Medical Adhesive-Related Skin Injuries and Associated Risk Factors in a Pediatric Intensive Care Unit

Pediatric nursing-sensitive outcomes in lower and medium complexity care units: A Delphi study

BACKGROUND

The effectiveness of pediatric care is made more challenging to analyze by the need for specialist nursing and by the specific characteristics of pediatric patients, as opposed to adult patients, such as ongoing rapid growth and development, and different physical, cognitive, and emotional demands. Previous research has identified "Pediatric Nursing-Sensitive Outcomes" (PNSOs) in intensive care unit settings, though pediatric intensive care beds only represent a very limited percentage of hospital beds. To improve care quality and safety for a larger population of patients, this study aims to identify PNSOs in lower and medium-complexity care units (LMCCUs).

METHODS

This study uses the Delphi method to gather expert opinion on priority PNSOs in LMCCUs, with a 75 % consensus pass threshold. A preliminary list of PNSOs was identified from a literature review and used as inputs for two Delphi rounds conducted between January and March 2023.

RESULTS

27 panelists were recruited and passed 17 PNSOs: pressure injury; failure to rescue; patient/family experiences; central line-associated bloodstream infections; surgical site infections; healthcare-associated infections; medication errors; hospitalization breastfeeding continuity; peripheral intravenous infiltrate or extravasation; pediatric falls; pain assessment and management; vital sign monitoring; nutrition; discharge planning; family-centered care practice; healthcare environment; nurse voluntary turnover.

CONCLUSION

This study contributes to research on PNSOs and builds consensus on priorities for LMCCUs. Future research should clinically evaluate these PNSOs and their association with organizational and professional variables often investigated in an adult but not a pediatric setting.

The prevalence, incidence and risk factors of medical adhesive-related skin injury in adult inpatients: A systematic review and meta-analysis

BACKGROUND

MARSI can occur in any population and clinical setting and is prevalent among patients who are frequently exposed to medical adhesives. It can disrupt the skin barrier and cause pain and infection, confusing patients and medical staff and making it necessary to understand its prevalence, incidence, and risk factors to improve patient health and medical safety.

OBJECTIVE

To systematically evaluate the prevalence, incidence and risk factors of medical adhesive-related skin injury in adult inpatients.

DESIGN

Systematic literature review and meta-analysis.

METHODS

A computer search was conducted on nine databases in both Chinese and English, covering studies from inception to July 10, 2024, evaluating the prevalence, incidence and risk factors of medical adhesive-related skin injuries. Meta-analyses were performed using Review Manager 5.4 and Stata 14 software.

RESULTS

The analysis included 22 studies, involving a total of 10510 research subjects. The meta-analysis of fourteen cross-sectional studies showed that the prevalence of medical adhesive-related skin injury in adult inpatients was 16 % [95 % CI: 13-18 %, Z = 10.95, P < 0.00001]. In the other seven additional cohort studies, the meta-analysis of incidence was 25 % [95 % CI: 17-33 %, Z = 5.90, P < 0.00001]. The results of the meta-analysis of risk factors showed that the following six factors: age>50 years (OR = 1.21, 95%CI: 1.05-1.41), dry skin (OR = 3.51, 95%CI: 1.55-7.95), history of MARSI (OR = 6.78, 95%CI: 1.69-27.15), history of skin allergies (OR = 3.82, 95%CI: 1.92-7.57), skin edema(OR = 3.59,95%CI:1.52-8.47), wet skin(OR = 3.57,95%CI:1.65-13.35) were risk factors.

Prevalence, Risk Factors, Causes, Assessments, and Prevention of Medical Adhesive-Related Skin Injury: A Scoping Review

OBJECTIVE

To evaluate research on medical adhesive-related skin injury (MARSI), focusing on its incidence, prevalence, risk factors, causes, assessments, and prevention.

DATA SOURCES

Searches were conducted on Wanfang Data, China National Knowledge Infrastructure, PubMed, Web of Science Core Collection, MEDLINE, EMBASE, and the Cumulative Index of Nursing and Allied Health Literature Plus with Full Text.

STUDY SELECTION

Using search terms "medical adhesive related skin injury", "MARSI", "adhesive skin injury", and "medical tape-induced skin injury", the authors selected 43 original articles published between January 1, 2001, and May 12, 2022, in English or Chinese.

DATA EXTRACTION

Extracted details included the first author; publication year; study location; study type; and specifics on MARSI, such as causes, affected body areas, assessment methods, incidence, prevalence, and prevention.

