Prospective, Case-Control Study Evaluating Effects of No-Sting Liquid Barrier Film on Skin Condition and Maturation of Stratum Corneum in Premature Neonates.

PURPOSE: To assess effects of a no-sting liquid barrier film (NSLBF) on the skin condition and maturation of the stratum corneum in premature neonates. DESIGN: This was a prospective, case-control study with each subject serving as their own control. SUBJECTS AND SETTING: The sample comprised 33 neonates, between 23 and 32 weeks of gestational age (GA). Participants received care in a level 4 neonatal intensive care unit in the northeastern United States. Data were collected between May 2018 and May 2019. METHODS: All participants had NSLBF applied to their left chest, left abdomen, and left anterior and posterior upper thigh. The right side was left untreated and served as self-control. Measurements of skin pH, hydration, transepidermal water loss (TEWL) and Neonatal Skin Condition Scores were obtained on both the untreated right and treated left sides of the body over a 14-day period on days 1, 3, 7, and 14. RESULTS: Worsening skin condition scores were observed on the treated side on days 7 and 14. There was an improvement in TEWL on the treated side, manifested as decrease in TEWL values. There was no difference in pH. At all points in time hydration was lower on the treated side. CONCLUSIONS: Worsening skin condition scores and hydration status on the treated side indicate an altered or delayed process of skin maturation. These findings suggest that no-sting liquid barrier (NSLB) application should be limited to skin under medical devices, dressings, tapes, and affected areas. In addition, we recommend allowing adequate intervals to allow physiologic stratum corneum maturation between applications of NSLB.

Association of Systemic or Intravitreal Antivascular Endothelial Growth Factor (Anti-VEGF) and Impaired Wound Healing in Pediatric Patients: Collagen to the Rescue.

BACKGROUND: Bevacizumab is a humanized monoclonal antibody to vascular endothelial growth factor (VEGF) that has been used as a systemic chemotherapy treatment of various malignancies in adults since 2000. It has been used for pediatric patients over the last decade. In addition, bevacizumab is used for neonatal intravitreal administration for retinopathy of prematurity, a major complication of preterm birth, characterized by incomplete and abnormal vascularization of the retina that can lead to retinal detachment and blindness without treatment. CASES: The objective of this multiple case series is to report impaired wound healing seen in 3 adolescents and 1 premature neonate receiving bevacizumab and to propose collagen-based dermal template as a choice for the management of such wounds. The 3 adolescents were undergoing treatment of malignancies and developed wound healing complication within weeks of receiving anti-VEGF. The premature neonate experienced an extravasation and had a slow wound healing trajectory after receiving intravitreal administration of bevacizumab for retinopathy of prematurity. All wounds achieved closure following topical treatment with a collagen dermal template. CONCLUSION: Use of bevacizumab is increasing in the pediatric population. Clinicians should be aware of compromised wound healing and higher likelihood of wound dehiscence after bevacizumab administration. We recommend waiting for at least 4 to 6 weeks between anti-VEGF administration (either systemic or vitreous) and elective surgical procedures, consistent with adult literature recommendations. If patient has an existing wound, we assert that bevacizumab should not be administered until that wound is healed. If wound healing is stalled, we recommend dermal template as a safe and effective accelerator of wound healing.

Reducing Peripheral Intravenous Catheter Extravasation in Neonates: A Quality Improvement Project.

