IAD: standard of care

In the previous chapters, we presented a general overview of the choice of products available for preventing and treating IAD. Many caregivers are confused over the wide selection of barrier products available. This confusion is very understandable as the products vary considerably in what they contain and how well their properties are documented. To aid caregivers in following guidelines, it is essential to present them with easy-to-follow principles. Our personal experiences are mainly based on products from 3M. While we may be biased here, this company has spent considerable resources globally to educate caregivers on how to prevent and treat IAD. Obviously, there are economic incentives for doing this, but one can't deny that this company has been highly determined in the fight against IAD. Another argument is that 3M has done a lot to document the effectiveness of its products.

 

 The following recommendations are thus mainly based on products from 3M. These may not be available to you, but in that case, you will have to try and improvise with similar products. The principles will remain the same.  

Preventing IAD in patients with low- moderate risk

 

These are incontinent patients but have luckily not yet developed IAD. The skin is not red (purple) or damaged in any other way. It is not always straightforward to determine which risk category a patient is in. But if the patient does not have diarrhea and has not had IAD previously, then they are probably in a low- moderate risk group. However, if you are unsure which risk the patient is in, it is always safer to place them in a higher risk category than vice-versa. Nobody should be allowed to criticize you for mistakenly placing a patient in a higher-risk group! It will not harm the patient to receive a little extra protection and will not tap your resources significantly. 

Incontinent patients in a low- moderate risk group do not need Cavilon Advanced as a barrier product. We recommend Cavilon barrier wipes applied at least once daily and at each fecal incontinence episode. Cavilon barrier cream should be applied twice daily - you only need a thin layer of barrier cream at each application. Use gentle movements of your hand when applying the barrier cream - do not massage the cream into the skin. Some caregivers think that they improve the skin's blood flow if it is massaged- this is wrong! On the contrary - rubbing the skin can cause damage. 

woundsafrica iad algo low risk.JPG

Figure1  We recommend Cavilon barrier wipes and Cavilon barrier cream to prevent IAD in patients who are in a low- moderate risk group. 

Preventing IAD in patients at high risk  

 

Remember - we are still not talking about patients who already have IAD here - we are still talking about preventing IAD! Examples of patients at high risk for developing IAD  are those with diarrhea - especially frequent diarrhea and urine incontinence at the same time. Other factors which place a patient in the high-risk group are, for example, incontinent patients in an intensive care unit (ICU) receiving nutrition solutions via feeding tube as these solutions often lead to thin feces or diarrhea. Critically ill patients or those with dementia, immobilized patients, and those with IAD previously are also high-risk patients. This list is by no means complete - for example, a patient who is sweating a lot due to an infection may be at high risk for IAD even if they have infrequent incontinence episodes. Again- do not be afraid to place your patient in the high-risk group if you are unsure if there is a moderate or, in fact, high-risk situation. Always upgrade the risk if you are unsure! 

 

In cases with a high risk for developing IAD, we recommend Cavlion Advanced as this gives superior protection compared to other barrier products. Note that when using Cavilon Advanced, you should not use wipes that have barrier products added, as this will result in a sticky surface and may reduce the function of Cavilon Advanced. Furthermore, sheets and underwear may adhere to the skin if these products are applied simultaneously.  

 

In cases with a high risk of developing IAD, we recommend using wipes without barrier function at least once a day and at each fecal incontinence episode and applying Cavilon Advanced twice weekly. 3M  states that more frequent applications will not deliver higher protection. In our experience, we have seen that twice-weekly application is enough in most cases. In the most severe cases, however, with very frequent diarrhea episodes, we have sometimes applied the product every second day but do not have any documentation to say that this was necessary. Apply the Cavilon Advanced everywhere you expect moisture from incontinence to get to the skin - one Cavilon " lollipop" is enough to cover about an A4 paper-sized area. If you have a large patient, you may have to use several "lollipops" each time. her er altså bruk av engangsklut uten barrierefunksjon minst en gang daglig og etter hver inkontinens episode med avføring.  You only need to brush once over an area of skin- repeated application of the product at each session does not lead to better protection. Wait for about one minute before putting on diapers or placing the patient on a sheet to avoid the garments sticking to the skin.

woundsafrica iad algo high risk.JPG

Figure 2 We recommend using Cavilon wipes without barrier function  and Cavilon Advanced to prevent IAD in patients who are at high risk

Treating existing IAD

If you have a patient with existing IAD, you have to treat the IAD and protect intact skin from further damage. Note that the treatment protocol we recommend here is precisely the same as under prevention in high-risk patients! Use Cavilon wipes without barrier function at least once daily and at each fecal incontinence episode. Cavilon wipes can also be used on damaged skin/ulcerations to clean away soiling. The same applies to Cavilon Advance- this too should be applied to the damaged skin/ulcerations to protect from further damage. Cavilon Advanced is unique in that it also attaches to moist åpen wound surfaces - it almost functions like a thin, artificial skin layer and seals wound surfaces temporarily. It will often provide pain relief as it seals nerve endings exposed on the wound surface.  

woundsafrica iad algo treatment.JPG

Figure 3 We recommend using Cavilon wipes without barrier function and Cavilon Advanced for treating manifest IAD.  Note that this is the same protocol as for the prevention of IAD in high-risk patients.