DATA SYNTHESIS

Medical adhesive-related skin injury frequently occurred on the face and at venipuncture sites. Acrylate-containing adhesives were more likely to cause MARSI. Risk factors include extended hospital stays, lower Braden Scale scores, mechanical ventilation, edema, poor skin condition, and use of certain medications. Incidence or prevalence exceeded 10% across populations, peaking at 60.3% in the pediatric surgical ICU. Mechanical injury had the highest incidence and prevalence among MARSI types. Studied interventions and quality improvement measures were effective in reducing MARSI.

CONCLUSIONS

Despite increasing interest, evidence for reducing MARSI is limited. Future research should focus on distinguishing MARSI types, clarifying incidence and prevalence, assessing risk factors, and implementing screening and quality improvement initiatives.

Prevention and management of medical adhesive-related skin injuries in tumor patients with peripheral central venous catheters: a best practice implementation project

INTRODUCTION

Peripheral central venous catheters are common vascular access devices used in patients with tumors. To prevent catheter shedding and displacement, it is essential to use medical adhesives to secure the catheters. Repeated adhesion and removal of medical adhesives can weaken the barrier function of the skin, leading to medical adhesive-related skin injuries (MARSI), which can increase the patients' pain and medical expenses.

OBJECTIVES

The objective of this project was to utilize the best evidence to prevent and manage MARSI in tumor patients with peripheral central venous catheters.

METHODS

This evidence-based audit and feedback project was theoretically informed by the JBI Evidence Implementation Framework. The framework involves seven phases in which a project team was established; measurable criteria were selected; baseline data were collected; improvement strategies were implemented to address gaps in compliance; a follow-up audit was conducted to assess improvements in compliance; and sustainability measures were considered. The project also used the JBI Practical Application of Clinical Evidence System (PACES) for project management, including data collection and analysis. The JBI Getting Research into Practice (GRiP) approach was also used to support implementation and compliance.

RESULTS

In the baseline audit, the compliance rate for the nine audit criteria was low. In the follow-up audit, the compliance rate significantly improved, with each audit criterion exceeding a minimum of 80%, and four audit criteria reaching 100%. Knowledge of MARSI among nurses and patients significantly improved (p  < 0.05) and the incidence of MARSI among patients with peripheral central venous catheters decreased.

CONCLUSIONS

This project successfully enhanced nurses' compliance with MARSI prevention and management and increased the knowledge and skills of both nurses and patients about MARSI.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A285.

Medical Adhesive-Related Skin Injury at 10 Years: An Updated Consensus

Awareness of medical adhesive-related skin injury (MARSI) has increased in the decade since a foundational consensus report was published in 2013. Additional research has provided greater knowledge of the epidemiology of MARSI, along with its assessment, prevention, and management. To summarize knowledge generated in the past decade and review our current understanding of MARSI, a panel of nine clinical experts from four countries (United States of America, United Kingdom, Canada, and Brazil) convened to discuss the literature published since the initial 2013 document and develop updated recommendations for clinical practice. The group formulated 20 updated consensus statements covering the assessment, prevention, and management of skin injuries related to adhesive medical devices and proposed next steps to address remaining gaps in research and knowledge of this complex and clinically relevant condition.

Effectiveness of breast milk in the healing of medical adhesive-related skin injuries in peripheral intravenous catheter securement: A randomized controlled trial

BACKGROUND

Skin injuries, which are more prevalent among premature infants, can prolong the hospital stay of preterms in neonatal intensive care units.

AIM

This study aimed to assess the effectiveness of breast milk in reducing the healing time of skin injuries caused using medical adhesive for securing peripheral intravenous catheters (PIVCs) in late preterm infants, which was evaluated using the Neonatal Skin Condition Scale (NSCS). A randomized controlled trial was conducted with two parallel groups in a 1:1 allocation ratio.

STUDY DESIGN

It was conducted in the Neonatal Intensive Care Unit of a hospital in Karaman, Turkey between August and November 2022 with 72 preterm infants born at 35-36 weeks with stable health status and having intravenous catheter securement to the skin with medical adhesive tapes, with the tapes remaining on the skin for a minimum of 24 h and a maximum of 32 h. Preterm infants were randomly assigned to breast milk or routine care groups. The site of the skin injuries was evaluated by two independent observers using the NSCS once every 60 min until the injury was completely healed. A one-way ANOVA and repeated measures analysis of variance was used to analyse the data.

RESULTS

The average postnatal age was 3.32 ± 0.99 days, and the total duration of medical adhesive tape on the skin was 28.21 ± 2.59 h. A significant difference was found between the mean skin condition scale scores of the infants in the breast milk group (F = 117.219, p < .001) and the routine care group (F = 122.247, p < .001) according to time within the group. The skin injuries of preterm infants in the breast milk group decreased significantly in the first 3 h after the procedure.

