Neonatal Skin Injuries

Size: px

Start display at page:

Download "Neonatal Skin Injuries"

Marianna Lewis
5 years ago
Views:

1 Neonatal Skin Injuries Barb Haney, RN, MSN, RNC-NIC, CPNP-AC The Children s Mercy Hospital, 2017

2 Disclosure I have no financial relationships with the manufacturers of any commercial products although I wish I had the perfect tape! 2

3 Objectives Recognize differences in premature, infant, adult skin Identify MARSI prevention Identify optimum skin care products for the NICU patient 3

4 Understand skin Evaluate products Skin Injuries Prevention essential not focus on treatment 4

5 Adaptation to Extrauterine Environment Warm, hydrated, friction-less sterile environment Sudden exposure to oxygenated harsh extrauterine environment fraught with micro-organisms, wide temperature & humidity changes Skin has to evolve for present and future survival 5

6 Neonatal Skin: Anatomic and Functional Differences Neonatal stratum corneum 30% thinner than adult, epidermis 20-30% smaller Keratinocyte cells smaller, higher cell turnover rate wounds heal faster! Dermis has shorter collagen fibers, absent reticular layer skin feels softer! 6

Stratum Corneum: Comparison of Adult, Term and Premature Infant Fetal skin development starts 4-5 wk By 4 th month epidermis & dermis show clear architectural

7 Stratum Corneum: Comparison of Adult, Term and Premature Infant Fetal skin development starts 4-5 wk By 4 th month epidermis & dermis show clear architectural arrangement but minimally functional Minimal SQ fat 10x TEWL Rapid maturation over first 2 weeks but can take 4 weeks (Neonatal Skin: Structure and Function, 1982) 7

8 Premature Infants and TEWL 8

9 Cohesion Between Epidermis and Dermis Top 2 layers of skin connected by fibrils Fewer and further apart in premature infants Implications for adhesive removal 9

10 Medical Adhesives Different grades of medical adhesives Critical devices. Challenging environments Not all acrylate adhesives are the same 10

11 Medical Adhesives Tape Dressings Electrodes Ostomy supplies Patches Securement devices IV securements Temp and O 2 sensor probes Tegaderm DuoDerm Derma Gel Mepilex dressings Many others 11

12 Medical Adhesives in the NICU Acrylates (Transpore, paper, cloth) Zinc oxide (pink tape) Hydrocolloids (Duoderm, Brava Hydrogel (electrodes) Polyurethane + acrylate (transparent dressings) Silicone 12

13 Silicone Adhesives Adhere well to skin, hair Gentle when removed, can be replaced Won t stick to plastic 13

14 MARSI Medical Adhesive Removal Skin Injury Adhesive removal is the primary cause of neonatal skin injury The Children s Mercy Hospital,

15 Epidermal Stripping 15

16 PollEverywhere What causes epidermal stripping? A. Aggressive tape adhesive B. Tackifiers such as mastisol/benzoin C. Incorrect tape removal D. Frequent re-taping of the same area E. All of the above 16

17 MARSI Skin Injuries Skin tears Tension Blisters 17

18 Irritant Contact Dermatitis Transparent dressing Hydrogel EKG electrodes

19 PollEverywhere How can Contact Dermatitis from medical adhesives be prevented? A. Assure skin is clean & dry before applying tape B. Avoid using tackifiers such as Mastisol/Benzoin C. Protect skin with alcohol-free skin prep, allowing to dry completely before applying tape D. All of the above 19

20 What can we do? Skin preparation Adhesive product selection Adhesive product application Adhesive product removal

21 Skin Prep Body part: contoured or flat? Potential to stretch? Edema, distention or movement? Skin condition: dry or moist? Oily? Intact or damaged? Length of wear: short time or longer wear time? Allow any skin prep to dry completely Remove excessive hair? Make sure skin is clean and dry AVOID tackifiers like Mastisol/Benzoin Routine use not recommended in newborns can increase epidermal stripping

