North Central Region WOCN 2018 Conference

9/11/2018

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North Central RegionWOCN 2018 Conference

Children’s Hospitals and Clinics of Minnesota

Deanna Johnson MA, APRN, NNP-BC, CWON

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Basic concept in neonatal skin and wound management

Identification and treatment of hospital acquired wounds and skin injuries

Trauma birth wounds

Congenital wounds

Neonatal ostomy basics

Complex pouching

Topics for Discussion

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Skin of the Preterm Infant

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Stratum Corneum

The adult stratum corneum in adults is 10 – 20 layers thick providing protection from infection and dehydration

In neonates <28 weeks gestation, the stratum corneum is 2 – 3 layers; at 23 – 24 weeks gestation this layer is negligible

The dermis is thin and underdeveloped, only 60% the thickness of an adult

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Poor cohesion between the dermis and epidermis

Preterm Skin

Fewer rete ridges&

dermal papilla

More vulnerable to edema, blistering, and epidermal stripping

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Communication/Body Image

Skin Immune System

Thermoregulation

Sensation

Metabolism

Barrier Protection

Functions of Skin

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Barrier Function

Transepidermalwater loss

ToxinsMicrobes

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Preterm Infant Skin Transition

The visible progression of preterm infant skin transition (Cornification)

Takes 2-8 weeks, longer with decreased gestation

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Term Infants and Newborns

At term the epidermis is almost the thickness of an adult, but does not yet have full barrier function

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Historical Lessons

1945, Dye Poisoning in Infancy

On February 28th 35 infant became acutely cyanotic with no signs of respiratory distress. On March 3rd, nurse alerted medical staff that diapers were freshly stamped with ink containing Aniline dye. Infants diagnosed with Analine poisoning leading to methemoglobinemia.Resulted in the death of one premature infant.

On September 15th, three more infants become acutely cyanotic. Traced back to freshly stamped washcloths which had been used to cleanse the diaper area. They were the smallest babies on the ward and had significant skin breakdown related to diarrhea.

2 of the 3 died.

Scott, E.P., et al Dye Poisoning in Infancy. J Pedatr. 1945;713-718

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Errors in Neonatology

1886/1945: Diaper Dye-Methemoglobinemia

1953: Sulfisoxazole-kernicterus

1956: Chloramphenicol-“gray baby”syndrome

1957: Novobiocin-Jaundiced

1952: Hexaclorophene-brain lesions

1969: Diaper Laundering-“Sweating” Syndrome

1972: Equipment cleaning-Jaundiced

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“The errors of the past are the success and wisdom of our future” –Tyron Edwards

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Risks of today- Silver Sulfadiazine

Sulfonamides compete with bilirubin for binding to plasma albumin. Unbound bilirubin can cross the blood-brain barrier, leading to hyperbilirubinemea and kernicterus.

Premature infants are at especially high risk due poor barrier function and liver immaturity. Bilirubin stained brain

https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/017381s050lbl.pdf

Christensen, R.D. Neonatal Death Suspected to be from Sepsis was Found to be Kernicterus with G6PD Deficiency. Pediatrics. 2013;132:e1694-e1698

Symptoms of acute bilirubin encephalopathy: lethargy, poor feeding, hypo/hypertonia, apnea, seizures, coma, death. Developmental delay and deafness.

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Agent Toxicity Comments

Alcohols (topicalantiseptics)

Hemorrhagic Necrosis Primary risk to occluded skin

Aniline (diaper dye) Methemoglobinemia Dye stamps from freshly labeled diapers

Boric Acid (diaper powder)

Vomiting, diarrhea, severe dermatitis, death

Neomycin Ototoxicity, deafness Premature infants

Povidone-iodine (topical antiseptic)

Hypothyroxinemia, goiter Especially in preterm infants

Silver sulfadiazine Hyperbilirubinemia,Kernicterus

Not recommended for infants <2 month

Lidocaine-prilocaine local anesthetic cream

SeizuresMethemoglobinemia,

Mancini, A. Skin. Pediatrics. 2004; 113(3):1114

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What can be used?

Produced during the third trimester, as the sebaceous glands become more active.

Made up of hydrated fetal skin cells that hold a large volume of water, embedded in lipid matrix.