CONCLUSION

Breast milk application was more effective than routine care in reducing the healing time of skin injuries.

RELEVANCE TO CLINICAL PRACTICE

It can be recommended to use breast milk to heal skin injuries in preterm infants.

Medical Adhesive-related Skin Injuries Caused by Eye Taping: A Case Report

This case report discusses medical adhesive-related skin injuries (MARSIs) caused by eye taping during an emergency open reduction internal fixation surgery under general anesthesia. The presented case involves a 72-year-old woman with a proximal humeral fracture, where 3M Transpore adhesive tape caused blisters on both eyelids. This tape is an acrylic-based medical adhesive and is commonly used to keep eyelids closed during general anesthesia. MARSIs can largely be prevented through evidence-based clinical guidance. Enhancing awareness of MARSIs among anesthesia providers and perianesthesia nurses is crucial to prevent and manage such injuries effectively.

Quality improvement initiative to reduce Medical Adhesive Related Skin injury (MARSI) in very preterm babies admitted to neonatal intensive care unit

INTRODUCTION

Sick preterm neonates are most vulnerable to developing skin injuries. Despite sound knowledge and application of evidence-based practices for preventing medical adhesive-related skin injury (MARSI), the incidence of MARSI was 30 events per 1000 adhesive application days in our unit.

AIMS AND OBJECTIVES

We aimed to reduce the median MARSI rate from the existing 30 per 1000 MARSI days to <5 per 1000 MARSI over 5 months from June 2023 to October 2023.

MATERIAL & METHODS

With the point-of-care quality improvement (QI) approach, a prospective study was planned to reduce the incidence of MARSI among sick very preterm newborns (<32 weeks gestational age) and eventually improve overall skin condition during hospital stay. Sequential Plan-Do-Study-Act cycles were implemented based on the identified risk factors recognised during recurring team discussions.

RESULTS

We demonstrated a reduction in the MARSI rate from 30 events per 1000 adhesive applications (during baseline assessment) to zero events per 1000 adhesive applications at the end of the study period. It was temporally related to the assessment of skin risk stratification at admission using a validated tool, regular assessment of neonatal skin condition score based on the skin risk stratification, and reinforcement of MARSI prevention bundle by application of barrier spray. Awareness regarding 'skin injury prevention' bundles was continually generated among healthcare professionals. The MARSI rate remained <5 events per adhesive application in the sustenance phase over 6 months.

CONCLUSION

Implementing evidence-based skin care practices resulted in a significant reduction in iatrogenic cutaneous injury events in very preterm neonates.

Iatrogenic skin injuries in infants admitted to neonatal intensive care units: An investigation in 22 Chinese units

OBJECTIVE

To investigate the incidence of iatrogenic skin injuries in neonates across 22 neonatal intensive care units (NICUs) in China.

DESIGN

Prospective study.

SETTING

22 NICUs in China.

PATIENTS

Infants admitted to NICU.

INTERVENTIONS

None.

MEASUREMENTS

The "Iatrogenic Skin Injuries Data Collection Form of infants" were used to collect the data during hospitalization.

MAIN RESULTS

A total of 8126 neonates who were hospitalized in 22 tertiary hospitals across 15 provinces, cities, and autonomous regions of China between December 1, 2019 and January 31, 2020 were analyzed. Five hundred and twenty-one infants had iatrogenic skin injuries, including 250 with diaper dermatitis (47.98%), 70 with physicochemical factor-related skin lesions (PCFRSIs) (13.44%), 81 with medical device-related pressure injuries (MDRPIs) (15.55%), and 69 with medical adhesive-related skin injuries (MARSIs) (13.24%), accounting for 91% of the total number of iatrogenic injuries. Among these, diaper dermatitis was closely related to the skin and feeding status. Furthermore, the risk was higher among neonates who had skin damage upon admission or were already fully fed orally. The influencing factors of MDRPIs and MARSIs were similar. They were negatively associated with gestational age and birth weight, and were closely related to the presence of various tubes.

CONCLUSIONS

Diaper dermatitis, PCFRSIs, MDRPIs, and MARSIs were the four common types of iatrogenic skin injuries in newborns. The various types of iatrogenic skin injuries were influenced by varying factors. Specialized nursing measurements can reduce the likelihood of these injuries.

