Non-occlusive Dressings Research Articles

Prospective Outcomes of Semi-occlusive Dressings Versus Non-occlusive Dressings Over Donor Sites for Split Thickness Skin Grafting

Prospective Outcomes of Semi-occlusive Dressings Versus Non-occlusive Dressings Over Donor Sites for Split Thickness Skin Grafting

Decreasing Skin Breakdown Around Central Lines in Patients Receiving Thiotepa Prior to Bone Marrow Transplantation.

Skin breakdown occurring around central line dressings increases the risk for infection and bacteremia in all patients. The risk is magnified when experienced in pediatric patients receiving marrow-ablative therapy. A staff nurse on an inpatient pediatric oncology and bone marrow transplant unit noted an increased incidence of skin breakdown around central line dressings in patients receiving Thiotepa prior to bone marrow transplantation. Although there is a wealth of information surrounding routine care of central venous access devices, there is little evidence surrounding care with impaired skin integrity. A staff nurse turned to expert opinion and consensus revealed the use of nonocclusive dressings for central lines. A new protocol for changing central line dressings was developed to decrease the rate of skin breakdown. The protocol utilized gauze and a self-adherent wrap instead of tape to secure central lines. Bone marrow transplant staff nurses were educated prior to the practice change, and compliance was monitored through observation and review of documentation in the electronic medical record. A retrospective chart review compared the rate of skin breakdown and central line associated blood stream infections pre- and postpractice change. The overall percentage of skin breakdown surrounding central lines was reduced by over 80%.

P1132EXIT-SITE CARE PROTOCOLS IN PORTUGAL AND ITS ASSOCIATION WITH CATHETER-RELATED INFECTIONS RATE

Abstract Background and Aims Exit-site infections (ESi) are frequent complications in peritoneal dialysis (PD) patients and their prevention and treatment are key aspects to lower peritonitis’ risk. The aim of this study was to evaluate the annual incidence rate of ESi and peritonitis in Portugal and to study possible associations between exit-site (ES) care protocols in each Portuguese unit and the number / rate of ESi and peritonitis. Method We performed a national study using two questionnaires at each Portuguese PD Unit: one about the incidence of catheter-related infections, the other characterizing patients’ education and ES care protocols. ESi and peritonitis were defined according to ISPD guidelines. Associations between variables were performed using T-student test or pairwise correlation test. STATA software was used. Results Of the 23 Portuguese PD Units, 14 units answered both questionnaires. In the last two years (2017 & 2018), those units followed 1453 patients. Portuguese ESi incidence rate was 0.41 episodes per year [1 episode per 29.2 months (MSSA incidence rate 0.13; MRSA incidence rate 0.03; Pseudomonas incidence rate 0.07)] and the peritonites incidence rate was 0.37 (1 episode per 32.5 months). We found a trend between the absolute number of ESi episodes and the number of peritonites in each unit (r=0.5, p=0.05). Although ESi prevention guidelines were known by 100% of the Portuguese units, only three out of 5 of the selected guidelines for this study were followed by 100% of the units: monitoring catheter-related infections on a yearly basis; using antibiotic prophylaxis at time of catheter placement and treating nasal carriage of S. aureus. The other 2 guidelines have variable implementation: 12 out of 14 units (86%) perform screening of nasal carriage of S. aureus and only 6 out of 14 (43%) of the units recommend daily topic antibiotic cream at the ES. We didn’t find associations between those differences and ESi incidence. Whenever S. aureus carriage is detected, 100% of the units proceed treating with mupirocine using different posology (twice or three times a day, 5 or 7 or 21 days, with/out chlorexidine). Also, the screening of nasal carriage of S. aureus is different: only pre catheter implantation (n=4); annually (n=4); semi annually (n=3); bimonthly (n=2). Oral antibiotics are prescribed after catheter placement in 4 units. We didn’t find statistical differences in ESi / peritonitis, comparing those practices. Regarding to ES care protocols, ESi rate was lower with non-occlusive dressing (0.38 vs. 0.57) immediately after catheter insertion. ESi and peritonitis rate were lower in units where bathing without ES dressing is advocated (n=9, 0.58 & 0.37 vs. 0.32 & 0.34). The use of bath sponge is associated with higher ESi rate (0.57 vs. 0.34). The use of colostomy bags in beach baths was associated with lower incidence rate of ESi compared to regular dressing or waterproof dressing (o.32 vs. 0.54). 100% of units use two different empirical antibiotics for initial ESi treatment. In the presence of chronic ESi, 3 units don’t perform shaving of external cuff and peritonitis rate is higher in those who do not apply this procedure (0.38 vs. 0.31). Conclusion in Portuguese PD units there is a wide variability in ISPD guidelines implementation and ES care protocols. We found that using non-occlusive dressing immediately after catheter insertion, removing ES dressing before shower, bathing not using a sponge and using colostomy bags at beach baths were associated with lower incidence rate of ESi. Shaving of the external cuff was associated with lower incidence rate of peritonitis. A regular national audit of PD Units is an important tool of quality improvement to clarify the best procedures for reduction of catheter-related infections in PD.