PURPOSE: Our objective was to reduce total and severe peripheral intravenous extravasation (PIVE) incidence by 40% in our neonatal intensive care unit. SETTING/APPROACH: This quality improvement initiative was performed at an academic, free-standing suburban children's hospital, in a level 4 neonatal intensive care unit from June 2017 to April 2018. Baseline extravasation data for a period of 6 months prior to the initiative were reviewed, along with a nursing knowledge questionnaire and random audits of catheter stabilization techniques. A Pareto chart and a key driver diagram were created to identify the most common causes of extravasations and lead to a series of process changes. We implemented 4 Plan-Do-Study-Act (PDSA) cycles: (1) dressing protocol for peripheral intravenous vascular (PIV) catheter securement that instituted standardized securement and safer equipment; (2) education on PIV assessment and maintenance, concentrating on hourly evaluation and documentation; (3) guidance algorithm for PIVE identification and treatment; and (4) escalation policy, limiting the number of placement attempts and increased use of a "superuser" team. OUTCOMES: The overall prevalence of extravasations decreased by 54%, from 73 preintervention to 40 at postintervention. At baseline, 52% (38/73) extravasations were severe; however, those in the severe category decreased by 35% (14/40) postintervention. The overall rate of adherence to the PIV catheter management algorithm approached 95%; whereas adherence to the securement guideline fluctuated between 80% and 98%. IMPLICATION FOR PRACTICE: The implementation of these new practice recommendations along with the education has resulted in a decreased rate and severity of extravasation. Frequent audits and reinforcements are integral to sustainment and to ensure accountability for the implemented procedures.

Use of Cryopreserved Human Umbilical Cord and Amniotic Membrane Allograft and Portable Negative Pressure Therapy in Dehisced Giant Omphalocele Repair: A Case Study.

BACKGROUND: A giant omphalocele is a rare congenital abdominal wall defect that measures more than 6 to 8 cm in any dimension. The child's abdominal visceral contents as well as the liver which are both covered by the amniotic sac protrude outside the abdomen through the umbilicus. Consequently, closing this defect is extremely challenging due to the risk for wound dehiscence. CASE: Baby C, a 1-year-old male infant, developed a dehisced abdominal wound after secondary repair of a giant omphalocele. Escharification of the amniotic sac was achieved with silver products, followed by intra-abdominal tissue expansion and skin closure. A conservative approach was undertaken with the use of cryopreserved human umbilical cord and amniotic membrane allograft in conjunction with portable negative pressure therapy. CONCLUSIONS: To the best of our knowledge, this is the first case study to evaluate the effect of cryopreserved human umbilical cord and amniotic membrane allograft in a dehisced neonatal abdominal wound due to a giant omphalocele or, in fact, neonatal wounds in general. Our experience with this case suggests that cryopreserved human umbilical cord and amniotic membrane allograft may create a superior healing trajectory and regeneration, avoidance of surgical intervention, and an early hospital discharge. Wound-supporting properties of amniotic allograft, in addition to lack of immunologic reactivity, offer an attractive option for a variety of pediatric and neonatal wounds.

Pressure Injuries of the Nose and Columella in Preterm Neonates Receiving Noninvasive Ventilation via a Specialized Nasal Cannula: A Retrospective Comparison Cohort Study.

PURPOSE: The aims of this study were to measure the incidence and severity of nasal septum injury in premature infants receiving continuous positive airway pressure (CPAP) via a noninvasive thin-walled cannula, and to evaluate the effect of a polyvinyl chloride foam barrier dressing in reducing these injuries. DESIGN: Retrospective chart review, comparison cohort study. SUBJECTS AND SETTING: The sample comprised 235 neonates with a gestational age of 28 weeks or younger. Their mean gestational age was 26 weeks (range 22-28 weeks) and mean birth weight was 840 g (range 430-1320 g). The study setting was a level 4, regional neonatal intensive care unit housed in a 200-bed freestanding children's hospital located in the Northeastern United States. METHODS: Data were collected during 3 periods. During all 3 data collection periods, we used a soft, thin-walled nasal cannula, with a relatively short, binasal prong interphase and small diameter tubing connected to a ventilator circuit capable of transmitting positive airway pressure in neonates. During data collection periods 1 and 3, we used a polyvinyl foam barrier dressing as a preventive intervention against nasal skin damage; specifically, we placed a precut barrier on the prongs to protect the nasal skin. One side of the barrier foam has an adhesive surface, which was placed against the prongs. Study period 2 differed; during this period neonates were treated with the nasal cannula without the foam barrier based on manufacturer experience suggesting the foam barrier is not needed for prevention of skin damage. Pressure injuries (PIs) that occurred during each study period were staged according to National Pressure Ulcer Advisory Panel definitions. RESULTS: Eighty neonates were evaluated during study period 1 (thin-walled nasal cannula plus foam barrier). We evaluated 27 neonates during period 2 (thin-walled nasal cannula and no foam barrier) and 128 were evaluated during study period 3 (thin-walled nasal cannula plus foam barrier). Six neonates (7%) developed PIs during period 1, and 2 (1.5%) developed during study period 3. All were stage 1 and 2 PIs, no full-thickness injuries, also referred to as columella necrosis developed during use of the thin-walled nasal cannula in combination with the foam barrier dressings. In contrast, 13 PIs (48%) of neonates managed during data collection period 2 (thin-walled nasal cannula with no foam barrier) developed PI, and 40% experienced stage 3 PI or columella necrosis. This difference reflects a 6-fold increase in nasal injury occurred when nasal continuous positive airway pressure (NCPAP) was administered without use of the protective barrier dressing. CONCLUSION: We found clinically relevant difference in the occurrences of nasal PI in neonates managed with NCPAP; occurrences of stage 3 PI were 6-fold higher when a thin-walled cannula was used without a protective foam barrier dressing.

