- Email: [email protected]
Medical Adhesives in the NICU
Medical Adhesives in the NICU Carolyn Lund RN, MS, FAAN PII: DOI: Reference:
S1527-3369(14)00087-7 doi: 10.1053/j.nainr.2014.10.001 YNBIN 50570
To appear in:
Newborn and Infant Nursing Reviews
Please cite this article as: Lund Carolyn, Medical Adhesives in the NICU, Newborn and Infant Nursing Reviews (2014), doi: 10.1053/j.nainr.2014.10.001
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ACCEPTED MANUSCRIPT Medical Adhesives in the NICU
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[email protected]
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Carolyn Lund RN, MS, FAAN
Clinical Nurse Specialist
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UCSF Benioff Children’s Hospital & Research Center
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Oakland, CA
758 Cayuga Ave
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San Francisco, CA 94112 Work/Home Phone: 510-428-3436
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Cell: 415-370-8008
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Fax: 510-428-3542
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 1 Abstract Skin injury from medical adhesives is a known problem for NICU patients. Medical adhesive-
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related skin injury (MARSI) for all patient populations includes mechanical problems such as skin stripping, skin tears, and tension blisters; dermatitis reactions such as irritant contact
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dermatitis and allergic dermatitis; and other complications such as skin maceration and folliculitis. The most common seen in neonatal patients is epidermal or skin stripping;
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chronically hospitalized infants may also experience irritant contact dermatitis to a variety of
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adhesive products.
Preventing MARSI is the goal, using the fewest and least irritating adhesive products; yet, secure
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fixation of medical life support equipment is imperative. This article will explore differences in neonatal skin that places NICU patients at risk for MARSI and selecting products that are most
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appropriate for the desired result. Barrier films and adhesive removers are also discussed in
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detail to determine which may be potentially beneficial to the NICU population.
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Key words: medical adhesive, medical adhesive-related skin injury (MARSI), epidermal (skin) stripping, medical tapes and dressings, skin barrier films, adhesive removers
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 2 Introduction Medical adhesives comprise an integral part of healthcare delivery in the Newborn Intensive
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Care Unit (NICU) and in virtually all other inpatient and outpatient settings, as a component of a variety of products, including tapes, dressings, electrodes and ostomy supplies. They are applied
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and removed many times a day in the typical NICU. Premature and full-term infants who require medical interventions and constant monitoring are exposed to adhesives for a wide variety of
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indications. They secure both critical life support equipment such as endotracheal tubes,
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intravenous and arterial catheters, and chest tubes, as well as monitoring devices such as electrocardiogram electrodes, pulse oximeter probes and temperature sensors.
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Skin injury from medical adhesives is a known problem among healthcare providers in the NICU. In the 2001 evidence-based practice project conducted in 51 US nurseries involving 2820
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premature and term neonates, adhesives were the primary cause of the observed skin breakdown.1 A descriptive cohort study conducted in Australia found the incidence of “pressure
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injuries” (which is a broader category of iatrogenic tissue damage that incudes epithelial
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stripping) in 247 neonates to be 31.2%; medical devices were the most common risk factor associated with the skin injuries.2 In the broader pediatric population, a 1-day prevalence audit reported 8% of hospitalized infants and children were found to have tape-related skin stripping,3 and the 2003 National Pediatric Pressure Ulcer and Skin Breakdown Prevalence Survey found the prevalence of skin stripping related to adhesive tape was 17%.4 Because of these studies and a general concern in all populations of hospitalized patients, the acronym “MARSI” was coined, standing for “medical adhesive-related skin injury”.5
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 3 In an effort to increase awareness of MARSI and define best practices for prevention of this skin injury, a consensus panel of 22 health care providers from a variety of disciplines (nursing,
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medicine, physical therapy) and specialties (neonatology, pediatrics, geriatrics, orthopedics, dermatology, infusion nursing, infectious disease) convened to establish consensus statements on
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the assessment, prevention, and treatment of MARSI. Additional goals included defining knowledge gaps regarding medical adhesives and skin safety, documenting the spectrum of care
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settings and medical applications where MARSI occurs, and identifying research priorities for development of new adhesive technologies and protocols for skin protection. Following this
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meeting, a white paper was published with the 25 consensus statements reached by the group.5
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This paper will explore the unique differences in newborn skin that places NICU patients at high risk for MARSI, and the types of MARSI seen in this population. Following this, background on
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the science of medical adhesives and how adhesives interact with the skin, and the types of
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adhesives and adhesive products commonly used in the NICU is described. In addition, products that protect skin from adhesive damage or facilitate removal of adhesives without injury to the
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skin will be discussed.
Physiologic and Anatomic Variations in Newborn, Premature, and Infant Skin Stratum Corneum and Epidermis The stratum corneum, which provides the important barrier function of the skin, contains 10 to 20 layers in the adult and in the full term newborn. Although full term newborns have been shown have skin barrier function comparable to adult skin6 using a measurement called transepidermal water loss (TEWL), there is now some evidence that the stratum corneum does not function as well as adult skin throughout the first year of life7 and is 30% thinner than that of adult skin.8 Directly underneath the stratum corneum, the basal layer of the epidermis is 20%
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 4 thinner than that of the adult, and the keratinocyte cells in this layer have a higher cell turnover rate which may account for the faster wound healing that has been observed in neonates.
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The premature infant has far fewer layers of stratum corneum, and is determined by their
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gestational age. At less than 30 weeks gestation, there may be as few as two or three layers,9 and
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the extremely premature infant of 23 to 24 weeks has negligible barrier function due to minimal stratum corneum.10 Because of the deficiency in layers of stratum corneum, large fluid and
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evaporative heat losses can occur in the first weeks of life, leading to significant alterations in electrolyte levels, hypernatremia and dehydration.11 Techniques used to reduce these losses
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include the use of polyethylene coverings immediately after delivery,12,13,14 and use of high levels of relative humidity (>70% RH) in incubators.15,16 Topical treatments such as the
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application of transparent adhesive dressings,17,18 and sterile topical ointment and skin
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protectants have been described in small studies,19,20 but remain controversial due to concerns for infection.21 The process of maturation of the skin barrier, particularly for infants of 23 to 25
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weeks gestation occurs over time,10,22 with measurements of mature barrier function found as
Dermis
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they reach 30-32 weeks postconceptional age.23
The dermis of the full term newborn is thinner and not as well developed compared to the adult dermis. The collagen and elastin fibers are shorter and less dense, and the reticular layer of the dermis is absent, which makes the skin feel so soft. There are less total lipids and fewer sebaceous glands in the dermal layer in infancy.8 Cohesion between Epidermis and Dermis The junction between epidermis and dermis contains fibrils that connect these two layers of the skin. In premature infants, the fibrils are fewer in number, with wide spaces between connecting
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 5 points.9 As the premature infant becomes more mature these fibrils increase in number and strength. Abnormal fibrils at the junction of the epidermis and dermis are found in certain types
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of the genetic skin disease, epidermolysis bullosa, a blistering skin condition that occurs with even minimal trauma to the skin.
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This decreased cohesion between epidermis and dermis places the premature newborn at risk for skin injury from removal of medical adhesives that are attached to the skin. When extremely
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aggressive adhesives are used, the bond between adhesive and epidermis may be stronger than
skin barrier function.24
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Risk of Toxicity from Topical Agents
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that between epidermis and dermis, resulting in stripping of the epidermal layer and decreased
Toxicity from topically applied substances has been reported in numerous case reports due to the
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increased permeability of both preterm and full term newborn skin. This is due to a number of
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factors including the fact that newborn skin is 20-40% thinner than adult skin, and the ratio of body surface to weight is nearly five times greater than older children and adults, placing them at
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increased risk of percutaneous absorption and potential. Examples of toxicity from percutaneous absorption include hexachlorophene bathing leading to encephalopathy and death in premature infants, and thyroid toxicity from povidone-iodine used for skin disinfection toxicity.25,26 Thus, using topical agents carries a risk should they be absorbed through the skin of the premature or term neonate. Other Challenges in the NICU with Medical Adhesives The skin of a normal term infant is covered with vernix caseosa, a “cheesy” substance composed of water (80%), lipids and proteins,27 sebum from sebaceous glands, broken-off lanugo, and desquamated cells from the amnion. Vernix production begins at the end of the second trimester
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 6 protecting the fetal skin against maceration from amniotic fluid, and chafing caused by crowding in utero. Although leaving residual vernix intact may be beneficial after delivery as it assists in
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the formation of the acid mantle, facilitates colonization by normal bacterial flora, and serves as
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a natural moisturizer for the skin,28,29,30 it also makes adherence of medical adhesives very
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difficult. Some manufacturers of EKG electrodes, for example, recommend preparing the skin surface with isopropyl alcohol to improve adherence, but this practice is very irritating to the
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skin.