A Novel Approach to Keloid Reconstruction with Bilaminar Dermal Substitute and Epidermal Skin Grafting.

Keloids represent a challenging problem. Surgical excision remains the definitive treatment for immediate lesion debulking, but recurrence rates are reported to be 45 to 100 percent. The authors present a staged reconstructive approach using a dermal regeneration substrate and epidermal grafting to minimize recurrence and donor-site morbidity. Keloids were completely excised down to normal subcutaneous tissue or perichondrium. A bilaminar dermal regeneration matrix was approximated to the entire wound, with the silicone lamina oriented superficially. Reconstruction was delayed for at least 21 days to allow for neodermal ingrowth. The silicone lamina was then removed, and an epidermal skin graft was harvested from the thigh and secured to the neodermis with nonocclusive dressing. Reconstructed defects and donor sites were assessed for recurrence of keloids and scar appearance. Five patients underwent treatment; two had keloids involving the superior helix of the ear (average area, 2.6 cm), two had keloids involving the chest (average area, 28 cm), and one had a keloid in the pubic region (area, 10 cm). All had failed at least one previous treatment with direct excision and steroid injections. Mean follow-up was 48.8 weeks (range, 38 to 60 weeks). Average time to complete wound epithelialization was 5.5 weeks. There were no infections or cellulitis. All reconstructed defects were aesthetically acceptable and remained flat without significant widening. There were no long-term complaints of pruritus or pain and there was no evidence of donor-site scarring. Epidermal grafting provides significant advantages when used with a dermal regeneration matrix. This approach obviates reliance on skin creep and flap undermining to achieve primary closure. Exclusion of dermis and significant extracellular matrix components limits contracture, further facilitating tension-free wound healing. Scarring response within the donor site and graft is also minimized. Therapeutic, IV.

Postinsertion central line site care: quality improvement in a medical cardiac ICU.

Using the Six Sigma quality improvement framework of Define, Measure, Analyze, Improve, and Control, nurses in the medical cardiac intensive care unit at a large academic medical center in the Midwest identified a gap in the quality of central line site care, evaluated the current state of site care, implemented an intervention to create an improvement in nursing performance of site care, quantified this improvement, and created a model for sustained quality control. Reasons for nonocclusive dressings were revealed and addressed. An unexpected benefit was found in a unifying sense of pride in improving patient care.