Effects of a surfactant-based gel on acute and chronic paediatric wounds: a panel discussion and case series.

On 20 November 2018, following the International Society for Paediatric Wound Care conference, a closed panel meeting took place in which the use of a surfactant-based gel (PluroGel (PMM), Medline Industries, Illinois, US) in paediatric wound care was discussed. The authors shared their experiences, thoughts, experimental data and clinical results. The panel identified the need for a product that can gently cleanse paediatric wounds and remove devitalised tissue without causing discomfort or skin reactions, as well as potentially promote healing. In adults, PMM has been shown to assist healing by hydrating the wound, controlling exudate and debriding non-viable tissue. Islands of neo-epithelium have also been reported to appear rapidly in different parts of the wound bed. No adverse effects on these proliferating cells have been observed. In vitro data suggest that PMM can remove biofilm, as well as potentially promote healing through cell salvage. The panel, therefore, set out to discuss their experiences of using PMM in the paediatric patients and to establish a consensus on the indications for its use and application in this population. This article will describe the main outcomes of that discussion and present case studies from paediatric patients with a variety of wound types, who were treated with PMM by members of the panel.

Topical Leptospermum Honey in the Management of Aplasia Cutis Congenita in Neonates: A Case Study.

BACKGROUND: Aplasia cutis congenita (ACC) is an uncommon, heterogeneous group of disorders characterized by focal or widespread absence of skin from certain parts of the body. Complications range from 20% to 50%; they are potentially life-threatening. There is no consensus on best treatment of ACC. We report on successful closure of aplasia cutis lesions using topical active Leptospermum honey (ALH). CASES: This article describes a case of a full-term neonate with a large ACC lesion. A conservative approach was taken in the care of this lesion, in accordance with appropriate wound care principles and the care of this medically fragile neonate. This included applying topical ALH twice a day and covering defects with a secure dressing. All lesions progressed to complete closure. Time to closure was either similar or shorter than published data. CONCLUSIONS: Our experience with these cases suggests that topical ALH may be an effective natural treatment option for neonates with ACC. This conservative management led to wound closure without topical or systemic antibiotics or prolonged hospital stay.

Treatment of Dehisced, Thoracic Neonatal Wounds With Single-Use Negative Pressure Wound Therapy Device and Medical-Grade Honey: A Retrospective Case Series.

