A Catheter Securement Strategy for Patients with Epidermolysis Bullosa

INTRODUCTION Epidermolysis bullosa (EB) is a group of rare, genetic, heterogeneous disorders characterized by mechanically fragile skin secondary to defects in anchoring filaments and collagen within the epidermis and dermis.1–4 Patients with EB have extremely fragile skin, and serious injury can result from minimal friction and/or shearing forces. Blisters and bullae progress to ulcerations, erosions, and scar formation, affecting the skin and mucous membranes. There are four major categories of EB: EB simplex, junctional EB, dystrophic EB, and Kindler EB.4,5 Across these categories is a wide spectrum of disease severity, and many patients have significant morbidity and early mortality. With repeated blisters, bullae, and scarring, resultant squamous cell carcinoma (SCC) occurs as a late complication.4 Patients with dystrophic EB and junctional EB are at increased risk of developing skin cancers during their lifetimes. In fact, SCC is the leading cause of death among patients with EB and often occurs after the second decade of life.4 Additional resources for patients, families, and care providers may be found through DEBRA, the Dystrophic Epidermolysis Bullosa Research Association of America.6 The authors’ institution has been designated a “Center of Excellence” for the care of patients with EB. It is a tertiary care, freestanding children’s hospital, and cares for a high volume of patients with EB across the age spectrum. Patients with EB commonly present for procedures involving the oral cavity and esophagus because the abnormalities in collagen are also present in oral and esophageal mucosal surfaces.3 The authors frequently care for patients presenting for esophageal dilations and dental restoration, which requires obtaining I.V. access and performing nasotracheal intubations, especially in the pediatric population.1 Further, the authors frequently care for patients with EB who are undergoing amputation for SCC, with individual patients often requiring multiple amputations.2 Patients with EB require vigilant care to maintain the integrity of their skin, particularly when securing I.V. catheters, central lines, and regional catheters.3 Traditional occlusive dressings result in the development of blisters and bullae upon dressing removal in these patients. Silicone-based adhesives are preferred for this population because they easily separate from the skin with the application of water, 0.9% sodium chloride solution, or adhesive remover.1 However, historically, all silicone-based adhesive dressings were opaque, hindering visualization of insertion sites. In addition, these dressings are nonocclusive, increasing the risk of developing a secondary infection and catheter dislodgement.1,2 In this report, the authors describe securing the peripheral I.V. catheters and peripheral nerve catheter of a patient with EB using a clear, antimicrobial-impregnated occlusive dressing made with silicone-based adhesive. The patient provided written informed consent for the publication of this case report and accompanying images. CASE PRESENTATION A 40-year-old White man with recessive dystrophic EB presented to the authors’ institution with recurrent SCC of his right arm, despite previous amputation of his right hand for the same diagnosis. These cancers developed as a complication of his recessive dystrophic EB. He was taken to the OR for revision amputation. The patient had a planned general anesthetic with two peripheral I.V. catheters (PIVs) for fluid and medication administration. A peripheral nerve catheter was planned to provide postoperative analgesia. To prevent further skin injury, all adhesives used for monitoring general anesthesia are modified for patients with EB. Just touching the patient’s skin with a nondirect force (shearing/rubbing) can cause significant blisters and bullae. The shear force that occurs with removal of standard adhesives is extremely damaging to the skin; therefore, standard adhesives should be avoided. The pulse oximeter was wrapped with a clear occlusive dressing so that no adhesive would contact the patient (Figure 1A). Given this patient’s pseudosyndactyly (mitten hand deformity of hands and feet in which the digits fuse together), previous amputation, and lack of digits on both upper and lower extremities, a pulse oximeter was placed on his earlobe. The adhesive on the ECG was trimmed and the modified electrodes were secured using silicone tape (Figure 1b; ECG needle electrodes placed subdermally that carry electrical current when connected to a power source are also an acceptable alternative to minimize skin damage). If a patient has no history of cardiac disease and regional anesthesia is not planned, ECG monitoring is typically deferred in pediatric patients with EB.Figure 1.: MODIFIED PULSE OXIMETRY PROBE AND ECG LEADA, The pulse oximetry probe was modified with a clear transparent occlusive to prevent adhesive contact with patient’s skin. B, Each ECG lead was trimmed to minimize adhesive contact with skin.Prior to the induction of anesthesia, the anesthesiologist placed a PIV in the patient’s left forearm. General anesthesia was induced with propofol, fentanyl, and sevoflurane. Spontaneous ventilation was maintained and a nasotracheal endotracheal tube was placed using a fiberoptic bronchoscope to minimize injury to the oral mucosa. The anesthesiologist placed a second PIV in the patient’s left leg, and inserted a right infraclavicular peripheral nerve catheter using ultrasound guidance. The anesthesiologist secured the catheters using a novel dressing with silicone-based adhesive that is occlusive and transparent and is impregnated