When the Smad signaling pathway is impaired, fibroblasts advance open wound contraction

In wound healing transforming growth factor β1 (TGFβ1), utilizing the Smad signaling pathway, advances connective tissue deposition, the transformation of fibroblasts into myofibroblasts and wound contraction. The compound SB-505124 disrupts the Smad signaling pathway by blocking activin receptor-like kinase phosphorylation of select Smad signaling proteins. Four full thickness excisional square 2 × 2 cm wounds were made on the rat dorsum. On day 2, the pair of wounds on the left received 1 μM SB-505124 in gel, and the pair on the right, controls, received gel alone. Wounds were covered with nonocclusive dressings and treated redressed daily for 4 days. No differences in day 14 wound sizes between treatment groups were found. H&E stained sections revealed increased cell density in SB-505124 treated wounds. Polarized light microscopy showed collagen fiber bundles birefringence intensity and organization were equivalent between treatment groups. Myofibroblast populations, identified by α-smooth muscle actin staining, were the norm in controls but absent in SB-505124 treated wounds, which was confirmed by Western blot analysis. Blocking the Smad signaling pathway diminished connective tissue deposition and generated a deficiency in myofibroblast numbers, but wound contraction was unimpaired. The absence of myofibroblasts may be related to the blocking of the Smad signaling pathway or it may be related to the generation of less tension in treated wounds, related to reduce deposited connective tissue. These findings support the notion that wound contraction does not require the generation of myofibroblast contractile forces, but rather the organization of newly deposited collagen fiber bundles by forces related to fibroblast locomotion.

Facial resurfacing: An overview

Facial resurfacing is a broad topic referring to procedures that change the texture and appearance of skin. Resurfacing procedures are broadly classified as ablative or nonablative. Ablative procedures are considered the first line treatment for the most common indications for facial resurfacing, which are photoaging and acne scarring. The goal of this review is to provide an overview of the factors that optimize the clinical efficacy of an ablative procedure, including careful patient selection, preoperative skin preparation, correct operative technique, and vigilant postoperative care, as well as review both the traditional and some of the latest technologies that effectively resurface facial skin.

Frequency of vaccinia virus isolation on semipermeable versus nonocclusive dressings covering smallpox vaccination sites in hospital personnel

Background The Centers for Disease Control and Prevention recommends a semipermeable occlusive dressing for hospital workers who receive smallpox vaccination. Objective The study was designed to determine the frequency of vaccinia virus isolation from the outer surface of semipermeable dressings and to compare the prevalence of vaccinia virus on the outer surface of semipermeable dressings with its prevalence on the outer surface of nonocclusive dressings. Methods A prospective, observational study was conducted on hospital employees who received smallpox vaccination at a military academic medical center. Subjects were instructed to wear a semipermeable dressing if they had direct patient contact. Employees without direct patient care had the option of wearing a semipermeable dressing or a nonocclusive dressing. Prior to a programmed dressing change, the outer surface of the bandage site was swabbed and cultured for virus. Samples were considered positive when cytopathic effects were observed, with results confirmed as vaccinia by polymerase chain reaction. Results A total of 212 cultures were obtained from 93 subjects. All cultures directly obtained from active lesions were positive (13/13). Positive cultures were obtained from 7% (10/135) of the semipermeable dressings and 23% (15/64) of the nonocclusive dressings ( P < .05). Ten percent (8/79) of the semipermeable dressings with purulent exudate observed underneath the bandage were culture positive, compared with 4% (2/56) of semipermeable dressings with no purulent exudate observed underneath the bandage ( P = .19). Conclusions Compared with nonocclusive dressings, the semipermeable dressing reduced, but did not eliminate, the frequency with which vaccinia virus was cultured from the surface of the dressing. Virus was present, but only rarely, on the dressing surface in the absence of purulent exudate under the semipermeable dressings.

