11 minute read

When Sticking is Not An Option

Jocelyn Hill, MN, RN, CVAA(c), VA-BC™ | Clinical Nurse Specialist for IV Therapy, Vascular Access and Chemotherapy/ Hematology at St. Paul’s Hospital, Providence Health Care in Vancouver, BC

The insertion of central vascular access device (CVAD) is done with full intention that the CVAD will stay in place for the duration of required clinical indication without complications. Adhesive-based dressings have been part of the standard of care for decades to cover and protect the CVAD site with the assumption that some dressings can fully secure a CVAD.1 Problems can arise when the patient’s disease process, trauma, or skin condition ceases to allow the adhesive to adhere to intact, healthy skin around the CVAD site.2,3 As a result, the clinician is challenged with how to protect and secure the VAD in place without using adhesives in any form, neither the dressing nor the securement device.2,4 The purpose of this article is to highlight an effective strategy and describe how a securement device that is adhesive-free can be used as an option to allow for the surrounding skin to heal once impaired. Two clinical scenarios and situations will be used to provide context and help guide clinical practice.

CLINICAL SCENARIO – 1

Figure 1: PICC in situ to upper arm with surrounding rashy skin. Patient has history of atopic eczema. Subcutaneous anchoring securement system (SASS - SecurAcath, Interrad Medical, Plymouth, MN) in place for optimal PICC securement and allows for alternative non-adhesive dressing of dry gauze and silicone tape. Photo courtesy of M. Brodie, Vancouver, BC Canada) A 30 year-old male patient (Mr. A) required a peripherally inserted central catheter (PICC) for home IV antibiotics for 6 weeks. The patient has a chronic condition of atopic eczema on is his hands and arms and he complains of sweating and severe itchiness with adhesive tapes and dressings. Mr. A presented with areas of reddish-pink, raised and scaly areas on his skin to his upper arms where the PICC is to be placed. The insertion procedure occurred with no complications with the use of a subcutaneous anchoring securement system (SASS - SecurAcath, Interrad Medical, Plymouth, MN) as the standard of care to prevent catheter pistoning at the site and malposition. The use of the SASS in this particular situation was even more beneficial as the routine care and maintenance of the PICC can now include the use of just gauze and silicone adhesive tape with a light gauze wrap (stockinet) without the skin contact and irritation from an acrylic adhesive found in most semi-permeable adhesive dressings. Using an adhesive dressing was not an option. The skin surrounding the PICC site was still typical for him with symptoms of atopic eczema but he tolerated the SASS well and his symptoms did not worsen during therapy. The patient was able to complete his home IV therapy without any interruptions or complications of catheter-related infection or malposition.

CLINICAL SCENARIO – 2

Figure 2: Tunneled silicone CVAD in situ on chest with subcutaneous cuff pulled out from exit site on Day 14 CONTINUED ON NEXT PAGE

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post insertion. Surrounding skin has some irritation and for additional comfort, a piece of wound contact layer dressing with silicone is applied under the SASS bottom platform. Photo by J. Hill, Vancouver, BC Canada) A 70 year-old female patient (Mrs. B) required a tunneled, cuffed CVAD for parenteral nutrition (PN) and infusates. Mrs. B. has been taught how to manage her PN at home as her nutritional requirements are life-long. On insertion of the CVAD by interventional radiology, sutures were used at the site to allow the tissue ingrowth cuff to adhere to the subcutaneous tissue in her upper chest area and a transparent, semi-permeable acrylic adhesive dressing was used to cover and protect the CVAD site. On removal of the sutures at day 14 (standard routine), the CVAD was accidently pulled on and the catheter migrated out by 3 cm with the tissue ingrowth cuff exposed at the exit site. Additionally, the skin surrounding the CVAD exit site was found to be red, itchy and weepy under the dressing. On consultation with the Clinical Nurse Specialist for Vascular Access, a SASS was recommended to eliminate further issues with malposition and to allow the surrounding skin to heal. An alternative to adhesive-type dressings for full securement was necessary. Insertion of the SASS was done without complication. Gauze and silicone adhesive tape was used to protect and cover the site until skin healed around the site. In addition, the patient also reported an increase in confidence that the catheter would not move or retract during cleaning of the skin around the CVAD. This security was an added benefit as she does her own dressing changes. The goal is to keep the CVAD free from complications for an indefinite period of time because of life-long parenteral nutrition requirements.

