Good morning everyone!
I really need some ideas, inputs, hypotheses for my situation!!! Please help me!
My little boy is TPN dependant. A PICC was iniated for his vascular access device, but then we had many instances where he would scratch on the dressing until he reaching the PICC and pull it out. We tried the tunneled PICC with a cuff (made in silicone)... he managed to pull it as well... same reason he was scratching + + + . His skin looks to be intact, no redness giving us no reason why he would be so itchy. The parents finally refused the tunneled PICC as they found that it was not convenient for their child. He has right now a Broviac (since september). He was still itchy but it was not enough to make him scratch and pierce the dressing. In the past few weeks, site became red, no pus, no pain... itchy, yes. We have swabbed it... neg. Last night, pt pulled his Broviac... hard enough to migrate his line :S
Has this ever happened to you? What should I do now? I have tried to look for info on silicone allergy, but I was not successful! But can it be after so long being in the pt? The Dacron cuff...after two months, shouldn't it be "incrusted" into patient?
Thanks so much!
Loretta, I was just doing a search on that topic and I can not get the site to open for the "share" so here is the URL I found it on. Silicon allergy is very rare and this article explains how an allergy can occur. Hope this helps. Valorie
http://allergies.ygoy.com/2009/09/07/are-you-worried-about-silicone-allergy/
Valorie Dunn,BSN, RN, CRNI, PLNC
Silicone used in VADs is not the same type of silicone used in breast implants. There has been one study by an allergist many years ago challenging volunteers with extracts of silicone from VADs and there were no reactions reported. I do not believe this is an allergy to silicone. Is the patient allergic to any thing else? If so, what and how many substances? My first thought is a possible allergy to the substances used in the adherent properties of the dressing. I have seen patients allergic to this because of acrylic. A healed Broviac could have gone without the dressing. But it is too late for that now. Have you tried changing the brand of dressing? Are you using CHG? Have you tried going back to povidone iodine? If changing any of these items does not alter the situation, I would want a referal to an allergist for proper testing for allergies.
Subcutaneous tissue should have grown into the Dacron cuffs after several weeks making it very difficult to pull out the catheter. "Incrusted" sounds like it implies infection and that is really not what is occurring. The tunnel may have been too large thus preventing the tissue ingrowth to the cuff.
True allergies are mediated by the presence of IgE. One must be exposed to the substance (antigen) for the antibody to form. Once the antibody has formed, continued or subsequent exposure to the antigen is what produces the reaction. So an allergice reaction will not occur with the first exposure. I doubt that this was a silicone allergy but it could be another allergy and the contined exposure to CHG or the dressing could have produced this over time.
Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I agree with Lynn that it is more likely to be something besides the catheter material. You could try to rule it out by comparing effects from poly and silicone PIVs, since you will need some VAD to bridge until the problem is resolved. Another thing you might look at is that he is developing some kind of neurological feedback loop, similar to chronic pain syndromes, where the phantom sensation persists even after the acute cause has ceased. Possibly some combination of a non-drowsy antihistamine and a mild sedative or amytriptilline type medication would help him de-escalate the response until he develops some tolerance. If it is a true allergy the reaction will only get worse until it is identified and stopped. However, many people are able to successfully work past an initial side-effect of pruritis by using something to break up the feedback loop.
Daniel Juckette RN, CCRN, VA-BC
There are no peripheral IVs (PIV) constructed of silicone. They are all made with either Teflon or polyurethane. Silicone is too soft to be manufacturered in an over-the-needle configuration. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I work in pediatrics with VADs. I have had many children with extremely sensitive skin and it is a process of elimination to figure out what the problem is. I don't know how old your pt is but developmentally, these pts usually do need a dressing to help keep the VAD stabilized, as their age implies an inability to cooperate and protect their lines. If this little patient is TPN dependent, then the problem must be solved. Sounds like he has not been home yet.
The most common reaction I see from dresssings is sensitivity to the transparent dressing. I emphasize to let the skin disinfectant completely dry and then also try skin prep. I have also used duoderm, ultra thin, as a skin barrier and then put the transparent dressing over the duoderm. Does this child sweat alot? Is moisture contributing to the problem? Could you switch to a tape and gauze dressing to see if the same reaction occurs? I often do not have as many supply choices as I would like due to the standardization of supplies in central supply. So my additional strategies include the following:
check with WOCN (wound ostomy and continence nurses) to see if they have any new products availabe to protect the skin and
contact vendors for samples to see if any can help resolve the problem
I have had some success with these approaches. Hope this helps and good luck to you and your patient.
Linda Tirabassi MN RN
Clinical Nurse Specialsit
Miller Children's Hospital
Long Beach CA 90803
[email protected]
Linda Tirabassi PhD RN CNS CPNP