Frequency of vaccinia virus isolation on semipermeable versus nonocclusive dressings covering smallpox vaccination sites in hospital personnel*1

Background The Centers for Disease Control and Prevention recommends a semipermeable occlusive dressing for hospital workers who receive smallpox vaccination. Objective The study was designed to determine the frequency of vaccinia virus isolation from the outer surface of semipermeable dressings and to compare the prevalence of vaccinia virus on the outer surface of semipermeable dressings with its prevalence on the outer surface of nonocclusive dressings. Methods A prospective, observational study was conducted on hospital employees who received smallpox vaccination at a military academic medical center. Subjects were instructed to wear a semipermeable dressing if they had direct patient contact. Employees without direct patient care had the option of wearing a semipermeable dressing or a nonocclusive dressing. Prior to a programmed dressing change, the outer surface of the bandage site was swabbed and cultured for virus. Samples were considered positive when cytopathic effects were observed, with results confirmed as vaccinia by polymerase chain reaction. Results A total of 212 cultures were obtained from 93 subjects. All cultures directly obtained from active lesions were positive (13/13). Positive cultures were obtained from 7% (10/135) of the semipermeable dressings and 23% (15/64) of the nonocclusive dressings (P < .05). Ten percent (8/79) of the semipermeable dressings with purulent exudate observed underneath the bandage were culture positive, compared with 4% (2/56) of semipermeable dressings with no purulent exudate observed underneath the bandage (P = .19). Conclusions Compared with nonocclusive dressings, the semipermeable dressing reduced, but did not eliminate, the frequency with which vaccinia virus was cultured from the surface of the dressing. Virus was present, but only rarely, on the dressing surface in the absence of purulent exudate under the semipermeable dressings.

Blue Ribbon Abstract Award, New Investigator Award: Reduction of the Central Venous Catheter-Associated Bloodstream Infection Rate in a Neurological/Neurosurgical Intensive Care Unit

BACKGROUND/OBJECTIVES: In 2002, routine surveillance of a 20-bed neurological/neurosurgical intensive care unit (NNICU) at Barnes-Jewish Hospital, a 1442-bed tertiary care university hospital, revealed a mean central venous catheter (CVC) bloodstream infection (BSI) rate of 9.9 infections per 1000 CVC days. This was higher than the 2002 National Nosocomial Infections Surveillance System pooled mean of 4.7/1000 CVC days. CVC BSIs are associated with increased morbidity and mortality rates and prolonged hospital stay. Risk factors for CVC BSI include breaks in aseptic technique during CVC insertion or site care and non-occlusive dressings. In accordance with evidence-based guidelines, interventions relating to hand hygiene, strict aseptic CVC insertion techniques, and meticulous CVC site care were implemented to lower the CVC–associated BSI rate. METHODS: The population consisted of NNICU patients with a CVC placed during their hospital stay which developed a CVC–associated BSI greater than 48 hours post insertion. The Centers for Disease Control (CDC) definitions for primary CVC–associated nosocomial BSI were used. During January–March 2003, staff participated in a mandatory educational program focusing on CDC hand hygiene recommendations and encouraging use of alcohol foam. In March 2003, use of chlorhexidine gluconate (CHG) was implemented for CVC insertion and site care, and incoming residents began receiving a self-study module on prevention of CVC–associated BSIs. RESULTS: Twenty-six primary BSIs occurred in 2699 catheter days during January–December, 2002 (9.9 BSI/1000CVC days). Primary BSIs decreased to thirteen in 2796 catheter days during January–December, 2003 (4.6 BSI/1000CVC days), a decrease of 54% (p=0.03). CONCLUSIONS: Educational interventions focusing on hand hygiene and aseptic technique for CVC insertion and site care, combined with implementation of CHG for CVC insertion and site care, successfully lowered the rate of CVC–associated BSIs in a NNICU.

The Evaluation of Topical Anesthetic Effects of a Liposome Encapsulated Mixture of Local Anesthetics (Lipo-MLA)

