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Show detailsContinuing Education Activity
Dakin solution, also called Dakin fluid or Carrel-Dakin fluid, is a dilute sodium hypochlorite (NaClO) solution commonly known as bleach. The sodium peroxide (NaO) and hydrochloric acid (HCl) mixture produces sodium hypochlorite. The main active agent in Dakin solution is created when the chlorine reacts with water in the environment to form hypochlorous acid (HClO). This hypochlorous acid produces a potent antibacterial effect in tissues. This activity reviews the mechanism of action, adverse event profile, toxicity, and administration of Dakin solution as it applies to the clinical setting.
Objectives:
- Identify the indications for the use of Dakin solution in a clinical setting.
- Explain the potential adverse effects of Dakin solution.
- Describe the various strengths of Dakin solution and which is best in the clinical setting.
- Explain the importance of improving care coordination among the interprofessional team to enhance patient care delivery when using Dakin solution for its intended indications.
Indications
Dakin solution, also called Dakin fluid or Carrel-Dakin fluid, is a dilute sodium hypochlorite (NaClO) solution commonly known as bleach.[1] The sodium peroxide (NaO) and hydrochloric acid (HCl) mixture produces sodium hypochlorite. The main active agent in Dakin solution is created when the chlorine reacts with water in the environment to form hypochlorous acid (HClO). This hypochlorous acid produces a potent antibacterial effect in tissues. Neutrophils of the human immune system produce small amounts of hypochlorous acid inside phagosomes, which are used to digest bacteria and viruses. Unlike stronger germicidal solutions that contain carbolic acid or iodine, Dakin does not damage living cells or lose potency in the presence of blood serum. It has a solvent action on dead cells that hastens the separation of dead tissue from living tissue. Sodium hypochlorite solution must be buffered before use. The most commonly used substances are boric acid and sodium bicarbonate.
English chemist Henry Dakin and French surgeon Alexis Carrel developed a Dakin solution to clean and rinse wounds. It was originally formulated as a battlefield wound antiseptic during World War I.[2] They devised the Carrel-Dakin treatment to irrigate wounds after surgical debridements were performed to preserve and save limbs. As a result of their work, Dakin solution has saved many lives (and limbs) since its creation.[3] The low cost and effectiveness of Dakin solution make this bactericidal antiseptic very popular in the healthcare field. It treats or prevents infections from cuts, abrasions, lacerations, skin ulcers, stage I to IV pressure ulcers, first- and second-degree burns, and even during surgery.[2] Its efficacy has been compared to negative pressure wound therapy for treating diabetic foot ulcer infections.[4] This is why Dakin solution (usually in a diluted form) continues to be used in practice today.[5]
Mechanism of Action
Dakin solution is a strong topical antiseptic widely used to clean infected wounds, ulcers, and burns.[6] Full-strength Dakin solution is usually diluted in water, depending on its intended use. A 0.5% solution of hypochlorite (containing approximately 5000 ppm free chlorine) is used for disinfecting areas contaminated with bodily fluids, including large blood spills (after the area has been cleaned with a detergent). Dilute Dakin solution (0.05% to 0.025%) can be used to irrigate, cleanse, or as a component in wet-to-dry dressings to treat or prevent skin and soft tissue infections.[5]
The mechanism of action of Dakin solution is mostly unknown, but it acts as a germicidal, bacteriostatic topical agent that can dissolve necrotic tissue debris. Dakin solution is effective against a broad spectrum of aerobic and anaerobic bacteria, viruses, fungi, and spores. It has bactericidal activity against a variety of organisms, including Enterococcus, Streptococcus mitis, Staphylococcus aureus, Staphylococcus epidermidis, Escherichia coli, Klebsiella pneumonia, Enterobacter cloacae, Serratia marcescens, Proteus mirabilis, and Pseudomonas aeruginosa. It has even been effective against organisms highly resistant to antibiotics, such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus.[7][1]
Administration
Due to its properties as an acid-based compound, Dakin solution can be corrosive to healthy tissue, especially at higher concentrations. An oil-based ointment such as petroleum jelly can be applied to surrounding healthy tissue to reduce skin irritation and prevent the debridement of viable tissue. Dakin solution also loses its antiseptic properties rapidly after application due to the instability of the compound. Therefore, gauze sponges soaked with Dakin used to pack necrotic wounds must be frequently changed. It is usually applied twice daily to lightly to moderately exudative wounds and twice daily for highly exudative or contaminated wounds.[5]
Adverse Effects
Dakin solution's most common side effects include redness, swelling, and skin irritation. The main concerns for using Dakin fluid are allergic reactions, skin hypersensitivity, and impaired wound healing, which can occur when using high concentrations of Dakin due to fibroblast toxicity.[8] Dakin solution is often used in pregnancy and lactation because there is limited systemic absorption. However, it is classified as a category C agent by the FDA. Dakin has shown adverse fetal effects in animal reproduction studies, but there have been no adequate, well-controlled human studies. For this reason, the potential benefits of the solution in pregnant women warrant its use, notwithstanding the possible risk to the fetus.