SKIN IMPAIRMENT / INJURY

In both scenarios presented, the patients had clinical indications for vascular access with the importance of therapy that is complication-free and intact skin integrity is important for patients’ quality of life during this time. Medical adhesive-related skin injury (MARSI) is a term that is used to describe a breakdown in skin integrity due to inappropriate use and or removal of adhesive on the skin as well as premature placement of a dressing before the skin antiseptic is allowed to dry.3,4,6 Catheter Associated skin injury (CASI) has recently been used to describe skin injury specifically from adhesive used to cover and protect VAD sites and catheters.4 For the most part, the use of adhesive dressings to cover and protect CVADs is effective with the caveat that proper application and removal of the dressing takes place. The use of approved skin antisepsis agents such as chlorhexidine gluconate (CHG) is also a factor in CASI.3,4 The skin antiseptic CHG solution must be completely dry before the contact with adhesive dressing material. Applying the dressing prematurely can create topical issues leading to skin injury. It is incorrectly assumed that patients are “allergic” to CHG and it has been discussed in various vascular access and infusion therapy forums that it is actually rare that patients develop a true CHG allergy.5 It is most likely that they have become sensitive, or reactive, to inappropriate dressing change methods.2,3,4,6 It is well-documented that skin injury from adhesive securement can be painful and cause the preventable catheter-related complications such as malposition and pistoning at the site due to lack of full securement properties.2,7

SASS STRATEGY

The use of a SASS is applicable on VADs such as midlines, PICCs and non-tunneled and tunneled CVADs.2,6,7 When tackling patient-specific issues such as MARSI, or CASI, the goals are for the patient experience and care to be positive and optimized respectively. With SASS technology, complete securement is achieved by being anchored under the skin rather than relying on an adhesive dressing stuck on top of skin that has compromised integrity8. The scenarios described speak to different situations where the SASS is inserted at time of CVAD insertion and post insertion when subcutaneous tissue ingrowth cuff adherence has failed. No matter what the indication for the CVAD is, or the duration of the therapy (short term, acute vs. chronic, long-term), proper catheter tip position is extremely important. The SASS helps to prevent accidental tip malposition caused by catheter migrations or dislodgements that

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occur during routine dressing changes, catheter site care and activities of daily living. 2,7,8,10

In both scenarios, routines for care and maintenance with dressing changes remained consistent with the use of CHG for skin antisepsis (with emphasis on full dry time) and the use of sterile 2x2 gauze and silicone-adhesive tape to secure the gauze covering the SASS and site – for Mrs. B, the addition of a wound contact layer dressing with silicone was used under the SASS platform for comfort on the chest. In scenario 1, this routine was done for the duration of short-term therapy and adhesive securement and cover dressings were not used. In scenario 2, the SASS remains in place providing good securement and we were able to use a transparent, semi-permeable, adhesive dressing to cover the site and area once the surrounding skin was fully healed. Mr. A received care from community nursing for the weekly PICC dressing changes and nurses were able to easily perform the procedure in the home without fear of accidently retracting the catheter at all. For Mrs. B, it has become a lot easier for her to do her own dressing changes as she is able to confidently clean her CVAD site fully by lifting up the catheter in the SASS without fear of pulling or migration at the site. With the SASS, the PICC was stabilized throughout Mr. A’s course of treatment and the PICC and SASS were removed at end of therapy. Mrs. B continues to rely on the SASS to fully secure her CVAD despite the subcutaneous tissue ingrowth cuff on the catheter not being under her skin and this is of great importance and benefit to her as she continues her parenteral nutrition indefinitely at home.

