Comparative Study: Use Of 0.9% Normal Saline Irrigation Liquid and 10% Povidone-Iodine in The Process of Laparatomy Sectio Caesarea Operation in Hospital

How to Cite Dedi Kurnia/Comparative Study: Use Of 0.9% Normal Saline Irrigation Liquid and 10% Povidone-Iodine in The Process of Laparatomy Sectio Caesarea Operation in Hospital. Vol. 1, No. 11, August 2022 DOI https://doi.org/10.54543/kesans.v1i11.99 e-ISSN/p-ISSN 2808-7178 / 2808-7380 Published by Rifa’Isntitute Comparative Study: Use Of 0.9% Normal Saline Irrigation Liquid and 10% Povidone-Iodine in The Process of Laparatomy Sectio Caesarea Operation in Hospital


Introduction
Wounds that arise from the surgical process are acute wounds that occur suddenly in the skin area with the wound healing time adjusted to the estimate if there are no complications, so that surgical wound management must be carried out properly so that the wound healing process can be as expected, and how to treat the wound. . Based on this, so that the wound healing process can match expectations and the estimated time, the researchers conducted a study on possible barriers to the wound healing process. This is in accordance with the research of Barung, Sapan, Sumanti, & Tubagus (2017), which suggests barriers to wound healing due to surgical wound infections, where these barriers are one of the main complications of surgery that can increase morbidity, mortality, and hospitalization costs. This causes the wound healing time to be longer or the wound takes longer to heal. Wounds that take a long time to heal will be accompanied by a decrease in the patient's immune system, so the wound can be susceptible to exposure to microorganisms that can cause infection.
Microorganisms that cause surgical wound infections can come from the body or from outside the body. The surgical wound infection is a complication of surgery that can arise during hospitalization or when the patient returns home. Furthermore, the risk factors that cause surgical wound infection are multifactorial, which are divided into 1) preoperative factors (hospitalization, use of prophylactic antibiotics, and skin disinfection before surgery); 2) intraoperative factors (duration of surgery, wound contamination, wound hemostasis and tissue damage); 3) postoperative factors (blood sugar, wound care and observation); and 4) the patient's own factors (preoperative infection factors, diabetes, long-term steroid use, smoking and malnutrition) (El-Neemany & Martens, 2017).
Another study conducted by Morison, M. J (2004), also suggested the inhibiting factors for wound healing, namely: 1) local factors present in the area where the wound is located so that it can slow down wound healing such as hypoxia, dehydration, excessive exudate, lowering of temperature. , necrotic tissue, excessive crusting, presence of foreign bodies, and repeated trauma; 2) general pathophysiological factors such as the physiological effects of naturally occurring aging; 3) Psychosocial factors; 4) Effect of cytotoxic drugs, radiotherapy and steroid therapy; and 5) Improper wound management, especially the type of fluid used for wound irrigation. Wound irrigation is considered as one of the most useful surgical site infection prevention methods for many surgeons as many as 97% of surgeons perform wound irrigation during surgery (APSIC, 2018).
The use of wound irrigation fluid or wound washing fluid used during intraoperative can also be an inhibiting factor, so that it can interfere with the wound healing process in the body. This is because the antiseptic content in the wound wash or wound cleanser can not only kill germs, but can also kill leukocytes, and kill pathogenic bacteria and fibroblast for the formation of new skin tissue (Thomas et al., 2009).
