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We recently had unpreprared 23+6 twins who suffered severe skin lesions due to electrode pads. We had to completly remove those for few days.

They also had skin burns from antiseptic chlorexhidine prep (which is unfortunatly well known).

What are your protocol or tips for managing skin care of the extremly preterm infant?

Thank you in advance

Here is a bundle we use for skin care in ELGANs below 24 wks.

I will not be able to provide supporting articles to most of what is done for this population and written here below.  Hoping you can find it useful for your team and ELGANs.

Resuscitation:

·      Receive baby in OR sheet (pre-warmed) and place in plastic bag from the OR sheet. Plastic bag an opening to deliver the head from the bag (pre-made) and an opening to over the umbilical stump to be made. Try to keep the bag closed as possible. https://www.ncbi.nlm.nih.gov/pubmed/24042134

·      Incubator to be pre-wormed with humidity of 85~90% and temp around 37 ~ 38 C.

·      No ECG lead; use UAC to obtain vitals or Sa02 probe to get HR

·      If no UAC, BP frequency on case-by-case basis; change site every time, do not leave cuff on.

·      Once out of plastic bag, place baby on Biatain Alginate sheet(s) (change sheet every 1 week); avoid skin contact with baby blankets, use Huck towel or OR sheet underneath Biatain.

·      Use disposable saturation probe.

·      Semi-sterile conditions: sterile gloves, hat and mask for all resuscitation team members. 

·      ETT to be handled with sterile gloves only.  

·     UVC, UAC insertion using checklist; clean skin with chlorhexidine 2% without alcohol swabsticks and rinse with sterile water.

·      Plastic bag; hat; warming mattress. Keep plastic bag on until baby in isolette with temperature within normal limits (36.5-37.5 C measured at axillary or back) and humidity level is stable (2-4h).

 

For 1st72 hrs of life

·      Humidity in isolette: 90 ~ 85%.

·      In case of skin breakdown: apply Adaptic  (non-adherent) and Nu-Gel Hydrogel and cover with hydrofiber wound dressing.

·      No bath until 7 days.

·      Minimize use of tape.

·      Routine diaper care with disposable wipes soaked in sterile water.

·      Open diaper.

·      No ECG leads.

·      Score skin health with a skin care score.

From 4 to 7  DOL

·      Humidity in isolette: 85%; wean by 5% daily after day 7 as temperature allows and based on skin condition. 

·      In case of skin breakdown:  apply Adaptic (non-adherent) and Nu-Gel Hydrogel and cover with hydrofiber wound dressing.

·      Delay bath until day 7.

·      Minimize use of tape.

·      Lay baby on Biotain Alginate sheet; change every 1 week until skin condition no longer requires.

·      Transition to PICC by day 7; If skin condition poor, keep UVC if in good position, until skin condition permits PICC (max 14 days).

·      Discontinue UAC by day 7.

Good luck.

 

 

Thanks @Stefan Johansson for sharing the difference in the practices, but I would like to clarify what you are contemplating. In Stockholm you wash with physiological sodium chloride infants <25 weeks, does this mean washing with physiological sodium chloride :

  • After sterilizing skin with chlorhexidine 2% for UVC and UAC  Or  Not using chlorhexidine 2% at all and only wash with physiological sodium chloride?

&

  • For routine diaper care using wipes soaked in physiological sodium chloride?

@Hamed I am no longer at the level-3 NICU at Karolinska but I cross-checked with @Alexander Rakow :
they apply nothing but sodium chloride 0.9% for cleaning the umbilicus for UAC/UVC insertion (meaning only gentle mechanical washing and no chlorhexidin)

For diaper change - I did not cross-check but think they use water 

Interesting discussion. Given we have had a explosion of 23 weeker a of late we are also having issues with chlorhexidine burns (use 2% solution). Very interested to hear that some centres only use 0.9% sodium chloride. This might be a very interesting practice to adopt! 

Our skin care team are in favor of not using chlorhexidine as @Stefan Johansson explained, which I personally go with, however, until date we are still using our current guideline as mentioned above. It could be a nice topic to do an RCT on.

  • Author

Many thanks to all of you.
Those informations are of huge value. I couldn't have find these in any review or article. I never heard before about Biatin Alginate or sodium chloride cleansing for example.

I feel also better to kwow that i'm not alone to be in trouble with skin care in those baby's 😉
There is nevertheless already many publications on this subject (e.g. some uses chlorexidine 0.2% with good results for < 26 weekers http://fn.bmj.com/content/103/2/F97) but i couldn't find anything on sodium chloride cleansing or general skin care (e.g. ECG leads, SpO2 probes, NIRS). Does any of you have any reference that i could submit to my team? 
I would anyway be pleased to read or even to modestly participate to an RCT (multicentric i guess due to the small number of those tiniest baby).

regards 
Antoine

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