Microdermal implants are growing trend — Will you know what to do?
Microdermal implants are growing trend — Will you know what to do?
Literature offers little help with positioning, moving issues
By Joy Daughtery Dickinson, Executive Editor
A patient shows up for outpatient surgery and informs you she has a microdermal implant. You're not sure exactly what that is or what that means in terms of pressure points, friction when moving, or other issues.
The time to educate yourself is now, sources say. There's just one problem.
"There is very little in the literature on how to care for patients with micro-dermal implants who present for operative or other invasive procedures," says Linda J. Wanzer, DNP, RN, CNOR, assistant professor, chair/director, Perioperative Clinical Nurse Specialist Program, Graduate School of Nursing, Uniformed Services University of the Health Sciences in Bethesda, MD. The issue isn't addressed in the recommended practices from the Association of periOperative Registered Nurses (AORN) either, says Wanzer, who has submitted a manuscript to AORN on "Practitioner and Institutional Readiness in Managing Patients with Piercing(s) in the Perioperative Setting."
Other names for the implants are "body modification" and "sporting jewelry." These implants are used to pierce the body permanently, according to http://www.dermalimplant.net. However, the appearance is skin decoration, the web site says. A microdermal implant typically consists of an anchor or footplate imbedded under the skin with a metal pin extension extending through the surface of the skin for the jewelry or appliance to be attached, Wanzer says.
There are three subgroups of implants, according to T. Forcht Dagi, MD, DMedSc, FAANS, FACS, serves as chair of the American College of Surgeon's Committee on Perioperative Care and a surgeon. He is a visiting professor at Harvard Medical School in Boston and professor at Queens University Belfast, Northern Ireland, UK.
The first type is subdermal, in which the anchor is implanted beneath the skin but doesn't go through the skin. Instead, a shape protrudes through the skin. The second type is a transdermal implant in which a piece of the anchor exits the skin and the patient screws in a decorative "topper." The third type is microdermal, or a single-point piercing, that penetrates the skin only once. They are smaller and have a small anchor below the skin and an interchangeable topper. "The transdermal tend to be larger, and the microdermal tend to be smaller," Dagi says.
Regardless of the type of implant, the problems are similar, which include pressure, skin breakdown, and infection, he says. Here are some suggestions:
• Show dignity and privacy.
"Assessment is a real key," says Bonnie G. Denholm, MS, BSN, RN, CNOR, perioperative nursing specialist at AORN. "Then communication is the other key."
Do as much preplanning as possible, Denholm advises. Identify all areas that are pierced or have subdermal implants, she says. Once the nurse finds out where they are, the locations should be communicated to all members of the team and included in the timeout at the beginning of the procedure, if possible, so it increases awareness.
Some patients aren't comfortable disclosing the implants, sources say. Confidentiality is a must, Denholm says. "There is a need to respect cultural beliefs or values," she says. Showing respect increases trust, "which makes it more likely they are going to tell you if they have an additional piercings you need to know about so you don't find a surprise once surgery starts," Denholm says.
• Pay special attention to positioning.
Pressure due to positioning is a primary issue with these implants, Wanzer says.
If you have a subdermal implant in the arm, shoulder, or bony surface, and the patient lies on that surface for surgery, then he or she can have breakdown of the skin from pressure, Dagi says. "The principal need is to identify and protect the skin from breakdown," he says.
Not all elements of the jewelry "system" can be removed without surgical intervention, Wanzer points out. "At a minimum, remove the `jewelry art/accessory' itself," she advises. Then the issue remains what can be done about the metal extension and the issue of pressure directly under the piercing footplate/anchor.
Rod Hicks, PhD, RN, FNP-BC, FAANP, FAAN, professor at Western University in Pomona, CA, says, "Staff would need to position the patient in a manner that prevents direct pressure on the surface that then radiates through the implant to the underlying tissue structures." Hicks is a co-author of Wanzer's AORN article.
Document any skin breakdown before and after the procedure, Denholm says. "Acknowledge you identified some additional pressure points and what you did about them," she says. "You can assess after the procedure to make sure the padding was effective."
Implants in the scalp can present particular challenges, Wanzer says. Use a gel headrest, as long as the metal part of the implant isn't resting on the pad itself, she says. "You may need to use the horseshoe headrest or potentially even the Mayfield headrest, depending on where the implant is in relation to the positioning needs for the procedure," Wanzer says.