22 Silicone Barrier Films Plastic polymers sprayed or wiped on skin to protect from trauma Alcohol-free products less irritating 22

23 Adhesive Product Selection What level of securement is needed? Critical securement or heavy tubing such as ET or NGT. Low to medium adhesion for anchoring dressings or securing lightweight tubes/devices such as IV tubing. Choose gentlest tape for the job Minimize touching the adhesive reduces ability to secure

24 Application techniques Choose gentlest tape for the job Minimize touching the adhesive reduces ability to secure Apply with sufficient pressure to activate pressure-sensitive adhesives but not stretched Spiraling down/up tubing adds securement with more surface area covered Secure the TUBE (omega technique/chevron) Ω Tape parallel to an incision: consider where tape needs to stretch Pressure needed at site? Place tape on one side of dressing, stretch over dressing and place on next side Tape parallel to an incision

25 Adhesive Product Removal DO NOT grip and rip!! Causes tenting of skin and separation of layers! L-O-W and S-L-O-W Fold back adhesive onto itself and peel back slowly Transparent dressing stretch to release adherence Adhesive removers

26 Adhesive Removal Products Alcohol/organic based solvents Contain hydrocarbon derivatives or petroleum distillates Toxicity Case report of skin injury & hemorrhage after exposure to Detachol Oil based solvent Paraffin based, mineral oil, citrus based Oily residue..can t replace adhesive Silicone-based remover Black, 2007

over one edge of film and pull back until the dressing begins to lift

27 Transparent Dressing Application Don t stretch as put down Press down for activation walking the border off Removal Use tape tabbing place tape over one edge of film and pull back until the dressing begins to lift Stretch to break the adhesion Support skin under film where stretch is occurring

28 Pressure Injury Device related Immobility Proceduures 28

29 Pressure Injury 29

30 PollEverywhere What are strategies to prevent pressure injuries? A. Pad devices B. Rotate devices such as NIV CPAP interfaces C. Reposition baby D. Remove linen wrinkles, caps/items/stuff in the bed E. Assess the skin under medical devices frequently F. Pressure redistribution surfaces G. All of the above 30

31 Disinfectants Necessary Evaluate risk/benefit efficacy systemic toxicity potential..preservatives skin irritation, chemical burns contact dermatitis 31

32 Disinfectants Increased risk of toxicity Stratum corneum less developed 2-3 layers in premature < 28 weeks Term newborn more layers but 30% thinner c/w adults Ratio surface area/body weight increased.. Increased absorptive surface Immature detoxification mechanisms in newborns kidney/liver Skin more permeable & fragile in some areas Antecubital, groin, axilla, groin (intertriginous areas) 32

33 PollEverywhere There is evidence available to recommend a single skin disinfectant product for all neonates. A. True B. False 33

34 Disinfectants Chlorhexidine gluconate (CHG) 2% CHG Aqueous 0.5%,2%, 3.15% in 70% alcohol Providone Iodine Isopropyl alcohol 34

35 Disinfectants - Efficacy Adults: CHG reduces CLABSI risk; CDC strongly recommends for insertion & dressing changes Neonates: CHG reduces skin colonization, reduces blood culture contamination but no evidence for reducing CLABSI Longer dwell times Skin only 20% source of infection 70% due to intraluminal (tubing source) Care of IV tubing, line access most important Mermel, L. Clin Infect Dis,

36 Disinfectants Thyroid Dysfunction 12-33% of exposed premature infants had thyroid dysfunction; 0 if not exposed Exposure of very premature infants to topical iodine disinfectants causes thyroid dysfunction the extent and long term effects unknown Aitken J. & Williams F., Arch Dis Child Fetal Neonatal Ed.,

prep, Neurotoxicity CHG inhibits neurite growth,?