Wound washing intra-operative should be an important concern. There are several types of irrigation fluids that can be used, such as: normal saline 0.9%, povidone-iodine 10%, sterile water, tap water, commercially available products (eg: foams, soaps, wipes and solutions with surfactants), hydrogen peroxide, polyhexamethylene biguanide (PHMB) 0.1%, octenidine, hypochlorous acid 0.01% (Wolcott & Fletcher, 2014) nd super Dedi Kurnia/KESANS Comparative Study: Use Of 0.9% Normal Saline Irrigation Liquid and 10% Povidone-Iodine in The Process of Laparatomy Sectio Caesarea Operation in Hospital oxidized solution and normal saline 0.9% (Gutierrez AA (2006). everal types of fluids that can be used, each has advantages and disadvantages in its use. However, of the several types of fluids, which are generally often used in every hospital for intraoperative use are povidone-iodine 10% and normal saline 0.9% AHCPR (Agency for Health Care Police and Research) in 2001, which suggested that the recommended cleaning fluid is normal saline 0.9%, because the fluid is a physiological fluid and will not harm the wound (Potter, P. A 2006). However, research conducted by Gitarja, W. S (2008), found that povidone-iodine will cause the wound to dry up and the wound is considered to have healed even though it can eventually cause blackened scars and scar tissue, the liquid is corrosive and damaging. Fibroblast tissue which is needed in the wound healing process.
In contrast to these studies, WHO stated that there was insufficient evidence to recommend or not recommend the use of irrigation of 0.9% normal saline to the incision wound prior to closure for the purpose of preventing SSI (operative site infection). However, based on the WHO guidebook, it was stated that based on the results of a metaanalysis of seven randomized control trials (RCTs) it was found that 10% povidoneiodine was more effective than 0.9% normal saline with OR: 0.31; 95% CI: 0.13-0.73; P=0.007. Therefore consideration of using water 10% povidone-iodine prior to wound closure is recommended especially for clean and clean-contaminated wounds, but concerns remain regarding allergic reactions and adverse metabolic events due to iodine uptake.
Currently, many surgeons are currently using normal saline 0.9% instead of 10% povidone-iodine. Many methods have been developed to assist wound healing, including intraoperative use to treat wounds, one of which is normal saline 0.9% povidone-iodine. So far, for the use of irrigation fluids, there are still pros and cons so that further research is needed, especially to prove which irrigation fluid is more effective in the wound healing process (APSIC, 2018).
Based on the results of an initial survey conducted by researchers at one of the hospitals (RS) in the city of Bandung, namely Bhayangkara TK II Sartika Asih Hospital, Bandung, data were obtained that the four doctors (2 general surgeons and 2 obstetricians and gynecologists) were in the hospital. They have different wound irrigation or wound washing techniques intra-operatively. Some used povidone-iodine 10% normal saline at the hospital, which is a POLRI referral hospital in West Java with C accreditation. In addition to this, researchers also found a problem, namely the absence of Standard Operating Procedures. (SOP) regarding what irrigation fluid should be used in laparotomy surgery which caused differences in the use of irrigation fluid for the four doctors. In addition, the results of a survey to other hospitals in the city of Bandung with a type C accredited hospital, namely Pindad Hospital, irrigation used during intraoperative all used 0.9% normal saline and had a specified SOP so that the use of irrigation fluid had been determined. This study aims to determine the difference between the use of normal saline 0.9% saline and povidone-iodine with the wound healing process after laparotomy sectio caesarea Dedi Kurnia/KESANS Comparative Study: Use Of 0.9% Normal Saline Irrigation Liquid and 10% Povidone-Iodine in The Process of Laparatomy Sectio Caesarea Operation in Hospital