PURPOSE: The purpose of this study was to report on our experience with a portable, single-use negative pressure wound therapy device used in combination with activated active Leptospermum honey (ALH) in the treatment of colonized or infected, dehisced, thoracic wounds in neonates with complex congenital heart disease. DESIGN: Retrospective, descriptive study. SUBJECTS AND SETTING: We reviewed medical records of 18 neonates and reported on findings from 11; the remaining 7 were not included secondary to incomplete records, transfer to a different institution prior to wound healing, or death. The median age of our patients was 12 days (range, 2 days to 5 weeks); their mean gestational age was 34 weeks. All of the neonates had acquired postoperative wound dehiscence that were colonized or infected and were treated in the neonatal intensive care unit (NICU) at Cohen Children's Medical Center (New Hyde Park, New York), a regional perinatal center with a level 4 NICU. METHODS: Wound cultures were obtained on all patients prior to treatment commencement. All cultures were repeated on day 4 of treatment. Systemic antibiotics were administered as necessary. No complications were observed related to the use of negative pressure wound therapy device and ALH. All patients were followed until discharge home or transfer to another facility. The pain scores during placement and removal were acceptable (between 1 and 3; median = 2) using the Neonatal Infant Pain Scale. Staff and parents indicated that the combination of ALH and the negative pressure wound therapy device did not interfere with daily care and parental bonding. CONCLUSIONS: Use of ALH and a single-use negative pressure wound therapy device was successful in this series of 11 neonates with complex congenital heart disease.

Point-of-Care Ultrasound Use in Neonatal Peripheral Intravenous Extravasation Injuries: A Case Series.

PURPOSE: The primary aim of this study was to examine and describe peripheral intravenous extravasation (PIVE) injuries using point-of-care ultrasound (POC-US). A secondary aim was to define skin tissue changes before and after hyaluronidase application using POC-US. DESIGN: Case series design. SUBJECTS AND SETTING: We report on 10 neonates with stage 3 or 4 PIVE who were studied clinically and with POC-US. All infants were studied during the December 2015 to September 2016 period in a large academic neonatal intensive care unit. METHODS: Initially, neonates with PIVE were staged using 3 criteria: physical findings, nature of the infusate, and the size of the injury. Next, we described different ultrasound appearances of the tissue injury in PIVE based on the type of the infusate (clear fluid, blood, or both). We then located the largest PIVE pocket and measured the skin elevation over it. Skin elevation ratio was measured at 3 time points: before hyaluronidase injection followed by 3 to 6 hours and 24 hours after hyaluronidase therapy. Each ultrasound examination of the skin injury was staged (severe, moderate, mild, or minimal) based on the skin elevation ratio obtained. In addition, we described changes in the skin using ultrasound before and after hyaluronidase treatment. RESULTS: Three types of ultrasound images based on the type of the extravasated fluid were described in detail. Based on the initial ultrasound measurements of the skin elevation ratio, 6 infants were staged with severe PIVE and 4 were staged as moderate PIVE. Finally, POC-US was used to describe the tissue changes before and after hyaluronidase injection. CONCLUSIONS: Point-of-care ultrasound may offer more structured and objective staging of PIVE injuries due to direct visualization of the skin tissue. This method needs to be further studied and introduced as a practical tool to complement physical examination of PIVE injuries.

Efficacy of Dialkylcarbamoylchloride-Coated Dressing in Management of Colonized or Infected Neonatal and Pediatric Wounds.

BACKGROUND: Wound healing is a dynamic process that normally follows a predictable cascade of events. A common cause of delayed wound healing or wound dehiscence is increased colonization with microbes, often leading to infection. Infection may impede the healing process by inducing an undesirable inflammatory response. Systemic antibiotics and topical antiseptics are mainstays of treatment, but their adverse side effects and the potential for emergence of resistant microbial strains have led to a search for alternative approaches for control of bioburden. CASES: We describe two neonates and one 10-year-old girl who experienced delayed wound healing treated with a nonmedicated dressing that exploits bacterial cell-surface hydrophobic interactions via a dressing with a fatty acid (dialkylcarbamoylchloride [DACC]) coating. This dressing was used in a colonized, unstageable occipital pressure injuries, an infected stage 4 pressure injury over a vertebra, and a dehisced surgical sternal wound. Complete closure was achieved in all wounds within 2 to 4 weeks. CONCLUSION: We employed a DACC-coated dressing that provides bacteriostatic activity without creating cytotoxicity or an inflammatory response.

Concentrated surfactant gel dressing for effective wound healing in pediatric patients: a case series.

