Mikel Gray

Incontinence-associated dermatitis: a consensus.

Incontinence-associated dermatitis (IAD) is an inflammation of the skin that occurs when urine or stool comes into contact with perineal or perigenital skin. Little research has focused on IAD, resulting in significant gaps in our understanding of its epidemiology, natural history, etiology, and pathophysiology. A growing number of studies have examined clinical and economic outcomes associated with prevention strategies, but less research exists concerning the efficacy of various treatments. In the clinical and research settings, IAD is often combined with skin damage caused by pressure and shear or related factors, sometimes leading to confusion among clinicians concerning its etiology and diagnosis. This article reviews existing literature related to IAD, outlines strategies for assessing, preventing, and treating IAD, and provides suggestions for additional research needed to enhance our understanding and management of this common but under-reported and understudied skin disorder.

Incontinence-Associated Dermatitis: A Comprehensive Review and Update

In 2009, a multinational group of clinicians was charged with reviewing and evaluating the research base pertaining to incontinence-associated dermatitis (IAD) and synthesizing this knowledge into best practice recommendations based on existing evidence. This is the first of 2 articles focusing on IAD; it updates current research and identifies persistent gaps in our knowledge. Our literature review revealed a small but growing body of evidence that provides additional insight into the epidemiology, etiology, and pathophysiology of IAD when compared to the review generated by the first IAD consensus group convened 5 years earlier. We identified research supporting the use of a defined skin care regimen based on principles of gentle perineal cleansing, moisturization, and application of a skin protectant. Clinical experience also supports application of an antifungal powder, ointment, or cream in patients with evidence of cutaneous candidiasis, aggressive containment of urinary or fecal incontinence, and highly selective use of a mild topical anti-inflammatory product in selected cases. The panel concluded that research remains limited and additional studies are urgently needed to enhance our understanding of IAD and to establish evidence-based protocols for its prevention and treatment.

Moisture-associated skin damage: Overview and pathophysiology

Moisture-associated skin damage (MASD) is caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents. MASD is characterized by inflammation of the skin, occurring with or without erosion or secondary cutaneous infection. Multiple conditions may result in MASD; 4 of the most common forms are incontinence-associated dermatitis, intertriginous dermatitis, periwound moisture-associated dermatitis, and peristomal moisture-associated dermatitis. Although evidence is lacking, clinical experience suggests that MASD requires more than moisture alone. Instead, skin damage is attributable to multiple factors, including chemical irritants within the moisture source, its pH, mechanical factors such as friction, and associated microorganisms. To prevent MASD, clinicians need to be vigilant both in maintaining optimal skin conditions and in diagnosing and treating minor cases of MASD prior to progression and skin breakdown.

Enzymatic wound debridement

Background Clinical experience and existing research strongly support debridement as a necessary component of wound bed preparation when slough or eschar is present. Multiple techniques are available, but the indications for each technique and their efficacy are not clearly established. There is little evidence to guide the clinician in the selection of a safe, effective debridement method for the patient with a chronic wound. Objectives We sought to identify evidence related to the efficacy of enzymatic debriding agents collagenase and papain-urea in the removal of necrotic tissue from the wound bed and its impact on wound healing. Search Strategy A systematic review of electronic databases was undertaken using key words: (1) debridement, (2) enzymatic debridement, (3) collagenases, (4) papain, (5) urea, and (6) papain-urea. All prospective and retrospective studies that compared enzymatic debridement using collagenase or papain-urea (with and without chlorophyllin) on pressure ulcers, leg ulcers, or burn wounds were included in the review. All studies that met inclusion criteria and were published between January 1960 and February 2008 were included. Results Collagenase ointment is more effective than placebo (inactivated ointment or petrolatum ointment) for debridement of necrotic tissue from pressure ulcers, leg ulcers, and partial-thickness burn wounds. Limited evidence suggests that a papain-urea–based ointment removes necrotic material from pressure ulcers more rapidly than collagenase ointment, but progress toward wound healing appears to be equivocal. Limited evidence suggests that treatment of partial-thickness burn wounds in children with collagenase ointment may require an equivocal time to treatment with surgical excision and that combination treatment may reduce the need for surgical excision. Insufficient evidence was found to determine whether collagenase ointment removes necrotic tissue from leg ulcers more or less rapidly than autolytic debridement enhanced by a polyacrylate dressing. Implications for Practice Enzymatic debriding agents are an effective alternative for removing necrotic material from pressure ulcers, leg ulcers, and partial-thickness wounds. They may be used to debride both adherent slough and eschar. Enzymatic agents may be used as the primary technique for debridement in certain cases, especially when alternative methods such as surgical or conservative sharp wound debridement (CSWD) are not feasible owing to bleeding disorders or other considerations. Many clinicians will select enzymes when CSWD is not an option. Clinical experience strongly suggests that combined therapy, such as initial surgical debridement followed by serial debridement using an enzymatic agent or enzymatic debridement along with serial CSWD, is effective for many patients with chronic, indolent, or nonhealing wounds.

