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3M Health Care AcademySM
© 3M 2015. All Rights Reserved
3M Health Care AcademySM
Site Protection, Securement and Skin Integrity: Skin Care Considerations for Vascular AccessDana McReynolds
3M Critical and Chronic Care Solutions Division
Author: Debra Thayer MS, RN, CWOCN
Lead Technical Service Specialist
3M Critical and Chronic Care Solutions Division
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Disclosure
Dana McReynolds is an employee of 3M Company
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Objectives
Describe the significance of skin damage at vascular access sites
Explain the mechanism of injury for at least 2 types of MARSI
Describe four key steps for MARSI prevention
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Why are we concerned with skin around a vascular access site?
Epidermis is the critical physical barrier to
entry of irritants and pathogens
1. Wysocki AB. Anatomy and Physiology of Skin and Soft Tissue. In Bryant, RA and Nix DP eds. Acute and Chronic Wounds: Current Management Concepts. 4th ed. St Louis, MO: Elsevier Mosby; 2012: 40-62.2. Roth,RR and James WD Microbial Ecology of the Skin. Annu. Rev. Microbiol. 1988; 42: 441-464.3. Abad, CL and Safdar, N. Catheter-related Bloodstream Infections. Infectious Disease. (Special Edition) 2011. McMahon Publishing
Epidermis skin layer
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Why are we concerned with skin around a vascular access site?
Epidermis is the critical physical barrier to
entry of irritants and pathogens
Skin damage disrupts/destroys normal
structural, chemical and microbial barrier1
1. Wysocki AB. Anatomy and Physiology of Skin and Soft Tissue. In Bryant, RA and Nix DP eds. Acute and Chronic Wounds: Current Management Concepts. 4th ed. St Louis, MO: Elsevier Mosby; 2012: 40-62.2. Roth,RR and James WD Microbial Ecology of the Skin. Annu. Rev. Microbiol. 1988; 42: 441-464.3. Abad, CL and Safdar, N. Catheter-related Bloodstream Infections. Infectious Disease. (Special Edition) 2011. McMahon Publishing
Epidermis skin layer
Skin Cells Removed
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Why are we concerned with skin around a vascular access site?
Epidermis is the critical physical barrier to
entry of irritants and pathogens
Skin damage disrupts/destroys normal
structural, chemical and microbial barrier1
Increased risk of infection2,3
Additional adverse outcomes:
▪ Pain and discomfort
▪ Potential inability to adhere dressing/devices
▪ Potential need to move vascular access device
1. Wysocki AB. Anatomy and Physiology of Skin and Soft Tissue. In Bryant, RA and Nix DP eds. Acute and Chronic Wounds: Current Management Concepts. 4th ed. St Louis, MO: Elsevier Mosby; 2012: 40-62.2. Roth,RR and James WD Microbial Ecology of the Skin. Annu. Rev. Microbiol. 1988; 42: 441-464.3. Abad, CL and Safdar, N. Catheter-related Bloodstream Infections. Infectious Disease. (Special Edition) 2011. McMahon Publishing
Epidermis skin layer
Skin Cells Removed
Damaged Skin
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How often does this happen?
Prevalence of MARSI at PICC sites-
study in Oncology population n=419
Total MARSI prevalence=29.8% (125)
Mechanical=58% (73)
Contact dermatitis=31% (39)
MASD=8% (11)
Folliculitis=1.6% (2)
Zhao H et al J Vasc Access 2017. Nov 8:0. doi:10.5301/jva.5000805
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For every complex problem there is an answer that is clear, simple, and wrong.
H. L. Mencken
When skin damage happens, there is a tendency to blame…
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CONCLUSION: “It is increasingly
common for vascular access
specialists to report superficial skin
damage at infusion sites, especially
with central venous access devices
that require repeated dressing
changes. Systemic factors such as
age, multiple and complex
comorbidities and chemotherapeutics,
and interventions specific to catheter
insertion and management can all
contribute to skin injury.”Thayer D. Skin Damage Associated with Intravenous Therapy: Common Problems and Strategies for Prevention. J of Infusion Nurs.2012; 36(6): 390-401.
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Understanding MARSI at Vascular Access Sites
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• Results from a 2012 Consensus Conference• Who? • 23 Key Opinion Leaders with specialized expertise across
disciplines
• What? • Establish consensus statements regarding the assessment,
prevention and treatment of adhesive skin injury• Not specific to vascular access
• How?