Thought to have a critical role in utero the formation of the stratum corneum

Decreases in amount at term, as the pulmonary surfactants facilitate detachment from fetal skin.

Vernix Caseosa

Protective substance that facilitates barrier function following delivery.

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Skin Care for Babies

Keep it very simple

Bland: Scent-Free, very few ingredients, and free of potential allergens

Natural: Free from (or minimal) preservatives and potential toxins

Neutral: pH balanced to the skin ~ 5.5

Don’t put anything on baby’s skin that you would not put on wounded skin (or in your eye).

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Skin Care for BabiesCleansers: Neutral pH

Emollients: Dimethicone or petrolatum based. Avoid products with lanolin.

Diaper wipes: Warm water and soft disposable cloth. Prewarmed saline wipes for preterm infants.

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Wound Products for Infants

Safe antimicrobial dressings

Honey

Honey alginates and hydrogels

Silver: safe in low amounts

Soft silicone dressings with Ag

Hydrofiber or alginate dressings with Ag

Antimicrobial impregnated guaze (AMD). Polyhexamethylene biguanide

(PHMB)

Use products containing iodine with caution

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Identification and treatment of hospital acquired wounds and skin injuries

Pressure Injuries

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Medical Device Related Pressure Injuries

85% of HAPIs at Children’s MN2018 YTD

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• Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchableerythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.

Pressure Injuries- Stage 1

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Pressure Injuries- Stage 2 Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled

blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries

commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel.

This stage should not be used to describe moisture associated skin

damage (MASD) including incontinence associated dermatitis

(IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin

tears, burns, abrasions).

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• Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

Pressure Injuries: Stage 3

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Staging pressure injuries in premature infants

Can this infant have a stage 2 pressure injury? If so, what would it look like?

What would a stage 3 pressure injury look like with very little subcutaneous tissue?

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• Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures

the extent of tissue loss this is an Unstageable Pressure Injury.

Pressure Injuries: Stage 4

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• Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.

Pressure Injuries- Unstagable

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• Intact or non-intact skin with localized area of persistent non-blanchabledeep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss.

Pressure Injuries- Deep Tissue Pressure Injury

Do not use DTPI to describe vascular,

traumatic, neuropathic, or dermatologic

conditions.

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“Affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.”

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• CPAP

• IV catheter hubs/StatLocks

• Fresh trachs and GTs

• vEEG

Medical Device-Related Pressure Injuries

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Deference to Expertise

WOCN- Expert on possible ways to off-load and cushion

Bedside nurse and medical team- expert on the patients

Respiratory therapist/vEEG techs/vascular access- expert on the

device

CNS- Expert on nursing process and policies

Nursing educator- Expert on knowledge communication to the bedside.

Informatics- Expert in clinical documentation

Medical device-related PI prevention

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Joining Together

Share selfishly and steal shamelessly

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Nasal CPAP/Prongs

Return to the concept of microclimate… macerated skin is weak skin.

Can we remove the pressure?

Can we offload the pressure?

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Bubble CPAP (bCPAP)

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Tracheostomy

Stage 3 HAPI

DTPI

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Tracheostomy

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Tracheostomy

Which wound is pressure injury?

Should the wound care plan be different for the pressure injuryor can we use the same principles?

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Video EEG Leads

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Bed Garbage

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Congenital Pressure Injuries

“The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear.”

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Moisture, Incontinence, Medical Adhesives, Friction, Chemical and thermal.

Everything Else…

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“should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).”

Remember….Pressure Injury

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Medical adhesive related skin injuries

Epidermal (skin) stripping

Tension blisters

Irritant contact dermatitis• Unusual in the neonatal period

Keep treatment simple. Treat epidermal stripping with frequent applications of petrolatum to soften crusting and facilitate healing.

Blisters usual flatten and heal without dressings.

Monitor for honey-colored crusting/drainage. The drainage may be yellow/green if infant has an elevated bilirubin level.

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MARSI- Prevention

Do not use tackifiers

Protective barrier film under adhesives

Adhesive remover wipes

Use silicone tapes for non-lifelines

Consider backing aggressive tapes (or creating a landing-pad) with a hydrocolloid

Hydrogel EKG patches

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Intertriginois Dermatitis/Intertrigo

Moisture Associated Skin Damage (MASD)

May use antimicrobial moisture-wicking.