THE INCIDENCE OF A POSITIVE ICE WATER TEST IN BLADDER OUTLET OBSTRUCTED PATIENTS: EVIDENCE FOR BLADDER NEURAL PLASTICITY

PURPOSE The ice water test triggers a C fiber, capsaicin sensitive spinal micturition reflex. We postulated that the ice water test is positive in a high proportion of patients with compared to those without bladder outlet obstruction. MATERIALS AND METHODS Prospective evaluation of 111 consecutive patients was undertaken. Symptoms of urgency, urge incontinence, nocturia and daytime frequency as well as the presence of neurological disease were obtained from history and physical examination. Fluorourodynamics, including ice water cystometry, and pressure-flow studies were done for all 111 subjects. Obstruction was defined using the Abrams-Griffith nomogram and urethral resistive index. A positive ice water test was defined as presence of uninhibited bladder contraction with instillation of 0C saline at 50 cc per minute up to a maximum of 250 cc. Detrusor instability was defined according to the International Continence Society criteria using room temperature saline instillation. RESULTS When patients with neurological disease were excluded, a positive ice water test was found in 71% of subjects with bladder outlet obstruction (12 of 17), which was significantly higher (p <0.0005, Yates corrected chi-square test) than the 7% positive ice water test rate in nonobstructed subjects (3 of 44). Conversely, the incidence of positive detrusor instability was not statistically different between the patients with or without bladder outlet obstruction. Of the subjects with neurological disease 85% (42 of 50) had a positive ice water test. The incidence of a positive ice water test was only 5 to 9% in patients with storage lower urinary tract symptoms. CONCLUSIONS A positive ice water test has been previously described in infants and individuals with neurogenic bladders. However, subjects with bladder outlet obstruction had a significantly higher incidence of a positive ice water test compared to those without it, supporting the hypothesis of an enhanced spinal micturition reflex possibly due to plasticity of bladder afferents after bladder outlet obstruction. The ice water test may be useful in prognosticating bladder outlet obstruction treatment outcomes and determining the etiology of treatment failure.

Nursing Interventions to Reduce the Risk of Catheter-associated Urinary Tract Infection: Part 2

BACKGROUND The US Centers for Medicare & Medicaid Services has enacted 2 policies that have focused considerable attention on the optimal use of indwelling catheters in the acute and long-term care settings and the prevention of complications including catheter-associated urinary tract infection (CAUTI). OBJECTIVES This is the second of a 2-part Evidence-Based Report Card reviewing current evidence pertaining to nursing actions for prevention of CAUTI in patients with short- and long-term indwelling catheters. Part 2 reviews multiple interventions for CAUTI prevention including staff education, monitoring of catheter use and CAUTI incidence, insertion technique, urethral meatal care, securement, use of a closed drainage system, bladder irrigation, frequency of catheter change, and antiseptic solutions in the drainage bag. SEARCH STRATEGY Nursing actions for prevention of CAUTI were identified based on search of electronic databases and Web-based search engines for national or international clinical practice guidelines focusing on this topic. Evidence related to the above nursing interventions was identified by searching electronic databases MEDLINE, CINAHL, the Cochrane Library, the ancestry of articles identified in these searches and Google scholar. RESULTS Limited evidence suggests that the following interventions reduce the incidence of CAUTI in patients managed by short-term indwelling catheterization: (1) staff education about catheter management, combined with regular monitoring of CAUTI incidence, (2) a facility-wide program to ensure catheterization only when indicated and prompt removal of indwelling catheters, (3) daily cleansing of the urethral meatus using soap and water or perineal cleanser, and (4) maintenance of a closed urinary drainage system. Mixed evidence suggests that use of a preconnected system reduces inadvertent interruption of a closed urinary drainage system and may prevent CAUTI. Limited evidence suggests that routine catheter changes every 4 to 6 weeks reduce CAUTI incidence in patients managed by long-term catheterization. Existed evidence suggests that the following interventions are not effective for reducing CAUTI incidence: (1) use of sterile technique for catheter insertion, (2) use of antiseptic solutions or ointments during routine meatal care, (3) use of a 2-chambered urinary drainage bag, (4) use of antiseptic filters incorporated into a urinary drainage bag, (5) bladder or catheter irrigation, (6) frequent changes of the urinary drainage bag, and (7) placement of an antiseptic solution in the urinary drainage bag. IMPLICATIONS FOR PRACTICE Evidence from parts 1 and 2 of this Evidence-Based Report Card provides a sound basis for designing an evidence-based program to prevent CAUTI. Essential elements of a CAUTI prevention program include staff education, ongoing monitoring of CAUTI incidence, monitoring catheter insertion and ensuring prompt removal, and careful attention to techniques for catheterization and catheter care.