• 2-day moderated discussion and Consensus-decision making
process
Where did “MARSI” come from?
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Finally, a definition
“A medical adhesive-related skin injury is an
occurrence in which erythema and/or other
manifestation of cutaneous abnormality (including,
but not limited to, vesicle, bulla, erosion, or tear)
persists 30 minutes or more after removal of the
adhesive.”McNichol L, Lund C, Rosen T, Gray M. J Wound Ostomy Continence Nurs. 2013; 40(4): 365-380.
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Several Common Forms of MARSI
MARSI
FolliculitisMacerationMechanicalIrritant Contact
DermatitisAllergic Contact
Dermatitis
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Irritant Contact Dermatitis (ICD)
Image courtesy of R. Huneke-Rosenberg
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Barrier disruption → increased risk of permeation
•Excessive hydration (e.g.
maceration)
• Loss of normally tight junctions
•Skin disease
•Damage (e.g. stripping)
•Extremes of age e.g. <27 weeks
gestation, the very old
•Characteristics of topical
• Size/structure of molecule
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http://www.hse.gov.uk/skin/imagelibrary.htm
Allergic Contact Dermatitis
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But!
“Any topically applied chemical substance
has the potential to induce an irritant or
hypersensitization reaction in any individual
at some time.” Shelanski, Phillips and Potts. Intl J Dermatol 1996 35(2); 138.
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Inflammation
Increased
permeability of
Stratum corneumpH changes
Maceration-the result of excessive hydration
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Friction contributes to skin damage
When skin is wet
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“Mechanical” injury results when the
skin to adhesive attachment
is stronger than the
skin to skin attachment
skin
adhesivebacking
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MARSI-“Stripping” Detachment of:-individual layers of the epidermis or
-the entire epidermis from the dermis
Referred to as a “skin tear”
Stratum Corneum
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• Mechanism of Damage
• Adhesive to skin attachment > skin-skin attachment
• Shear force
• Epidermis pulls away from dermis
• Secondary to “strapping” (i.e. stretching) &/or edema/distention
MARSI-Tension Blisters
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Collagen Elastin
Fat
Normal changes of aging increase risk
Image from www.consumerguides.com
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Preventing MARSI at Vascular Access Sites
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1) Understanding and recognizing risk factors
Underlying illnessImmuno-suppressionTreatment of medical
conditionsSkin Changes a/w
Sun Exposure Extremes of age
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Available adult data-not specific to Vascular Access
1Farris MK, J WOCN;42(6):589-598; 2Konya, J Clin Nurs 2010;19:1236-42
Elderly
21%Median daily MARSI
rate1
• A 28-day prevalence study of adult patients in an acute care setting found the median daily prevalence of all medical adhesive-related skin injuries was 21.1% for patients 65 to 74 years1
• Elderly patients admitted to a long-term care facility (n=155, 65 years and older) had a 15.5% cumulative incidence rate for adhesive-related skin injuries2
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Collagen Elastin
Fat
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Available peds data-not specific to VA
1McLane KM, J WOCN 2004;31:168-78; 2Noonan C, Pediatr. Nurs. 2006;21 (6):445-53;
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Pediatric
Prevalence of skin tears in a pediatric
population of patients with skin
breakdown1
• 1-day skin prevalence audit in a university-affiliated children’s hospital audited 252 patients (average age= 4.5 years, range 0.6-11yrs) Findings: 8% had epidermal stripping from tape products2
• A large chart review across 9 hospitals and 1,064 children reported skin tear prevalence of 17% , the second most common skin breakdown after diaper dermatitis1
17%• Functional skin maturity @ approx.
34 weeks gestation
• < 27 weeks @ high risk for adhesive
injury
• Thin stratum corneum
• Weak epidermal-dermal junction
• Stunted rete ridges
• Minimal fat
• Note! Healthy full-term babies have
good barrier function
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Vascular access specific data emerging
28
Oncology study-patients with PICCs
Age ≥50yo
Hematologic malignancies
Zhao H et al J Vasc Access 2017. Nov 8:0. doi:10.5301/jva.5000805
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2) Understand and address key causal factors
Type of adhesive Skin Preparation Application Technique Removal Technique
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•Wrong adhesive for clinical need
•No (or inadequate) skin preparation
• Incorrect or careless application
• Incorrect or careless removal
Preventable causes of MARSI
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Adhesive Technology
Backing Technology
Clinical Performance
• Adhesion level• Conformability• Breathability• Gentleness• Ability to stretch • Ability to tear
Step 1: Selecting the Right Adhesive Product
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Silicone adhesive Acrylate adhesives
If silicone adhesives are gentler, then why don’t we use them more often?
