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Donna Fritz
Strange skin reaction

Patient has a Bard PowerPICC that was inserted into L basilic vein above antecubital fold. He is rec'g 5FU continuous for 5 days then off for 2 X about 5 1/2 wks.  At about 2 wks, he began developing a maculopapular rash that appeared to start under the dressing (Chloraprep & Sorbaview).  The RN assured me she let the Chloraprep dry, so it is not that rash.  Wound care was called and they recommended Caraklenz, so that was used for about 3 days.  (Is Caraklenz sterile?)   One could see the outline of the TSM dressing, although the rash had projected further out beyond the dressing.  We changed his dressing to eliminate adhesive, exc for Stat-lock, and chlorhexidine, using alcohol, gauze wrapped with Kerlix, then tape on the Kerlix to hold it in place.  We even eliminated the bandnet.  As the rash grew, the exit site developed drainage, so PICC was pulled.  (This is now 3 wks into his therapy.)  A new line was put in on the R basilic vein a week ago.  Pov-iodine was used for insertion and then wiped off with sterile saline.  We used alcohol, gauze, Kerlix and Coban.  Within 2 days, it was beginning to develop slight erythema (about 5 in X 4 in) without a linear border.  By the 4th day, we had a maculopapular rash that was spreading and on Friday, had a couple of welts above the PICC insertion site.

We have always gotten good blood return from his PICC, so I don't think it's any sort of local 5FU reaction from tissue infiltration (fibrin sheath).  Would a polyurethane allergy look like this?  Even though the PICC has been OUT of his L arm for 6 days, the edge of the rash on that arm is still red and continuing to expand slightly.  If it's a localized infection, it doesn't look like any I've ever seen.  I'm puzzled!  His old PICC site has discoloring (brown and fading) from his mid forearm up to his axilla, but primarily on the ventral side of his arm.  I'll send pics to Sarah to post here or in the gallery.

Any help would be greatly appreciated.

lynncrni
There have been studies to

There have been studies to identify if patients can develop allergies to polyurethane material, but those were all negative. I am not saying that it can not happen, however allergy to the catheter would be rare. I have seen patients be allergic to acrylic in the adhesive of dressing material, but you eliminated that with the 2nd PICC. The brown fading color indicates exposure to the 5FU as I have seen this brown color change follow the vein pathway from 5FU infusions. Did he have any other signs or symptoms of an allergy - tongue or throat swelling, itching anywhere, the rash on other parts of his body? Don't have any concrete answers, however it could be beneficial to have him seen by an allergist to discover or rule out all the possibilities that could affect his future care. 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

Donna Fritz
Lynn, Thanks for your

Lynn,

Thanks for your response.  I'm puzzled by the 5FU comment as he is getting it via a PICC line.  The vein discoloration I have only seen with PIV administration.  The brown is the maculopapular rash as it's resolving, so it is not in a distribution over veins.  Could you clarify?

lynncrni
I was thinking a possible

I was thinking a possible hole in the PICC causing some leakage into the vein of the extremity, basilic I assume. I have also only seen the brown discoloration with PIV infusion of 5FU. 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

Donna Fritz
Lynn, to answer your other

Lynn,

to answer your other questions, no other symptoms of allergy.  No rash other than extending locally on ventral arms.

Donna Fritz
OK, just looked at this guy

OK, just looked at this guy today.  On the resolving L arm, the erythema at the border of the brown fading color now has also turned brown, so whatever process was going on has stopped in the previous PICC arm.  On his R arm with current PICC, the erythema more uniform and slightly more intense today and is primarily in the area of the biatin + gauze dressing, although it extends out about 1 inch beyond in all directions.  The welts he had on Friday have subsided and are tan rather than red in color.  But he has a new blister on the edge of the gauze/biatin area.  The erythema is NOT on the back side of his arm (triceps area).  I'm hoping Sarah will post the pics soon.  Our plan at this point is to do a PICC exchange to a silicone cath.

lynncrni
Worth a try. Let us know what

Worth a try. Let us know what happens. 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

Donna Fritz
update/follow-up

Just saw our pt.  We exchanged his Bard PowerPICC for a Groshong PICC [silicone] on Tuesday.  Site is much improved today.  Much less itching, no new areas of active erythema, fading brown in color.  Same diameter.  We have changed nothing else.  The only preliminary conclusion I can come to is that it is a polyurethane allergy.  We will see him tomorrow again and I hope I only have good things to report.

Donna Fritz
pics are posted

Saw the pt yesterday, 7 days post PICC exchange for a silicone PICC.  Site continues to improve, so we've added back the biopatch, chlorhexidine and TSM in sequence over several days.  No further flare-ups.  The pics from 11/16 look more red in the picture than they do in person.  Sarah has posted the sequence in the gallery as "suspected polyurethane allergy."

lynncrni
As you know polyurethane is

As you know polyurethane is quite common in numerous healthcare products. Have you considered getting a referral for this patient to an allergist for skin testing to truly diagnosis his allergy? This could be critical to his future care. Also, I strongly encourage you to write this as a case report and get it published. I do not know of any other reports of this nature that are available to us. 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

Donna Fritz
update--TSM dsg

Pt was sent up by MD from clinic today.  He had the TSM dsg placed last Friday, with a change on Monday to evaluate his skin.  TSM was placed again as his skin was still improving.  Today, he has a small 5 mm blister along one edge of the dressing.  He has renewed erythema and itching where the TSM is touching his skin.  He has NO itching or erythema in a 1 inch radius around the PICC as he has a  biopatch on and it elevates the TSM off of his skin.  The sales rep for this TSM product was here on Friday and indicated that this dressing has polyurethane in it (Centurion product).  Seems to be further evidence for a polyurethane allergy.