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Another factor complicating the application and removal of medical adhesive products is the use of thermoregulation devices. Radiant warming tables and convectively heated incubators are
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necessary for most neonates admitted to the NICU during initial stabilization and for premature infants for many days, weeks or months; the use of high ambient humidity levels; (>70%) in
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incubators is often employed in the care of extremely low birth weight prematures (< 28-30
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weeks gestation) during the first weeks of life to mitigate the excessive transepidermal water loss and evaporative heat loss that occurs due to their undeveloped stratum corneum. These thermal
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management techniques and devices may cause instability of many adhesive products, resulting in adhesives inadvertently falling off. Radiant heat from warming tables can also cause some adhesives to attach more firmly. An additional concern is the population of NICU patients with chronic illnesses such as complex congenital heart disease, short bowel syndrome, bronchopulmonary dysplasia or other conditions that necessitate their remaining hospitalized for many, many months, often with oxygen cannulas, feeding tubes, central venous catheters and other adhesive products in use. In this population an increase in contact dermatitis in response to a variety of adhesive products is being
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 7 observed, challenging the clinician to find alternative adhesive products that the infant does not react to in this way.
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Medical Adhesives and Medical Adhesive Products
The US Food and Drug Administration more defines a medical adhesive tape or adhesive
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bandage as “a device intended for medical purposes that consists of a strip of fabric material or plastic, coated on one side with an adhesive, and may include a pad of surgical dressing without
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a disinfectant. The device is used to cover and protect wounds, to hold together the skin edges of
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a wound, to support an injured part of the body, or to secure objects to the skin”.31 Medical adhesive tapes/dressings/devices are composed of several layers. The type of backing
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and adhesive used determine the properties and performance of the adhesive product. For example, tape backings can be composed of paper or paper blends, plastic, silk (woven
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polyester), soft (non-woven) cloth, traditional cloth, or foam and/or elastic. Examples of types of
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adhesives used in tapes and dressings include acrylates, silicones, hydrogels, hydrocolloids, and polyurethanes, as well as those that are natural-rubber latex based or contain zinc oxide (Table
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1).5,32,33
Medical adhesives are pressure sensitive; firm pressure applied to the surface of the medical tape/dressing/device will “activate” the adhesive by increasing the surface area contact. Over time, the adhesive will warm and flow to “fill in” the gaps between the adhesive and the irregularities in the skin surface, increasing the strength of the bond. The length of time for this process differs among different types of adhesive products. Some “softer” adhesives, such as silicone, have a lower surface tension and fill in these gaps quickly and maintain the same level of adherence over time. Others adhesives, such as the acrylates, act more slowly, and adherence increases over time to a state of maximal adherence, and then gradually the bond weakens. This
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 8 is why, whenever possible, leaving an adhesive in place even when not in use can assist in the removal process when the adhesive bond starts to lessen.
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Medical Adhesive-related Skin Injury
Skin injury results when the skin to adhesive attachment is stronger than skin cell to skin cell
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attachment. As a result, the epidermal layers separate or the epidermis separates completely from the dermis. Adhesive removal itself results in detachment of varying amounts of superficial
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epidermal cell layers even in adult skin; and repeated application and removal results in changes in skin barrier function; measurable disruption in skin barrier function has been reported after 10
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consecutive removal of tape containing acrylate adhesives in adults.34-36
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Classification of MARSI includes mechanical injuries such as epidermal stripping, tension injury or blistering, and skin tears. Epidermal stripping is frequently the mechanism seen in MARSI for
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neonates (Figure 1), while skin tears are more common in the elderly population and involve a
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separation of skin layers.37 Tension injury or blistering is seen in orthopedic patients but can also be seen in neonates (Figure 2), and is caused by a separation of the epidermis and dermis
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resulting from distension of skin under an unyielding tape or dressing, inappropriate strapping of tape or dressing during application, or when a joint or other area of movement is covered by unyielding tape.38,39
Another category of MARSI is dermatitis reactions such as irritant contact dermatitis, and allergic dermatitis.40-42 Complete differentiation between an irritant and an allergic response is somewhat difficult. In the first, a non-allergic contact dermatitis occurs as a result of chemical irritation; the skin appears red, is well marginated with precise borders (Figure 3), and usually resolves in a day or two if the adhesive is removed and not replaced. In allergic dermatitis, a cellmediated immunologic response occurs in response to a component of the adhesive or backing of
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 9 the tape or dressing; the skin is red with vesicles and a pruritic dermatitis results, persisting for up to a week.
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Other types of MARSI include maceration of the skin because of moisture being trapped against the skin for a long period of time; the skin appears white/gray in color, is wrinkled and is
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susceptible to damage from friction or irritants. Folliculitis, an inflammatory reaction in the hair
commonly seen in the NICU population.
Medical Adhesives: Tapes and Products
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Preventing MARSI in the NICU
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follicle that can appear as papules or pustules, can also be considered a MARSI, but is not
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Adhesive products are selected based on the intended purpose, as well as the anatomic location the adhesive will be attached. An important patient consideration is the type of device being
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secured; different products may be better suited for securing critical devices such as endotracheal
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tubes, vascular access devices, chest tubes, and in some cases, nasogastric tubes as compared to a monitoring sensor that must be replaced to different locations several times a day.
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When securing critical devices a higher level of adhesion product, usually acrylate or hydrocolloid, with a stronger “backing” such as cloth or silk is selected. There are many types of taping techniques for endotracheal tubes that have been utilized over the years, some using hydrocolloid platforms on which the cloth or silk tape is placed. Commercially available products are also made for this purpose. Despite the creative approaches, unplanned extubations continue to plague NICU care providers and have spawned a number of quality improvement projects to reduce this complication of care.43 Vascular access devices are secured with clear, transparent polyurethane dressings that contain acrylate adhesion so that the insertion site is clearly visible. However, to prevent dislodgment
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 10 other types of tape are often added to the device; an example is the “chevron” technique to further anchor the catheter or tubing
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Plastic perforated tape such as Transpore tape is often selected for its ease of use, as it can be torn into small pieces easily, thereby reducing the amount of tape in contact with the skin. Paper
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tape, found to cause less irritation and skin stripping compared to plastic perforated tape with repeated dressing changes in adults,44 does not easily mold to surfaces in the NICU patient, and
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does not have adequate adhesion for critical tubes.
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Silicone tapes and adhesive products are becoming more common and have promising qualities. Initially, a silicone mesh dressing, Mepitel™ (Molnlcke Health Care) was introduced for
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management of burns in pediatric patients. A randomized controlled study comparing this dressing to standard silver sulfadiazine plus cotton gauze dressing showed that not only were the
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dressing changes less painful, the scald burns epithelialized twice as rapidly and with less eschar
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formation.45 Other silicone products from this company include a silicone tape, silicone foam dressings, and cotton dressings with silicone borders. Several companies are now producing
choose.
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silicone tape and silicone bordered dressings so the NICU care providers have a wide variety to
Advantages from silicone adhesive products include that they are very gentle to this skin, and attach quickly to the skin due to low surface tension. Silicone tapes are removed easily and painlessly over hairy areas. Attaching electroencephalograph electrodes is an example of how this feature can be applied (Figure 4). A study in adults greater than 55 years of age, comparing silicone tape with paper tape which is also thought to be very gentle, found the silicone tape did not alter skin barrier function, measured by (TEWL) using an evaporimeter, even after daily removal and re-application. The paper tape did result in measurable changes in TEWL.36
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 11 A disadvantage of silicone tapes is that there is poor adherence to plastic or to other silicone products. Thus, their use is limited at this time, and clinical applications such as securing
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nasogastric tubes, urinary catheters, or nasal cannulas are not advised.