Background: This study investigated the effect of topical analgesic effects of a liposome encapsulated mixture of local anesthetics (lipo-MLA) compared with EMLA. Methods: 3% lipo-MLA (0.5% tetracaine base, 2.5% lidocaine base) and 5% lipo-MLA (1% tetracaine base, 4% lidocaine base) were encapsulated into liposomal vesicles made with egg yolk phosphatidylcholine, cholesterol and phosphatidyldioleoyl. 3% lipo-MLA and EMLA were applied to volunteers' forearms bilaterally with and without an occlusive dressing. The topical anesthetic effects of the lipo-MLA and EMLA as a control were evaluated by the pinprick test in 28 adult volunteers after 60 minutes of application. The analgesic influence of the concentration of local anesthetics was also compared with 3% and 5% lipo-MLA under a non-occlusive dressing. Results: Analgesic effects of the 3% lipo-MLA were similar with EMLA under an occlusive dressing for 60 minutes. In addition, analgesic effects of the 3% lipo-MLA under a non-occlusive dressing were more potent than EMLA. Lipo-MLA under a non-occlusive dressing showed more potent analgesic effect than lipo-MLA under an occlusive dressing. 5% lipo-MLA was more potent than 3% lipo-MLA under a non-occlusive dressing. Conclusions: Lipo-MLA has more potent analgesic effects than EMLA without an occlusive dressing and 5% lipo-MLA is more potent than 3% lipo-MLA. Therefore, lipo-MLA appeared to be an improved topical analgesic formulation which provides a more potent and convenient topical application. (Korean J Anesthesiol 2001; 40: 420-426)

Healing of full-thickness wounds in pigs: effects of occlusive and non-occlusive dressings associated with a gel vehicle

This study, based upon a pig model, was conducted to investigate the effects of moist and dry healing conditions on wound closure (epithelialization, granulation tissue, contraction) of full-thickness wounds. Thirty-two full-thickness square wounds (3 cm × 3 cm) covered with either an occlusive polyurethane dressing (Tegaderm®) or a non-occlusive dressing (Melolin®) were evaluated. The effect of the presence or the absence of a gel (3% Idroramnosan®) was also investigated with both dressings. The dressings were renewed twice a week. The time required for wound closure was 19.2 ± 1.6 days for Tegaderm® and 26.6 ± 3.0 days (means ± SD) for Melolin®, respectively. The healing time of the full-thickness porcine wounds was significantly ( P < 0.001) reduced by the occlusive dressing. Equivalent results were found with the 3% gel, indicating that the gel can be used as a neutral vehicle. The healing rate, calculated according to Gilman's method, was also significantly ( P < 0.001) enhanced by the occlusive dressing. This progression was 0.073 ± 0.004 cm/day and 0.050 ± 0.009 cm/day (means ± SD) for Tegaderm and Melolin, respectively. The contribution of contraction to wound closure was similar in all wounds, indicating that the occlusive dressing did not have an effect on wound contraction. Histological evaluation was performed on full-thickness skin biopsies of whole wound harvested from the time of wound closure to 3 months after. At any time point, no significant histological variations were observed between the different treated wounds. This study demonstrates in a porcine model that for full-thickness wounds, as for split-thickness wounds, occlusive dressing enhances healing rate and shortens the time for wound repair. The shortened healing time is a function primarily of the effect of occlusive dressing on epithelialization, especially the third phase of wound resurfacing.

Inhibition of tissue transglutaminase and ɛ (γ‐glutamyl) lysine cross‐linking in human hypertrophic scar

Immunohistochemical staining with monoclonal antibody to tissue transglutaminase was used to study cryostat sections of human skin wounds. The enzyme was found in acute wounds and chronic hypertrophic scars but not in normal mature scars. Because tissue transglutaminase is responsible for the formation of isopeptide cross-links, a two-stage high-performance liquid chromatographic analysis was used to quantitate the epsilon (gamma-glutamyl) lysine cross-link produced by various types of wound tissues. Eighteen patients with hypertrophic scars between 6 months' and 10 years' duration after injury underwent a double-blind trial with putrescine 50 mmol/L in a eutectic vehicle for 2 months under nonocclusive dressings (Biofill). For the control portion of the same or different scar, sham vehicle and non-occlusive dressing were simultaneously applied. Both scars were harvested at biopsy or elective revision surgery 2 months later. After homogenization and exhaustive proteolysis, digests were studied with the use of high-performance liquid chromatography analysis. The results of treatment were a significant decrease in the levels of isopeptide cross-link formation from 0.018 +/- .006 nmol/micromol amino acids in untreated scars to 0.008 +/- .001 nmol/micromol amino acid in the treated group (p < 0.05). The isopeptide cross-link content in treated scars was nearly as low as that in normal mature scars (0.003 +/- 0.001 nmol/micromol amino acid). These results show that cross-link formation by tissue transglutaminase activity is inhibited during treatment of hypertrophic scar by putrescine. These results support the possible therapeutic use of topical putrescine in the treatment of hypertrophic scar formation.