Safety and efficacy of silicone tape for indwelling urinary catheter fixation in intensive care patients-A randomized clinical trial

BACKGROUND

Critically ill patients are more vulnerable to medical adhesive-related skin injuries (MARSI), whose prevention is a constant challenge and one of the main quality indicators of nursing care. MARSI associated with indwelling urinary catheter (IUC) fixation is a relevant adverse event, mainly because of the constant involuntary traction and high skin vulnerability of the fixation site. Silicone adhesive tape has appreciable qualities for fragile skin among the range of adhesives, leading to the inference that it reduces the risk of MARSI.

AIM

To compare silicone adhesive tape for IUC fixation with acrylate tape regarding its safety and efficacy.

STUDY DESIGN

This was a randomized controlled trial blinded to the patients and evaluator. Data were collected from an intensive care unit (ICU) of a tertiary university hospital in Brazil. Patients with IUC and no MARSI at the fixation site were considered eligible. The omega (Ω) fixation technique was used for IUC fixation. A total of 132 participants were enrolled and divided into two research groups: 66 patients in the intervention group (silicone tape) and 66 in the control group (acrylate tape). Outcomes were the incidence of MARSI, patient outcome in the ICU and hospital and partial, total and overall spontaneous detachment of the tapes.

RESULTS

The overall incidence of MARSI was 28%, with 21% in the silicone group and 35% in the acrylate group, with no statistically significant difference (p = .121), including the severity of the lesions (p = .902). However, partial (p = .003) and overall (p < .001) detachment of the tapes were more frequent in the silicone group.

CONCLUSIONS

Silicone tape is no safer than acrylate tape for IUC fixation and is less adhesively effective.

RELEVANCE TO CLINICAL PRACTICE

There is no evidence to support the extensive use of silicone tape in this context.

Incidence and risk factors for medical adhesive-related skin injury in catheters of critically ill patients: A prospective cohort study

BACKGROUND

The skin in contact with the adhesives used to secure catheters is vulnerable to medical adhesive-related skin injury (MARSI). The incidence of these injuries and the risks associated with their development have not been accurately estimated previously in critically ill patients.

AIM

The aim of this study was to investigate the incidence and risk factors for MARSI in catheters of critically ill patients.

METHODS

A prospective cohort study was conducted in adult intensive care units of two Brazilian university hospitals. A total of 150 patients (439 catheters) were included. The skin exposed to the catheter fixation adhesives (central venous, nasogastric, nasoenteral, and indwelling urinary) was examined daily by four trained researchers. The patients' sociodemographic and clinical data were collected from their electronic medical records. The association between independent variables and MARSI was investigated by bivariate statistics, followed by a multiple logistic regression.

RESULTS

The MARSI incidence was 42% (86.5 MARSIs per 1000 patient-days). Advanced age, prolonged hospital stay, dry skin, repetitive adhesive removal, low Braden Scale score, and hypoalbuminemia were associated with MARSI (p < .05). According to the multivariate logistic regression, dry skin increased the chance of MARSI by 5.2 times (odds ratio: 5.2; 95% confidence interval: 2.4-11.1), while the Braden Scale score was a protective factor, showing 30% less chance of MARSI for each added score (odds ratio: 0.7; 95% confidence interval: 0.6-0.9). A higher incidence of MARSI was observed in nasoenteral catheters and in those fixed with adhesive using natural rubber. The MARSI types were predominantly mechanical (70.3%): skin stripping (41.3%), skin tear (26.1%), and tension injury or blister (2.9%).

CONCLUSIONS

MARSI is a common event in adult intensive care units, and most risk factors are modifiable. Preventive actions are potentially capable of reducing incidence, optimising financial resources, and improving clinical results.

Replacing Monitoring Electrodes on Infant Skin Every 12 Versus 24 Hours

OBJECTIVE

To examine the effect of varying the frequency of monitoring electrode replacement on skin moisture and condition of infants hospitalized in the pediatric ICU.

METHODS

The population of the study consisted of 1- to 12-month-old infants receiving treatment in the pediatric ICU. The control group of the study (n = 33) included infants whose monitoring electrodes were replaced every 24 hours during monitoring, and the experimental group (n = 33) included infants whose monitoring electrodes were replaced every 12 and 24 hours during monitoring. Before assessment, the skin moisture of the monitoring areas was measured and evaluated with the Skin Condition Assessment Scale.

RESULTS

When the difference in skin moisture was compared for all measurement areas of the infants before monitoring and at the 24-hour mark, an increase in moisture was seen in both groups, and the difference in the experimental group was greater than that in the control group. Increased moisture is a risk factor for medical device-related pressure injuries. When comparing between-group differences in skin condition, the researchers noted a greater increase in skin condition score in the experimental group. An increased score indicates that the infant's skin condition is worsening.

