In my last blog, I reviewed skin function and overall skin health as well as skin injury specifically related to chemical burns. This month, I will address the risk and prevention of skin injury from adhesives and management of related skin breakdown.
Adhesive injury is the most common source of skin breakdown in infants in the NICU.1 Particularly in premature skin, the layers of skin called the epidermis, outermost layer, and dermis, the next layer, are not as strongly bonded. Therefore, upon removal of adhesives these layers are pulled apart and the epidermal layer is removed with the adhesive. This results in skin breakdown and increased risk of infection, pain and if a large enough area is involved, fluid and temperature loss. Many studies talk about a decrease in skin barrier function which can also result in fluid or temperature loss without visible skin breakdown. This can be measured with a device and therefore, is used as a measure of skin damage in research.
There are many devices that must be secured in order to provide the care needed. Some are life sustaining, such as the endotracheal tube and therefore, every precaution is taken to avoid inadvertent removal. Strong adhesives are one of the best ways to ensure stability. However, in the process of ensuring that tubes and lines stay securely in place, adhesives can cause breakdown, particularly with removal. Lund et al found changes in skin barrier function after one removal of a plastic perforated tape commonly used to secure tubes and such in the NICU.2 Interestingly, hydrocolloids that many of us think of as being more “gentle” showed changes in skin barrier function when removed prior to 24 hours in two studies.2, 3 The adhesion increases over the first 24 hours and then begins to decrease. Therefore, if left in place for longer than 24 hours or allowed to lift spontaneously, this change in skin barrier function was not observed. Hydrogel adhesives can be less damaging and are often used for securing electrodes and temperature probes. However, this is not secure enough for devices that are life-sustaining such as endotracheal tubes and/or central catheters.
These studies just show that all adhesives can be damaging unless used appropriately and with care. A barrier underneath the adhesive is advocated in order to protect the skin (AWHONN, 2013). This barrier may be a polyurethane or transparent adhesive dressing. However, this is adhesive as well. Therefore, damage can occur when removed. The idea is to allow this transparent dressing to remain in place while changing the overlying adhesive. This is helpful for cases where the device must be changed more frequently such as a feeding tube. There are several devices on the market in recent years that allow an adhesive base, usually hydrocolloid, to remain in place while allowing removal and replacement of the device. This works particularly well for items like feeding tubes and urinary catheters where repositioning or replacement may be necessary. Various other liquid barriers are available. However, these should be reviewed for ingredients prior to use on premature infants. Some may contain alcohol or other ingredients that may actually be damaging to fragile skin. The most recent AWHONN skin care guidelines recommend a silicone-based liquid barrier under adhesives for protection.4
The method of removal of the adhesive is also important. The transparent adhesive dressings can usually be removed by simply stretching the dressing. This pulls it off the skin and removes the adhesive. Op-site™ can be removed by placing alcohol on the surface of the dressing (not on the skin). This dissolves the adhesive and makes it easy to remove. Other adhesives such as hydrocolloid or tape if it is absolutely indicated, should not be removed until after 24 hours. Even if the device is removed, the hydrocolloid/tape can be left in place until later and then removed. Upon removal, it should be removed by folding back on itself and using warm water or mineral oil/petrolatum (if no additional adhesive is needed in that area).4 This should be done slowly to allow the adhesive to be removed without removing the epidermal skin layer.
In the unfortunate event that the skin is damaged during adhesive removal, this is usually a surface injury. While this can be very painful and may offer a portal for infection, it can heal quickly. The most important principle in wound healing is to keep it moist. These surface injuries resulting from adhesive removal respond well to application of petrolatum or petrolatum-containing moisturizer to keep it moist. This hastens the movement of new cells to regenerate the area that has been damaged. So aptly stated in one reference, every living thing needs moisture, including skin! Dry skin is more prone to damage and dry wounds crack and bleed, leading to further damage. These surface injuries do not need additional dressings in most cases. However, if moisture cannot be maintained, a silicone or hydrocolloid dressing can help in maintaining moisture. These should just be allowed to stay in place until they come off by themselves, particularly the hydrocolloid as it may cause further damage if removed but can provide a healing environment if left in place. Complete healing of this type of surface injury usually occurs within a few days if kept moist. Keeping it moist also decreases scar formation.
Adhesive use is necessary in any intensive care setting. In the NICU, it is important to keep devices in place but must be balanced by the potential damage that can occur. Less damaging types of adhesives are hydrogel, silicone-based or hydrocolloid. Each of these has advantages and disadvantages. Careful consideration of the condition and maturity of the infant’s skin and priority to maintain the security of the device is necessary.
1. Lund CH, Osborne JW, Kuller JM, Lane AT, Lott JW, Raines DA. Neonatal skin care: Clinical outcomes of the AWHONN/NANN evidence-based clinical practice guideline. Journal of Obstetric, Gynecologic and Neonatal Nursing. 2001;30:41-51.
2. Lund CH, Nonato LB, Kuller JM, Franck LS, Cullander C, Durand DJ. Disruption of barrier function in neonatal skin associated with adhesive removal. Journal of Pediatrics. 1997;131:367-372.
3. Zilmer R, Agren MS, Gottrup R, Karlsmark T. Biophysical effects of removal of adhesive dressings on peri-ulcer skin. Journal of Wound Care. 2006;15:187-191.
4. Association of Women’s Health, Obstetric and Neonatal Nurses. Neonatal Skin Care: Evidence Based Clinical Practice Guideline. (3rd ed). AWHONN:2013.
Did you miss part 1 of Sandy’s neonatal skin care blog series,
Skin Care Challenges in the Very Low Birth Weight Neonate?
Click here to read the full blog entry.