Consider topical antibiotic (mupirocin) if weeping/crusting is present.

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MASD- Incontinence Associated Dermatitis

Irritant contact diaper dermatitis

Maceration

Denudement

Apply a thick layer of zinc oxide barrier paste

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Diaper Rash- YeastCandida

In skin folds

Satellite lesions and bright red patches

Check mouth and mother’s nipples for thrush

Treat with topical antifungal under barrier paste or a antifungal barrier ointment

Treat thrush

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Candida in the preterm infant

Hint: If this were a mucous membranesurface, what would you guess?

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IV Infiltration and Extravasation• Infiltration: inadvertent administration of nonvesicant

solution or medication into surrounding tissue

• Non-vesicant solution, depending on volume, can cause deep skin damage

• Extravasation: inadvertent administration of vesicant solution or medication into surrounding tissue.

• In pediatric patients, occurs frequently due to immature skin structures

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Venous and Arterial Line Complications

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Antiseptic Skin Preparations

Sardesai, S., Kornacka, M., Walas, W., & Ramanathan, R.; Iatrogenic skin injury in the neonatal intensive care unit, The Journal of Maternal-Fetal and Neonatal Medicine, 2010

Parsada Lashkari, H. Chow, P. Godame, S. Aqueous 2% chlorhexidine-induced chemical burns in an extremely premature infant. ADC Fetal& Neonatal. http://fn.bmj.com/content/97/1/F64. Downloaded on 9/15/2017

Betadine & Alcohol

2% Aqueous CHG

CHG & Alcohol

CHG & Alcohol

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Antiseptic Skin Preparations

Alcohol preparations can cause skin necrosis.

Betadine carriers a high risk for iodine overload. Preterm infants at greatest risks for hypothyroidism and possible neurodevelopmental delays.

Chlorhexidine gluconate can cause skin burns. Potential for CHG toxicity??

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Gentle application, with minimal scrubbing. Allow to dry completely. Do not allow to pool in skin folds. Consider removing the antiseptic solution after the procedure with sterile saline.

At Children’s Minnesota we use Betadine and sterile saline for babies for less than 28 weeks gestations. We then transition to CHG.

Burns are treated with Medical Grade Honey and silicone foam dressings

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Thermal Skin and soft tissue injuries

Scalding Injury from warming

Fat necrosis from body cooling

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Skin scarring condition specific to extremely preterm infants, caused by traumatizing the dermis

Anetoderma of Prematurity

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DTI resulting in columellar scarring


How are we staging PIs in premature infants?

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Birth TraumaForceps, vacuum, and other

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Neonatal Birth Trauma

Birth related skin injuries very rarely require wound care and most often heal without scarring or alopecia.

Leave crusting as a biologic dressing and allow to heal spontaneously. Dressings offer poor wound coverage due to being suspended over the scalp by the hair. Also become tacky and gummy in the hair.

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Why are these NOT pressure injuries?

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For full thickness wounds, use Bactroban to prevent infection. Otherwise allow to heal spontaneously. Can result in scarring and may require Plastics

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Congenital anamalies

Imperforate Anus

Hirschprungs disease

Cloacal defect

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Complications of prematurity and infectionNecrotizing Enterocolitis (NEC)

Spontaneous intestinal perforation

Common reasons for GI ostomies

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Goals- Same as adults

Protect Surrounding Skin

Control Drainage

Patient Comfort

Attitudes and perspectives

Ostomy Care

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Types of Ostomies

End Stoma

Loop Stoma Double-Barrel Stoma

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Barrier Ring

- Start soft and flexible

Elastic Barrier strips

- Babies are abdominal

breathers and require flexible barriers

Integrated gas filter

-Babies are gassy!

Helpful Accessories

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Product Considerations

One stoma or two (or three or more!)

Type of ostomy: some barriers limit cutting surface

Size of the abdomen: parents will want to start small, but this may not always be in their best interest.

Type of Effluent: for high stomas, consider a urostomy pouch with a high endurance barrier.

