Skin care of the tiniest

[AntoineBachy]

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

[Hamed]

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 1^st72 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.

 

 

[Stefan Johansson]

Thanks @Hamed for sharing those detailed guidelines!

Here in Stockholm, the guidelines are very similar. I think the only major difference is that we wash with physiological sodium chloride for infants <25 weeks.

[Hamed]

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?

[Stefan Johansson]

@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 

[RMM]

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! 

[Hamed]

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.

[Stefan Johansson]

This discussion reminded me about this trial in ADC... although average gestational age was ~27 weeks, I guess very few, if any, were infants born at 22-24 week.

But iodine-disinfectant should be avoided (better safe than sorry!)

http://fn.bmj.com/content/103/2/F101

[tarek]

Really wonderful discussion.

Thanks

@AntoineBachy for raising this question

@Hamed i am always waiting for your replies

@Stefan Johansson a lot of thanks for such beautiful 99nicu

Chapter 12 Clinical procedures_ABMU Neonatal Guideline v 2017 1.pdf

[AntoineBachy]

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

[tarek]

@AntoineBachy

https://clinicaltrials.gov/ct2/show/results/NCT00947518

[M C Fadous Khalife]

We use chlorhexidine for extremely preterm babies and we use dakin for older ones but never had burns or any other problems for umbilical catheter insertion 

[David]

Hi!

We use  octenidine, unfortunately we only have access to a solution contaning alcohol - although an alcohol-free preparation is possible to produce via the pharmacy. We rarely see  necrosis and scarring (although reported in the literature).

[NICU RN 7]

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Posted June 10

 

 

Resuscitation:

·      Receive baby in sterile towel (pre-warmed) and place in plastic sheet (NeoWrap or household plastic wrap) on warmer (Giraffe Poptop) with a warming mattress in place and activated.  Our focus at delivery is on keeping the baby warm and limiting movement as much as possible, so a sterile thermal hat is also put in place.  

·     We use gel pad leads in micropreemie size for ECG (NeoTech Micro) and temp probe (Accutemp Plus), and velcro/cloth pulse oximeter probes  (LNCS NeoPT-3) Gel pads lose adhesion very quickly in humidiity, and probe positions are changed Q12 hours with cares

·      Lines are placed and respiratory support tubing is secured before lowering top of Giraffe to isolette position.  Humidity is added to 80%, and the ambient temperature is put on "skin" to keep skin temp at 36.5.

·      Once humidity is effective, plastic sheet is removed and infant is placed in supportive cotton wraps (Snuggle).  Linens are changed Q24 hours

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

For 1^st72 hrs of life

·      Humidity in isolette: 80%.

·      No bath.

·      No tape except for ETT securement

·      Routine diaper care with water wipes.

·      Score skin health with a skin care score Q6 hours

        No weights, touch only Q6 hours or when necessary

·      Transition to PICC at 48 hours of life if no signs of infection.; If skin condition poor, keep UVC if in good position, until skin condition permits PICC (max 14 days).

We continue daily linen changes until PICC Is DC'd

We continue Q6 hour cares until approximately 32 weeks, or until infant is consistently uncomfortable more quickly

[Petri Mansvelt]

We are cleaning the skin with chlorhexidine 2% for the insertion of UVC /UAC in extreme premature neonates.

After cleaning let the skin dry for at least 30 seconds befor turning any light on the abdomen.

We have almost no leasions at the unit.

 

[Hamed]

On 7/27/2018 at 5:26 AM, NICU RN 7 said:

clean skin with chlorhexidine 2% without

@NICU RN 7 thanks,  could you please clarify this sentence " clean skin with chlorhexidine 2% without" ?

[cmcdermott]

We use chlorhexidine 0.05% solution for Umbilical lines and some PICC lines and take great care to ensure that the solution is only applied to the smallest area necessary and does not spill down the side of the baby and under their back.  We have rarely seen burns with this concentration.