I have a client in my home health that requires weekly dressing changes to her central line.
Initially the client had a couple of small red areas under the dressing that looked like she perhaps had scratched herself.
However as time has passed this reddened area has progressed and is now a full blown rash ..isolated only to the area under the dressing.
Initially we were using tegaderm and she went to her doctor who prescribed medipore dressings to see if that would improve the rash. It has worsened. Most recently we applied another tegaderm type dressing designed to be applied by "one hand" I do not recall the specific name on it. We are waiting now to see if the rash improves. However meantime I am TRYING to find something that is suitable for a sterile central dressing that is more breathable as I believe the heat and humidity may be contributing to the rash development under the dressings. She has never had a sensitivity to any tape in the past. We also omitted the skin prep adhesive on the most recent dressing change.
Thus far...despite the rash the site itself looks very good and the skin..although it has this rash is not at this point in time "open". I have instructed her to monitor the area for any signs of drainage or other infection. She is to see her MD on thursday of this week.
If any of you know of any dressing that might help her I would appreciate your input. Additionally is there any sort of skin cleanser out there with hydrocortisone or benadryl infused in that could be used to clean the site. Obviously this would have to be a "sterile" applicator.
chlorhexidine allergy is a possibility..however initially there was no rash under the area that was covered by the biopatch and certainly i was cleaning the entire site with both alcohol and chlorhexidine. it is only this past week that the skin that is under the biopatch has been affected.
Other than the rash, the insertion site looks great.
She is A & O, and probably COULD do the dressing herself, however she is elderly and very intimidated. Our thought on my last visit was for her to do the drsg and if she did ok then from here forth let her do it herself..however this rash is so ugly I am hesitant to not have it assessed weekly by a RN
Thanks for all your comments/suggestions..keep them coming:D
I had a very similar experience a couple months ago with a group of PICC clients. The rashes resolved when I switched to a different lot # of dressing kits.
I've seen patients allergic to the dressing, and I've also seen patients allergic with what the site was being cleansed with. I was place a piece of dressing on one area of her skin (away from the line), and swab what it's being cleansed with elsewhere. See which she reacts to. Keep changing that until you find something that works.
chlorhexidine allergy is a possibility..however initially there was no rash under the area that was covered by the biopatch and certainly i was cleaning the entire site with both alcohol and chlorhexidine. it is only this past week that the skin that is under the biopatch has been affected.
Other than the rash, the insertion site looks great.
She is A & O, and probably COULD do the dressing herself, however she is elderly and very intimidated. Our thought on my last visit was for her to do the drsg and if she did ok then from here forth let her do it herself..however this rash is so ugly I am hesitant to not have it assessed weekly by a RN
Thanks for all your comments/suggestions..keep them coming:D
I was going to suggest the possibility of a reaction to the chlorhexidine too. Even if she wasn't having a reaction to CHG before, she may of became sensitized to it and now has a reaction. Or it could be that the dressing is applied before the CHG has fully dried. I believe the manufacturer recommends allowing 30-60 seconds of drying. Proper drying is needed not only to prevent skin irritation, but it is also needed to fully clean the area. Its not just the solution that cleans, but its the friction when applying and the drying that does the most good.
Whatever the problem is, I hope it is fixed soon. I'm sure this rash doesn't feel good to your client. Maybe see if she can have a consult with a dermatologist?
We use Opsite IV 3000, it prevents the accumulation of moisture beneath the dressing and provides a dry environment which inhibits bacterial proliferation
From what you have described, TAC around 2 months old and the onset and nature of the rash I do not think it is a CHG allergy. The true allergic reactions to CHG I have witnessed tended to be fairly quick, either upon minutes of the very first application or within several days. The allergic reactions tended to present as more generalized raised redness vs a small rash turning into larger one. CHG can be very irritating to open wounds and does tend to present as a small rash which tends to grow.
I have seen several rashes like what you have described. Reddness that first appreared to be scratches that turned into fullblown rashes...