Additional considerations are the length of the procedure and the side that the procedure will impact, Denholm says. For example, she says, determine if the implant will be in the way of the surgeon's approach. Also consider whether the procedure will last longer than two hours, Denholm says. "That's a guideline at which the procedure is considered a longer one," with more risk for injury related to pressure, she says.
• Take special care when moving patients.
The primary issue when moving is integumentary compromise due to trauma at the site during patient transfer procedures, Wanzer says. Issues can include tugging, shearing, or the implant getting caught in drapes, gown, cords, or other items, she says.
After removing the jewelry art/accessory, "place gauze over the metal extension, and tape it in position to avoid getting caught on equipment, drapes, or bedding material, etc.," Wanzer says.
Subdermal implants also could be at risk during moves, Denholm says. "With subdermal, they're probably more secure under the skin, but depending on how deep they are, there could be a risk to tear tissue if you don't use proper lifting techniques," she says.
In summary, preop assessment, communication, and documentation are all key pieces, Denholm says. "Identify all barriers for optimal outcomes so you can plan for them," she advises. (For concerns related to potential electric arcing, see story, above right. For information on corneal implants, see story, below.)
Resource
For more information and to see photographs of microdermal implant piercings, go to http://www.dermalimplant.net.
Could that implant cause electric arcing? If electrocautery is used during surgery on a patient with a microdermal implant, do you need to be concerned about potential electric arcing? Yes, if there is not proper grounding and you have a metal implant, sources tell Same-Day Surgery. "The key is to do an assessment ahead of time so you have time to plan," says Bonnie G. Denholm, MS, BSN, RN, CNOR, perioperative nursing specialist at AORN. "Notify the manufacturer of the electrocautery unit and dispersive electrodes so you can get advice on the pathway of electricity if the implant will be in the way." Check with the surgeon to determine whether bipolar energy is an option, Denholm says. "That takes away the risk of alternative site burn that may be related to a metal implant," she says. The risk for burns is minimized if using isolated generator technology, says Linda J. Wanzer, DNP, RN, CNOR, assistant professor, chair/director, Perioperative Clinical Nurse Specialist Program, Graduate School of Nursing, Uniformed Services University of the Health Sciences in Bethesda, MD. Minimize direct contact with the active electrode, Wanzer advises, and use "holster" devices for the electrode pencil. To avoid the concentration of radio frequency current leakage to one area, do not loop or wrap electrode cords around objects to secure on the drapes, Wanzer says. Use special precaution near or over the area of where the metal piercing is located, she adds. Remove pieces of the implant that can be removed, says T. Forcht Dagi, MD, DMedSc, FAANS, FACS, serves as chair of the American College of Surgeon's Committee on Perioperative Care and a surgeon. He is a visiting professor at Harvard Medical School in Boston and professor at Queens University Belfast, Northern Ireland, UK. Drape the body parts with the implants out of the surgical field, Dagi advises. If possible, nothing in the skin and nothing unprotected that pierces the skin should be in contact with something that could create a circuit, he says. "Create a barrier between the skin and any metallic surface that can close a circuit," Dagi says. Take precautions, even with subdermal implants, he says. "I know of no case in which this has happened, but I would still worry about the possibility of the burn if the subdermal implant is so close to the skin that you get a closed circuit and current from electrocautery might arc through the skin and create a burn," Dagi says. The answer is to pad, isolate, and take precautions to make sure there's not a circuit, he summarizes. |
Corneal implants carry special concerns A new form of implants, under the cornea, concern outpatient surgery staff who might be placing those patients in the prone position. Corneal implants involve metal pieces that are placed under the conjunctiva so that a decorate shape is seen just to the outside of the iris. The concern is that the prone position puts direct pressure on the eyes, says Linda J. Wanzer, CIV, USUHS, COL(ret), DNP, MSN, RN, CNOR, assistant professor, chair/director, Perioperative Clinical Nurse Specialist Program, Graduate School of Nursing, Uniformed Services University of the Health Sciences in Bethesda, MD. Consider taking these actions, Wanzer advises:
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A patient shows up for outpatient surgery and informs you she has a microdermal implant. You're not sure exactly what that is or what that means in terms of pressure points, friction when moving, or other issues.Subscribe Now for Access
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