Treating IAD with concomitant fungal infection 

 

Fungus like candida albicans thrives in moist and warm environments. Not surprisingly, we often see these types of fungal infections in patients with IAD. Sometimes it is easy to spot this; at other times, a fungal infection might easily be overseen. We often see fungal infections when the skin barrier is broken and the patient has a moist wound surface. If you see a whitish slime layer on the wound's surface, this may be indicative of fungal colonization. Other signs of fungal infection are skin inflammation ( which may appear reddish or purplish in color depending on the patient's skin color) and that these inflamed areas are continuously moist. A patient with a fungal infection will often complain about increasing pain levels.

You can take a microbiological swab and test for fungus, but that is not obligatory. In most cases, you will get a positive fungus culture anyway - even in IAD cases where there is no actual fungal infection because fungus will most likely be present regardless. Therefore: the suspicion of a fungal infection alone is enough to justify the implementation of an antifungal treatment regime.  

Many caregivers treat fungus with antifungal creams like Clotrimazole ( for example, Canesten). This is something we previously used ourselves. In our experience, this is not an optimal treatment. Firstly, these creams usually take many days before you see an effect- often at least 5-7 days. Secondly, not all fungal types respond to this particular antifungal cream. Thirdly, applying a barrier product like Cavilon Advanced is impracticable when we have covered the affected area with cream. If we apply the Cavilon Advanced first, the antifungal cream will not properly reach the fungus. It is a Catch-22 situation. 

Therefore, we recommend using the gentian violet 0,1% solution as your antifungal treatment. In the previous chapter, we wrote more about the properties of gentian violet and will not repeat this here. It is an FDA- approved product for short-term treatment of fungal infections of the skin. Note that some gentian violet solutions contain alcohol- do not use these as they will be painful upon application!

Clean the skin with wipes without barrier function first and let it dry for å minute or pat the area dry. Apply the gentian violet generously on all moist areas with damaged skin. A cotton swab is ideal for application. Do not touch the bottle's opening with a contaminated swab - otherwise, you will contaminate the whole bottle of gentian violet! Use gloves when working with gentian violet; otherwise, your fingers will be purplish for days. Note that the dye will easily transfer to all sorts of clothing materials and ruin them forever - it doesn't wash out! Make sure you don't spill gentian violet on the floor! We know several people who have ruined their bathroom by accidentally overturning a bottle of gentian violet! If you have accidentally spilled gentian violet, it can sometimes be removed by using disinfection alcohol. Not all alcohols work equally well here- you may have to try different alcohols. This was a digression about cleaning up an accidental spill of gentian violet, but it may come in useful. 

Apply the gentian violet a few times at each session until you see that the top layers of the skin/ulcer are well saturated with blue/purple dye. Let this dry for about a minute, then apply the Cavilon Advanced. Once you have applied Cavilon Advanced, it is impossible to apply more gentian violet as the surface is sealed. First after about three days, when the Cavilon Advanced layer is gone, it will be possible to apply more gentian violet. If there is a severe case of fungal infection, we usually only use wipes without barrier function and gentian violet for about three days before we start using cavilon Advanced to eliminate as much fungus as possible first. Sometimes the gentian violet needs to be applied twice daily - this is the case in wound surfaces with heavy exudate where the gentian violet is "washed away" in the course of the day. After about ten days of using wipes, gentian violet, and Cavilon Advanced, the fungal infection is usually eradicated or at least under control. We rarely need to use gentian violet for more than two weeks. 

We would also like to mention another useful product with fungal infections: Sorbact. This mesh-like product traps microorganisms within the mesh, and many clinics have adopted this product to treat fungal infections with IAD. The protocol is Cavilon wipes without barrier function, Cavilon Advanced, and placing the Sorbact mesh on all compromised skin. It may be challenging to keep it in place, but it works very well when placed between the buttock areas, for example. It also works very well with moisture-associated infections under the breasts and other skin folds. We have a separate chapter about this- " wounds in skin folds."

 

woundsafrica iad algorithm.JPG

Figure 4 We recommend using Cavilon wipes without barrier function, gentian violet 1% as an antifungal agent, and Cavilon Advanced for treating IAD with suspected fungal infection. It may be useful to apply gentian violet for 2-3 days to eradicate as much fungus as possible before applying the first layer of Cavilon Advanced. This is our own experience, and we have no other documentation for this practice other than our own results.