North Central Region WOCN 2018 Conference Children’S Hospitals and Clinics of Minnesota Deanna Johnson MA, APRN, NNP-BC, CWON

9/11/2018

North Central Region WOCN 2018 Conference Children’s Hospitals and Clinics of Minnesota Deanna Johnson MA, APRN, NNP-BC, CWON

1 9/11/2018

Topics for Discussion

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

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

Preterm Skin

Poor cohesion between the dermis and epidermis

Fewer rete ridges & dermal papilla

More vulnerable to edema, blistering, and epidermal stripping

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Functions of Skin Communication/Body Image Skin Immune System Thermoregulation Sensation Metabolism Barrier Protection

Barrier Function

Toxins Microbes

Transepidermal water loss

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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

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.

Errors in Neonatology

1886/1945: Diaper Dye- 1952: Hexaclorophene- Methemoglobinemia brain lesions

1953: Sulfisoxazole- 1969: Diaper Laundering- kernicterus “Sweating” Syndrome

1956: Chloramphenicol- 1972: Equipment cleaning- “gray baby”syndrome Jaundiced

“The errors of the past are 1957: Novobiocin- the success and wisdom of Jaundiced 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

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

Christensen, R.D. Neonatal Death Suspected to be from Sepsis was Found to be Kernicterus with G6PD Deficiency. Pediatrics. 2013;132:e1694-e1698 13 | © 2015 https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/017381s050lbl.pdf

Agent Toxicity Comments

Alcohols (topical Hemorrhagic Necrosis Primary risk to occluded antiseptics) skin Aniline (diaper dye) Methemoglobinemia Dye stamps from freshly labeled diapers Boric Acid (diaper Vomiting, diarrhea, powder) severe dermatitis, death Neomycin Ototoxicity, deafness Premature infants

Povidone-iodine (topical Hypothyroxinemia, goiter Especially in preterm antiseptic) infants Silver sulfadiazine Hyperbilirubinemia, Not recommended for Kernicterus infants <2 month Lidocaine-prilocaine local Seizures anesthetic cream Methemoglobinemia,

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What can be used? Vernix Caseosa

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. Protective substance that facilitates barrier function following delivery.

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 Babies

Cleansers: 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.

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

Pressure Injuries- Stage 1

• Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema 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.

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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).

Pressure Injuries: Stage 3

• 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.

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Staging pressure injuries in premature infants

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

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

Pressure Injuries: Stage 4

• 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.

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Pressure Injuries- Unstagable

• 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- Deep Tissue Pressure Injury

• Intact or non-intact skin with localized area of persistent non-blanchable deep 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.

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

Medical Device-Related Pressure Injuries

• CPAP • IV catheter hubs/StatLocks • Fresh trachs and GTs • vEEG

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Medical device-related PI prevention 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

Joining Together

Share selfishly and steal shamelessly

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Nasal CPAP/Prongs

Can we remove the pressure? Can we offload the pressure?

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

Bubble CPAP (bCPAP)

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Tracheostomy

DTPI

Stage 3 HAPI

Tracheostomy

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Tracheostomy

Which wound is pressure injury?

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

Video EEG Leads

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Bed Garbage

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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Everything Else… Moisture, Incontinence, Medical Adhesives, Friction, Chemical and thermal.

Remember…. Pressure Injury

“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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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.

MARSI- Prevention

Do not use Protective barrier film under tackifiers 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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Moisture Associated Skin Damage (MASD) Intertriginois Dermatitis/Intertrigo

May use antimicrobial moisture-wicking.

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

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- Yeast Candida 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 membrane

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

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Venous and Arterial Line Complications

Antiseptic Skin Preparations

2% Aqueous CHG Betadine & Alcohol

CHG & Alcohol CHG & Alcohol

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

52 | © Parsada2015 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

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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?? ______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

Thermal Skin and soft tissue injuries

Fat necrosis from body cooling

Scalding Injury from warming

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Anetoderma of Prematurity

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

Anetoderma of Prematurity

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Anetoderma of Prematurity

DTI resulting in columellar scarring

How are we staging PIs in premature infants?

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Birth Trauma Forceps, vacuum, and other

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. 60 | © 2015

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Neonatal Birth Trauma

Why are these NOT pressure injuries?

Neonatal Birth Trauma

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 Wounds

Aplasia Cutis-

Congenital absence of skin

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Giant Omphalocele

Neonatal Ostomies

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Common reasons for GI ostomies

Congenital anamalies Imperforate Anus Hirschprungs disease Cloacal defect

______

Complications of prematurity and infection Necrotizing Enterocolitis (NEC) Spontaneous intestinal perforation

Ostomy Care Goals- Same as adults

Protect Surrounding Skin

Control Drainage

Patient Comfort

Attitudes and perspectives

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Types of Ostomies

End Stoma

Loop Stoma Double-Barrel Stoma

Helpful Accessories

Barrier Ring - Start soft and flexible

Elastic Barrier strips - Babies are abdominal breathers and require flexible barriers

Integrated gas filter -Babies are gassy!

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Ostomy Care 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- Neonatal Pitfalls

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

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Before pouching…

Pouching example with two barriers

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Pouching example

Thank You

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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