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Research Critique

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Chlorhexidine gluconate and neonatal skin integrity: A research critique
Grand Canyon University
Introduction to Nursing Research
NRS-433V-0101
November 01, 2013

Chlorhexidine gluconate and neonatal skin integrity: A research critique
The goal of this research study was to “determine the effects of chlorhexidine gluconate (CHG) skin inflammation and stratum corneum barrier integrity at peripherally inserted central catheter (PICC) sites among patients in the neonatal intensive care setting” (Visscher et al., 2009, p. 802). The benefit of this study was decreased central line associated blood stream infections, the risks of the study were very limited data on the use of CHG on neonatal skin and possible skin irritation beyond dryness or erythema, but a burn. The researchers of this study did identify that the mean gestational age of the infants in this study was 32 1/7 weeks, + 4.7. There were very few infants < 29 weeks gestation, so the researchers were unable to include that age group in the study. Some risks that were not originally identified and became apparent throughout the study was the trauma or irritation caused to the skin with the repeated removal of the tegaderm and the repeated use of CHG. The Institutional Review Board approved this study, and the parents/guardians of the infants provided written informed consent. Although the actual subject did not have the option to participate or not, the parents/guardians of the infants had the choice to participate or not, and all chose to participate voluntarily.
The major variable in this research study are clearly defined. The independent variables in this study were the CHG + dressing, dressing alone, and the control area of skin. The dependent variable in this study was the skin condition, measured by erythema, dryness/scaling, and stratum corneum barrier integrity. Data was collected prior to line insertion, if possible, and then at weekly dressing changes for three weeks. The PICC site with the CHG + dressing was compared to the site with just a dressing and compared to the control site of the infants’ skin with nothing on it. Each site was evaluated for erythema and dryness using standardized scales and transepidermal water loss (TEWL) area was measured with a closed chamber device. As long as the infants were able to be evaluated at least twice, they remained in the study. The infants were recruited from January to October 2007.
The evaluators, six PICC-certified nurses and an investigator, could not be blind to the treatments, due to the clinical design of the study and the NICU setting. The researchers compared erythema, dryness and TEWL “using analysis of variance (ANOVA) and appropriate pairwise comparisons at insertion and at dressing changes at weeks 1, 2, and 3” (Visscher et al., 2009, p. 803). The study had a within-subject design, used paired t-tests of erythema before and 2 min after CHG application to determine the immediate response (P < 0.05), and linear mixed models repeated measures procedures (covariance-type diagonal, F-statistics, P < 0.05). The method of Bonferroni was used in this study.
The researchers of this study found that repeated use of CHG and Tegaderm does in fact result in greater skin compromise at the insertion site of the PICC line. The PICC site, CHG + dressing, and the site with dressing alone had increased erythema, dryness, and TEWL compared to the control site throughout all three weeks. The findings of this study are very realistic and NICU nurses should have complete confidence in the results of this study. There are some limitations to this study, which the authors disclose. On major limitation of this study is that the size of the group of premature infants < 29 weeks GA was only 14, resulting in limited data. The data was presented in three different graphs, depicting the difference in each category, erythema, dryness and TEWL for each week of the study and each site being assessed. The results of this study can be implemented in the NICU on an everyday basis. More neonates receive PICCs these days and are at risk for central line associated blood stream infections. Any study that produces data that shows a decrease in infection rates, or steps to help decrease the risk of infection, is valuable to NICU nurses and physicians. This study shows both the risk and the benefits of CHG and Tegaderm use with PICC lines. The authors of this study suggest that there be more infants of the GA of < 29 weeks for the next study, as these are the most vulnerable patients. The authors also noted that there was not a test site of just CHG on the skin and nothing else, not allowing the researchers to segregate the contribution of the antiseptic system. As noted by the authors, further research should be completed on this subject to provide more complete data.

References
Visscher, M., DeCastro, M. V., Combs, L., Perkins, L., Winer, J., Schwegman, N., ... Bondurant, P. (2009). Effect of chlorhexidine gluconate on the skin integrity at PICC line sites. Journal of Perinatology, 29(12), 802-807. http://dx.doi.org/10.1038/jp.2009.116

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