Hydrogel adhesives are available as electrocardiogram (EKG) electrodes and temperature probe
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covers. They should not be used in situation where adherence is critical, however; even their use to secure a temperature probe is a concern because dislodgment or inadequate adherence could
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result in an inaccurate skin temperature measurement and cause either under- or overheating an
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infant using skin servo-control mode of thermoregulation in either an incubator or a radiant warming table.
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Hydrocolloid adhesives are used as a “platform” under adhesive products such as ostomy pouches, and have been used in the NICU under a variety of adhesive tapes because they mold
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well to surfaces and withstand moisture. Products incorporating hydrocolloid adhesives are
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available and include endotracheal tube holders and umbilical catheter taping devices. Although observational studies reported that hydrocolloid adhesives were more gentle upon removal,
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compared to adhesive tapes with acrylates,46 a study that compared plastic perforated tape, hydrocolloid adhesive made from pectin and hydrogel adhesive found that both the plastic tape and hydrocolloid caused measurable disruption to the skin using TEWL measurements of skin barrier function.24 Skin Barrier Products Skin barrier products provide a protective coating between the epidermis and adhesives, and can reduce the risk of MARSI, as well as protecting skin from body fluids, exudates, urine and stool. These are available as liquid wipes, applicators or sprays, and may be formulated from a variety of substances including acrylates, polymers both organic and inorganic, and silicone. After
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 12 application, the liquid part of the barrier evaporates and leaves a transparent, breathable protective coating.
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Studies have shown that silicone barrier films reduce erythema and skin stripping following
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removal of adhesives in various patient populations, including neonates.47-49 Using products that
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are alcohol-free is recommended, as the alcohol component can cause pain when applied to skin that is excoriated, such as can be seen with peristomal or peri-wound care. One study involving
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60 premature infants greater than 33 weeks gestation used a barrier film to reduce TEWL and
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improve skin integrity and found it as beneficial as petrolatum ointment in this population.20 However, further research is needed in NICU patients before widespread use of barrier films is
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endorsed.50 Adhesive Removers
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Adhesive removers are sometimes used to prevent discomfort and skin disruption when adhesives are removed from the skin. There are three categories of adhesive removers:
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alcohol/organic-based solvents, oil-based solvents, and silicone-based removers.51 The alcohol-
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organic-based removers contain hydrocarbon derivatives or petroleum distillates that have potential or proven toxicities. Toxicity is a major concern, especially in premature infants with their underdeveloped stratum corneum, increased skin permeability, larger surface area/body weight ratio, and immature hepatic and renal function. A case report of toxic epidermal necrolysis in a premature infant resulted from the use of a solvent in this category.52 Mineral oil, petrolatum and citrus-based products may be helpful in removing adhesives but cannot be used if the site must be used again for reapplication of adhesives, such as with the retaping of an endotracheal tube.
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 13 Silicone-based removers form an interposing layer between adhesive and skin, evaporate readily after application, and do not leave a residue.51The use of silicone-based removers has been
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advocated for patients with extremely fragile skin, such as infants with epidermolysis bullosa.53 Future studies with silicone-based removers are encouraged in the NICU population. Removing
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adhesives with water-soaked cotton balls sometimes helps, and gently pulling the adhesive parallel to the skin surface rather than straight up at a 90-degree angle may facilitate removal
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with less skin trauma.33
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Other Issues Bonding Agents or Tackifiers
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Substances that increase the “stickiness” of adhesives, called bonding agents or tackifiers, are used to increase cohesive strength of adhesives; an example is the use to enhance wound closure
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tapes to surgical incisions. Examples of these agents include tincture of Benzoin and Mastisol. The use of these products for routine adhesive applications in the NICU is not recommended,
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particularly if removal will occur in several days’ time. This is because the bond that these
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agents forms with the adhesive to the epidermis is stronger that the fragile cohesion between epidermis and dermis, and can result in epidermal stripping when removed.50 Contact Irritant Dermatitis The problem of irritant contact dermatitis reactions to adhesives is being seen in infants who are chronically hospitalized for diseases such as complex congenital heart disease, bronchopulmonary dysplasia, and short bowel syndrome. These infants may require months of therapy that involves adhesives to attach nasal cannulas, nasogastric feeding tubes, and vascular access devices, as well as monitoring electrodes and sensors.
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 14 As described previously, there are several distinguishing characteristics that separate the contact irritant reactions from true allergic reactions. This has been studied in adults, who underwent
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extensive patch-testing to various adhesive products as well as some of the substances often used with adhesive dressings and bandages that could be the source of allergic responses; in one
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study, the allergic contact reaction was to tincture of benzoin.40,54
It seems that most of the skin reactions to adhesives are mechanical and more likely to occur
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when the adhesives were left on the skin for longer than 2 days; the strength of the adhesive used
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is another variable that may be important. The NICU infants who display this reaction to adhesive have not been studied at this time. However, NICU care providers are searching for
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products that their patients can tolerate without an irritant reaction. Prevention strategies are not currently known, but the role of skin damage and loss of barrier function seen with adhesive
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removal in the neonatal patient24 may have a role in the pathogenesis of contact irritant
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dermatitis to medical adhesives. Anetoderma of Prematurity
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Another potential morbidity that has been related to adhesive use in very low birth weight infants is anetoderma of prematurity. This is defined as atrophic patches of skin due to thinning of the dermis. This was first reported by Prizant,55 when nine infants born at four different hospitals were found to have atrophic skin lesions at 6 to 10 months of age; these lesions were distributed over both sides of the abdomen, the upper arms, chest and thighs (Figure 5). The authors suggested that pressure, a change in flow of ions or moisture under electrodes or adhesives may case an inflammatory response and subsequent damage to the elastic tissue of the dermis. Cases reported from a single hospital found anetoderma of prematurity in premature infants 25 to 30 weeks gestation, with birth weights ranging from 725-1250 grams. Many of the 11 infants had
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 15 significant morbidities including bronchopulmonary dysplasia, necrotizing enterocolitis and ileal perforation, and experienced longer hospital stays than a group of matched control infants.
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Placement of monitoring leads at the site of the atrophic patches was noted in 8 infants, and often the anetoderma was preceded by ecchymosis. The authors became concerned that pressure may
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have been part of the problem, as the infants were sometimes lying on their electrodes; they instituted a policy to avoid having infants lying on their leads. With that intervention they found
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fewer cases. However, traction when adhesives are removed is also suspected, since some of the anetoderma involved peri-umbilical skin where adhesives were used to secure umbilical
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catheters.56
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Conclusion
The challenges of using medical adhesives in NICU patients are significant and involve
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premature, full term and chronically hospitalized infants. Although securing life support devices
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is imperative to patient safety, skin injury from medical adhesives is also of significance. Research on the use of silicone barrier films and adhesive removers is needed, as these may
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reduce the incidence of MARSI in this population. Studies to demonstrate the “gentleness” of silicone adhesives and the development of silicone adhesive products may also prove beneficial. Awareness and vigilance on the part of NICU care providers is necessary to draw attention to the problem of MARSI in our NICU infants, and may also help to reduce the incidence.
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 16 References 1. Lund C, Osborne J, Kuller J et al: Neonatal skin care: clinical outcomes of the
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3. Noonan, C., Quigley, S., & Curley, M. A. Q. (2006). Skin integrity in hospitalized infants and children: a prevalence survey. Journal of pediatric nursing, 21(6), 445–453. .2006.
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ACCEPTED MANUSCRIPT Lund – Medical Adhesives 17 10. Agren J, Sjors G, Sedin G (1998). Transepidermal water loss in infants born at 24 and 25 weeks of estation, Acta Paediatr 87:1185-1190.
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ACCEPTED MANUSCRIPT Lund – Medical Adhesives 18 20. Brandon, D. H., Coe, K., Hudson-Barr, D., Oliver, T., & Landerman, L. R. (2010).
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premature infants. Journal of Perinatology, 30(6), 414–419.
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Measurement of transepidermal water loss in newborn infants. Clinics in Perinatology, 12, 79–99.
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23. Kalia, Y. N., Nonato, L. B., Lund, C. H., & Guy, R. H. (1998). Development of skin barrier
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function in premature infants. Journal of Investigative Dermatology, 111, 320–326.