After investigation we found that in fact in our case they were scratches, the patients were scratching the dressing sites and although in most cases the transparent dressing remained intact the skin was still slightly damaged underneath. We found that the CHG and/or moisture was actually irritating the small wounds and turning them into rashes rather than an actual allergic reaction.
We connected the dots when we remembered similar rashes from shaving, which we only clip now and the fact the rashes first presented as redness in symmetrical lines...plus several of the patients were witnessed scratching.
Our solution was in three parts;
I.
a) We made sure that after the CHG cleansing, the area was thoroughly dried.
b) Skin barrier was applied and allowed to thoroughly dry.
II
a) A padding barrier in the form of gauze and Kerlex or netting was used to prevent direct scratching. Since it is only a barrier and not a dressing it could remain in place for the full 7 days.
III
a)The transparent dressing was substituted for a sterile gauze dressing for 1 week to allow the wounds to heal.
You are right on thinking that changing a gauze dressing q48hrs is going to get super expensive. If the solutions I and II do not work I would recommend having the line DC'd and replaced at another site. You do not want to spend a fortune on changing dressings nor do you want the rash to develop into cellulitus. Replacing a TAC is far cheaper than having a Nurse out there every other day doing dressing changes.
Yes I had thought of that, but not sure how her insurance company will feel about this as the medication and dressings will be lifelong.
and every 48 hours will get mighty costly
I wonder how the cost of q48h dsg changes would compare to the cost of specialized wound care if this pts' skin integrity, instead of being restored, worsens to the point of compromising the central line itself?
From what you have described, TAC around 2 months old and the onset and nature of the rash I do not think it is a CHG allergy. The true allergic reactions to CHG I have witnessed tended to be fairly quick, either upon minutes of the very first application or within several days. The allergic reactions tended to present as more generalized raised redness vs a small rash turning into larger one. CHG can be very irritating to open wounds and does tend to present as a small rash which tends to grow.
I have seen several rashes like what you have described. Reddness that first appreared to be scratches that turned into fullblown rashes...
After investigation we found that in fact in our case they were scratches, the patients were scratching the dressing sites and although in most cases the transparent dressing remained intact the skin was still slightly damaged underneath. We found that the CHG and/or moisture was actually irritating the small wounds and turning them into rashes rather than an actual allergic reaction.
We connected the dots when we remembered similar rashes from shaving, which we only clip now and the fact the rashes first presented as redness in symmetrical lines...plus several of the patients were witnessed scratching.
Our solution was in three parts;
I.
a) We made sure that after the CHG cleansing, the area was thoroughly dried.
b) Skin barrier was applied and allowed to thoroughly dry.
II
a) A padding barrier in the form of gauze and Kerlex or netting was used to prevent direct scratching. Since it is only a barrier and not a dressing it could remain in place for the full 7 days.
III
a)The transparent dressing was substituted for a sterile gauze dressing for 1 week to allow the wounds to heal.
You are right on thinking that changing a gauze dressing q48hrs is going to get super expensive. If the solutions I and II do not work I would recommend having the line DC'd and replaced at another site. You do not want to spend a fortune on changing dressings nor do you want the rash to develop into cellulitus. Replacing a TAC is far cheaper than having a Nurse out there every other day doing dressing changes.
These kinds of posts are VERY INFORMATIVE for an ADN student like me. I have learned a lot from reading these kinds of posts. I am finding that having access to a community of nurses with extensive and varied experience is contributing to my learning exponentially. I, for one, appreciate the time that all of you spend on here to increase knowledge and facilitate sharing of information.
I've seen a number of patients whose skin gets reddened and irritated under the CL dressings, mostly tegaderm. We've attributed it to moisture accumulation as well. Since my patients are in acute care, it's easier to to do the sterile gauze, change every 48 hour thing, and it does seem to help. Has anyone considered changing her to a mediport? That way it only needs to have the dressing while the port is accessed.
kids
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