Issue: Volume 65 - Issue 2 - February 2019 ISSN 2640-5245
Index: Wound Management & Prevention 2019;65(2):8–12.
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Introduction
Skin is the largest organ and, in a preterm baby, the one injured the most frequently. Preterm neonatal skin is poorly prepared to transition to the dry, cool, organism-rich outside environment. The stratum corneum (SC) layer is barely present, leading to increased transepidermal water loss, electrolyte and temperature fluctuations, increased transcutaneous absorption of caustic substances, decreased protection from microbes, and increased susceptibility to dermatitis. Unlike a full-term infant’s skin, preterm skin lacks vernix, which is important for the formation of the acid mantle, hydration via fatty acid donation, and provision of an antimicrobial barrier. SC cell cohesiveness, important for preventing mechanical trauma, is lacking. Fewer dermal/epidermal fibrils connect the layers, leading to stronger adhesion between epidermis and an outer dressing than between the dermal/epidermal bond. The dermis is 30% of adult thickness, with basically no subcutaneous fat support. These characteristics amplify the risks for pressure injury, epidermal stripping, dermatitis, and bacterial colonization and invasion.
Medical adhesive-related skin injury (MARSI) is the number 1 cause of iatrogenic neonatal cutaneous injury, yet because adhesives are so widespread, familiar, and necessary, caregivers fail to recognize the imminent danger they represent. Ten percent (10%) to 15% of neonatal graduates leave the neonatal intensive care unit (NICU) with a scar; approximately 5% are functionally and cosmetically significant. Chemical burns from topical antiseptics complicate neonatal care from day 1. No safe antiseptics and antimicrobials exist and no definitive recommendations have been issued on use of topical antiseptic/chemical injury in the neonatal population. Chlorhexidine (CHG), alcohol, and iodine are used, all with potential for cutaneous injury and systemic absorption.
Alcohol-based products produce the best temporary skin decolonization, along with highest risk for chemical burns. Iodine-based antiseptics seem as effective as CHG in most studies; a few studies claim slightly better efficacy of CHG/alcohol (potentially due to the dual action with alcohol). Thyroid abnormalities versus the theoretical risk of neurotoxicity with inhibition of L1-mediated neurite and cytotoxicity to fibroblasts, odontoblasts, and erythrocytes are associated with iodine and CHG use, respectively. The literature1-5 does not show significant long-term benefit of CHG for skin decolonization in neonates (improvement in mortality, decrease in central line-associated blood stream infection in developed countries), especially neonates <1500 g or 2 months of age. However, the need for multiple invasive procedures continuously poses a dilemma with regard to antiseptic use. My belief is no antiseptic is safe, and the efficacy of the 3 most used antiseptics is somewhat similar, with effective skin decolonization within an immediate time period.3-5 In my unit, we commonly use 10% povidone iodine solution and sometimes 2% CHG/70% alcohol solution for sterile procedures. Caretakers must remember to clean the skin with sterile normal saline (NS) once the procedure is completed to minimize systemic absorption and cutaneous burns.
Epidermal stripping. Epidermal stripping is a subtype of MARSI. Studies have documented that certain dressings (eg, films with acrylate adhesives and hydrocolloids) increase the risk of epidermal stripping. Silicone-based is the only atraumatic dressing on the market; it should be used as much as possible in the neonatal population, but unfortunately its mild tackiness and weaker adherence may preclude use with life-saving devices. In addition, many silicone-based dressings are not sufficiently translucent and may not be used where visualization is paramount. Recommendations from a consensus summit6 addressing medical device-related skin tears and epidermal stripping, published in 2013, suggest exercising caution when using nonsilicone tapes and film and hydrocolloid dressings on injured skin and skin at risk for epidermal stripping. The assumption that modern hydrogel electrocardiogram leads, temperature probes, and tube securement adhesives are safe for pediatric skin is false, but knowledge of this fact often is lacking.
Few products mitigate the risk for MARSI. A nonalcoholic liquid skin barrier may provide a protective layer between the epidermis and adhesives as well as minimize irritation from caustic substances. Bonding agents (such as tincture of benzoin or Mastisol [Ferndale Pharma Group, Ferndale, MI]) should not be used in the neonatal population. These agents can increase epidermal stripping, and cases of skin necrosis have been described. A silicone-based adhesive remover should be used with all adhesives; it releases the adhesive bond without leaving the residue (the downfall of oil-based solvent or the toxicity of an alcohol-based remover), allowing immediate dressing repositioning if desired or complete removal without pain and injury to the SC.
In summary, MARSI represents a common and challenging scenario in the management of preterm neonates. The question is, how do we mitigate skin damage?
Neonatal Skin Injury Treatment by Acronym
The debridement, infection, moisture/edge (DIME) model provides an approach to neonatal skin injury.
Debridement. Gentle cleaning of the dry exudate can be considered. Autolytic with or without mechanical debridement may include use of a hydrogel, medical-grade honey gel, or surfactant-based gel for softening and removing exudate, enhanced by a mechanical monofilament debrider.
Infection. If colonization/infection is suspected or feared, consider using a honey-based dressing or one with hydrophobic technology (a dialkylcarbamoyl chloride-coated [DACC] wound contact dressing). These 2 natural alternatives to traditional antimicrobials will reduce the inflammatory load on the immature neonatal system and promote debridement (honey is an autolytic and DACC is a mechanical or autolytic debrider if used in a combination with hydrogel).
Moisture/Edge. Moisture balance is paramount to promoting keratinization; therefore, wound dressings that are atraumatic and are appropriately moisture-retentive should be used.
I encourage use of silicone-based dressings on already compromised skin. As long as the skin is intact and dry, these dressings can be changed every few days (as with honey, gel, and DACC products), minimizing further trauma. Sometimes we utilize foam as a primary protective, nonadherent, absorptive dressing, covered loosely by cling gauze. Use of an adhesive releaser is paramount in any adhesive dressing removal.
Case Report
A 6-day old, 23-week gestation, 500-g neonate was admitted to my unit after the parents requested the transfer on the grounds of multiple injuries to his skin at the original institution. “Why had nobody prepared us for the terrible skin injuries?” they asked me. Indeed, why?
My patient’s abdominal skin injury followed umbilical line placement. The baby’s skin had been disinfected with 2%CHG-70% isopropyl alcohol solution, followed by placement of a hydrocolloid dressing to immobilize the lines. The position of the lines was not appropriate, leading to dressing removal <24 hours after placement. On day 2, erythema, denuded skin, and hemorrhagic exudate were noted. The dressing was removed again, the wound was cleaned with NS, and a new acrylate film dressing was placed. At the same time, a transcutaneous carbon dioxide probe was removed from the left upper thorax and left abdomen, causing new epidermal stripping. The area was cleaned and covered with an acrylate film. The wounds continued to worsen, at which point the patient was transferred (see Figure 1).
We used a combination of medical- grade honey gel covered by foam and gauze (see Figure 2). Once the dry exudate was softened, gentle debridement with a monofilament debrider was performed. The compromised areas healed completely within 2.5 weeks (see Figure 3 and Figure 4).
In conclusion, neonates are at high risk for MARSI. Use of antiseptics can complicate the overall injury. Nonalcoholic liquid skin barrier and silicone adhesive releaser can prevent the majority of injuries. In the event a wound occurs, neonatal care should be based on natural, nontoxic products along with atraumatic dressings.
Affiliations
Dr. Boyar is Director of Neonatal Wound Services, Cohen Children’s Medical Center of New York, New Hyde Park; and an Assistant Professor of Pediatrics, Zucker School of Medicine, Hofstra/Northwell, Hempstead, NY.