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24. Lund, C. H., Nonato, L. B., Kuller, J. M., Franck, L. S., Cullander, C., & Durand, D. J. (1997). Disruption of barrier function in neonatal skin associated with adhesive removal.
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Journal of Pediatrics, 131, 367–372 25. Mancini, A. J. (2004). Skin. Pediatrics, 114, 114–119. 26. Siegfried E (2008). Neonatal slin care and toxicology (chapter 5) in Textbook of Neonatal Dermatology, Eichenfield L, Frieden I, Esterly N (eds), Philadelphia: W. B. Saunders Co. 27. Rissmann R, Groenink HWW, Gooris GS, et al. Temperature-induced changes in structural and physicochemical properties of vernix caseosa, J Invest Dermatol 128:292-299, 2008. 28. Hoath, S., Narendran, Visscher (2001). The biology and role of vernix. Newborn and Infant Nursing Reviews,1, 53-58.
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 19 29. Visscher M, Utturkar M, Pickens W, et al. Neonatal skin maturation—vernix caseosa and
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free amino acids. Pediatric Dermatology, 2011, 28:122-132.
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30. Visscher, M., Narendran, V., Pickens, W., LaRuffa, A., Meinzen-Derr, J., Allen, K., et al. (2005). Vernix caseosa in neonatal adaptation. Journal of Perinatology, 25, 440–446.
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31. United States Department of Health and Human Services. Medical adhesive tape and
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adhesive bandage. 21CFR880.5240.http://www.access-
data.fda.gov/scripts/cdrh/cfdocs/cfCFR/CFSearch.cfm?FR=880.5240.Revised April 1, 2012.
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32. Cutting, K. F. (2008). Impact of adhesive surgical tape and wound dressings on the skin, with reference to skin stripping. Journal of wound care, 17(4), 157–158, 160–162.
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33. Lund C, Tucker J, Adhesion and newborn skin. In Hoath SB, Maibach HI, eds. Neonatal
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Skin: Structure and Function, 2nd ed., New York: NY: Marcel Dekker, pp. 299-324, 2003.
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34. Lo J, Oriba H, Maibach H et al: Transepidermal potassium, ion, and water flux across delipidized and cellophane tape-stripped skin, Dermatologica 180:66, 1990
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35. Van der Valk P, Maibach H. A functional study of the skin barrier to evaporative water loss by means of repeated cellophane stripping. Clin Exp Dermatol, 1990, 15:180-182. 36. Grove G, Zerweck C, Houser T, et al. A randomized and controlled comparison of gentleness of 2 medical adhesive tapes in healthy human subjects. Journ of Wound, Ostomy and Continence Nurs, 2013, 40:51-59. 37. Le Blanc K, Baranoski S. Skin tears: state of the science concensus statements for the prevention, prediction, assessment, and treatment of skin tears. Adv Skin Wound Care, 2011, 24 (suppl 1):2-15.
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 20 38. Jester R, Russell L, Fell S, et al. A one hospital study of the effect of wound dressings and other related factors on skin blistering following total hip and knee arthroplasty. J Orthop
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Nurs,2000, 4:71-77.
39. Koval K, Egol K, Pollatsch D, et al. Tape blisters following hip surgery: a prospective,
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randomized study of two types of tape. J Bone Jt Surg, 2003, 85:1884-1887.
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40. Widman T, Oostman H, Storrs F. Allergic contact dermatitis from medical adhesive bandages in patients who report having a reaction to medical bandages. Dermatitis, 2007,
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19:32-37.
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41. Conway J, Whettam J. Adverse reaction to wound dressings. Nurs Stand, 2002, 16:52-60 42. Norris P, Storrs F. Allergic contact dermatitis to adhesive bandages. Dermatol Clin, 1990,
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8:147-152.
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43. Merkel L, Beers K, Lewis M, et al. Reducing unplanned extubations in the NICU. Pediatrics,
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2014, 133:e1367-1372.
44. Weber, B., Speer, M., Swartz, D., Rupp, S., O’Linn, W., & Stone, K. (1987). Irritation and stripping effects of adhesive tapes on skin layers of coronary bypass graft patients. Heart & Lung, 16, 567–572. 45. Gotschall, C. S., Morrison, M., & Eichelberger, M. (1998). Prospective, randomized study of the efficacy of Mepitel on children with partial-thickness scalds. Journal of Burn Care and Rehabilitation, 19, 279–283.
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 21 46. Dollison, E. J., & Beckstrand, J. (1995). Adhesive tape vs. pectin-based barrier use in
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preterm infants. Neonatal Network, 14, 35–39.
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47. Campbell K, Woodbury M, Whittle H, et al. A clinical evaluation of 3M no sting barrier film. Ostomy Wound Manage., 2000, 46:24-30.
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48. Irving, V. (2001). Reducing the risk of epidermal stripping in the neonatal population: An
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evaluation of an alcohol free barrier film. Journal of Neonatal Nursing, 7, 5–8.
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49. Shannon R, Chakravarthy D. Effect of a water-based no-sting protective barrier formulation on skin protection from medical adhesive trauma. Int Wound J, 2009, 6:82-88.
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50. Association of Women’s Health, Obstetric and Neonatal Nurses: Evidence-based clinical
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practice guideline: neonatal skin care (3nd Edition), Washington, DC, 2013, AWHONN. 51. Black, P. (2007). Peristomal skin care: an overview of available products. British journal of
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nursing, 16(17), 1048, 1050, 1052–1054.
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52. Ittman, P. I., & Bozynski, M. E. (1993). Toxic epidermal necrolysis in a newborn infant after exposure to adhesive remover. Journal of Perinatology, 13, 476–477. 53. Stephen-Haynes, J. (2008). Skin integrity and silicone: Appeel “no-sting” medical adhesive remover. British Journal of Nursing (Mark Allen Publishing), 17(12), 792–795. 54. Marks J, Rainey M. Cutaneous reactions to surgical preparations and dressings. Contact Dermatitis, 1984, 10:-5. 55. Prizant T, Lucky A, Frieden I, et al. Spontaneous atrophic patches in extremely prenature infants: anetoderma of prematurity. Arch Dermatol, 1996, 132:671-674.
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 22 56. Goujon E, Beer, F, Gay S, et al. Anetoderma of prematurity: an iatrogenic consequence of
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neonatal intensive care. Arch Dermatol, 2010, 146:565-576.
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 23 Figures and Table Legend Figure 1. Two infants with epidermal stripping from removal of medical adhesives.
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Figure 2. Tension blisters on the finger following removal of medical adhesive tape that was securing hand to IV board.
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Figure 3. Two infants with irritant contact dermatitis reaction from medical adhesives; one caused by transparent adhesive dressing, the other from hydrogel EKG electrodes.
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be removed from hair with less discomfort.
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Figure 4. EEG electrodes attached to scalp using silicone adhesive tape in two infants; these can
Figure 5. Anetoderma of prematurity seen in extremely low birth weight infant (left lower
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quadrant of the abdomen, left chest); these atrophic patches of skin due to thinning of dermis
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layer are often seen where electrodes or other medical adhesives have been applied.
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 24 Table 1. Types of Medical Adhesives Backing Uses Cloth Secure medical devices (ETT, Silk IV, NG tube, oxygen cannula) Polyester (woven, non-woven) Paper, Plastic Foam, Polyurethane (film) Film Ostomy care Platform underneath tape Integrated into adhesive products (ETT holder, umbilical catheter securement) Plastic EKG electrodes Reflective cover Temperature probes Woven polyester Secure EEG electrodes Plastic “Platform” between skin and tape Border of wound dressings Plastic Use only on top of hydrocolloid platform
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Adhesive Type Acrylates
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Hydrocolloid
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Hydrogel
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Silicone
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Zinc Oxide
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S1527-3369(14)00087-7 doi: 10.1053/j.nainr.2014.10.001 YNBIN 50570
To appear in:
Newborn and Infant Nursing Reviews
Please cite this article as: Lund Carolyn, Medical Adhesives in the NICU, Newborn and Infant Nursing Reviews (2014), doi: 10.1053/j.nainr.2014.10.001
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Medical Adhesives in the NICU
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[email protected]
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Carolyn Lund RN, MS, FAAN
Clinical Nurse Specialist
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UCSF Benioff Children’s Hospital & Research Center
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Oakland, CA
758 Cayuga Ave
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San Francisco, CA 94112 Work/Home Phone: 510-428-3436
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Cell: 415-370-8008
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Fax: 510-428-3542
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 1 Abstract Skin injury from medical adhesives is a known problem for NICU patients. Medical adhesive-
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related skin injury (MARSI) for all patient populations includes mechanical problems such as skin stripping, skin tears, and tension blisters; dermatitis reactions such as irritant contact
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dermatitis and allergic dermatitis; and other complications such as skin maceration and folliculitis. The most common seen in neonatal patients is epidermal or skin stripping;
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chronically hospitalized infants may also experience irritant contact dermatitis to a variety of
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adhesive products.