37 Disinfectant CHG & Toxicity Chemical burns Irritant contact dermatitis Clings to the stratum corneum cells even after rinsing Anaphylaxis Mucous membranes, repeated exposure surgical prep, Neurotoxicity CHG inhibits neurite growth,?? if CHG crosses the blood-brain barrier 70% had measurable CHG levels increased 2 days after exposure Lund, Advances in Neonatal Care,

38 Disinfectants - Alcohol Chemical burns reported in babies wk 38

39 Skin Antisepsis in Neonate What Should We Use? No robust evidence to recommend any topical antiseptic over another Large trials with clinically relevant endpoints are now underway CHG/70% IA vs PI prior to PICC or umbilical catheter insertion in preterm infants; n=304 (European Medicines Agency) Efficacy study comparing 2%CHG/IA vs. 2% aqueous CHG for PIV insertion; 462 infants <1500 g; primary outcome bacterial colony count (NLM, Clinical Trials #NCT ) Survey indicates that 61% of NICUs use CHG some restrict by weight, GA Chapman, Aucott, Milstone (2012) J Perinat 32:4-9 Ponnusamy, et al., Curr Opin Infect Dis,

40 FDA labeling for CHG/alcohol products Use with care in premature infants less than 2 months of age. These products may cause irritation or chemical burns. 40

41 PollEverywhere What should be done to minimize the risk of skin irritation and chemical burns when disinfecting skin before invasive procedures? A. Avoid pooling of solutions under the baby B. Remove all disinfectants as completely as possible with sterile water or saline after the procedure is complete C. Use sterile water only for skin antisepsis before an invasive procedure D. A & B 41

42 Diaper Dermatitis Prevention is key Standardized approach 42

43 References Aitken J, Williams FL. (2014). A systematic review of thyroid dysfunction in preterm neonates exposed to topical iodine. Arch Dis Child Fetal Neonatal Ed. 99(1):F21-8. Black, P. (2007). Peristomal skin care: An overview of available products. British Journal of Nursing, 16, 1048, 1050, Chapman, AK, Aucott, SW, & Milstone, AM. (2012). Safety of chlorhexidine gluconate used for skin antisepsis in the preterm infant. Journal of Perinatology, 32:4-9. Dryer, JA. (2013). Newborn skin care. Seminars in Perinatology, 37, 3-7. Lund C. (2018). Bathing and beyond. Advances in Neonatal Care. 16(5S), S13-S20. Lund, C. (2014). Medical adhesives in the NICU. Newborn & Infant Nursing Reviews. 14(4): Lund, C.(2013). Neonatal skin care evidence-based clinical practice guideline, 3 rd edition. AWHONN Maibach, HI, Boisits, EK,(1982). Neonatal Skin: Structure and Function. Dekker, M, Universitiy of Michigan. 43

44 References McManus Juller, J. (2018). Infant skin care products what are the issues?. Advances in Neonatal Care. 16(5S) S3-S12. McNichol, L., Lund, C., Rosen, T., Gray, M. (2013). Medical adhesives and patient safety: state of the science. Journal of Wound Ostomy Continence Nursing. Vol. 40 No. 4. July/August, 55. Mermel, LA. (2011). What is the predominant source of intravascular catheter infections? Clinical Infectious Diseases, 52, Ponnusamy,V, et al.(2014). Skin antisepsis what should we use? Curr Opin Infect Dis. 27(3), Sathiyamurthy et al. (2016). Antiseptic use in the neonatal intensive care unit a dilemma in clinical practice: an evidence based review. World J Clin Pediatr, 5(2), Usatine, RP, Riojas, M. (2010). Diagnosis and Management of Contact Dermatitis. Am Fam Physician Aug 1;82(3):

Evidence-Based Skin Care for Newborns

Evidence-Based Skin Care for Newborns PEC Fall, 2015 Objectives Discuss pertinent elements of national guidelines related to NB skin care Identify areas in your setting that might be enhanced by use of