Method
The design used in this research is an ex post facto comparative, namely research that compares the existence of one or more variables in different samples with a retrospective (Sugiyono, 2011). Data retrieval using This study uses secondary data studied from the medical records of Bhayangkara Hospital TK II Sartika Asih Bandung in 2019, from patient characteristics data including perioperative with researchers wanting to know the condition of the wound on day 5-7 postoperative laparotomy, which was irrigated on during intra-operative closure subcuticular with the use of different fluids, respondents were divided into two groups, namely group one using povidoneiodine and the second group using 0.9% normal saline.
In this study, in laparotomy, infection will be identified at this time and then associated with risk factors, namely irrigation fluid used intra-operatively before closure of the surgical wound.

Schematic of Comparative Study Design
Description: R : Respondent O1 : Use of wound irrigation using povidone-iodine 10% O2 : Use of wound irrigation using normal saline 0.9% X1 : Observation of post-operative lapparatus after using povidone-iodine 10% X2 : Observation of post-operative laparotomy after normal 0.9%

Population and Sample
The population in this study were patients with post-operative laparotomy SC in 2019, totaling more than 618 patients from 2 doctors or doctors in charge of patients (DPJP) who were at Bhayangkara TK II Sartika Asih Hospital Bandung. sampling technique in this study uses a non-probability sampling technique, namely a sampling technique that does not provide equal opportunities / opportunities for each member of the population to be sampled, using the census technique or the total population is a sampling technique where all members of the population are sampled all (Sugiyono, P.D. 2018).
The sample in this study were 440 respondents, namely post-laparatomy SC who had wounds and were irrigated povidone-iodine 10%normal saline at the time of intraoperative with the inclusion criteria of SC laparotomy taken. From the data contained in the medical record, he has good general condition, normal vital signs, does not have a history of surgery for more than five hours, is not anemic, has normal weight and has no comorbidities at the time of pre-operative. Sampling taken from medical records is data from respondents who came after post-operative days 5-7 or at the time of the first control. The sample, consisting of 2 different DPJPs and 2 DPJPs performed wound irrigation intra-operatively, some used 0.9% normal saline and some used povidone-iodine during wound irrigation before skin closure.
This research was conducted at Bhayangkara TK II Sartika Asih Hospital, Bandung The results of this study discuss the univariate analysis of the percentage of the incidence of infection, both in wounds that receive normal saline 0.9% intra-operatively and in wounds that received povidone-iodine 10% intra-operatively. Furthermore, in the analysis of bivariate data, the researchers discussed the differences in the use of irrigation fluids given intra-operatively.

Variable Frequency Distribution of Fluids
Data analysis in this section describes the variable frequency distribution of fluids used for intra-operative and the state of the wound at the first control at 5-7 postoperative days.  Based on Table 2, a small percentage of the incidence of infection occurred in patients with povidone-iodine as many as 36 respondents (12%). The same thing also happened in patients with normal saline irrigation of 0.9%, it was known that only a small proportion had infection, namely as many as 7 respondents (5%).

Differences in the Use of Normal Saline 0.9% and Povidone-iodine Wound Healing the Laparotomy SC