with both chlorhexidine and silver to reduce the risk of infection (IV Clear, Covalon; Figures 2 and 3). Silicone tape (Mepitac, Mölnlycke) was used to outline the dressings and improve the adherence to the skin.Figure 2.: PLACING AND SECURING THE PIVA, A 20-gauge PIV was placed into the patient’s left lower extremity in an area of intact skin. B, A dual-antimicrobial clear silicone adhesive dressing was placed over the catheter and the white strip was removed. C, A dual-antimicrobial clear silicone adhesive dressing is placed over the catheter. D, Silicone gentle-fixation tape outlines a dual-antimicrobial clear silicone adhesive dressing to ensure adherence.Abbreviation: PIV, peripheral I.V. catheter.Figure 3.: SECURING THE INFRACLAVICULAR PERIPHERAL NERVE CATHETERA dual-antimicrobial clear silicone adhesive dressing outlined with silicone gentle-fixation tape was used to secure the infraclavicular peripheral nerve catheter. A modified ECG lead secured with silicone gentle fixation tape is also shown.The patient had an uneventful anesthetic and surgical course and was admitted to the inpatient floor postoperatively. His PIVs remained in place until the time of discharge on postoperative day 2. The nurse used water to facilitate removal of the PIV dressings and did not observe any skin injury following removal. The patient was discharged to home with his peripheral nerve catheter, which he removed himself on postoperative day 3. He reported easy removal and no skin injury from the dressing. All three dressings were secure for the intended duration of treatment, and no complications (skin injury, infection, or infiltration) were noted. DISCUSSION Unique precautions are required when caring for patients with EB, particularly regarding the securement of peripheral lines, central lines, and peripheral nerve catheters. Although standard catheter dressings are transparent and occlusive, they should be avoided in this patient population because the traction caused by removing a traditional adhesive dressing leads to further blister and bullae formation in patients with EB and may significantly damage the skin. At the authors’ institution, clinicians historically used opaque nonsterile silicone tape to secure catheters. An additional strip was placed across the hub with gauze wrapped around the extremity, further obscuring visualization of the catheter insertion site. In addition, an opaque, nonsterile silicone foam dressing was placed over the indwelling peripheral nerve and central venous catheters, completely obscuring the insertion sites. Although using these modified dressings minimized skin damage in patients with EB, these modifications were not without risk. Applying dressings that are nonocclusive and nonsterile increases the risk of infection for peripheral nerve and central venous catheters. Further, the inability to frequently evaluate the catheter insertion site places the patient at increased risk for an unidentified extravasation injury and catheter dislodgement if the opaque dressing is taken down to visualize the insertion site. In contrast, the transparent dressing with silicone-based adhesives used in this case separates easily from the skin with water, 0.9% sodium chloride solution, or adhesive spray remover. There is no traction, friction, or shear force applied to remove the dressing, thus protecting the patient’s fragile skin from further blister or bullae formation. Although the manufacturer states that use of an adhesive remover is unnecessary for these silicone-based dressings, the authors take these additional precautions to prevent skin injury in patients with EB. Further, because this dressing is impregnated with chlorhexidine and silver, which have antimicrobial properties, there is reduced risk of catheter-associated infection. The transparency of the dressing enables easy visualization of the insertion site, facilitating early recognition of catheter site infection or line extravasation. As compared with the authors’ historical technique, the occlusive properties of this dressing decrease the risk of secondary infection. To the best of the authors’ knowledge, there are currently two transparent dressings available with silicone-based adhesive: Simpurity IV Derm Transparent Film (Safe n Simple) and IV Clear. To improve adhesion, silicone gentle fixation tape may be added to the border of the transparent silicone dressing, especially when catheters are expected to be indwelling for more than 24 hours. CONCLUSIONS Transparent dressings with silicone-based adhesives are the ideal catheter dressing for patients with EB and should be considered in other patients with fragile skin disorders, including those with pemphigus or Stephens-Johnson syndrome and patients who have sustained burns. The dressing used in this case report has silicone-based adhesive, which separates easily from the skin; is transparent, enabling unobstructed visualization of the insertion site; and is occlusive and antimicrobial. Thus, it is superior to the authors’ previous securement techniques for patients with fragile skin.1,2 Transparent dressings with silicone-based adhesives are now routinely used in patients with EB throughout the authors’ institution. The authors have used this dressing in more than 50 separate patient encounters, including with one patient who had a prolonged stay in the ICU that required multiple dressing changes. No patients have experienced skin damage from this method of securement, and returning patients and families frequently request this technique for catheter securement. The authors’ institution has updated the department catheter securement guidelines for patients with EB to reflect this practice change.