PICC dressing will not adhere

Does your hospital carry mastisol? It works wonders for patients where stuff just doesn't stick to them. I work in a PICU and I've used it on central line dressings, foley stat looks, and ett tape!

No. I do not believe that is in our formulary. I will inquire. Thank you.

If the area is constantly moist from oozing/weeping skin then I believe the proper thing to do is to apply a gauze dressing which is to be changed qshift/24hrs per protocol/appearance.

There is no point in placing an occlusive dressing over weeping skin because once the dressing becomes wet it is no longer "pristine" and requires changing.

Many facilities policy is if the dressing can't stick r/t an ongoing skin issue like you have described, then it needs a gauze dressing over it that's changed every 24 hours. Can you get a securement device like a a stat lock on it? Or is it anchored using sutures or another device like a securacath? Just curious how the line itself is secured.

Where is the PICC line inserted at? You may be able to wrap kerlix around an upper arm site to secure the transparent dressing (or gauze) without using tape directly on the patients skin. You would still have to remove the kerlix per your hospitals policy at intervals to inspect the site though.

One of the IV nurses is going to come here and probably give the best advice. There are some amazing IV nurses who frequent this board.

Our policy is a gauze dressing can be left in place for up to 72 hours or until it becomes soiled. If a securement device can't be used then the hub should be sutured although I hate this because it means there's potential for skin break down underneath the catheter because it can't be repositioned.

Incidentally, we have discovered that the patients who actually blister are not allergic to the Tegaderm dressing. What's happening is the CHG antiseptic is not allowed to dry (takes a full 5 minutes) before applying the dressing and they are getting chemical burns.

One thing you can try is silver mesh dressings over the blistered areas and then a large Tegaderm if there's enough intact skin for it to stick.

Here is an example of an open blister.

Any suggestions or hints would be much appreciated!!

I have a patient with a reaction with blisters and oozing. This has happened before in the past. Today I used only alcohol swabs and an IV3000 dressing. I secured the edges with hydrocolloid. The dressing came loose almost immediately.

How would you secure a dressing when the surrounding area is damp from drainage?

If you have an open draining wound you should not be using a transparent semi-permeable dressing (TSM) like a Tegaderm or IV3000 dressing but using a gauze dressing and changing it q48hrs according to the Infusion Nurses Society Standards of Practice (2011) standard 46, E. A little known fact too is that paper based tapes tend to be one of the best performing tapes under moist conditions with soft clothe tsapes like Medipore coming in right behind them.

Does your hospital carry mastisol? It works wonders for patients where stuff just doesn't stick to them. I work in a PICU and I've used it on central line dressings, foley stat looks, and ett tape!

Tackifiers like Mastisol and TSM dressings are not a great choice with open, draining wounds where there has already been a medical adhesive related skin injury (MARSI).

We should be thinking gentle, absorption, breath-ability...not gluing plastic to a wound.

Our policy is a gauze dressing can be left in place for up to 72 hours or until it becomes soiled. If a securement device can't be used then the hub should be sutured although I hate this because it means there's potential for skin break down underneath the catheter because it can't be repositioned.

Incidentally, we have discovered that the patients who actually blister are not allergic to the Tegaderm dressing. What's happening is the CHG antiseptic is not allowed to dry (takes a full 5 minutes) before applying the dressing and they are getting chemical burns.

One thing you can try is silver mesh dressings over the blistered areas and then a large Tegaderm if there's enough intact skin for it to stick.

::SNIP::

There are dressings that are classified by the FDA as securement dressings” that can provide some securement as an alternative to using dedicated securement devices which may provide an alternative to sutures.

I am really happy that you point out that CHG scrubs can have an extended dry time. In fact, if the location is in a moist environment with hair then the prep may need up to 1 hour of dry time according to the IFU of a popular CHG scrub!

Chemical sensitivities can cause blisters but also the mechanical pulling of the dressing. One really has to assess the location and shapes of the blisters to have insight into the cause. If a nurse stretches a dressing on a patient you may see a pattern of blisters (or rash) along the border of the dressing. It is very common for patients with ports to have blisters on the superior aspect of the dressing border, this is due to the breasts and stomach pulling down the skin of the upper chest and the dressing exerting a pulling force on the superior aspect of the dressing.

Funny trivia fact, almost all medical adhesives from all the brands including the tapes, dressings, electrodes, securement devices etc use an acrylate adhesive. The same chemical. What the manufacturer does is slightly change the properties of the adhesive to be more aggressive or more gentle etc to tailor it to the specific product. Almost all of these adhesives, and I am talking 98%+ of EVERY medical adhesive, is made out of the same plant from the same company.

Makes me laugh when someone says they are allergic to this tape but not that tape etc. Its how it is used, not what it is made of.

Mastisol or benzoin are good options to help dressing adhere- the anesthesiologists that I work with use them routinely on swan and triple lumen dressings. If you don't find it in the formulary, check with the OR- my facility doesn't consider it a med and it's available in the supply room. I would just get an okay from someone before using it just to CYA.

The problem with tackifiers is that they are associated with a higher rate of MARSI including skin-tears and blisters like what the OP is dealing with.

Essentially gluing a piece of plastic to a wound is generally not a good idea.

Anesthesiologists are the WORST at dressings. All they want to do is the least amount of work for the maximum yield for the short period of time that they have the patient without regard to what happens after the 45 minutes they have them.

Ever seen how they connect to a central line or how they prepare their meds? CRBSI oh my!

Our protocol for "unhappy" skin under PICC dressings in the community:

1. Ensure your cleanser has had enough time to dry. Typically we're told to give 90 seconds per swab. If things aren't going well, extend this to a good five or six minutes. If that doesn't work...

2. Change the cleanser. Instead of using the CHG/alcohol swab stick, use the one that's 100% CHG. Or use iodine and then clean off with SNS. If that doesn't work and things get worse...

3. Use a different dressing. We usually use the Tegaderm IV dressings, but we also have a really expensive silicone-backed dressing (Mepitel IV AM, I believe) available that works well if we're sitting at this step. In some cases I might go from the Tegaderm to IV 3000 (depending on the situation) because IV 3000 is ever-so-slightly more breathable. Note that when moving away from the Tegaderm IV we have to add securement (usually we use steri-strips - we don't often get folks coming out with Securacaths yet, but that's becoming slightly more common...). If that doesn't work and things get worse...

4. All else fails, we move to a dry dressing (gauze) changed q24h. I've only gotten to this point once, out of probably dozens of home IV clients I've worked with. I usually cover with a sterile 4x4 (or several, whatever) and wrap securely with kling if I can be reasonably sure the client is with it and won't dislodge it, to avoid adding more adhesive to their already upset skin. If I'm not sure about that, I'll paper tape if I have to. Of course, use a dressing that is a level of absorbency appropriate for the drainage. If a 4x4 is getting soaked then obviously use something more absorbent. And if THAT'S the case, I definitely have consulted with a physician and/or my educator to figure out what the heck has this person's skin SO angry!