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Step 1: Selecting the Right Adhesive Product
3 main categories used for vascular access:Dressings for site protection
Device securement Tape for tubing support and stabilization
Select the most appropriate adhesive product based on intended
purpose…location…and ambient conditions present at…site.
Skin moisture/wetness is major consideration
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Step 2) Prepare the skin
Clip excess hair with clipper or sterile scissorsDo not shave
Gorski L, Hadaway L, Hagle ME, McGoldrick M, Orr M, Doellman D. Infusion therapy standards of practice. J Infus Nurs. 2016; 39(suppl 1):.S64
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Allow antiseptic prep to dry completely!!!
How long you ask?
As long as it takes!
or
Rickard C, Ullman A, Marsh N, anmf.org.au May 2017; 24(16)
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Forms a protective interface between the adhesive and skin Adhesive removal removes barrier film, not epidermal cells
This
Not this
Best Practice: protect skin with an alcohol-free barrier film
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Medical Adhesives and Patient Safety: State of the Science: Consensus Statements for the Assessment, Prevention, and
Treatment of Adhesive-Related Skin InjuriesJournal of Wound Ostomy Continence Nursing. 2013;40(4):365-380.
Central Vascular Access Device (CVAD) Stabilization Standard 37, page S72-74
• Apply barrier solutions to skin exposed to adhesive dressing to reduce risk of Medical Adhesive-Related Skin Injury (MARSI). (Level I)
Gorski L, Hadaway L, Hagle ME, McGoldrick M, Orr M, Doellman D. Infusion therapy standards of practice. J Infus Nurs. 2016; 39(suppl 1):S1-S159.
What is the basis for this?
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Barrier films vs.Tackifiers
• Barrier films
• Chemistry=
• Polymer(s) dissolved in a solvent
• Intended effect
• Form an interface between adhesive
coating and skin
• Allow adhesion
• Protect skin by acting as sacrificial
substrate-film is removed vs. cells*
*ability to do this will vary depending on formulation
• Adhesion promoters (aka
“Tackifiers”)
• Chemistry=
1. gum mastic, alcohol and methyl
salicylate (oil of wintergreen) +/-
acetone (various brands) or
2. Balsamic resin from specific bark
(benzoin tincture)
• Intended effect
• Enhance/increase adhesion
• Concern-known potential for sensitization
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“Limit or avoid substances, such as compound tincture of benzoin, which increases the stickiness of adhesives”.
McNichol L, et al. J Wound Ostomy Continence Nurs. 2013; 40(4): 365-380.
Best Practice recommendations re: tackifiers
“Compound tincture of benzoin should not be used due to increased
risk of MARSI because it may increase the bonding of adhesives to skin, causing
skin injury when the adhesive based [engineered stabilization device] (ESD)
is removed" (Level I-highest recommendation)
Gorski L,et al. J Infus Nurs. 2016;39 (suppl 1): S 73,82.
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1-Hunter, K. Personal communication. Thayer D. J Infus Nurs. 2012; 35(6): 390-401.
Step 3) Apply the adhesive product properly
Downward
pull
Diagonal pull
Hunter’s Turgor Restriction-related Skin Injury Theory
Stretching
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Firm pressure applied to the surface of
medical tape will activate adhesive and
increase surface area contact
Medical Adhesives Are Pressure Sensitive
Step 3) Apply the adhesive product properly
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Step 4) Remove the adhesive product properly
Importance of peel angle
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Step 4) Remove the adhesive product properly
Importance of peel line
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Step 4) Remove the adhesive product properly
Technique for removing transparent film dressings
Tape methodStretch method
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18.Consider use of medical adhesive removers
to minimize discomfort and skin damage
associated with removal of adhesive
products.
Not addressed by INS standards
No best practice identified for vascular access
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Skin damage associated with infusion therapy…
• increases risk of colonization and infection
• systemic and therapy-related factors contribute
―its not just about adhesives and allergy
•prevention is key!
―several simple interventions can make a difference!
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Thank you!
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