Preventing MARSI is the goal, using the fewest and least irritating adhesive products; yet, secure
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fixation of medical life support equipment is imperative. This article will explore differences in neonatal skin that places NICU patients at risk for MARSI and selecting products that are most
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appropriate for the desired result. Barrier films and adhesive removers are also discussed in
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detail to determine which may be potentially beneficial to the NICU population.
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Key words: medical adhesive, medical adhesive-related skin injury (MARSI), epidermal (skin) stripping, medical tapes and dressings, skin barrier films, adhesive removers
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 2 Introduction Medical adhesives comprise an integral part of healthcare delivery in the Newborn Intensive
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Care Unit (NICU) and in virtually all other inpatient and outpatient settings, as a component of a variety of products, including tapes, dressings, electrodes and ostomy supplies. They are applied
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and removed many times a day in the typical NICU. Premature and full-term infants who require medical interventions and constant monitoring are exposed to adhesives for a wide variety of
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indications. They secure both critical life support equipment such as endotracheal tubes,
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intravenous and arterial catheters, and chest tubes, as well as monitoring devices such as electrocardiogram electrodes, pulse oximeter probes and temperature sensors.
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Skin injury from medical adhesives is a known problem among healthcare providers in the NICU. In the 2001 evidence-based practice project conducted in 51 US nurseries involving 2820
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premature and term neonates, adhesives were the primary cause of the observed skin breakdown.1 A descriptive cohort study conducted in Australia found the incidence of “pressure
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injuries” (which is a broader category of iatrogenic tissue damage that incudes epithelial
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stripping) in 247 neonates to be 31.2%; medical devices were the most common risk factor associated with the skin injuries.2 In the broader pediatric population, a 1-day prevalence audit reported 8% of hospitalized infants and children were found to have tape-related skin stripping,3 and the 2003 National Pediatric Pressure Ulcer and Skin Breakdown Prevalence Survey found the prevalence of skin stripping related to adhesive tape was 17%.4 Because of these studies and a general concern in all populations of hospitalized patients, the acronym “MARSI” was coined, standing for “medical adhesive-related skin injury”.5
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 3 In an effort to increase awareness of MARSI and define best practices for prevention of this skin injury, a consensus panel of 22 health care providers from a variety of disciplines (nursing,
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medicine, physical therapy) and specialties (neonatology, pediatrics, geriatrics, orthopedics, dermatology, infusion nursing, infectious disease) convened to establish consensus statements on
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the assessment, prevention, and treatment of MARSI. Additional goals included defining knowledge gaps regarding medical adhesives and skin safety, documenting the spectrum of care
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settings and medical applications where MARSI occurs, and identifying research priorities for development of new adhesive technologies and protocols for skin protection. Following this
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meeting, a white paper was published with the 25 consensus statements reached by the group.5
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This paper will explore the unique differences in newborn skin that places NICU patients at high risk for MARSI, and the types of MARSI seen in this population. Following this, background on
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the science of medical adhesives and how adhesives interact with the skin, and the types of
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adhesives and adhesive products commonly used in the NICU is described. In addition, products that protect skin from adhesive damage or facilitate removal of adhesives without injury to the
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skin will be discussed.
Physiologic and Anatomic Variations in Newborn, Premature, and Infant Skin Stratum Corneum and Epidermis The stratum corneum, which provides the important barrier function of the skin, contains 10 to 20 layers in the adult and in the full term newborn. Although full term newborns have been shown have skin barrier function comparable to adult skin6 using a measurement called transepidermal water loss (TEWL), there is now some evidence that the stratum corneum does not function as well as adult skin throughout the first year of life7 and is 30% thinner than that of adult skin.8 Directly underneath the stratum corneum, the basal layer of the epidermis is 20%
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 4 thinner than that of the adult, and the keratinocyte cells in this layer have a higher cell turnover rate which may account for the faster wound healing that has been observed in neonates.
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The premature infant has far fewer layers of stratum corneum, and is determined by their
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gestational age. At less than 30 weeks gestation, there may be as few as two or three layers,9 and
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the extremely premature infant of 23 to 24 weeks has negligible barrier function due to minimal stratum corneum.10 Because of the deficiency in layers of stratum corneum, large fluid and
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evaporative heat losses can occur in the first weeks of life, leading to significant alterations in electrolyte levels, hypernatremia and dehydration.11 Techniques used to reduce these losses
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include the use of polyethylene coverings immediately after delivery,12,13,14 and use of high levels of relative humidity (>70% RH) in incubators.15,16 Topical treatments such as the
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application of transparent adhesive dressings,17,18 and sterile topical ointment and skin
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protectants have been described in small studies,19,20 but remain controversial due to concerns for infection.21 The process of maturation of the skin barrier, particularly for infants of 23 to 25
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weeks gestation occurs over time,10,22 with measurements of mature barrier function found as
Dermis
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they reach 30-32 weeks postconceptional age.23
The dermis of the full term newborn is thinner and not as well developed compared to the adult dermis. The collagen and elastin fibers are shorter and less dense, and the reticular layer of the dermis is absent, which makes the skin feel so soft. There are less total lipids and fewer sebaceous glands in the dermal layer in infancy.8 Cohesion between Epidermis and Dermis The junction between epidermis and dermis contains fibrils that connect these two layers of the skin. In premature infants, the fibrils are fewer in number, with wide spaces between connecting
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 5 points.9 As the premature infant becomes more mature these fibrils increase in number and strength. Abnormal fibrils at the junction of the epidermis and dermis are found in certain types
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of the genetic skin disease, epidermolysis bullosa, a blistering skin condition that occurs with even minimal trauma to the skin.
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This decreased cohesion between epidermis and dermis places the premature newborn at risk for skin injury from removal of medical adhesives that are attached to the skin. When extremely
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aggressive adhesives are used, the bond between adhesive and epidermis may be stronger than
skin barrier function.24
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Risk of Toxicity from Topical Agents
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that between epidermis and dermis, resulting in stripping of the epidermal layer and decreased
Toxicity from topically applied substances has been reported in numerous case reports due to the
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increased permeability of both preterm and full term newborn skin. This is due to a number of
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factors including the fact that newborn skin is 20-40% thinner than adult skin, and the ratio of body surface to weight is nearly five times greater than older children and adults, placing them at
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increased risk of percutaneous absorption and potential. Examples of toxicity from percutaneous absorption include hexachlorophene bathing leading to encephalopathy and death in premature infants, and thyroid toxicity from povidone-iodine used for skin disinfection toxicity.25,26 Thus, using topical agents carries a risk should they be absorbed through the skin of the premature or term neonate. Other Challenges in the NICU with Medical Adhesives The skin of a normal term infant is covered with vernix caseosa, a “cheesy” substance composed of water (80%), lipids and proteins,27 sebum from sebaceous glands, broken-off lanugo, and desquamated cells from the amnion. Vernix production begins at the end of the second trimester
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 6 protecting the fetal skin against maceration from amniotic fluid, and chafing caused by crowding in utero. Although leaving residual vernix intact may be beneficial after delivery as it assists in
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the formation of the acid mantle, facilitates colonization by normal bacterial flora, and serves as
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a natural moisturizer for the skin,28,29,30 it also makes adherence of medical adhesives very
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difficult. Some manufacturers of EKG electrodes, for example, recommend preparing the skin surface with isopropyl alcohol to improve adherence, but this practice is very irritating to the
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skin.