The labeling on Dakin solution may cause some confusion for healthcare providers regarding its strength. The labels list strengths as full strength at 0.5%, half strength at 0.25%, and quarter strength at 0.125%. This terminology can confuse healthcare providers, considering that half and quarter strengths correspond to 0.5% and 0.25%, respectively. Of note, most hospitals use a modified Dakin solution of 0.025% for wound care, and studies have suggested that concentrations of Dakin solution greater than 0.025% may potentially be harmful to wound healing.[9]
Contraindications
Contraindications to using Dakin solution include hypersensitivity to sodium hypochlorite, chlorine compounds, or any formulation component. Concomitant use of taurolidine (an antimicrobial used to prevent catheter infections) may enhance sodium hypochlorite's adverse/toxic effect. Specifically, concomitant use of taurolidine and sodium hypochlorite may increase the risk of metabolic acidosis.[1]
Monitoring
Wounds only need to be monitored to ensure proper healing. If there appears to be an adverse reaction when applying Dakin solution, it should be discontinued immediately.
Toxicity
Ingesting diluted sodium hypochlorite generally causes only mild stomach irritation; however, swallowing larger amounts can cause more serious symptoms, including chest pain, delirium, hypotension, burns to the gastrointestinal tract, shock, bradycardia, nausea, and vomiting.[10] The concentration of sodium hypochlorite in industrial-strength bleach is high and may cause severe injury.[8] Never mixing ammonia with sodium hypochlorite (bleach or bleach-containing products) is important. This mixture can produce toxic chlorine gas that can cause choking and serious breathing problems. HCl is formed when chlorine gas contacts moist tissues like the eyes or lungs. HCl is a digestive juice that damages tissue; it can damage the airways, cause asphyxiation, and result in death. It is important to note that activated charcoal does not effectively treat (adsorb) sodium hypochlorite. Treatment depends on the severity of the toxicity with medical management for mild-moderate cases of toxicity to surgery if there are perforations noted along the gastrointestinal tract.
Enhancing Healthcare Team Outcomes
Dakin solution bactericidal antiseptic is very popular. Clinicians (MDs, DOs, DPMs, NPs, and PAs), surgeons, nurses, and pharmacists should know its use, appropriate concentrations, and potential adverse effects. It treats or prevents infections from cuts, abrasions, lacerations, skin ulcers, stage I to IV pressure ulcers, first- and second-degree burns, and even during surgery. An interprofessional team approach to its use provides the best patient outcomes.[11]
References
- 1.
- Levine JM. Dakin's solution: past, present, and future. Adv Skin Wound Care. 2013 Sep;26(9):410-4. [PubMed: 23958873]
- 2.
- Georgiadis J, Nascimento VB, Donat C, Okereke I, Shoja MM. Dakin's Solution: "One of the most important and far-reaching contributions to the armamentarium of the surgeons". Burns. 2019 Nov;45(7):1509-1517. [PubMed: 30591251]
- 3.
- Sabbatani S, Fiorino S. The treatment of wounds during World War I. Infez Med. 2017 Jun 01;25(2):184-192. [PubMed: 28603241]
- 4.
