WCET thank Hollister Journal Sustaining Partner for Sponsorship of this Webinar on

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1 In Celebration of World Ostomy Day Welcome to the WCET Webinar on Peristomal Complications by Janice Colwell RN, MS, CWOCN, FAAN Denise Hibbert, RGN, MSc, BSc, STN, ONC, FSSCRS WCET Education Committee Chairperson Webinar Moderator Thank you to: WCET Education Committee Jen Wood, WCET Central Office Administrator WCET thank Hollister Journal Sustaining Partner for Sponsorship of this Webinar on Current State of the Art and Science of Peristomal Complications by Janice Colwell RN, MS, CWOCN, FAAN 1

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4 Current State of the Art and Science of Peristomal Complications Janice Colwell, RN,MS,CWOCN,FAAN Advanced Practice Nurse University of Chicago Medicine Definition of Terms Peristomal Skin Complications (PSCs) Skin inflammation, injury or damage that occurs within 3-4 inches of the skin surface surrounding the stoma or Skin inflammation in the area covered by the pouching system Pouching system Skin barrier Adhesive tape Skin barrier rings, paste, powder Skin barrier strips Other items used to secure the seal Ex: liquid skin barrier, adhesive sprays 8 4

5 Types of Peristomal Skin Moisture Associated Skin Damage 1 Inflammation and denudation of the skin adjacent to a stoma associated with exposure to effluent such as urine or stool Medical Adhesive Related Injury 2 Erythema and/or other manifestation of cutaneous abnormality (including, but not limited to, vesicle, bulla, erosion, or tear) persists 30 minutes or more after removal of the adhesive 1 Gray M, et al, 2013, JWOCN 2 McNichol L, et al, 2013, JWOCN Types of Peristomal Skin Complications Pressure 1 Medical device injury or from pressure such as clothing or activity Allergic Contact Dermatitis Inflammatory response to chemicals 2 Carcinoma Pressure ulcers Herpes Peristomal abscess Peristomal Pyoderma Fistula 1 Salvadalena,, 2016, WOCN Core Curriculum 2 Colwell & Beitz, 2007, JWOCN 5

6 Peristomal Complications Incidence/Prevalence Ranges reported: 29-63% 1-4 Many are unaware they have a problem % of visits to stoma clinic 8 Pain, high product usage, poor QOL and increase in cost 9-11 Risk Factors: 12 Obesity and emergency surgery factors body mass index are at risk for stoma retraction and necrosis Surgeon experience and specialization are implicating factors for stoma-related complications, particularly in the emergently created stomas Diabetes, smoking, increased age 1 Arumugan et al, 2003, Colorectal Dis, 2 Lindholm et al, 2013, JWOCN, 3 Persson et al, 2010, Colorectal Dis, 4 Salvadalena 2013 JWOCN, 5 Herlufsen,e t al, 2006, Br J Nurs, 6 Lyon et al, 2000, BJ Derm, 7 Nybaek 2009, Act Derm Ven, 8 Jemec et al 2008 Br J of Derm, 9 Meisner et al, 2012 Plos One, 10 Nichols et al 2011 Gas Nrsg, 11 Pittman et al, 2008 JWOCN, 12 Steinhagen, et al. Intestinal Stomas: Postoperative Stoma Care & Peristomal Skin Complications Clin Colon Rectal Surg 2017;30: Peristomal Skin Complications Peristomal Moisture Associated Skin Damage (PMASD) Irritant dermatitis Pseudoverrucous lesions Definition 1 Inflammation & erosion of skin adjacent & erosion of skin adjacent to the stoma Presentation: Skin loss reflective of exposure to stoma effluent Acute: partial thickness skin loss Chronic: hyperkeratosis 1 Colwell & Beitz, 2007, JWOCN 6

7 Peristomal Skin Complications: PMASD Treatment: Identify Etiology Inappropriate size of skin barrier (skin barrier opening does not match stoma size/shape) Inappropriate fit of the skin barrier (convex vs non convex) Assess and adjust stoma volume and consistency Prolonged wear time (allowing erosion of the skin barrier) PMASD Assessment Fecal Stomas Urostomy 7

8 PMASD Assessment: Hyperplastic/ Pseudoverrucous PMASD Assessment: Hyperplastic/ Pseudoverrucous 8

9 Peristomal Skin Complications: PMASD Treatment: Identify the Etiology Inappropriate size of skin barrier (skin barrier opening does not match stoma size/shape) Round stoma Peristomal Skin Complications: PMASD Treatment: Identify the Etiology Inappropriate size of skin barrier (skin barrier opening does not match stoma size/shape) Oval stoma 9

10 Peristomal Skin Complications: PMASD Treatment: Identify Etiology Convex vs. Flat Skin Barriers Flat Peristomal Skin Complications: PMASD Treatment: Identify Etiology Convex vs. Flat Skin Barriers Skin Folds, Retraction Convex Skin Folds Skin Folds 10

11 Peristomal Skin Complications: PMASD Treatment: Identify Etiology Assess and adjust stoma volume and consistency Considerations High liquid output may erode the skin barrier allowing stoma output onto the skin Average ileostomy output = 1200 ccs/24 hours Variable amount between ccs/24 hours Treatment options Nutrition intervention Medication Patient Intake and output measurement Weight Peristomal Skin Complications: PMASD Treatment: Identify the Etiology Prolonged wear time (allowing erosion of the skin barrier) 11