Lynn, yes, I hope to write it up.  I also need to talk with the manufacturer about it.  Pt is facing surgery for his GI malignancy.  The hem/onc doc has put into his record/allergy list that he is allergic to PU vascular access catheters.  We will need to add TSMs to that.  I will talk with pt and docs about allergy testing.

Pics are posted in the gallery and I will have the ones from today added to that list.

lynncrni
Yes, I would require a

Yes, I would require a consult with an allergist sooner rather than later since this is a very atypical presentation for traditional allergy. The last thing you want to do is miss the true cause of what he is really allergic to. It could be PU but this requires confirmation. Good luck 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

lynncrni
I just had a chance to look

I just had a chance to look at your pictures and have many more questions. Were these signs and symptoms limited to this local area? Any systemic signs and symptoms such as itching, rash in other places or respiratory issues, throat swelling, etc? I am still having a hard time agreeing that this is an IgE-mediated allergy to polyurethane. Sure would like to know what an allergist MD says about this before I told this patient he was definitely allergic to polyurethane. 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

Donna Fritz
Certainly agree with you that

Certainly agree with you that an allergy visit would help us determine what allergy it is.  The rash was not generalized; however, with the first PICC in his left arm, the rash went from his L upper chest/axilla down to his forearm. 

Thinking about the sequence again, we elimated chlorhexidine and TSM, but he still had erythema and maculopapular rash.  Did not improve until PICC was exchanged for silicone.  Improved for about 3 days, then developed again after TSM was applied.  I will update you if he gets an allergist to evaluate him.

marie-josee
Strange skin reaction

After reading and looking at those pictures my first tought would be chlorexidine not totaly dried but since that's not the case I would try a test on a small area inside of the forearm, clean with chlorexidne, let dry a good 3 min then apply a 1"x 1" of dressing and watch.  Another suggestion might be to use a skin barrier film like Cavilon under the dressing.

Marie-Josee Theriault

Clinical ressource nurse

Hopital Dr George L-Dumont

Susan Rainey
Silicone PICC dressing

We've recently begun formal trials for a product that has thus far demonstrated amazing results for pts with skin issues.  One of our PICC RN's did some research regarding the adherent but non-adhesive properties of silicone dressings and contacted a silicone dressing manufacturing company called Molnlycke Healthcare.  The company is currently developing a PICC-specific dressing but we have developed a method for using products currently available to create a secure PICC dressing that allows visibility of the insertion site and catheter securement without any adhesive materials coming into contact with pt skin. Only pts with apparent skin sensitivity to the routinely utilized PICC dressing components are being included in our trial, and so far we have noted improvement and healing in 100% of our pts included in this product trial.  Has anyone else experienced similar results using silicone dressing products? 

Sue Rainey, RN

Diagnostic Imaging/PICC Team

Olympic Medical Center

Susan Rainey RN, Olympic Medical Center

Donna Fritz
patient follow-up note

This pt described in the original post had an APR for his rectal cancer so he now has a colostomy.  He did not need a CVC during his hospital stay.  He did have an epidural catheter, but there was no redness that developed from this (not sure what brand we use--whether PU or silicone) as stated by anesthesia when it was pulled.  HOWEVER, as I was scanning the progress notes, on about day 6, surgeon noted that he had blisters that had developed around his colostomy wafer.  My heart sank as I'm not sure his colostomy is low enough for regulation of his stools, so he's got to have a bag.

I went to see him with my camera.  Big, ugly blisters from the 12-3 o'clock position. . . a couple had already popped, but one was still in tact.  The bag and wafer had been changed about 48 hrs or so earlier.  Interestingly, where the adhesive wafer HAD BEEN that was visible to me, there was intact skin.  The blisters looked to be OUTSIDE of the area where the wafer had been.  I also noted that the wafer was smaller than the upper part of the bag itself and the the bag overlapped the wafer and was touching his skin.  Blisters were about the width of the overlapped bag.  ALSO of interest, where his foley stat lock had been on his anterior thigh, there were no skin irregularities where most of the adhesive had been, but along a one inch strip in the middle of it he had a red rash (below the snap for the foley).  This strip is made of a different, foam-like material rather than the very thin material used on the sides.  I hope to get pics posted in the next few days of his colostomy site.  He had no blisters on the inferior side where the bag hangs, but he was wearing underwear at the time which came up right to his wafer, so he may have been wearing pajama bottoms through much of his hospital stay.

My recommendation to him was that it was more likely to be PU than adhesive and that it might help to use t-shirt type material to cover his colostomy bag and use a drawstring or something to cinch it around the bag where it attaches to his body.  AND to see derm or an allergist to determine what he's dealing with.

 

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