Data analysis in this section will describe the significant differences between the fluid variables used for intraoperative and the wound condition at the time of control. The first is the 5-7th postoperative day.  Table 3 based on the results of statistical analysis of the Chi-square test, shows that there is a significant comparison between the two types of anesthesia used for surgery, namely general narcotic anesthesia and spinal anesthesia for postoperative side effects with a value (p-value = 0.026).
Dedi Kurnia/KESANS Comparative Study: Use Of 0.9% Normal Saline Irrigation Liquid and 10% Povidone-Iodine in The Process of Laparatomy Sectio Caesarea Operation in Hospital

Percentage of Fluid Variable Frequency Distribution The
Percentage results of the fluid variable frequency distribution in this study, showed that the two types of fluids used for irrigation, both normal saline 0.9% and povidoneiodine 10% had a percentage of the incidence of infection only a small part of each. each total population that causes infection based on the standard infection prevention and control (PPI) which states the standard of infection must be below 2% per month. This is seen based on medical records during the first control day 5-7 postoperatively. However, when viewed from the number of respondents adjusted to the total number of respondents for each treatment, respondents with povidone-iodine experienced the most infections compared to 0.9% normal saline.
It is also supported by Wolcott & Fletcher (2014) who suggested that composition of 0.9% saline has low toxicity to wounds, and has limited ability to reduce bacterial load. In line with this, Potter & Perry (2005) lso suggested that normal saline 0.9% is an isotonic solution that is safe for the body, does not cause irritation, protects granulation tissue from dry tissue conditions, maintains moisture around the wound, in addition to the use of fluids. This can minimize the risk of postoperative infection in the wound healing process. It is well known that postoperative infection is one of the most common hospital infections and contributes substantially to postoperative morbidity and mortality. In addition, postoperative infections can increase the cost of care and length of stay in the hospital (Barung, Sapan., Sumanti, & Tubagus, 2017).
Preventive measures to prevent postoperative infection are needed, starting from perioperative one of which is by paying attention to the use of irrigation fluids to be used intraoperatively. Wound irrigation of intraoperative subcutaneous soft tissue before skin closure is an easy and economical option to reduce postoperative infection rates and has been widely used in clinical practice. However, there is currently no definite recommendation regarding the use of normal 0.9% saline for intraoperative because research results supporting its use are lacking. Furthermore, regarding normal saline 0.9% in the WHO guidelines, it was stated that there was not enough evidence found to recommend or not recommend the use of irrigation of 0.9% normal saline to incisions before skin closure for the purpose of preventing SSI. Moreover, the National Institute for Health and Care Excellence (NICE) SSI prevention guidelines oppose the application of wound irrigation (APSIC., 2018).
However, doctors and nurses use normal saline 0.9% to keep the wound surface moist so as to promote the development and migration of epithelial tissue. Carefully cleaning the wound with normal 0.9% saline is a common method of wound healing and debridement of wet or dry wounds. Unlike the case with normal saline 0.9% for intraoperative wound irrigation, the type of 10% povidone-iodine solution which is an antiseptic-based solution has been recommended but still needs to be used with caution due to the high level of toxicity to the skin (APSIC., 2018).