- Duarte B, Formiga A, Neves J. Dakin's solution in the treatment of severe diabetic foot infections. Int Wound J. 2020 Apr;17(2):277-284. [PMC free article: PMC7948601] [PubMed: 31721437]
- 5.
- McCullough M, Carlson GW. Dakin's solution: historical perspective and current practice. Ann Plast Surg. 2014 Sep;73(3):254-6. [PubMed: 25121415]
- 6.
- Duarte B, Cabete J, Formiga A, Neves J. Dakin's solution: is there a place for it in the 21st century? Int Wound J. 2017 Dec;14(6):918-920. [PMC free article: PMC7949605] [PubMed: 28198104]
- 7.
- Schmidt K, Estes C, McLaren A, Spangehl MJ. Chlorhexidine Antiseptic Irrigation Eradicates Staphylococcus epidermidis From Biofilm: An In Vitro Study. Clin Orthop Relat Res. 2018 Mar;476(3):648-653. [PMC free article: PMC6260035] [PubMed: 29443852]
- 8.
- Aubut V, Pommel L, Verhille B, Orsière T, Garcia S, About I, Camps J. Biological properties of a neutralized 2.5% sodium hypochlorite solution. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010 Feb;109(2):e120-5. [PubMed: 19969489]
- 9.
- Cardile AP, Sanchez CJ, Hardy SK, Romano DR, Hurtgen BJ, Wenke JC, Murray CK, Akers KS. Dakin solution alters macrophage viability and function. J Surg Res. 2014 Dec;192(2):692-9. [PubMed: 25130774]
- 10.
- Slaughter RJ, Watts M, Vale JA, Grieve JR, Schep LJ. The clinical toxicology of sodium hypochlorite. Clin Toxicol (Phila). 2019 May;57(5):303-311. [PubMed: 30689457]
- 11.
- Armstrong DG, Bohn G, Glat P, Kavros SJ, Kirsner R, Snyder R, Tettelbach W. Expert Recommendations for the Use of Hypochlorous Solution: Science and Clinical Application. Ostomy Wound Manage. 2015 May;61(5):S2-S19. [PubMed: 28692424]
Disclosure: Michael Keyes declares no relevant financial relationships with ineligible companies.
Disclosure: Zohaib Jamal declares no relevant financial relationships with ineligible companies.
Disclosure: Rachel Thibodeau declares no relevant financial relationships with ineligible companies.
- Review Historical review of Dakin's solution applications.[J Plast Reconstr Aesthet Surg....]Review Historical review of Dakin's solution applications.Ueno CM, Mullens CL, Luh JH, Wooden WA. J Plast Reconstr Aesthet Surg. 2018 Sep; 71(9):e49-e55. Epub 2018 Jun 8.
- Antimicrobial efficacy of chlorine agents against selected oral pathogens.[Clin Oral Investig. 2023]Antimicrobial efficacy of chlorine agents against selected oral pathogens.Almhöjd US, Lehrkinder A, Roos-Jansåker AM, Lingström P. Clin Oral Investig. 2023 Sep; 27(9):5695-5707. Epub 2023 Aug 22.
- Tissue-dissolving capacity and antibacterial effect of buffered and unbuffered hypochlorite solutions.[Oral Surg Oral Med Oral Pathol...]Tissue-dissolving capacity and antibacterial effect of buffered and unbuffered hypochlorite solutions.Zehnder M, Kosicki D, Luder H, Sener B, Waltimo T. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002 Dec; 94(6):756-62.
- Review The clinical toxicology of sodium hypochlorite.[Clin Toxicol (Phila). 2019]Review The clinical toxicology of sodium hypochlorite.Slaughter RJ, Watts M, Vale JA, Grieve JR, Schep LJ. Clin Toxicol (Phila). 2019 May; 57(5):303-311. Epub 2019 Jan 28.
- The Continued Utility and Viability of Dakin's Solution in Both High- and Low-resource Settings.[Arch Bone Jt Surg. 2020]The Continued Utility and Viability of Dakin's Solution in Both High- and Low-resource Settings.Ottesen TD, Qudsi RA, Kahanu AK, Baptiste BJ, Woolley PM, Socci AR, Dyer GSM. Arch Bone Jt Surg. 2020 Mar; 8(2):198-203.
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