Efficacy of Dehydrated Human Amniotic Membrane Allograft for the Treatment of Severe Extravasation Injuries in Preterm Neonates

Vita Boyar, MD; Colleen Galiczewski, NNP

Disclosures

Wounds. 2018;30(8):224-228. 

In This Article

Abstract and Introduction

Abstract

Introduction: A peripheral intravenous (PIV) catheter is placed in 60% to 70% of neonatal intensive care unit (NICU) infants. Extravasation injuries occur in 18% to 33%, with 70% in neonates < 27 weeks of gestational age. Despite such frequent use of PIV therapy, evidence on best practice, injury prevention, management, and treatment of extravasations is lacking.

Objective: This case series of 4 neonatal patients describes the experience and efficacy of using a dehydrated human amniotic membrane allograft (dHAMA) in the treatment of severe extravasation injuries.

Materials and Methods: The 4 preterm, critically ill neonates, all with stage 4 extravasations, were treated with 1 to 2 applications of the dHAMA to facilitate the repair process. Prior to treatments, standard of care included either enzymatic (collagenase ointment) or autolytic debridement (active Leptospermum honey) followed by mechanical debridement prior to allograft placement.

Results: The 4 full-thickness wounds exhibited recalcitrant healing. The dHAMA invigorated the wounds after standard management failed to induce repair. Application was easy and follow-up care was minimal. All wounds healed without contractures and with minimal soft scars and normal pigmentation at the 1- to 2-month follow-up visits.

Conclusions: The dHAMA proved to be an effective, safe, and easy-to-apply treatment in this case series, leading to regeneration and healing of deep neonatal wounds associated with extravasations.

Introduction

Every year 1 in 10 babies is born prematurely.[1] Advances in care and technology have allowed previously nonviable neonates to continue their journey, despite extreme prematurity and impairments of various organs. The most common procedure used in the neonatal intensive care unit (NICU) is peripheral intravenous (PIV) catheter placement.[2] Intravenous (IV) route of medication delivery revolutionized medicine but not without complications; the most common complication is the delivery of infusate into the subcutaneous tissues instead of the vein.[2] Incidences of neonatal infiltrations vary. A PIV is placed in 60% to 70% of infants admitted to the NICU.[2] Extravasation injuries occur in 18% to 33% of PIVs, with 70% in extremely preterm babies of < 27 weeks gestational age.[3] Despite such a frequent use of PIV therapy, evidence on best practice, injury prevention, management, and treatment of extravasations is less than optimal. The lack of adequate visual description of the damage caused by internal mechanical and chemical forces necessitates extrapolation of the treatment area based on the original IV placement site and physical exam. Treatment options are limited; many are based on adult or pediatric studies.[3]

In the authors' experience, full-thickness injuries occur in 10% to 15% of severe neonatal extravasations. Neonates have strong regenerative capabilities, but many factors can contribute to a slow healing trajectory: immaturity, critical illness, inability to mount a strong cellular response, suppression of immune system, and often lack of knowledge of neonate-compatible skin products.[4] The risks of a protracted open wound are numerous: secondary infection, pain, prolonged hospital stay, scar formation, functional limitation, parental angst, and potential for future litigation.[4] Wound healing typically occurs in an organized, step-wise trajectory, but certain phases may become prolonged and lead to recalcitrant wounds. The principles of wound healing should be applied to such wounds to optimize their healing potential.

The amniotic membrane has been used in medicine since the early 20th century.[5] Gynecology, ophthalmology, burn, surgery, and neurosurgery are a few adult disciplines that use this modality; pediatric burn centers are starting to utilize unique properties of amnion. AMNIOEXCEL (dHAMA; Integra LifeSciences, Plainsboro, NJ) is a minimally manipulated dehydrated human amniotic membrane allograft (dHAMA) with intact, malleable tissues that retains important components for dynamic reciprocity of healing. As described by Schultz et al,[6] dynamic reciprocity is an ongoing, bidirectional interaction among cells and their surrounding microenvironment. It is especially important during healing as certain chemicals and cells play pivotal roles in regulating tissue regenerative responses.[6]

Amniotic membrane provides an anchor for a developing fetus throughout pregnancy; its structural integrity and metabolic plasticity allow change, growth, and remodeling under the governing of paracrine factors.[5] In the same way it structurally supports a developing fetus, dHAMA offers a scaffold for wound healing elements, providing anti-inflammatory effects, promotion of cellular differentiation and adhesion, infection suppression, neovascularization, pain suppression, epithelization without immunogenicity (paramount to the immature preterm immune system), and an antiscarring effect.

Application of new innovative biologics in the preterm population is in its infancy. There is limited data on neonatal wounds, treatments, and outcomes in general. The purpose of this study is to describe the authors' experience with and the efficacy of dHAMA in the treatment of severe extravasation injuries in the neonatal population.

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