Optimal Management of Incontinence-Associated Dermatitis in the Elderly

Incontinence-associated dermatitis (IAD), sometimes referred to as perineal dermatitis, is an inflammation of the skin associated with exposure to urine or stool. Elderly adults, and especially those in long-term care facilities, are at risk for urinary or fecal incontinence and IAD. Traditionally, IAD has received little attention as a distinct disorder, and it is sometimes confused with stage I or II pressure ulcers. However, a modest but growing body of research is beginning to provide insights into the epidemiology, etiology, and pathophysiology of IAD. In addition, recent changes in reimbursement policies from the US Center for Medicare and Medicaid Services regarding pressure ulcer prevention has focused attention on the differential diagnosis of IAD versus pressure ulcer, and its influence on pressure ulcer risk. Color, location, depth, and the presence or absence of necrotic tissue are visual indicators used to differentiate IAD from pressure-related skin damage. Prevention is based on avoiding or minimizing exposure to stool or urine combined with a structured skin-care program based on principles of gentle cleansing, moisturization, preferably with an emollient, and application of a skin protectant. Treatment of IAD focuses on three main goals: (i) removal of irritants from the affected skin; (ii) eradication of cutaneous infections such as candidiasis; and (iii) containment or diversion of incontinent urine or stool.

Does regular repositioning prevent pressure ulcers

BACKGROUND Prolonged exposure to pressure is the primary etiologic factor of a pressure ulcer (PU) and effective preventive interventions must avoid or minimize this exposure. Therefore, frequent repositioning of the patient has long been recommended as a means of preventing PU. OBJECTIVES To review the evidence on the efficacy of repositioning as a PU prevention intervention. SEARCH STRATEGY A systematic review of electronic databases MEDLINE and CINAHL, from January 1960 to July 2008, was undertaken. Studies were limited to prospective randomized clinical trials or quasi-experimental studies that compared repositioning to any other preventive interventions or any study that compared various techniques of repositioning such as turning frequency. Only those studies that measured the primary outcome of interest, PU incidence, were included in our review. RESULTS Limited evidence suggests that repositioning every 4 hours, when combined with an appropriate pressure redistribution surface, is just as effective for the prevention of facility- acquired PUs as a more frequent (every 2 hour) regimen. There is insufficient evidence to determine whether a 30° lateral position is superior to a 90° lateral position or a semi-Fowlers position. IMPLICATIONS FOR PRACTICE The current regulatory and legal environment has focused increased attention on PU prevention. Pressure redistribution methods and the frequency of application are among the first factors scrutinized when a PU develops. Our clinical experience validates that regular movement of the immobilized patient is important, but evidence defining the optimal frequency of repositioning or optimal positioning is lacking.

MASD part 2: Incontinence-associated dermatitis and intertriginous dermatitis: A consensus

A consensus panel was convened to review current knowledge of moisture-associated skin damage (MASD) and to provide recommendations for prevention and management. This article provides a summary of the discussion and the recommendations in regards to 2 types of MASD: incontinence-associated dermatitis (IAD) and intertriginous dermatitis (ITD). A focused history and physical assessment are essential for diagnosing IAD or ITD and distinguishing these forms of skin damage from other types of skin damage. Panel members recommend cleansing, moisturizing, and applying a skin protectant to skin affected by IAD and to the perineal skin of persons with urinary or fecal incontinence deemed at risk for IAD. Prevention and treatment of ITD includes measures to ensure that skin folds are dry and free from friction; however, panel members do not recommend use of bed linens, paper towels, or dressings for separating skin folds. Individuals with ITD are at risk for fungal and bacterial infections and these infections should be treated appropriately; for example, candidal infections should be treated with antifungal therapies.

Incontinence-associated Dermatitis: Consensus Statements, Evidence-based Guidelines for Prevention and Treatment, and Current Challenges

In 2010, an international consensus conference was held to review current evidence regarding the pathology, prevention, and management of incontinence-associated dermatitis (IAD). The results of this literature review were published in a previous issue of this Journal. This article summarizes key consensus statements agreed upon by the panelists, evidence-based guidelines for prevention and management of IAD, and a discussion of the major challenges currently faced by clinicians caring for these patients. The panelists concur that IAD is clinically and pathologically distinct from pressure ulcers and intertriginous dermatitis, and that a consistently applied, structured, or defined skin care program is effective for prevention and management of IAD. They also agreed that differential assessment of IAD versus pressure ulceration versus intertriginous dermatitis remains a major challenge. Panel members also concur that evidence is lacking concerning which products and protocols provide the best outcomes for IAD prevention and treatment in individual patients. Issues related to differential assessment, product labeling and utilization, staff education, and cost of care are the primary focus of this article.