CONCLUSIONS

Replacing the monitoring electrodes every 24 hours positively affected skin moisture and condition, whereas replacing them every 12 hours negatively affected skin moisture and condition.

Clinical applications of contactless photoplethysmography for vital signs monitoring in pediatrics: A systematic review and meta-analysis

Background

Contactless photoplethysmography (PPG) potentially affords the ability to obtain vital signs in pediatric populations without disturbing the child. Most validity studies have been conducted in laboratory settings or with healthy adult volunteers. This review aims to evaluate the current literature on contactless vital signs monitoring in pediatric populations and within a clinical setting.

Methods

OVID, Webofscience, Cochrane library, and clinicaltrials.org were systematically searched by two authors for research studies which used contactless PPG to assess vital signs in children and within a clinical setting.

Results

Fifteen studies were included with a total of 170 individuals. Ten studies were included in a meta-analysis for neonatal heart rate (HR), which demonstrated a pooled mean bias of -0.25 (95% limits of agreement (LOA), -1.83 to 1.32). Four studies assessed respiratory rate (RR) in neonates, and meta-analysis demonstrated a pooled mean bias of 0.65 (95% LOA, -3.08 to 4.37). All studies were small, and there were variations in the methods used and risk of bias.

Conclusion

Contactless PPG is a promising tool for vital signs monitoring in children and accurately measures neonatal HR and RR. Further research is needed to assess children of different age groups, the effects of skin type variation, and the addition of other vital signs.

Clinical applications of contactless photoplethysmography for monitoring in adults: A systematic review and meta-analysis

Contactless photoplethysmography (cPPG) is a method of physiological monitoring. It differs from conventional monitoring methods (e.g., saturation probe) by ensuring no contact with the subject by use of a camera. The majority of research on cPPG is conducted in a laboratory setting or in healthy populations. This review aims to evaluate the current literature on monitoring using cPPG in adults within a clinical setting. Adhering to the Preferred Items for Systematic Reviews and Meta-analysis (PRISMA, 2020) guidelines, OVID, Webofscience, Cochrane library, and clinicaltrials.org were systematically searched by two researchers. Research articles using cPPG for monitoring purposes in adults within a clinical setting were selected. Twelve studies with a total of 654 individuals were included. Heart rate (HR) was the most investigated vital sign (n = 8) followed by respiratory rate ((n = 2), Sp02 (n = 2), and HR variability (n = 2). Four studies were included in a meta-analysis of HR compared to ECG data which demonstrated a mean bias of -0.13 (95% CI, -1.22-0.96). This study demonstrates cPPG can be a useful tool in the remote monitoring of patients and has demonstrated accuracy for HR. However, further research is needed into the clinical applications of this method.

Incidence and Predictive Model of Medical Adhesive-Related Skin Injury in Cancer Patients Managed With Central Venous Access Devices: A Retrospective Study

PURPOSE

The purpose of this study was to determine the prevalence of medical adhesive-related skin injury (MARSI) at the site of central venous access device (CVAD) implantation in patients with cancer, identify risk factors associated with MARSI in patients with cancer, and create a nomogram for predicting risk of MARSI.

DESIGN

Retrospective, single-center study.

SUBJECTS AND SETTING

The sample comprised 1172 consecutive patients who underwent CVAD implantation between February 2018 and February 2019; their mean age was 55.7 years (SD: 13.9). Data were collected at the First Affiliated Hospital of Xi'an Jiaotong University, located in Xi'an, China.

METHODS

Demographic and pertinent clinical data were collected from patient records. Routine dressing changes were performed every 7 days for peripherally inserted central venous catheters (PICCs) or 28 days for ports except in patients with existing skin injuries. Skin injuries related to use of medical adhesives and persisting for more than for 30 minutes were classified MARSI. Data were used to develop a nomogram for predicting MARSI. The accuracy of the nomogram was verified by calculating the concordance index (C-index) and drawing a calibration curve.

RESULTS

Among the 1172 patients, 330 (28.2%) had undergone PICC implantation, and 282 (24.1%) experienced 1 or more MARSIs representing an incidence rate of 1.7 events per 1000 CVAD days. Statistical analysis identified previous MARSI history, the need for total parenteral nutrition support, other catheter-related complications, a history of allergy, and PICC implantation as associated with a higher likelihood of developing for MARSI. Based on these factors, we established a nomogram for predicting the risk of developing MARSI in patients with cancer who underwent CVAD implantation. The C-index of the nomogram was 0.96, and the calibration curve of the nomogram showed that the predictive ability of the nomogram was strong.