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Another factor complicating the application and removal of medical adhesive products is the use of thermoregulation devices. Radiant warming tables and convectively heated incubators are
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necessary for most neonates admitted to the NICU during initial stabilization and for premature infants for many days, weeks or months; the use of high ambient humidity levels; (>70%) in
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incubators is often employed in the care of extremely low birth weight prematures (< 28-30
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weeks gestation) during the first weeks of life to mitigate the excessive transepidermal water loss and evaporative heat loss that occurs due to their undeveloped stratum corneum. These thermal
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management techniques and devices may cause instability of many adhesive products, resulting in adhesives inadvertently falling off. Radiant heat from warming tables can also cause some adhesives to attach more firmly. An additional concern is the population of NICU patients with chronic illnesses such as complex congenital heart disease, short bowel syndrome, bronchopulmonary dysplasia or other conditions that necessitate their remaining hospitalized for many, many months, often with oxygen cannulas, feeding tubes, central venous catheters and other adhesive products in use. In this population an increase in contact dermatitis in response to a variety of adhesive products is being
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 7 observed, challenging the clinician to find alternative adhesive products that the infant does not react to in this way.
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Medical Adhesives and Medical Adhesive Products
The US Food and Drug Administration more defines a medical adhesive tape or adhesive
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bandage as “a device intended for medical purposes that consists of a strip of fabric material or plastic, coated on one side with an adhesive, and may include a pad of surgical dressing without
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a disinfectant. The device is used to cover and protect wounds, to hold together the skin edges of
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a wound, to support an injured part of the body, or to secure objects to the skin”.31 Medical adhesive tapes/dressings/devices are composed of several layers. The type of backing
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and adhesive used determine the properties and performance of the adhesive product. For example, tape backings can be composed of paper or paper blends, plastic, silk (woven
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polyester), soft (non-woven) cloth, traditional cloth, or foam and/or elastic. Examples of types of
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adhesives used in tapes and dressings include acrylates, silicones, hydrogels, hydrocolloids, and polyurethanes, as well as those that are natural-rubber latex based or contain zinc oxide (Table
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1).5,32,33
Medical adhesives are pressure sensitive; firm pressure applied to the surface of the medical tape/dressing/device will “activate” the adhesive by increasing the surface area contact. Over time, the adhesive will warm and flow to “fill in” the gaps between the adhesive and the irregularities in the skin surface, increasing the strength of the bond. The length of time for this process differs among different types of adhesive products. Some “softer” adhesives, such as silicone, have a lower surface tension and fill in these gaps quickly and maintain the same level of adherence over time. Others adhesives, such as the acrylates, act more slowly, and adherence increases over time to a state of maximal adherence, and then gradually the bond weakens. This
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 8 is why, whenever possible, leaving an adhesive in place even when not in use can assist in the removal process when the adhesive bond starts to lessen.
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Medical Adhesive-related Skin Injury
Skin injury results when the skin to adhesive attachment is stronger than skin cell to skin cell
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attachment. As a result, the epidermal layers separate or the epidermis separates completely from the dermis. Adhesive removal itself results in detachment of varying amounts of superficial
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epidermal cell layers even in adult skin; and repeated application and removal results in changes in skin barrier function; measurable disruption in skin barrier function has been reported after 10
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consecutive removal of tape containing acrylate adhesives in adults.34-36
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Classification of MARSI includes mechanical injuries such as epidermal stripping, tension injury or blistering, and skin tears. Epidermal stripping is frequently the mechanism seen in MARSI for
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neonates (Figure 1), while skin tears are more common in the elderly population and involve a
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separation of skin layers.37 Tension injury or blistering is seen in orthopedic patients but can also be seen in neonates (Figure 2), and is caused by a separation of the epidermis and dermis
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resulting from distension of skin under an unyielding tape or dressing, inappropriate strapping of tape or dressing during application, or when a joint or other area of movement is covered by unyielding tape.38,39
Another category of MARSI is dermatitis reactions such as irritant contact dermatitis, and allergic dermatitis.40-42 Complete differentiation between an irritant and an allergic response is somewhat difficult. In the first, a non-allergic contact dermatitis occurs as a result of chemical irritation; the skin appears red, is well marginated with precise borders (Figure 3), and usually resolves in a day or two if the adhesive is removed and not replaced. In allergic dermatitis, a cellmediated immunologic response occurs in response to a component of the adhesive or backing of
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 9 the tape or dressing; the skin is red with vesicles and a pruritic dermatitis results, persisting for up to a week.
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Other types of MARSI include maceration of the skin because of moisture being trapped against the skin for a long period of time; the skin appears white/gray in color, is wrinkled and is
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susceptible to damage from friction or irritants. Folliculitis, an inflammatory reaction in the hair
commonly seen in the NICU population.
Medical Adhesives: Tapes and Products
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Preventing MARSI in the NICU
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follicle that can appear as papules or pustules, can also be considered a MARSI, but is not
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Adhesive products are selected based on the intended purpose, as well as the anatomic location the adhesive will be attached. An important patient consideration is the type of device being
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secured; different products may be better suited for securing critical devices such as endotracheal
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tubes, vascular access devices, chest tubes, and in some cases, nasogastric tubes as compared to a monitoring sensor that must be replaced to different locations several times a day.
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When securing critical devices a higher level of adhesion product, usually acrylate or hydrocolloid, with a stronger “backing” such as cloth or silk is selected. There are many types of taping techniques for endotracheal tubes that have been utilized over the years, some using hydrocolloid platforms on which the cloth or silk tape is placed. Commercially available products are also made for this purpose. Despite the creative approaches, unplanned extubations continue to plague NICU care providers and have spawned a number of quality improvement projects to reduce this complication of care.43 Vascular access devices are secured with clear, transparent polyurethane dressings that contain acrylate adhesion so that the insertion site is clearly visible. However, to prevent dislodgment
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 10 other types of tape are often added to the device; an example is the “chevron” technique to further anchor the catheter or tubing
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Plastic perforated tape such as Transpore tape is often selected for its ease of use, as it can be torn into small pieces easily, thereby reducing the amount of tape in contact with the skin. Paper
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tape, found to cause less irritation and skin stripping compared to plastic perforated tape with repeated dressing changes in adults,44 does not easily mold to surfaces in the NICU patient, and
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does not have adequate adhesion for critical tubes.
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Silicone tapes and adhesive products are becoming more common and have promising qualities. Initially, a silicone mesh dressing, Mepitel™ (Molnlcke Health Care) was introduced for
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management of burns in pediatric patients. A randomized controlled study comparing this dressing to standard silver sulfadiazine plus cotton gauze dressing showed that not only were the
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dressing changes less painful, the scald burns epithelialized twice as rapidly and with less eschar
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formation.45 Other silicone products from this company include a silicone tape, silicone foam dressings, and cotton dressings with silicone borders. Several companies are now producing
choose.
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silicone tape and silicone bordered dressings so the NICU care providers have a wide variety to
Advantages from silicone adhesive products include that they are very gentle to this skin, and attach quickly to the skin due to low surface tension. Silicone tapes are removed easily and painlessly over hairy areas. Attaching electroencephalograph electrodes is an example of how this feature can be applied (Figure 4). A study in adults greater than 55 years of age, comparing silicone tape with paper tape which is also thought to be very gentle, found the silicone tape did not alter skin barrier function, measured by (TEWL) using an evaporimeter, even after daily removal and re-application. The paper tape did result in measurable changes in TEWL.36
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 11 A disadvantage of silicone tapes is that there is poor adherence to plastic or to other silicone products. Thus, their use is limited at this time, and clinical applications such as securing
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nasogastric tubes, urinary catheters, or nasal cannulas are not advised.
Hydrogel adhesives are available as electrocardiogram (EKG) electrodes and temperature probe
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covers. They should not be used in situation where adherence is critical, however; even their use to secure a temperature probe is a concern because dislodgment or inadequate adherence could
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result in an inaccurate skin temperature measurement and cause either under- or overheating an
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infant using skin servo-control mode of thermoregulation in either an incubator or a radiant warming table.
