087: Exit Site Multiethnic Different Skin Type of Only Dressing Silver
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EXIT SITE MULTIETHNIC DIFFERENT SKIN TYPE OF ONLY DRESSING SILVER 1. Cinzia CALORE, 1. Tiziana FOTIA, 1. M.Grazia STOCHINO, 1. Morena GIOACHIN, 1. Barbara PARIANI, 1. Enrico CARETTA. 2. Fabio FUMAGALLI, 2. Stefania FANELLI, 2. Aurelio LIMIDO 3. Paola CORTESI, 3 Alessandro MENTO, 3 Giada VRENNA, 3 Filomena MARINO 3. Giacomo COLUSSI 1. NEPHROLOGY and DIALYSIS department - Asst Valle Olona, Gallarate, Angera and Somma Lombardo Hospitals 2. NEPHROLOGY and DIALYSIS department - Asst “Fatebenefratelli Sacco” Milan Hospital 3. NEPHROLOGY and DIALYSIS department - Asst “Grande Ospedale Metropolitano Niguarda” Milan Hospital INTRODUCTION: In Italy some 18% of hemodialysis patients use a long-term central venous catheter as a vascular access. Its use could create a risk of infective sistematic and local complications. In recent decades, the spread throughout Europe of a multiethnic population, imposed to health workers pay more attention to the recognition of dermatological diseases with clinical aspects other than those of Caucasian skin to which we are used to. In different populations of the planet there is a large variety of "colors" of the skin (phototypes I-VI) depending on the amount and type of melanin. The skin types ranging from I in the populations with very light/reddish skin to VI with a black skin, including the intermediate skin types with slightly dark skin or olive. (Eg Indian, Pakistani, South American, Mongolian populations). The observational study was done by 5 hospitals in Northern Italy: • Gallarate, Somma Lombardo and Angera are the closest facilities to the Malpensa International airport, with access to passengers on dialysis, in transit from all over the world. • FBF and Niguarda are located in Milan, the second most populated city in Italy, which recently hosted Expo 2015, with more than 21 million visitors. The five centers regularly receive 380 patients, 77 of them, some 20% (graphic n°1) coming from four continents. However the events of the reporting period increased movement of people, belonging to different ethnic groups, staying sometimes for short periods of time. METHODOLOGY: Due to the anatomical, structural and physiological differences between clear and dark skin, it is difficult to recognize the typical signs of skin diseases. An example is the inflammation that occurs with erythema on clear skins, while assumes greyish color on dark skins. These characteristics led the teams of 5 Northern Italy hospitals to evaluate strategies for the recognition of the infection, of the exit site and subsequent evaluation of the resolution. These easy resolutions were accomplished with the use of nonstick silver-based film dressing, without using antibiotics. We used two main tools: Table 1: skin typing scale (human skin classification based on color; Fitzpatrick test) Table 2: Infection degree exit site Table 2: The definition of bleeding degree Degree 0 Degree 1 Degree 2 Degree 3 Bleeding 1 Bleeding 2 Bleeding 3 Bleeding 4 Healthy skin, without Hyperemia <1 cm Hyperemia > 1 cm Hyperemia, Crust Slightly stained Light bleeding Significant signs of inflammation to the exit point, and < 2 cm to the exit secretion, bleeding (phlogosis) with +/- fibrin point, with +/- fibrin pus, +/- fibrin 0 = healthy skin; 1 = reddened skin with less than 1cm extension; 2 = reddened skin with more than 1cm extension and signs of inflammation; 3 = Hyperemia with secretion pus The Fitzpatrick scale (also Fitzpatrick skin typing test; or Fitzpatrick phototyping scale) is a numerical classification schema for human skin color.Erythema as a sign of infection is easily reflected on the pale skin. In addition, the clear skin tends to heal without results, while darker skin has a remarkable tendency to develop discolorations post-inflammatory both hypo and hyperpigmentation. Hototype 4 (olive skin) Phototype 2 (light skin) Phototype 2 (light skin) Phototype 4 (olive skin) Catheter long-term subclavian reddened Catheter long-term subclavian