Ostomy Care

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Application Pearls

Dry Skin

Warm barrier before and after placement

Trouble Shooting

Fill creases

Creases change as baby grows

Read the back of the barrier

Ostomy Care- Neonatal Pitfalls

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References•Lund C, Kuller J, Lane A, Lott JW, Raines D. Neonatal skin care: the scientific basis for practice. JOGNN. 1999;28: 241-254.•Kalia Y, Nonato L, Lund C, Guy R. Development of skin barrier function in preterm infants. J Invest Dermatol. 1998: 111; 320-326. •Fluhr JW, Darlenski R, Taieb A, Hachem J-P, Baudouin C, Msika P, De Belilovsky C, Berardesca E. Functional skin adaptation in infancy- almost complete but not fully complete. Experimental Dermatology. 2010; 19: 483-492.•Fluhr JW, Darlenski R, Lachmann N, Baudouin C, Msika P, De Belilovsky C, Hachem J-P. Infant epidermal skin physiology: adaptation after birth. Br J Dermatol. 2012; 166: 483-490.•Lund C. Medical adhesives in the NICU. Newborn & Infant Nursing Reviews. 2014; 14:160-165.•Goujon E, Beer F, Gay S, Sandre D, Gouyon J-B, Vabres P. Anetoderma of prematurity: An iatrogenic consequences of neonatal intensive care. Arch Dermatol. 2010; 5: 565-567.•Maffeis L, Pugni L, Pietrasanta C, Ronchi A, Fumagalli M, Gelmetti C, Mosca F. Iatrogenic anetoderma of prematurity: a case report and review of the literature. Case Reports in Dermatological Medicine. 2014; Article ID 781493, 4 pages.•Boralevi F. Hubiche T. Leaute-Labreze C, Saubusse E, Fayon M, Roul S, Maurice-Tison S, Taieb A. Epicutaneous aeroallergen sensitization in atopic dermatitis infants- determining the role of epidermal barrier impairment. Allergy. 2008; 63: 205-210. •Spergel J, Paller A, Atopic dermatitis and the atopic march. J Allery Clin Immunol. 2003; 112:S118-27.•Chang M, Nakrani R, Six children with allergic contact dermatitis to methylisothiazolinone in wet wipes (baby wipes). Pediatrics. 2014; 133(2): e434-e438.•Ponnusamy V, Venkatesh V, Clarke P. Skin antisepsis in the neonate: what should we use? Curr Opin Infectious Disease. 2014; 27: 244-250.•Chapman A, Aucott S, Gilmore M, Advani S, Clarke W, Milstone A. Absorption and tolerability of aqueous chlorhexidine gluconate used for skin antisepsis prior to catheter insertion in preterm neonates. J Perinatol. 2013; 33(10):768-771.•O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. Healthcare infection control practices advisory committee. http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf. Published 2011. Accessed July 7, 2016.•Chapman A, Aucutt S, Milstone A. Safety of chlorhexidine gluconate used for skin antisepsis in the preterm infant. J Pernitol. 2012; 32: 4-9.•Aitken J, Williams F, A systematic review of thyroid dysfunction in preterm neonates exposed to topical iodine. Arch Dis Child Fetal Neontal Ed. 2014; 99: F21-F28.•Kiechl-Kohlendorfer U, Berger C, Inzinger R. The effect of daily treatment with an olive oil/lanolin emollient on skin integrity in preterm infants: a randomized controlled trial. Pediatric Dermatology. 2008; 25 (2): 174-178.• Connor JM, Soll R, Edwards WH. Topical ointment for preventing infection in preterm infants. The Cochrane Collaboration. 2009, Issue 3. •Cleminson J, McGuire W. Topical emollient for preventing infection in the preterm infant. The Cochrane Collbaoration. 2016, Issue 1, Art Nu: CD001150•Robertson, AF. Reflections on Errors in Neonatology: I. The “Hands-off “ years, 1920 to 1950. J of Perinatology. 2003; 23:48-55•Robertson, AF. Reflections on Errors in Neonatology: II. The “Heroic” Years, 1950 to 1970. J of Perinatology. 2003 23:154-161

North Central Region WOCN 2018 Conference

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