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Hydrocolloid adhesives are used as a “platform” under adhesive products such as ostomy pouches, and have been used in the NICU under a variety of adhesive tapes because they mold
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well to surfaces and withstand moisture. Products incorporating hydrocolloid adhesives are
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available and include endotracheal tube holders and umbilical catheter taping devices. Although observational studies reported that hydrocolloid adhesives were more gentle upon removal,
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compared to adhesive tapes with acrylates,46 a study that compared plastic perforated tape, hydrocolloid adhesive made from pectin and hydrogel adhesive found that both the plastic tape and hydrocolloid caused measurable disruption to the skin using TEWL measurements of skin barrier function.24 Skin Barrier Products Skin barrier products provide a protective coating between the epidermis and adhesives, and can reduce the risk of MARSI, as well as protecting skin from body fluids, exudates, urine and stool. These are available as liquid wipes, applicators or sprays, and may be formulated from a variety of substances including acrylates, polymers both organic and inorganic, and silicone. After
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 12 application, the liquid part of the barrier evaporates and leaves a transparent, breathable protective coating.
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Studies have shown that silicone barrier films reduce erythema and skin stripping following
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removal of adhesives in various patient populations, including neonates.47-49 Using products that
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are alcohol-free is recommended, as the alcohol component can cause pain when applied to skin that is excoriated, such as can be seen with peristomal or peri-wound care. One study involving
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60 premature infants greater than 33 weeks gestation used a barrier film to reduce TEWL and
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improve skin integrity and found it as beneficial as petrolatum ointment in this population.20 However, further research is needed in NICU patients before widespread use of barrier films is
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endorsed.50 Adhesive Removers
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Adhesive removers are sometimes used to prevent discomfort and skin disruption when adhesives are removed from the skin. There are three categories of adhesive removers:
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alcohol/organic-based solvents, oil-based solvents, and silicone-based removers.51 The alcohol-
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organic-based removers contain hydrocarbon derivatives or petroleum distillates that have potential or proven toxicities. Toxicity is a major concern, especially in premature infants with their underdeveloped stratum corneum, increased skin permeability, larger surface area/body weight ratio, and immature hepatic and renal function. A case report of toxic epidermal necrolysis in a premature infant resulted from the use of a solvent in this category.52 Mineral oil, petrolatum and citrus-based products may be helpful in removing adhesives but cannot be used if the site must be used again for reapplication of adhesives, such as with the retaping of an endotracheal tube.
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 13 Silicone-based removers form an interposing layer between adhesive and skin, evaporate readily after application, and do not leave a residue.51The use of silicone-based removers has been
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advocated for patients with extremely fragile skin, such as infants with epidermolysis bullosa.53 Future studies with silicone-based removers are encouraged in the NICU population. Removing
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adhesives with water-soaked cotton balls sometimes helps, and gently pulling the adhesive parallel to the skin surface rather than straight up at a 90-degree angle may facilitate removal
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with less skin trauma.33
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Other Issues Bonding Agents or Tackifiers
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Substances that increase the “stickiness” of adhesives, called bonding agents or tackifiers, are used to increase cohesive strength of adhesives; an example is the use to enhance wound closure
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tapes to surgical incisions. Examples of these agents include tincture of Benzoin and Mastisol. The use of these products for routine adhesive applications in the NICU is not recommended,
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particularly if removal will occur in several days’ time. This is because the bond that these
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agents forms with the adhesive to the epidermis is stronger that the fragile cohesion between epidermis and dermis, and can result in epidermal stripping when removed.50 Contact Irritant Dermatitis The problem of irritant contact dermatitis reactions to adhesives is being seen in infants who are chronically hospitalized for diseases such as complex congenital heart disease, bronchopulmonary dysplasia, and short bowel syndrome. These infants may require months of therapy that involves adhesives to attach nasal cannulas, nasogastric feeding tubes, and vascular access devices, as well as monitoring electrodes and sensors.
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 14 As described previously, there are several distinguishing characteristics that separate the contact irritant reactions from true allergic reactions. This has been studied in adults, who underwent
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extensive patch-testing to various adhesive products as well as some of the substances often used with adhesive dressings and bandages that could be the source of allergic responses; in one
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study, the allergic contact reaction was to tincture of benzoin.40,54
It seems that most of the skin reactions to adhesives are mechanical and more likely to occur
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when the adhesives were left on the skin for longer than 2 days; the strength of the adhesive used
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is another variable that may be important. The NICU infants who display this reaction to adhesive have not been studied at this time. However, NICU care providers are searching for
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products that their patients can tolerate without an irritant reaction. Prevention strategies are not currently known, but the role of skin damage and loss of barrier function seen with adhesive
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removal in the neonatal patient24 may have a role in the pathogenesis of contact irritant
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dermatitis to medical adhesives. Anetoderma of Prematurity
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Another potential morbidity that has been related to adhesive use in very low birth weight infants is anetoderma of prematurity. This is defined as atrophic patches of skin due to thinning of the dermis. This was first reported by Prizant,55 when nine infants born at four different hospitals were found to have atrophic skin lesions at 6 to 10 months of age; these lesions were distributed over both sides of the abdomen, the upper arms, chest and thighs (Figure 5). The authors suggested that pressure, a change in flow of ions or moisture under electrodes or adhesives may case an inflammatory response and subsequent damage to the elastic tissue of the dermis. Cases reported from a single hospital found anetoderma of prematurity in premature infants 25 to 30 weeks gestation, with birth weights ranging from 725-1250 grams. Many of the 11 infants had
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 15 significant morbidities including bronchopulmonary dysplasia, necrotizing enterocolitis and ileal perforation, and experienced longer hospital stays than a group of matched control infants.
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Placement of monitoring leads at the site of the atrophic patches was noted in 8 infants, and often the anetoderma was preceded by ecchymosis. The authors became concerned that pressure may
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have been part of the problem, as the infants were sometimes lying on their electrodes; they instituted a policy to avoid having infants lying on their leads. With that intervention they found
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fewer cases. However, traction when adhesives are removed is also suspected, since some of the anetoderma involved peri-umbilical skin where adhesives were used to secure umbilical
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catheters.56
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Conclusion
The challenges of using medical adhesives in NICU patients are significant and involve
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premature, full term and chronically hospitalized infants. Although securing life support devices
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is imperative to patient safety, skin injury from medical adhesives is also of significance. Research on the use of silicone barrier films and adhesive removers is needed, as these may
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reduce the incidence of MARSI in this population. Studies to demonstrate the “gentleness” of silicone adhesives and the development of silicone adhesive products may also prove beneficial. Awareness and vigilance on the part of NICU care providers is necessary to draw attention to the problem of MARSI in our NICU infants, and may also help to reduce the incidence.
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 16 References 1. Lund C, Osborne J, Kuller J et al: Neonatal skin care: clinical outcomes of the
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AWHONN/NANN evidence-based clinical practice guideline, J Obstet Gynecol Neonatal
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Nurs 30:41, 2001.
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2. August D, Edmonds L, Brown D, et al. Pressure injuries to the skin in a neonatal unit: fact or fiction. Journal of Neonatal Nursing, 2013, 20:129-137.
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3. Noonan, C., Quigley, S., & Curley, M. A. Q. (2006). Skin integrity in hospitalized infants and children: a prevalence survey. Journal of pediatric nursing, 21(6), 445–453. .2006.
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4. McLane KM, Bookout K, McCord S, et al. The 2003 national pediatric pressure ulcer and skin breakdown prevalence survey: a multisite study. J Wound, Ostomy & Continence Nurs.,
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5. McNichol, L, Lund, C, Rosen, T, Gray, M. (2013) Medical adhesives and patient safety: State of the science. Journal of Wound, Ostomy and Continence Nurses Society, 40:365-380.
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6. Yosipovitch G, Maayan-Metzger A, Merlob PP et al (2000). Skin barrier properties in
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ACCEPTED MANUSCRIPT Lund – Medical Adhesives 17 10. Agren J, Sjors G, Sedin G (1998). Transepidermal water loss in infants born at 24 and 25 weeks of estation, Acta Paediatr 87:1185-1190.