CONCLUSIONS

We evaluated patients with cancer who were undergoing CVAD and identified that previous MARSI history, patients needing total parenteral nutrition support, other catheter-related complications, allergic history, and PICC implantation (compared with ports) were associated with a higher likelihood for developing MARSI. The nomogram we developed showed a good ability for predicting the risk of developing MARSI and may assist nurses to predict MARSI in this population.

The Science of Skin: Measuring Damage and Assessing Risk

Significance: Healthy skin provides a barrier to contaminants. Breaches in skin integrity are often encountered in the patient health care journey, owing to intrinsic health issues or to various procedures and medical devices used. The time has come to move clinical practice beyond mere awareness of medical adhesive-related skin injury and toward improved care and outcomes. Recent Advances: Methods developed in research settings allow quantitative assessments of skin damage based on the measurement of baseline skin properties. These properties become altered by stress and over time. Assessment methods typically used by the cosmetic industry to compare product performance could offer new possibilities to improve clinical practice by providing better information on the status of patient skin. This review summarizes available skin assessment methods as well as specific patient risks for skin damage. Critical Issues: Patients in health care settings may be at risk for skin damage owing to predisposing medical conditions, health status, medications taken, and procedures or devices used in their treatment. Skin injuries come as an additional burden to these medical circumstances and could be prevented. Technology should be leveraged to improve care, help maintain patient skin health, and better characterize functional wound closure. Future Directions: Skin testing methods developed to evaluate cosmetic products or assess damage caused by occupational exposure can provide detailed, quantitative information on the integrity of skin. Such methods have the potential to guide prevention and treatment efforts to improve the care of patients suffering from skin integrity issues while in the health care system.

The prevalence of medical adhesive-related skin injury caused by protective dressings among medical staff members during the 2019 coronavirus pandemic in China

AIM

To explore the prevalence and risk factors for medical adhesive-related skin injury (MARSI) caused by protective dressings among medical staff members during the 2019 coronavirus disease pandemic (COVID-19) in China.

MATERIALS AND METHODS

A cross-sectional survey was conducted using a questionnaire. The questionnaire was released through the Questionnaire Star website and was completed online. The prevalence of MARSI was calculated and risk factors were analyzed using a multiple regression model.

RESULTS

A total of 414 front-line medical staff members treating COVID-19 patients were enrolled from 46 hospitals across four provinces and two municipalities. Overall, 83.1% used protective medical adhesive dressings applied to the head and face to prevent skin damage from personal protective equipment. The prevalence of MARSI caused by adhesive dressings was 41.9%. By multiple regression analysis, the type of dressing, duration of dressing usage, and pain score were risk factors for MARSI development.

CONCLUSIONS

The high prevalence indicates MARSI is common among front-line medical staff members, especially those using hydrocolloid dressings and longer durations of dressing usage. Pain upon dressing removal can be severe and increased the risk of MARSI. We call for paying more attention to MARSI and recommend multisite studies with larger sample sizes to enhance the generalizability of these findings.

Effectiveness of Non-Pharmacological Methods, Such as Breastfeeding, to Mitigate Pain in NICU Infants

Neonates do experience pain and its management is necessary in order to prevent long-term, as well as, short-term effects. The most common source of pain in the neonatal intensive care unit (NICU) is caused by medically invasive procedures. NICU patients have to endure trauma, medical adhesive related skin injuries, heel lance, venipuncture and intramuscular injection as well as nasogastric catheterization besides surgery. A cornerstone in pain assessment is the use of scales such as COMFORT, PIPP-R, NIPS and N-PASS. This narrative review provides an up to date account of neonate pain management used in NICUs worldwide focusing on non-pharmacological methods. Non-steroidal anti-inflammatory drugs have well established adverse side effects and opioids are addictive thus pharmacological methods should be avoided if possible at least for mild pain management. Non-pharmacological interventions, particularly breastfeeding and non-nutritive sucking as primary strategies for pain management in neonates are useful strategies to consider. The best non-pharmacological methods are breastfeeding followed by non-nutritive sucking coupled with sucrose sucking. Regrettably most parents used only physical methods and should be trained and involved for best results. Further research in NICU is essential as the developmental knowledge changes and neonate physiology is further uncovered together with its connection to pain.

Incidence of Medical Adhesive-Related Skin Injuries and Associated Factors After Pediatric Congenital Heart Surgery: A Prospective Cohort Study

PURPOSE

The aim of this study was to identify the incidence, characteristics, and factors associated with medical adhesive-related skin injuries (MARSI).

DESIGN

Prospective cohort study.