TAKE HOME MESSAGE AND CONCLUSION

The clinical situations presented have shown how SASS technology can provide an effective strategy and alternative when skin integrity is compromised. The SASS will provide securement of the catheter with or without an adhesive dressing and can be inserted at time of catheter insertion or post-insertion with proper technique. Once skin integrity is compromised to the CVAD site and surrounding skin, adhesive dressings and securement may contribute to further injury if they are used.3,4,6 Avoiding unnecessary adhesives for dressings and securement and a period of time without adhesive allows skin healing to take place without the risk of catheter migration or dislodgement. Complications such as skin injury and catheter migration, or malposition, can lead to interrupted treatment impacting overall therapy.

To be a vascular access specialist is to be able to expertly conduct routine procedures on typical patients and have the capability to adapt to atypical patients ensuring equally positive outcomes. If every patient and situation were routine, we wouldn’t need specialists. This discussion explored situations that were outside “the norm,” but not unheard of, for patients with CVADs. The increased awareness and adoption of SASS technology for all CVADs can prevent complications such as catheter malposition and help skin to heal when MARSI/CASI occurs.2,4,7,8 Preventing vascular access-related complications such as discussed here, is a priority not just for vascular access specialists, but for everyone on the health care team. This allows for provision of quality patient care and to focus on other aspects of the clinical situation in the patient’s journey to overall therapy, health and well-being.

REFERENCES

1. 3M Infection Prevention. A history of 3M Tegaderm brand. Skin & Wound Care Division 3M Health Care. www.3M.com/Tegaderm . Accessed October 15, 2021.

2. Hawes ML. Vascular access device securement for oncology patients and those with chronic diseases. British Journal of Nursing. 2021 Apr 22;30(8):S20-5.

3. Thayer D. Skin Damage Associated With Vascular Access: Understanding Common Mechanisms of Injury and Strategies for Prevention. Journal of Radiology Nursing. 2021 Mar 1;40(1):61-8.

4. Broadhurst D, Moureau N, Ullman AJ. Central venous access devices site care practices: an international survey of 34 countries. The Journal of Vascular Access. 2016 Jan;17(1):78-86.

5. U.S. Food & Drug Administration. FDA drug safety communication: FDA warns about rare but serious allergic reactions with the skin antiseptic chlorhexidine gluconate. Drug Safety Communication (PDF). Updated

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February 2, 2017. https://www.fda.gov/drugs/drugsafety-and-availability/fda-drug-safety-communicationfda-warns-about-rare-serious-allergic-reactions-skinantiseptic Accessed October 15, 2021.

6. Fumarola S, Allaway R, Callaghan R, et al. Overlooked and underestimated: Medical adhesive-related skin injuries. Journal of Wound Care. 2020;29(suppl 3c): S1S23.

7. Brescia F, Pittiruti M, Roveredo L, Zanier C, Morabito A, Santarossa E, Da Ros V, Montico M, Fabiani F. Subcutaneously anchored securement for peripherally inserted central catheters: Immediate, early, and late complications. The Journal of Vascular Access. 2021 Jun 17:11297298211025430.

8. Pinelli F, Pittiruti M, Van Boxtel T, Barone G, Biffi R, Capozzoli G, Crocoli A, Elli S, Elisei D, Fabiani A, Garrino C. GAVeCeLT-WoCoVA consensus on subcutaneously anchored securement devices for the securement of venous catheters: current evidence and recommendations for future research. The Journal of Vascular Access. 2021 Sep;22(5):716-25.

9. SecurAcath. Instructions for use. Interrad Medical. https:// securacath.com/wp-content/uploads/2020/05/1386002-rF-IFU-SecurAcath-US.pdf . Accessed October 21, 2021.

10. McParlan D, Edgar L, Gault M, Gillespie S, Menelly R, Reid M. Intravascular catheter migration: A crosssectional and health-economic comparison of adhesive and subcutaneous engineered stabilisation devices for intravascular device securement. The Journal of Vascular Access. 2020 Jan;21(1):33-8.

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