Catheter subclavian Reddened Catheter subclavian Improvement only Catheter long-term femoral Detected Catheter long-term jugular reddened skin detected Step 2 Resolution after 6 dressings skin Step 3 and Bleedinge 2 after 4 dressings hyperemia, secretion with pus Step 3 Catheter long-term femoral after skin detected Step 2 and Catheter long-term jugular Resolution and Bleedinge 2 with crust with silver-based film with crust with silver-based film and Bleedinge 2 slightly stained 6 treatment with silver-based film Bleedinge 2 with crust after 6 dressings with silver-based film RESULTS: During the assessment period, between June 2013 and November 2015, there were 70 patients with tunneled Central Venous Catheter, with different types, length and place of piling. In total we made 22 measurements with a resolution through dressing with nonstick silver based film. The results were compared with the previous methodology that included the use of localized antibiotic therapy. Moreover we would like to highlight the difficult diagnosis and management of certain disease states, such as the recognition of the onset of infection, in patients of different ethnic origin. The emergence of the first states of redness of the exit site of tunneled CVC (stage 1) is easily found in Caucasian patients, with the use of dressings with non-stick Silver-based films. The resolution of the problem that brought the lesion to a 0 stage, was obtained after 4/5 dressings (Figure 2 - Flow chart). Graphic 2: Flow chart for the use of nonstick silver-based film The emergence of the first states of redness of the exit site of tunneled CVC (stage 1) in patients with olive or black skin, was visually detected only when the state of inflammation had already evolved into stage 2 and there was already a bleeding stage 1 (crust formation). The use of dressings with non-stick silver-based film (Exit Pad-Ag®) allowed the resolution of the problem by moving the lesion to a stage 0, after 5/6 dressings and without leaving discolored post-inflammatory outcomes (Figure 2 - Flow Chart). Graphic 1: multiethnic population on dialysis (non Italian) Graphic 3: pharmaceutical expenditure Multiethnic population resident in the five dialysis centers Spread by continent Pharmaceutical expenditure exit site infection treatmen Europe (not italy) Africa America Asia Comparision between treatment based on antibiotic 9% oi ntment and nonstick silver based film 30% 52% Antibiotic Ointments Costo medio espresso in Euro 9% per dieci Dressing with trattamenti silver based film 0 20 40 60 80 100 CONCLUSIONS: The multi-ethnic societies require for medical personnel both knowledge and recognition of diseases that present with non-typical clinical features, due to different typologies between dark and light skin. The nursing team of the dialysis departments, started an observational study of exit site infections and treatment modalities. We developed a uniform behavior in the recognition and management of the exit site dressing promptly recognizing the signs of infection in both patients with light skin and in those with dark one. In this period in which we adopted the use as a curative and preventive dressing, we have highlighted a positive response in both, its ease of use and the positive results obtained. In addition we got a significant cost saving for the reduction of the pharmaceutical expenditure and the reduction of use of antibiotics (Graphic 3) Last, but not least the focus on prevention allows us a saving of human resources. BIBLIOGRAFIA: - Fitzpatrick, T. B. (1975). "Soleil et peau" [Sun and skin]. Journal de Médecine Esthétique (in French) (2): 33–34 - Rosen T. (1995). Black dermatology testo atlante. Bari: Pigreco ed. - Pettini S., Settesoldi L., Galli R., Poli A., 2011. Complicanze infettive nel paziente dializzato portatore di Cvc: l'esperienza fiorentina [on line]. Disponibile da: http://www.ipasvi.it/ecm/rivista-linfermiere/rivista-linfermiere-page-6-articolo-71.htm [consultato il 18 aprile 2014] - Morrone A., Franco G., (2002) Diversità e analogie tra pelle nera e bianca. Il mio paziente, n° 16-1/15, 42-49.