stop wound healing? In patients with impaired blood flow, it most likely can as shown by the case below:
Here the islands of epithelial cells seen at 14 days were killed off with the application of saline wet-to-dry dressings required by the hospital pharmacy committee which at the time did not allow the use of Sea Soaks.
Soak solutions may be adjusted in tonicity to provide an osmotic pull far above that gained by commercial vacuum devices. Osmotic pressure [mmHg] = 19.3 x Osmolarity (milliosmole/liter). Normal osmolality is about 280 millosmols equivalent roughly to diluted Sea Soaks. Undiluted Sea Soaks has about 840 milliosmols, three times as much. Sea Soaks thus has 19.3 x 280 or a 5404 mmHG osmotic pressure pull versus distilled water and undiluted Sea Soaks 16212 mmHG or 10808 mmHg more. "Cup therapy" has long been practiced as an economical vacuum technique. A heated cup is placed over a wound and allowed to cool thus producing a vacuum within it. A cup with a radius of 6cm and an inner radius of 5.5cm has a rim area of 3.1416 x 36 - 3.1416 x 30.25 or 5.75 x 3.1416 or 18.06 sq cm. Atmospheric pressure is 14.7 lbs/sq inch or 2.28 lbs/sq cm. If the pressure within the cup is reduced 2 lbs/sq inch, or 0.31 lbs/sq cm, then 35 lbs pressure is being exerted on the cup by the atmosphere giving a pressure of 1.94 pounds per sq cm under the rim or 12.5 lbs/sq inch. Such pressure on the rim leaves a significant dent in the skin and may impede blood flow under the rim. Such calculations are unnecessary with the use of Sea Soaks and Sea Soaks Concentrate. Further, sequential soaks using Sea Soak Concentrate in the Miniboot to debride and clean a wound followed by the application of dilute Sea Soaks containing an appropriate antibiotic has the advantage of using great osmotic force to introduce the antibiotic into cells and tissue where bacteria may otherwise hide untouched.