12 Medical Adhesive Related Skin Injury (MARSI) Definition: Erythema and/or other manifestation of cutaneous abnormality (including, but not limited to, vesicle, bulla, erosion, or tear) persists 30 minutes or more after removal of the adhesive Defined area of skin damage beneath adhesive Other terms: skin stripping, skin tears Medical Adhesive Related Skin Injury (MARSI) Treatment Address Etiology: Adhesive releaser Adhesive remover Gentle removal Topical Treatment Thin hydrocolloid Thin Hydrocolloid Push Pull Removal Adhesive remover 12

13 PMASD: Topical Treatment Topical Treatment Skin barrier powder 1 Liquid skin barrier Thin hydrocolloid sheet 1 Salavadalena, WOCN Core Curriculum, 2016 Peristomal Skin Complication History: 60 yr. old female Ulcerative colitis/ileostomy for 20 years Kidney failure: transplant Lung failure: transplant Non healing peristomal issues Differential Dx Extended wear time Poor skin barrier fit Moisture associated skin damage 13

14 Interventions Decreased wear time Increase fit around stoma Skin barrier rings/paste Extended wear barrier Peristomal Skin Complication Significant findings Pain in some areas Areas increasing in size All topical and therapies unsuccessful Considered: silver nitrate Topical: triamcinolone spray and crème Biopsy of area Adenocarcinoma Peristomal Skin Complication: Cancer Inflammatory bowel disease Using reusable equipment Presented with inability to maintain pouch seal Bladder cancer Ileal conduit Hard firm painful peristomal area CT: metastatic disease 14

15 Identify offending agent Substitute product Topical: anti inflammatory Triaminicolone spray Oral antihistamine PSC: Allergic Contact Dermatitis PSCs: Pressure Ulcers/Injuries Morbidly obese patient with bladder cancer End loop with support bridge High marking Tension on the rod Left in for one month Result: pressure ulcer from support bridge 15

16 PSCs: Pressure Ulcers/Injuries PSCs: Pressure Ulcers/Injuries Treatment: Address Etiology Fit of skin barrier Avoid convexity Consider light or soft if necessary No belt Topical Therapy Dressing choice Foam Thin hydrocolloid 16

17 Historical Perspective Evolution of Skin Barriers Karaya Hydrocolloids Standard wear barrier: sheet Pouching Systems: Skin Barrier Options Stoma opening Cut to fit Precut Moldable Precut Moldable 17

18 Pouching Systems: Skin Barrier Options Skin barrier shape Flat Convex Light Soft Deep Hoeflok, et al JWOCN 2013 Pouching Systems: Skin Barrier Options Outer footprint Oval Round Square 18

19 Pouching Systems: Skin Barrier Options Skin Barrier Material Hydrocolloid Regular wear Extended wear Combination Skin Barrier Material Infused Honey Ceramides Aloe vera The basic principle of ostomy care: a consistent seal that provides security and maintains the peristomal skin Tool Box 19

20 Etiology Portal hypertension Peristomal Complications: Varices Management Avoid pressure Careful removal Bleeding control 32 year old female Crohn s dx, status post proctocolectomy On no maintenance Crohn s Disease medications Present with warm painful area next to stoma Differential Diagnosis: Pyoderma Abscess Other? Peristomal Complication 20

21 Progressive pain, warmth Presentation with beige drainage Placed on antibiotics Ten days later developed stool from the area Peristomal Complication Final diagnosis: Crohn s flare with fistula Peristomal Complication Peristomal Fistula 21

22 Peristomal Abscess Peristomal Skin Complication 98 year old male Rectal cancer/apr Colostomy Caregiver noted blisters Son sent image 22

23 Peristomal Skin Complication: Herpes Treatment: Antiviral Burrow s Solution soaks Adhesive releaser Peristomal Skin Complications Snap Shot Cottam et al, =n 34% developed problems within 3 weeks after surgery Risk factors Stoma height BMI Emergent surgery 1 Colorectal Diseases, 9(9); 834 Carlsson et al, =n 23 (11%) developed peristomal complications 16-mild 5-severe 2-PPG Risk factors Stoma related Stenosis Opening at skin level 2 OWM, 62(10),

24 Peristomal Complications: What We Know Increase in the numbers of obese patients Many of the stoma patients have loop stomas Decrease in inpatient length of stay Lack of outpatient stoma patient follow up Limited resources outside of acute care Pain / discomfort Complexity in management of ostomy care Quality of life may be reduced 1 Increase in healthcare costs 2 PSCs Implications 1 Pittman J, et al. JWOCN, Meisner S et al PloSOne. 24

25 Peristomal Skin Goal should be maintaining peristomal skin integrity vs reactive (managing PSCs) How do we achieve: Education Product selection and adjustment Ongoing support 49 Thank you! To my patients who allow me to take images while they are encountering problems To my patients who allow me to help them To WCET for allowing me to spend some time with you all! My contact info: 25

26 your webinar questions to: W C E T WCET