Medical Adhesives in the NICU

Preventing Marsi in the NICU

Medical Adhesives: Tapes and Products

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 secured; different products may be better suited for securing critical devices such as endotracheal 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.

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 dislodgement, other types of tape are often added to the device; an example is the "chevron" technique to further anchor the catheter or tubing.

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 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 neonates and does not have adequate adhesion for critical tubes.

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 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 dressing changes less painful, the scald burns epithelialized twice as rapidly and with less eschar 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 silicone tape and silicone bordered dressings so the NICU care providers have a wide variety to choose.

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 (EEG) electrodes is an example of how this feature can be applied (Fig. 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 that 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]

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 nasogastric tubes, urinary catheters, or nasal cannulas are not advised.

Hydrogel adhesives are available as electrocardiogram (EKG) electrodes and temperature probe covers. They should not be used in situation where adherence is critical; however, even their use to secure a temperature probe is of concern because dislodgement or inadequate adherence could result in an inaccurate skin temperature measurement and cause either under- or overheating an infant using skin servo-control mode of thermoregulation in either an incubator or a radiant warming table.

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 well to surfaces and withstand moisture. Products incorporating hydrocolloid adhesives are available and include endotracheal tube holders and umbilical catheter taping devices. Although observational studies reported that hydrocolloid adhesives were more gentle upon removal, 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 application, the liquid part of the barrier evaporates and leaves a transparent, breathable protective coating.

Studies have shown that silicone barrier films reduce erythema and skin stripping following removal of adhesives in various patient populations, including neonates.^[47–49] Using products that 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 60 premature infants greater than 33 weeks gestation used a barrier film to reduce TEWL and 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 endorsed.^[50]

Adhesive Removers

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: alcohol/organic-based solvents, oil-based solvents, and silicone-based removers.^[51] The alcohol–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.

Silicone-based removers form an interposing layer between adhesive and skin, evaporate readily after application, and do not leave a residue.^[51] The use of silicone-based removers has been 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 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° angle may facilitate removal with less skin trauma.^[33]

Other Issues

Bonding Agents or Tackifiers. 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 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, particularly if removal will occur in several days' time. This is because the bond that these agents forms with the adhesive to the epidermis is stronger than 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.

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 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 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 when the adhesives were left on the skin for longer than 2 days; the strength of the adhesive used is another variable that may be important. NICU infants who display this reaction to adhesives have not been studied at this time; however, NICU care providers are searching for 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 removal in the neonatal patient^[24] may have a role in the pathogenesis of contact irritant dermatitis to medical adhesives.

Anetoderma of Prematurity. 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 (Fig. 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 to 1250 g. Many of the 11 infants had significant morbidities including bronchopulmonary dysplasia, necrotizing enterocolitis and ileal perforation, and experienced longer hospital stays than a group of matched control infants. 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 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 fewer cases. Traction when adhesives were removed was also suspected, since some of the anetoderma involved peri-umbilical skin, where adhesives were used to secure umbilical catheters.^[56]

NAINR. 2014;14(4):160-165. © 2014  Elsevier Science, Inc.