固定經鼻式連續正壓呼吸器管路引起醫療黏性產品相關皮膚損傷之發生率及相關因素

Abstract

研究背景：醫療黏性產品相關之皮膚損傷（Medical adhesive-related skin injuries, MARSIs）是住院嬰幼兒常見也常被忽略的皮膚傷害，臨床照護上雖然已為了預防呼吸管路造成的壓力性損傷而使用人工皮保護皮膚，但仍發生紅斑、皮膚炎、過敏、浸潤及撕裂傷等皮膚傷害，上述皮膚傷害不止增加管路滑脫風險，亦會引發後續感染、延長住院天數及增加健康照護成本的支出；然而多數醫護人員對MARSIs不了解，且國內外文獻並無針對使用人工皮之皮膚損傷預防措施及皮膚照護指引，亦無人工皮用於固定經鼻式連續正壓呼吸器（nasal continuous positive airway pressure, nCPAP）管路之MARSIs發生率與相關危險因子調查研究。 研究目的：探討人工皮用於固定經鼻式連續正壓呼吸器管路造成MARSIs之發生率及相關危險因素。 研究方法：本研究使用前瞻性研究設計，於臺大兒童醫院嬰兒加護病房進行，研究對象為使用經鼻式連續正壓呼吸器之0-12個月嬰兒及收案單位之護理師，於2020年6月至2021年12月進行收案，於裝置nCPAP呼吸器前及每次更換人工皮時拍攝皮膚狀況之照片，並以新生兒皮膚狀況量表（Neonatal Skin Condition Score, NSCS）進行皮膚狀況評估；此外，以修正式德爾菲法（Modified Delphi method）發展「固定經鼻式連續正壓呼吸器管路之MARSIs知識量表」，調查護理人員對於MARSIs之知識與照護行為，研究資料以SPSS 28.0.0統計套裝軟體進行資料分析。 結果：本研究共納入52位新生兒及嬰兒，其中29位為男生（55.8%）、年齡以出生天數小於30天佔78.8%居多；疾病診斷以心臟疾病為主（63.7%）、呼吸或其他疾病為27人（32.7%）；平均住院天數為6.3天；呼吸器平均使用天數為6.3天。NSCS的評分項目中，皮膚乾燥的發生率為63.5%（33人）、紅斑的發生率為100%（52人）、損傷的發生率為100%（52人）；在NSCS的嚴重程度得分方面，各部位得分以5-6分居多，鼻部的平均分數最高（5.1 – 5.86分）、右臉頰次之（4.88 – 5.79分）、左臉頰最低（4.72 – 5.71分）；在嚴重度分析上，各部位輕中度皮膚損傷的發生率約為75 – 86.5%、重度皮膚損傷的發生率為13.5 – 25%，上述資料顯示nCPAP使用人工皮黏貼撕除後的MARSIs發生率為100%，且會發生重度皮膚損傷。分析MARSIs之相關因素顯示女生（p = .029）、nCPAP使用天數長（p < .001）、人工皮更換次數高（p < .001）的鼻部皮膚損傷風險越高；而年齡小（p = .010）及nCPAP使用天數長（p < .001）的臉頰皮膚損傷風險較高。 討論及結論：本研究發現嬰幼兒使用經鼻式連續正壓呼吸器管路時皆會發生MARSIs，且本研究中的發生率及嚴重程度較過去的研究為高，以年齡、人工皮更換次數及nCPAP使用天數為顯著的相關因子，未來應制定固定經鼻式連續正壓呼吸器管路照護指引，並定期辦理相關訓練課程，讓護理人員能獲取MARSIs相關知識，減少不必要的更換次數，進而降低病患醫療黏性產品使用所造成之皮膚損傷風險。

Background: Medical adhesive-related skin injuries (MARSIs) are common yet oftentimes neglected cutaneous injuries in hospitalized neonates and infants. Despite routine clinical uses of hydrocolloid dressings to prevent pressure injuries on the skin caused by ventilator tubing, skin injuries such as erythema, dermatitis, blisters, and skin tears still occur. These adhesive-related skin injuries not only increase the risk of device dislodgement, but also contribute to subsequent infection, prolonged hospitalization, and increase of healthcare cost and expenses. Many healthcare workers are not aware of the severity of MARSIs. No reference is available to guide the use of hydrocolloid dressings in preventing MARSIs and the wound care for MARSIs. No studies have been published on the use of hydrocolloid dressings in the securement of nasal continuous positive airway pressure (nCPAP) tubing as well as the associated incidence and risk factors of MARSIs. Purpose: This study investigates the incidence and risk factors of MARSIs caused by hydrocolloid dressings in the securement of nCPAP tubing. Method: The subjects of prospective study included infants aged from 0 to 12 months who used nCPAP and their nurses at the Infant Intensive Care Unit in National Taiwan University Children’s Hospital between June 2020 to December 2021. Photos of the subjects’ skin were taken prior to the placement of nCPAP and each time the hydrocolloid dressings were changed. The skin condition was evaluated using the Neonatal Skin Condition Score (NSCS). To evaluate the knowledge and care routine of the nursing staff, the nCPAP-related MARSIs Nursing Knowledge Scale was developed using the modified Delphi method. The study results were analyzed using IBM SPSS Statistics Version 28.0.0 software. Result: This study included 52 neonates and infants, 29 of whom were male (55.8%). The majority of the subjects were younger than 30 days old (78.8%). The most common diagnosis of the subjects were cardiac conditions (63.7%), and the second most common being respiratory or other conditions (32.7%). The average hospitalization length was 6.3 days, and the average ventilator usage was 6.3 days. In the scoring items of the NSCS, the respective incidences of “Dryness”, “Erythema” and “Breakdown/excoriation” were 63.5%, 100%, and 100%. Most regions received scoring of 5 to 6. The nasal region received the highest score (5.1-5.86), followed by the right cheek (4.88 – 5.79). The area receiving the lowest score was the left cheek (4.72 – 5.71). The overall incidence of mild to moderate skin injury is 75 – 86.5%, and that of severe skin injury is 13.5 – 25%. The results showed that after the usage and removal of hydrocolloid dressings with nCPAP, the incidence of MARSIs was 100%, and severe skin injury was possible. Analysis of factors associated with MARSIs showed that female(P=.029), using longer period of nCPAP (p < .001), and frequency replacements of hydrocolloid dressing (p< .001) had a higher risk of nasal skin injury. In addition, the younger (p= .010) and using nCPAP in a longer period (p<.001) were significantly associated with higher risk of skin injury on the cheeks. Discussion and Conclusion: This study demonstrated that MARSIs always occur with the use of nCPAP in neonates and infants, and the incidence in this study is higher than previously reported. Age, frequency of dressing change, and duration of nCPAP use were significantly associated with the occurrence of MARSIs. Guidelines for the nursing care of nCPAP securement should be devised in the future. Further efforts should be focusing on related training courses for the nursing staff to promote knowledge related to MARSIs, reduce unnecessary replacements, and prevent skin injury related to the use of medical adhesive products.