BACKGROUND: CSG dressing is water-soluble and helps to hydrate the wound, control exudate, and provide gentle debridement by virtue of a high concentration of surfactant micelles. The primary objective of this retrospective case series is to report on the feasibility of CSG use in pediatric wounds and its mechanism of action. The secondary aim was to measure pain during application and removal of CSG. METHODS: Eight pediatric patients ranging in age from newborn to a few months old with wounds requiring medical intervention were treated with CSG. The CSG dressing was applied twice daily at initiation of treatment in some patients, but mostly once daily. NIPS was utilized for pain measurements. RESULTS: Near-complete healing of wounds was observed by the end of treatment duration, which was only a few days. The calm temperament of these patients during dressing changes and objective NIPS suggested minimal to no pain. None of the patients experienced any adverse events related to the use of this dressing. CONCLUSION: The CSG dressing could be the dressing of choice in this population to enhance debridement and maintain moist healing and support granulation, either proactively or if other treatments fail.

Successful management of moisture-, friction-, and trauma-associated skin damage in the pediatric and neonatal population using cyanoacrylate skin protectant.

INTRODUCTION: Moisture-associated skin damage occurs in 4% to 37% of the pediatric population. Commonly described treatments can be challenging to apply to small neonatal wounds, and concerns exist about absorption, cutaneous side effects, and use in certain populations (eg, preterm neonates). OBJECTIVE: This single-center, retrospective case series evaluated the use of cyanoacrylate liquid skin protectant (CSP) to manage moisture-, friction-, and trauma-associated pediatric and neonatal wounds. MATERIALS AND METHODS: Fifteen pediatric and neonatal patients with wounds of various etiologies were treated with 1 to 3 applications of CSP. The product is a purple-colored liquid that comes in a small-sized and large-sized applicator and immediately adheres to the skin, taking approximately 1 minute to dry. One to 2 coats were applied to the affected area. Subsequent applications were prescribed as needed, depending on the skin condition. Before CSP application, some patients underwent different treatments deemed necessary by the treating practitioners. RESULTS: There were 7 neonate patients (age range, 4 days-3 weeks), with a gestational age of 25 weeks to full term. Wounds included incontinence-associated dermatitis; peristomal, gastrostomy-associated, and tracheostomy-associated dermatitis; and skin tears. In the 8 older patients (age, 1-5 months; 10 years; 12 years; 16 years), wounds included gastrostomy and tracheostomy-associated dermatitis and granulation tissue, epidermal stripping from adhesive dressing removal, intertriginous dermatitis, and lesions resulting from graft-versus-host disease. Application of CSP facilitated the healing of dermatitis and peristomal excoriations as well as facilitated skin dryness, leading to increased wear time of a peristomal appliance. Peristomal dryness contributed to less friction and likely was the reason for granulation tissue recession. CONCLUSIONS: Cyanoacrylate liquid skin protectant can be considered in the management of pediatric moisture- and friction-associated cutaneous injuries, skin tears, and exudative wounds. It can be used as a stand-alone therapy or in combination with standard of care.

Successful Management of Complex Pediatric and Neonatal Wounds With Methylene Blue and Gentian Violet Foam Dressings.

INTRODUCTION: Topical antimicrobial treatment of wounds in pediatric, and especially neonatal, patients can be challenging due to increased systemic absorption, damaging inflammatory cytokines, and oxygen radicals released by bacterial death. A product combining all wound bed preparation principles is desired. Methylene blue and gentian violet (MB/GV) foam dressings can keep wound beds moist, decrease ongoing inflammation, provide antibacterial coverage, and promote healthy wound edges. OBJECTIVE: This article examines the use of MB/GV antibacterial foams in pediatric patients. Cases included infants with giant omphalocele epidermal stripping, dehisced abdominal wounds, peristomal dermatitis, and peripheral intravenous extravasations and adolescents with stage 4 pressure injuries. The treatment goals were to optimize the wound bed through debridement, elimination of bioburden, providing moisture balance, and enhancement of granulation tissue growth. MATERIALS AND METHODS: Eight patients (6 infants and 2 adolescents) received MB/GV foam dressings every 2 to 3 days along with standard of care (SOC) management. RESULTS: Effective debridement, bioburden elimination, moisture balance, and edge enhancement were achieved in all wounds. All wound beds were well-prepared to receive other SOC products as needed. Three cases were considered for negative pressure wound therapy (NPWT), but NPWT was not used because of challenging clinical characteristics and wound locations. Instead, MB/GV polyvinyl alcohol foam provided capillary wicking action that enhanced wound closure without NPWT. No side effects were observed. CONCLUSIONS: Methylene blue and gentian violet foam dressings appear to be a safe clinical option for antibacterial coverage, moisture management, and debridement in neonatal and pediatric patients.