SUBJECTS AND SETTINGS

The sample comprised 136 children in the postoperative period after congenital heart surgery. The study setting was in a 31-bed pediatric surgical intensive care unit (ICU) of a university hospital in Sao Paulo, Brazil.

METHODS

Patients were followed from admission, with daily skin assessments, until the onset of MARSI or ICU discharge. Outcomes were compared by Fisher's exact test, Pearson's χ2 test, Mann-Whitney test, Brunner-Munzel test, and Welch 2-sample t test.

RESULTS

The incidence of MARSI was 60.3%, with 85 injuries in 82 patients. The highest occurrence was on postoperative day 2 (27 wounds; 31.8%). The most frequent medical adhesive associated with MARSI was transparent film dressing (n = 74; 86.6%). Factors associated with MARSI were age (P = .000), number of devices inserted (P = .000), Braden Q Scale score (P = .005), duration of surgery (P = .021), cardiopulmonary bypass duration (P = .000), duration of mechanical ventilation (P = .000), and length of ICU stay (P = .000). Children who developed MARSI received more blood components (P = .039), vasopressors (P = .000), and corticosteroids (P = 0.000); required longer sedation (P = .000); and had more edema (P = .001).

CONCLUSION

This high incidence indicates the need for greater awareness and prompt action in response to MARSI. Polyurethane transparent film without concurrent use of a skin barrier product should be avoided.

Medical adhesive-related skin injury in cancer patients: A prospective cohort study

Objective:

to estimate the incidence of medical adhesive-related skin injury in the peripheral venous catheter fixation region in critical cancer patients, to identify risk factors, and to establish a risk prediction model for its development.

Method:

a prospective cohort study with a sample of 100 adult and aged patients hospitalized in an intensive care unit. The data were analyzed using descriptive, bivariate and multivariate statistics with Cox regression.

Results:

the incidence of medical adhesive-related skin injury was 31.0% and the incidence density was 3.4 cases per 100 people-days. The risk factors were as follows: alcoholism, smoking habit, hospitalization due to deep vein thrombosis, acute respiratory failure, immediate postoperative period, heart disease, dyslipidemia, use of antiarrhythmics, blood transfusion, friction injury, pressure injury, turgor, edema, hematoma, petechiae, low values in the Braden scale, clinical severity of the patient, elasticity, moisture, texture and color. The predictive model consisted in the following: decreased skin turgor, presence of hematoma and edema.

Conclusion:

medical adhesive-related skin injury at the peripheral venous catheter insertion site has a high incidence in critical cancer patients and is associated with decreased turgor, presence of hematoma and edema, evidence that can support the clinical practice.

Impact of and risk factors for pediatric acute kidney injury defined by the pROCK criteria in a Chinese PICU population

BACKGROUND

The definition of pediatric AKI continues to evolve. We aimed to find a better AKI definition to predict outcomes and identify risk factors for AKI in a Chinese PICU.

METHODS

This study consisted of 3338 patients hospitalized in a Chinese PICU between 2016 and 2018. AKI was defined and staged using pROCK criteria, which were compared with KDIGO criteria. AKI outcomes, including mortality, daily cost and length of stay (LOS), were assessed. Risk factors for AKI were also estimated.

RESULTS

The incidence of AKI in the PICU was 7.7% according to pROCK criteria. The characteristics of patients with KDIGO-defined AKI who did not meet the pROCK were similar to those without AKI. pROCK outperformed KDIGO in predicting mortality with a higher c index in the Cox models (0.81 versus 0.79, P = 0.013). AKI, as well as AKI stages, were associated with higher mortality (HR: 10.5, 95%CI: 6.66-19.5), daily cost (β = 2064, P < 0.01) and LOS (β = 2.30, P < 0.01). Age, comorbidities, mechanical ventilation (MV), pediatric critical illness score (PCIS) and exposure to drugs had significant influence on AKI occurrence.

CONCLUSIONS

The mortality predictability of pROCK was slightly greater than that of KDIGO. Older age, underlying comorbidities, MV, decreased PCIS and exposure to drugs were potential risk factors for AKI.

IMPACT

Two AKI criteria, pROCK and KDIGO, were significantly associated with an increased risk of mortality and pROCK was slightly greater than that of KDIGO. Older age, comorbidities, mechanical ventilation, decreased PCIS and exposure to drugs were potential risk factors for AKI. This study first used the pROCK criteria to provide an epidemiologic description of pediatric AKI in Chinese PICU. This study compared the AKI outcomes across the pROCK and KDIGO AKI criteria, indicating the prior utility for AKI classification in Chinese children. This study indicated that the potential risk factors for AKI were older age, comorbidities, mechanical ventilation, decreased PCIS and exposure to drugs.