Dedi Kurnia/KESANS Comparative Study: Use Of 0.9% Normal Saline Irrigation Liquid and 10% Povidone-Iodine in The Process of Laparatomy Sectio Caesarea Operation in Hospital
Based on some of these differences, the researchers conducted research, with the type of analytical research being ex post facto comparative. This aims to determine the difference in the use of normal saline 0.9% and povidone-iodine 10% intra-operatively. The data taken in this study are secondary data seen from the medical record of the patient's first control, namely on the 5-7th day after laparotomy surgery SC. However, the researcher felt that he had limitations, namely not being able to directly see the wound at the time of the first control patient so that the results obtained were only the results of reports in the medical record. This is due to the COVID-19 pandemic, so researchers cannot freely observe and assess the post-operative. Another limitation of this study is that researchers have difficulty in conducting a more in-depth discussion due to the limitations of the latest literature.

Differences in the use of normal saline 0.9% and Povidone-iodine Wound Healing Process the Laparotomy SC
Results of statistical analysis using Chi-square, showed that there was a significant difference between the two types of fluids used for intra-operative namely normal saline 0.9% and povidone-iodine 10% with the incidence of postoperative infection on day 5-7 at the time of the first control with a value (p. = 0.021) this shows that there are differences in wound irrigation using 0.9% normal saline and povidone-iodine due to different fluid characteristics.
Characteristics of normal saline 0.9% is a physiological solution with the body so it does not cause irritation and supports the growth of granulation. However, normal saline 0.9% is not an antiseptic so it cannot kill bacteria found in wounds, so its use is usually on clean wounds ( Lilley., Collins, & Snyder 1999). Laparotomy wound irrigation usually uses 0.9% normal saline . However, there is no adequate data regarding the impact of using this fluid on the prevention of SSI. The results of the RCT did not show a significant difference between irrigation with normal saline and no irrigation (OR: 1,09; 95% CI: 0,44-2,69; P=0,85).
WHO does not have sufficient evidence to recommend or discourage the use of irrigation of0.9% normal saline prior to closure of incisions for the purpose of preventing HAIs. Moreover, the HAIs prevention guidelines from the National Institute for Health and Care Excellence (NICE) oppose the application of wound irrigation (APSIC., 2018). owever, in contrast to Potter & Perry (2005) said that normal saline 0.9% is an isotonic solution that is safe for the body, does not cause irritation, protects granulation tissue from dry tissue conditions, maintains moisture around the wound and helps wounds undergo the wound healing process. operation. Nurses use normal saline 0.9% to keep the wound surface moist so that it can promote the development and migration of epithelial tissue. Carefully cleaning the wound with normal 0.9% saline is a common method of wound healing and debridement of wet or dry wounds.
Unlike the case with the characteristics found in povidone-iodine 10% which is bacteriostatic at a level of 640μg/ml and bactericidal at a level of 960 g/ml. In 10% povidone-iodine has 1% iodine which is able to kill bacteria in 1 minute and kill spores Dedi Kurnia/KESANS Comparative Study: Use Of 0.9% Normal Saline Irrigation Liquid and 10% Povidone-Iodine in The Process of Laparatomy Sectio Caesarea Operation in Hospital within 15 minutes. The mechanism of action of 10% povidone-iodine begins after direct contact with the tissue, the elemental iodine will be released slowly with the activity of inhibiting bacterial enzyme metabolism so that it interferes with bacterial multiplication which causes bacteria to become weak. complex compound of iodine with povidone. Povidone-iodine 10% has a composition of not less than 9.0% and not more than 12.0% iodine, calculated on the basis of the dried substance.solution 10% povidone-iodine reacts acidly to litmus paper. The solubility of 10% povidone-iodine is soluble in water and in ethanol, practically insoluble in chloroform, in carbon tetrachloride and in ether, in hexane, in acetone (Depkes RI, 1995).
Iodine that is absorbed or enters the bloodstream can cause systemic effects by causing tissue anoxia shock. Excessive use of iodine can inhibit the process of wound granulation, so that the side effects of 10% povidone-iodine when used on large damaged skin surfaces (eg burns) because iodine can be absorbed and increase serum levels so that it can cause acidosis, neutropenia and hypothyroidism. (Tjay, T. H. 2007).
WHO guidelines showed that 10% povidone-iodine was more effective than 0.9% normal saline in a meta-analysis that included seven RCTs (OR: 0.31; 95% CI: 0.13-0.73; P =0.007). Therefore, consideration of using 10% povidone-iodine prior to wound closure is recommended especially for clean and clean-contaminated wounds, but with the requirement that the patient's condition has a history of 10% povidone-iodine or not. Meanwhile, the Centers for Disease Control (CDC) recommends considering intraoperative irrigation of deep or subcutaneous tissues using a liquid-based iodophor solution for the prevention of SSI, but with weak recommendations. In addition, according to the National Institute for Health and Clinical Excellence (NICE) provides guidelines that irrigation of 10% povidone-iodine can reduce the incidence of SSI.
Therefore to prevent SSI, 10% povidone-iodine is only recommended for use on intact skin, and so they do not recommend the use of 10% povidone-iodine for surgical incisions prior to closure to prevent SSI. The clinical signs of iodine toxicity were not reported in the studies cited by WHO, but there are still concerns regarding allergic reactions and adverse metabolic events due to iodine uptake. This is in line with research conducted by Mahomed et al., (2016) that irrigation using 10% povidone-iodine solution may lead to an increased risk of postoperative readmission of intravenous antibiotics. The disadvantages of 10% povidone-iodine are that it has a broad spectrum of antimicrobial activity, is cytotoxic to healthy cells and granulation tissue in higher concentrations and often irritates the skin. Therefore, a 10% lack of povidone-iodine is good to use only for external skin disinfection so that bacteria do not rise to the incision wound.
According to Singh, S (2010), the side effects that arise with the use of 10% povidone-iodine are irritation, toxic reactions to skin fibroblasts, lungs, keratinocytes, and osteoblasts, sunburn and discoloration of the skin after using povidone-Iodine 10%. In addition, WHO raised concerns about the potential toxic effects of 10% povidoneiodine on fibroblasts, mesothelium, and tissue healing. (APSIC., 2018).