Outcomes of a Quality Improvement Program to Reduce Hospital-acquired Pressure Ulcers in Pediatric Patients.

Hospital-acquired pressure injuries (PIs) present a significant challenge to pediatric providers. PURPOSE: The purpose of this quality improvement program was to develop and implement a debrief protocol and to evaluate compliance with and the implementation of a comprehensive prevention bundle to decrease the overall incidence and severity of pediatric pressure ulcers (PUs)/PIs in a free-standing children's hospital. METHODS: As a member of the Children's Hospitals Solution for Patients Safety national network, a PU Hospital Acquired Conditions (HAC) team was created in 2013, followed by the development and implementation of a PU occurrence debrief tool and discussion guide and implementation of multiple staff educational strategies and a comprehensive prevention bundle. The PU occurrence debriefing occurred within 24 to 48 hours of a PU. Incidence data were collected annually from 2014 until 2017. RESULTS: Compliance on implementation and documentation of bundle elements ranged from 88% to 94%, and PU/PI incidence decreased by 30% from 2014 to 2016 and by 40% in 2017. The overall PU rate was 0.0057 in 2014, 0.0050 in 2015, 0.0036 in 2016, and 0.0023 in 2017; 65% of all PUs were device-related. Of those, >50% were related to respiratory devices, 25% to peripheral intravenous catheters/central lines, 10% to tracheostomies, and 15% to other devices. Respiratory device-related PUs decreased by 50% in the pediatric intensive care unit, by 80% in the neonatal unit, and eliminated completely in extracorporeal membrane oxygenation patients. CONCLUSION: The debriefing process, debriefing tool, educational programs, and prevention bundle reduced the rate of hospital-acquired PIs in pediatric patients and propagated a culture of safety.

Efficacy of Dehydrated Human Amniotic Membrane Allograft for the Treatment of Severe Extravasation Injuries in Preterm Neonates.

INTRODUCTION: A peripheral intravenous (PIV) catheter is placed in 60% to 70% of neonatal intensive care unit (NICU) infants. Extravasation injuries occur in 18% to 33%, with 70% in neonates < 27 weeks of gestational age. Despite such frequent use of PIV therapy, evidence on best practice, injury prevention, management, and treatment of extravasations is lacking. OBJECTIVE: This case series of 4 neonatal patients describes the experience and efficacy of using a dehydrated human amniotic membrane allograft (dHAMA) in the treatment of severe extravasation injuries. MATERIALS AND METHODS: The 4 preterm, critically ill neonates, all with stage 4 extravasations, were treated with 1 to 2 applications of the dHAMA to facilitate the repair process. Prior to treatments, standard of care included either enzymatic (collagenase ointment) or autolytic debridement (active Leptospermum honey) followed by mechanical debridement prior to allograft placement. RESULTS: The 4 full-thickness wounds exhibited recalcitrant healing. The dHAMA invigorated the wounds after standard management failed to induce repair. Application was easy and follow-up care was minimal. All wounds healed without contractures and with minimal soft scars and normal pigmentation at the 1- to 2-month follow-up visits. CONCLUSIONS: The dHAMA proved to be an effective, safe, and easy-to-apply treatment in this case series, leading to regeneration and healing of deep neonatal wounds associated with extravasations.