Medical Adhesives-Related Skin Injury in a Pediatric Intensive Care Unit: A Single-Center Observational Study

PURPOSE

The purpose of this study was to identify the purpose, type, and site of medical adhesives (MAs) used for patient care and to measure the incidence of medical adhesive-related skin injury (MARSI) among patients in a pediatric intensive care unit (PICU).

DESIGN

A prospective observational study.

SUBJECTS AND SETTING

The sample comprised 60 children hospitalized at a 13-bed PICU in a university-affiliated tertiary care hospital in Yangsan (southeastern Korea) from August 2 to October 25, 2017. The median age was 2.9 months, and the composition of male and female was 34 (56.7%) and 26 (43.3%), respectively.

METHODS

The skin of all participants was examined by first-line staff nurses every shift and occurrences of MARSI were confirmed by a wound care specialist. Characteristics of MA use were analyzed with descriptive statistics, and incidence rates of MARSI were calculated using 3 methods: (1) rate per 100 patients, (2) rate per 100 MAs, and (3) rate per 1000 days of MA use. Chi-squared (χ) tests were conducted to analyze associations between MARSI and sex, age group, and primary service type (medical vs surgical).

RESULTS

The total number of MAs used was 414 and the total day of use of MAs was 1424.8. Medical adhesives most frequently used were endotracheal tube fixation devices (55/414) and fixation devices for the face (167/414). The number of MARSI occurrences was 35 cases in 23 patients; skin stripping was the most common form of MARSI (26/35). The incidence rate was 58.3 MARSIs per 100 patients, 8.5 MARSIs per 100 MAs, and 24.6 MARSIs per 1000 days of MA use. The MARSI incidence rate was significantly different based on age group (P = .014).

CONCLUSION

We observed a frequent occurrence of MARSI among patients in the PICU, especially in patients requiring long-term use of MAs such as central line dressings or in MAs placed in high-moisture areas such as near an endotracheal tube. We highlight the importance of regular skin inspection and frequent but gentle replacement of MAs for prolonged use of MAs in critically ill children.

Proof of Concept of a Surrogate High-Adhesion Medical Tape Using Photo-Thermal Release for Rapid and Less Painful Removal

Medical tapes often hold critical devices to the skin so having high adhesion for the lifespan of this product is of great importance. However, the removal process is challenging for caregivers and patients alike, often a painful process that can cause medical adhesive-related skin injury (MARSI). By using an industrial thermally sensitive tape, a surrogate photosensitive tape was developed that switched from the equivalent of high-adhesion medical tape to low-adhesion medical tape. This resulted in an 86% reduction in the average peel strength when heated from 45 to 55 °C using a custom test apparatus. To photo-release the prototype tape (PT), a near-infrared (NIR) absorbing layer was painted on the visibly clear thermal-sensitive tape and an NIR optical wand using 15-LEDs (940 nm) with thermal feedback control was designed and tested. Preliminary performance of photo-to-thermal conversion was numerically modeled with transient results matching experimental measurements with 96.8% correspondence. Using the verified energy conversion model of the surrogate photosensitive tape, a new NIR optical wand was designed for rapid and noncontact release of a future medical tape at 10 deg lower than the release temperature (RTemp) of the custom adhesive, called UnTape. Numerical simulations compared to the thermal skin pain threshold of 45 °C predicts photo-release within 1.1 s of NIR exposure (85.5% absorption in PT at &lt; 1.3 W/cm2). The unique properties of the multifunctional UnTape system (tape and portable NIR wand) may allow even stronger skin adhesion for critical medical devices while concurrently reducing the risk of MARSI upon photo release and easy removal.

Bioinspired, Microstructured Silk Fibroin Adhesives for Flexible Skin Sensors

Wearable epidermal sensors are of great importance to the next generation of personalized healthcare. The adhesion between the flexible sensor and skin surface is critical for obtaining accurate, reliable, and stable signals. Herein we present a facile approach to fabricate a microstructured, natural silk fibroin protein-based adhesive for achieving highly conformal, comfortable, adjustable, and biocompatible adhesion on the skin surface. The microstructured fibroin adhesive (MSFA) exhibits reliable and stable bonding force on skin surfaces, even under humid or wet conditions, and can be easily peeled off from the skin without causing significant pain. Such an MSFA can greatly improve the sensitivity and reusability of epidermal strain sensors because of its conformal and tunable adhesion on skin surfaces. The MFSA has a great potential to be applied as a functional adhesive for various epidermal electronic sensors in the era of personalized healthcare.