The majority (75%) of medical device-related pressure injuries are facility-acquired¹ and more likely to occur 3 days faster than nonmedical facility-acquired, device-related pressure injuries.²

Continuous and excessive moisture is one of many factors that place a patient at risk for developing pressure injures.³ The devices involved in managing tracheostomies present challenging scenarios; sutures holding the tracheostomy device tight over the clavicle, postoperative swelling, drainage, and secretions all contribute to the development of pressure injuries under the faceplate.

Dressings used in exudate management in these wounds include fiber-based technologies such as hydrofibers, alginates, and more recently, hydroconductive fibers. Routine tracheostomy care in our facility consisted of using nonwoven drain gauze or hydrophilic foam dressings, requiring 2 to 6 dressing changes per day due to saturation. Even with frequent dressing changes, the skin beneath the tracheostomy often was observed to remain moist and red.

Hydroconductive dressings have the ability to remain intact (ie, not disintegrate) in the wound and under medical devices. In addition to exudates, these dressings can physically adsorb negative elements such as microbes, debris/necrotic tissue, biofilm matter, matrix metalloproteinases, and inflammatory cytokines, thus preventing damage to tissue around wounds such as tracheostomies.^4-8

Understanding the issue at hand, recommendations were made to the primary surgeons in our facility who create tracheostomies to change practice. A quality improvement project with a hydroconductive dressing (Drawtex, Urgo Medical) was conducted from November 11, 2019, through August 3, 2020, to determine whether pressure injuries that are caused and aggravated by excessive moisture can be mitigated. Hydroconductive dressings were placed intraoperatively when possible at the time of tracheostomy creation. All patients who had a tracheostomy on admission, as well as all patients who had one placed at our facility, were included; no exclusions for clinical reasons (eg, comorbidities)were imposed. Patients were observed over the duration of their entire hospital stay from the time of tracheostomy surgery. While trialing the hydroconductive dressing around the tracheostomy, patients were evaluated every 1 to 2 days to check dressing integrity and the condition of the patients’ skin. 

Through close monitoring, a protocol was developed to help nurses and respiratory therapists best manage the tracheostomy. Patients were provided their first dressing changes within the first 2 to 3 days postoperatively, then 1 to 2 times per week. During the trial, the wound care nurse placed the hydroconductive dressing within 1 to 2 days postoperatively on those patients that did not receive one in the operating room, as well as on patients who did not have one in place at the time of admission. 

Among the 15 patient participants (Table 1, Page 1 and Page 2; 12 men, 3 women ranging in age from 26 to 86 years), 2 developed a pressure injury; these 2 patients did not have the hydroconductive dressing placed at time of surgery for 1 of 3 reasons: 1) the surgeon who placed the tracheostomy did not usually perform tracheostomies and lacked knowledge of the new trial dressing, 2) an emergent tracheostomy was performed in the middle of the night, or 3) the tracheostomy was placed at an outside facility. 

The first patient to receive the hydroconductive dressing at time of tracheostomy had the dressing sutured in place. However, suturing the dressing to the patient made removal challenging. Subsequent dressing applications were done by placing 3 cuts through the dressing to accommodate sutures for easy removal. 

Only 2 patients (patients 3 and 7) required more frequent dressing changes than protocol due to copious secretions. Patient 3 had an emergent tracheostomy placed initially. A hydroconductive dressing was placed postoperatively and then the tracheostomy was found to be decannulated; therefore, the surgeon replaced it emergently and sutured the tracheostomy down tightly to secure it the second time. No dressing was placed under the tracheostomy due to lack of availability of the dressing when this emergent procedure was done. Within 2 days, the patient had developed a Stage 3 pressure injury. After placement of the hydroconductive dressing and continued management of the site, the pressure injury was almost completely resolved within 3 weeks; no further follow-up was possible because the patient had transferred to a skilled nursing facility (Figure 1).

Patient 7’s tracheostomy was performed at an outside facility, where Xeroform gauze (Covidien) was placed around the tracheostomy site. This patient arrived at our facility on postoperative day 6; the skin beneath the tracheostomy faceplate could not be assessed thoroughly due to tight suture placement. The gauze was carefully removed on the day of admission to our facility, and the hydroconductive dressing was placed around the tracheostomy faceplate to help manage moisture. One day later (post-op day 7), sutures were removed and a device-related Stage 2 pressure injury was noted. A fresh hydroconductive dressing was applied at that time.

The other 13 patients in our evaluation were observed to have dry and intact skin under the hydroconductive dressings, regardless of the extent of saturation; as such, the sequelae of device-related pressure injuries were avoided. Figure 2 shows an example of tracheostomy protocol in patients who did not have/develop a pressure injury. Of note: in patients 3 and 7, the new protocol facilitated positive outcomes: one pressure injury resolved and one was almost resolved prior to discharge.

Managing tracheostomies with a hydroconductive dressing at the time of tracheostomy surgery can be an effective method to keep the skin beneath and around a tracheostomy clean, dry, and intact. The hydroconductive dressing used in this evaluation was able to mitigate an unavoidable scenario that places a patient at risk for pressure injury development. The pressure from a medical device that must be sutured in place for immobilization in the setting of moisture from the secretions and drainage from the trachea/surgical site places a patient at risk for pressure injury development. Using a hydroconductive dressing was shown to be a viable way to not only manage new and existing tracheostomies, but also prevent the occurrence of associated pressure injuries. 

Pearls for Practice is made possible through the support of Urgo Medical, Fort Worth, TX (www.urgomedical.com). The opinions and statements of the clinicians providing Pearls for Practice are specific to the respective authors and not necessarily those of Urgo Medical, Wound Management & Prevention, or HMP Global. This article was not subject to the Wound Management & Prevention peer-review process.