Continuing Education Activity

2-Octyl cyanoacrylate is one of the most commonly used commercially-available wound adhesives. Current indications include any easily approximated surgical incision wound or properly cleaned lacerations from trauma in areas that are dry and have minimal friction. Additionally, 2-octyl cyanoacrylate is approved for use in combination with subcuticular sutures for deeper or higher tension wounds, though its use in higher tension areas should be limited to immobilized areas. This activity reviews the indications, contraindications, administration, and adverse effects of 2-octyl cyanoacrylate for wound closure, and highlights the role of the interprofessional team in the effective use of this substance.

Objectives:

• Identify the indications and contraindications for the usage of 2-octyl cyanoacrylate.
• Explain how to use 2-octyl cyanoacrylate for wound closure.
• Summarize the risk of wound infection associated with 2-octyl cyanoacrylate for wound closure with that of suture repair.
• Review how an interprofessional approach to care can improve the application of 2-octyl cyanoacrylate and render therapy more efficient and effective.

Indications

2-octyl cyanoacrylate is one of the most commonly used, commercially-available wound adhesives. It received initial approval in 1998 as an alternative to closure of skin wounds with 5-0 or smaller suture, staples, or adhesive strips by the Federal Drug Administration (FDA) in the United States. Current indications include all easily approximated wounds from surgical incisions or properly cleaned lacerations from trauma in areas that are dry and have minimal friction. It additionally was approved for use in combination with subcuticular sutures for deeper or higher tension wounds. Original FDA labeling included a warning against use in high tension areas without immobilization.  This recommendation has support from findings in 1999 by Saxena and Willital in a randomized, controlled trial that showed no difference in rates of wound dehiscence and scar formation between usual suture repair and 2-octyl cyanoacrylate closure on properly immobilized high-tension areas.[1] While listed as a contraindication in the initial FDA labeling, mucosal repair may be an additional area where 2-octyl cyanoacrylate could be a consideration. A case report has highlighted the repair of a 7-year old’s tongue laceration, and a blinded comparison between sutures and 2-octyl cyanoacrylate for cleft lip repair showed equivalent cosmesis when comparing wound dehiscence and scar formation.[2][3]

Mechanism of Action

Before application, 2-octyl cyanoacrylate molecules exist as monomers. Upon exposure to anions provided by skin moisture or wound exudate, the monomers of 2-octyl cyanoacrylate quickly polymerize in an exothermic reaction that binds to the most superficial epithelium.[4] 2-octyl cyanoacrylate forms a water-tight barrier atop the approximated wound edges creating a cyanoacrylate bridge to allow uninterrupted wound healing. 2-octyl cyanoacrylate has also been shown to have intrinsic anti-microbial activity against gram-positive (including methicillin-resistant Staphylococcus aureus) and non-pseudomonas gram-negative bacteria.[5][6] While incompletely understood, one hypothesized mechanism consists of 2-octyl cyanoacrylate destabilizing the cell capsule of gram-positive bacteria through electromagnetic interactions between the negative charge of 2-octyl cyanoacrylate and the positive charge of the bacterial capsule.

Administration

2-octyl cyanoacrylate comes in gel form, and more recent iterations of the product include a high viscosity form, a mini-applicator, and a combination mesh/glue system. The high viscosity form has similar indications as of the original adhesive but is marketed as a complement to deep dermal sutures and as reducing unintended migration of the gel during application due to the higher viscosity. The newest evolution of 2-octyl cyanoacrylate is a system of serial administration of self-adhering mesh to the wound, followed by the application of 2-octyl cyanoacrylate on top of the mesh. Proper local anesthesia, wound irrigation, and antiseptic technique are all necessary before closure with 2-octyl cyanoacrylate, with petroleum jelly easily accessible for adhesive removal if needed. The wound edges should be approximated and slightly everted manually. The maximal bonding strength occurs within 2.5 minutes, and three layers should be applied to the wound. If the repair is taking place on the face, care should be taken not to allow the gel to drip near or into the eyes, ears, or nose. Caution should be taken to avoid letting the gel to dry, thereby gluing the practitioner’s hand or glove to the patient.

Adverse Effects

The risk of wound infection with 2-octyl cyanoacrylate repair is statistically similar to the risk of wound infection with usual suture repair.[7][8][9] Common adverse reactions for 2-octyl cyanoacrylate and all wound closure techniques include edema, erythema, and pain around the wound site. Excessive warmth at the application site can occur if large droplets of the polymer are allowed to settle on the skin. Due to the strength and swift polymerization of 2-octyl cyanoacrylate, inadvertent adhesion of the body or tools may occur, in which case the practitioner should apply either acetone or petroleum jelly for improved separation.[10] Additionally, care should be taken to avoid the wound itself during application since the adhesive can cause foreign body reactions.

Contraindications

Explicit contraindications to using 2-octyl cyanoacrylate include gangrenous, actively infected, or decubitus injuries. Use on patients with a known hypersensitivity to cyanoacrylate or formaldehyde is also an absolute contraindication. Several conditions that were not studied for the initial FDA approval and are inappropriate for 2-octyl cyanoacrylate include wounds in high moisture or friction areas such as the axilla or other intertriginous areas, animal or human bites, stab or puncture wounds, vermillion surface wounds, and patients with burst stellate lacerations. 2-octyl cyanoacrylate is also not recommended in patients with peripheral vascular disease, clotting disorders, insulin-dependent diabetes, or a personal or family history of keloid formation or hypertrophy.

Monitoring

When using 2-octyl cyanoacrylate, there is no follow up needed as the epithelial layer and adhesive will slough off in 5 to 10 days spontaneously. After the application of 2-octyl cyanoacrylate, it is essential to maintain good wound hygiene, avoiding excess scrubbing or picking that may increase rates of dehiscence. While 2-octyl cyanoacrylate is a waterproof barrier, it is advisable to avoid prolonged exposure to water that may cause premature erosion of the adhesive. No topical antibiotics or other medications should be applied on top of the adhesive, as this may adversely affect the barrier integrity. As with all wounds, patients should be instructed to monitor closely for signs of wound dehiscence or infection such as erythema, edema, or purulent discharge.

Toxicity

The earliest precursors of 2-octyl cyanoacrylate, including ethyl-2 cyanoacrylate, had similar bonding capabilities but rapidly broke down into cyanoacetate and formaldehyde leading to local inflammatory reactions. 2-octyl cyanoacrylate has overcome this issue by utilizing longer chain products leading to a slower release that can undergo safer, natural excretion. Those who have a hypersensitivity to cyanoacrylate or formaldehyde can develop contact dermatitis if 2-octyl cyanoacrylate is applied.

Enhancing Healthcare Team Outcomes

The practical application of 2-octyl cyanoacrylate is most efficient with an interprofessional approach among the healthcare team, especially in pediatrics. Assistance in irrigating, application, and securing the patient, if needed, is best shared among nursing, physicians, and patient care technicians. This wound care process is where specialized wound-care nurses can play a significant role in ensuring proper care of the wound, as well as training other ancillary personnel, and providing patient education followup wound care.  They are also in a position to recognize any issues or concerns that may arise, and report these promptly to the physician managing the case. This type of interprofessional coordination between doctors, nurses, and other ancillary staff on the healthcare team is essential when using 2-octyl cyanoacrylate successfully, leading to improved patient care and outcomes. [Level V]