Povidone-Iodine in The Process of Laparatomy Sectio Caesarea Operation in Hospital
Wound healing is a form of business process to repair the damage that has occurred. The main component in the wound healing process is collagen in addition to epithelial cells. The collagen requires fibroblasts which are the cells responsible for synthesizing collagen. Furthermore, related to wound healing, it naturally goes through several phases, namely: 1. Acute inflammatory phase (0-3 days), which includes hemostasis, release of histamine and other mediators from damaged cells, and migration of white blood cells (leukocytes). polymorphonuclear and macrophages) to the site of the damaged tissue; 2. The destructive phase (1-6 days), which includes cleaning of dead and devitalized tissue by polymorphonuclear leukocytes and macrophages; 3. The proliferative phase (3-24 days), which occurs when new blood vessels, strengthened by connective tissue, infiltrate the wound; 4. The maturation phase (24-365 days), which includes the reepithelialization, wound contraction and connective tissue reorganization (Morison, M.J. 2004). In connection with this, if the wound healing process is longer or not like the process, the possibility of the wound healing process is hampered.
There are several factors that can inhibit wound healing, namely: 1) Local adverse factors at the wound site that can slow wound healing, including hypoxia, dehydration, excessive exudate, temperature drops, necrotic tissue, excessive crusting, presence of foreign bodies, and trauma repetitive; 2) Pathophysiological factors also affect the condition of wound healing, often complex, but some delays in wound occur due to the lack of available substances needed for the wound healing process, such as oxygen, amino acids, vitamins and minerals; 3) Intact wounds in healthy young adults are a good barrier against mechanical trauma and infection, as well as the efficiency of the immune system, cardiovascular system and respiratory system which allows wound healing to occur faster so that age contributes to delayed healing; 4) Lifestyle and psychosocial factors can affect wound healing. For example, smoking, alcohol, drug abuse, eating habits, obesity, malnutrition and levels of mobilization and activity. In addition, depression and mental illness can also affect the achievement of goals; 5) The therapy used by the patient also affects the delay in wound healing such as: Cytotoxic drugs, radiotherapy and steroid therapy in some circumstances can slow wound healing. Cytotoxic drugs such as vincristine have a very pronounced effect on wound healing because they interfere with cell proliferation. Long-term steroid therapy can also slow healing; and 6) In addition to therapeutic drugs used, unwise use of antiseptics can also cause problems in slowing wound healing, inappropriate use of topical antibiotics and other wound care medicinal ingredients, as well as careless wound dressing techniques are causes of delayed healing that can be avoided. Therefore, this study was conducted on the 5-7th post-operative because the wound was still kept clean, so that during control it could be known whether there was an infection or not.
Correspondingly, the infection can be a factor inhibiting wound healing. Based on the data obtained from the medical record, the researchers then analyzed using the Chisquare and it was found that there was a significant difference between the two types of fluids used for wound irrigation during intra-operatively, namely normal saline 0.9% and Dedi Kurnia/KESANS Comparative Study: Use Of 0.9% Normal Saline Irrigation Liquid and 10% Povidone-Iodine in The Process of Laparatomy Sectio Caesarea Operation in Hospital povidone-iodine. 10% with the incidence of postoperative infection on 5-7 days at the time of the first control with a value (p. = 0.021).
Everal other studies have suggested factors that can affect wound healing, namely age, anemia, personal hygiene followed by nutritional status (nutrient consumption) and comorbidities, (Vianti, 2015), (Chen, Han, Wang, & Li, 2017), (Damayanti, 2014), (Puspitasari., Ummah & Sumarsih, 2011), (Rivai., Koentjoro & Utarini, 2013), (Perangin., Isnaniah, & Rizani, 2014), (Gelaw., Aweke, & Astawesegn, 2017). This study used secondary data, namely medical records, then analyzed and found a significant difference between the two types of irrigation fluids, namely normal saline 0.9% and povidone-iodine 10%. The results of the analysis are supported by several theories/opinions/research which suggest that there are differences in composition between the two types of liquids, and have advantages and disadvantages. In connection with this, so that it can cause a healing effect on different postoperative wounds. It can be concluded that both fluids can be used for intraoperative with different characteristics that affect the post-operative.
The results of the research analysis showed that there were significant differences between the two irrigation fluids, but according to several theories and research, the differences were due to differences in the composition and characteristics of the irrigation fluids that had been used. However, the irrigation fluid can still be used for intraoperative purposes.
Furthermore, in this study there are still research limitations related to the inhomogeneity of the concentrate and components of the two irrigation fluids, this research was also not carried out directly. Therefore, the condition of the wound cannot be directly assessed and the researcher cannot explore other things related to the patient such as lifestyle

Conclusion
This study showed that there was a statistical difference between the two types of irrigation fluids, namely normal saline 0.9% and povidone iodine on the wound healing process by having different characteristics and composition of the fluid with a p-value of 0.021. The use of irrigation for normal saline 0.9% is a physiological solution with the body so that it does not cause irritation and supports the growth of granulation. However, normal saline 0.9% is not an antiseptic so it cannot kill bacteria found in dirty wounds so it is only good for clean wounds. However, for povidone-iodine, which is bacteriostatic, it has 1% iodine which can kill bacteria in 1 minute and kill spores in 15 minutes. However, excessive use of iodine can inhibit the wound granulation process. Due to the different compositions and characteristics of SC wound irrigation, it is better to use povidone-iodine first for 1 minute then irrigated with 0.9% normal saline.
Dedi Kurnia/KESANS Comparative Study: Use Of 0.9% Normal Saline Irrigation Liquid and 10% Povidone-Iodine in The Process of Laparatomy Sectio Caesarea Operation in Hospital