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11. Bhatia, J. (2006). Fluid and electrolyte management in the very low birth weight neonate. Journal of Perinatology: Official Journal of the California Perinatal Association, 26 Suppl 1,
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16. Gaylord M, Wright K, Lorch K et al. (2001). Improved fluid management utilizing humidified incubators in extremely low birth weight infants. J Perinat, 21:438-443. 17. Mancini A, Sookdeo-Drost S, Madison K et al (1994). Semipermeable dressings improve epidermal barrier function in premature infants, Pediatr Res 36:306-314. 18. Bhandari V., Brodsky N. & Porat R, (2005). Improved outcome of extremely low birth weight infants with tegaderm application to skin. Journal of Perinatology, 25:276-281. 19. Beeram, M., Olvera, R., Krauss, D., Loughran, C., & Petty, M. (2006). Effects of topical emollient therapy on infants at or less than 27 weeks’ gestation. Journal of the National Medical Association, 98(2), 261–264.
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 18 20. Brandon, D. H., Coe, K., Hudson-Barr, D., Oliver, T., & Landerman, L. R. (2010).
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22. Sedin, G., Hammarlund, K., Nilsson, G. E., Stromberg, B., & Oberg, P. A. (1985).
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24. Lund, C. H., Nonato, L. B., Kuller, J. M., Franck, L. S., Cullander, C., & Durand, D. J. (1997). Disruption of barrier function in neonatal skin associated with adhesive removal.
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Journal of Pediatrics, 131, 367–372 25. Mancini, A. J. (2004). Skin. Pediatrics, 114, 114–119. 26. Siegfried E (2008). Neonatal slin care and toxicology (chapter 5) in Textbook of Neonatal Dermatology, Eichenfield L, Frieden I, Esterly N (eds), Philadelphia: W. B. Saunders Co. 27. Rissmann R, Groenink HWW, Gooris GS, et al. Temperature-induced changes in structural and physicochemical properties of vernix caseosa, J Invest Dermatol 128:292-299, 2008. 28. Hoath, S., Narendran, Visscher (2001). The biology and role of vernix. Newborn and Infant Nursing Reviews,1, 53-58.
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 19 29. Visscher M, Utturkar M, Pickens W, et al. Neonatal skin maturation—vernix caseosa and
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free amino acids. Pediatric Dermatology, 2011, 28:122-132.
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30. Visscher, M., Narendran, V., Pickens, W., LaRuffa, A., Meinzen-Derr, J., Allen, K., et al. (2005). Vernix caseosa in neonatal adaptation. Journal of Perinatology, 25, 440–446.
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31. United States Department of Health and Human Services. Medical adhesive tape and
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adhesive bandage. 21CFR880.5240.http://www.access-
data.fda.gov/scripts/cdrh/cfdocs/cfCFR/CFSearch.cfm?FR=880.5240.Revised April 1, 2012.
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32. Cutting, K. F. (2008). Impact of adhesive surgical tape and wound dressings on the skin, with reference to skin stripping. Journal of wound care, 17(4), 157–158, 160–162.
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34. Lo J, Oriba H, Maibach H et al: Transepidermal potassium, ion, and water flux across delipidized and cellophane tape-stripped skin, Dermatologica 180:66, 1990
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35. Van der Valk P, Maibach H. A functional study of the skin barrier to evaporative water loss by means of repeated cellophane stripping. Clin Exp Dermatol, 1990, 15:180-182. 36. Grove G, Zerweck C, Houser T, et al. A randomized and controlled comparison of gentleness of 2 medical adhesive tapes in healthy human subjects. Journ of Wound, Ostomy and Continence Nurs, 2013, 40:51-59. 37. Le Blanc K, Baranoski S. Skin tears: state of the science concensus statements for the prevention, prediction, assessment, and treatment of skin tears. Adv Skin Wound Care, 2011, 24 (suppl 1):2-15.
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 20 38. Jester R, Russell L, Fell S, et al. A one hospital study of the effect of wound dressings and other related factors on skin blistering following total hip and knee arthroplasty. J Orthop
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40. Widman T, Oostman H, Storrs F. Allergic contact dermatitis from medical adhesive bandages in patients who report having a reaction to medical bandages. Dermatitis, 2007,
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41. Conway J, Whettam J. Adverse reaction to wound dressings. Nurs Stand, 2002, 16:52-60 42. Norris P, Storrs F. Allergic contact dermatitis to adhesive bandages. Dermatol Clin, 1990,
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43. Merkel L, Beers K, Lewis M, et al. Reducing unplanned extubations in the NICU. Pediatrics,
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44. Weber, B., Speer, M., Swartz, D., Rupp, S., O’Linn, W., & Stone, K. (1987). Irritation and stripping effects of adhesive tapes on skin layers of coronary bypass graft patients. Heart & Lung, 16, 567–572. 45. Gotschall, C. S., Morrison, M., & Eichelberger, M. (1998). Prospective, randomized study of the efficacy of Mepitel on children with partial-thickness scalds. Journal of Burn Care and Rehabilitation, 19, 279–283.
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 21 46. Dollison, E. J., & Beckstrand, J. (1995). Adhesive tape vs. pectin-based barrier use in
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preterm infants. Neonatal Network, 14, 35–39.
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47. Campbell K, Woodbury M, Whittle H, et al. A clinical evaluation of 3M no sting barrier film. Ostomy Wound Manage., 2000, 46:24-30.
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48. Irving, V. (2001). Reducing the risk of epidermal stripping in the neonatal population: An
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evaluation of an alcohol free barrier film. Journal of Neonatal Nursing, 7, 5–8.
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49. Shannon R, Chakravarthy D. Effect of a water-based no-sting protective barrier formulation on skin protection from medical adhesive trauma. Int Wound J, 2009, 6:82-88.
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50. Association of Women’s Health, Obstetric and Neonatal Nurses: Evidence-based clinical
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practice guideline: neonatal skin care (3nd Edition), Washington, DC, 2013, AWHONN. 51. Black, P. (2007). Peristomal skin care: an overview of available products. British journal of
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nursing, 16(17), 1048, 1050, 1052–1054.
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52. Ittman, P. I., & Bozynski, M. E. (1993). Toxic epidermal necrolysis in a newborn infant after exposure to adhesive remover. Journal of Perinatology, 13, 476–477. 53. Stephen-Haynes, J. (2008). Skin integrity and silicone: Appeel “no-sting” medical adhesive remover. British Journal of Nursing (Mark Allen Publishing), 17(12), 792–795. 54. Marks J, Rainey M. Cutaneous reactions to surgical preparations and dressings. Contact Dermatitis, 1984, 10:-5. 55. Prizant T, Lucky A, Frieden I, et al. Spontaneous atrophic patches in extremely prenature infants: anetoderma of prematurity. Arch Dermatol, 1996, 132:671-674.
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 22 56. Goujon E, Beer, F, Gay S, et al. Anetoderma of prematurity: an iatrogenic consequence of
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neonatal intensive care. Arch Dermatol, 2010, 146:565-576.
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 23 Figures and Table Legend Figure 1. Two infants with epidermal stripping from removal of medical adhesives.
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Figure 2. Tension blisters on the finger following removal of medical adhesive tape that was securing hand to IV board.
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Figure 3. Two infants with irritant contact dermatitis reaction from medical adhesives; one caused by transparent adhesive dressing, the other from hydrogel EKG electrodes.
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be removed from hair with less discomfort.
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Figure 4. EEG electrodes attached to scalp using silicone adhesive tape in two infants; these can
Figure 5. Anetoderma of prematurity seen in extremely low birth weight infant (left lower
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quadrant of the abdomen, left chest); these atrophic patches of skin due to thinning of dermis
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layer are often seen where electrodes or other medical adhesives have been applied.
ACCEPTED MANUSCRIPT Lund – Medical Adhesives 24 Table 1. Types of Medical Adhesives Backing Uses Cloth Secure medical devices (ETT, Silk IV, NG tube, oxygen cannula) Polyester (woven, non-woven) Paper, Plastic Foam, Polyurethane (film) Film Ostomy care Platform underneath tape Integrated into adhesive products (ETT holder, umbilical catheter securement) Plastic EKG electrodes Reflective cover Temperature probes Woven polyester Secure EEG electrodes Plastic “Platform” between skin and tape Border of wound dressings Plastic Use only on top of hydrocolloid platform
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Adhesive Type Acrylates
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Hydrogel
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Silicone
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Zinc Oxide
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