Primary Cutaneous Aspergillosis Near Central Venous Catheters in Patients With the Acquired Immunodeficiency Syndrome

Aspergillosis in patients with the acquired immunodeficiency syndrome is unusual, and the clinicopathologic features of primary cutaneous aspergillosis in this setting are undefined. Our findings show that the manifestations can differ from those of primary cutaneous aspergillosis in other immunocompromised patients. Two men with the acquired immunodeficiency syndrome developed foci of primary cutaneous aspergillosis beneath adhesive tape near central venous catheter sites. Typical lesions were flesh-colored to pink, umbilicated papules that clinically resembled molluscum contagiosum. Biopsy specimens showed variably ruptured follicles that contained collections of fungal hyphae typical of Aspergillus species. Cultures in one case identified Aspergillus fumigatus. The use of nonocclusive dressings and local wound care resulted in involution of several lesions. Primary cutaneous aspergillosis begins as saprophytic involvement of hair follicles secondary to the altered microenvironment beneath adhesive tape. Systemic antifungal therapy is prudent, but in the absence of neutropenia or other traditional risk factors for dissemination, it appears that Aspergillus in patients with the acquired immunodeficiency syndrome can produce relatively indolent cutaneous lesions with a tendency to resolve once precipitating factors are removed.

The Effect of Antiseptics and the Moist Wound Environment on Ulcer Healing: An Experimental and Biochemical Study

The effect of topical aqueous chlorhexidine (0.5% and 5%) and Eusol has been studied on the healing of 2 cm skin defects in rats, with measurements of DNA and collagen synthesis as biochemical markers. Healing was also compared under an occlusive dressing (Comfeel Ulcer Dressing, Coloplast) and a non-occlusive dressing (Jelonet, Smith and Nephew). Healing was significantly delayed under Jelonet dressings compared with the Comfeel groups. The hydroxyproline levels, 4 d after wounding were: chlorhexidine 5% 1.82 μg mg−1 (1.46–11.57), Eusol 1.78 (1.13–3.52), Jelonet 2.04 (1.89–3.91), Comfeel 3.21 (1.99–3.46), Comfeel–saline 3.09 (1.99–3.46), chlorhexidine 5% 3.61 (1.47–6.28). The moist wound environment provided by the Comfeel dressings was the most conducive to healing in this study. Chlorhexidine, at a recommended strength of 0.5% (or less), did not impair healing and can safely be used if an antimicrobial is required.

A comparison of the morbidity associated with occlusive and non-occlusive dressings applied to peripheral intravenous devices

A comparison of the morbidity associated with occlusive and non-occlusive dressings applied to peripheral intravenous devices

A comparison of the morbidity associated with occlusive and non-occlusive dressings applied to peripheral intravenous devices

A comparison of the morbidity associated with occlusive and non-occlusive dressings applied to peripheral intravenous devices

A comparison of the morbidity associated with occlusive and non-occlusive dressings applied to peripheral intravenous devices

In a non-randomized controlled study of the effects of an occlusive polymer dressing on the morbidity associated with intravenous (iv) cannulation, it was found that the polymer dressing adversely affected the rate of cannula tip colonization, but that this could not be generally related to an increased risk of thrombophlebitis. A strong association was found between Staphylococcus aureus colonization and thrombophlebitis. It is proposed that the materials, method of manufacture and the use to which the cannula is put are more important in the genesis of the minor complications of iv cannulation than the type of dressing.