Tools
2-Octyl Cyanoacrylate
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 sutures, 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 dry areas 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 considered. 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
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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 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 to the facial region, 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 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, no follow-up is needed as the epithelial layer and adhesive will spontaneously slough off in 5 to 10 days. After applying 2-octyl cyanoacrylate, it is essential to maintain good wound hygiene, avoiding excess scrubbing or picking that may increase dehiscence rates. 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, applying, 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 on follow-up 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 clinicians (MDs, DOs, PAs, NPs), 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 5]
References
Saxena AK, Willital GH. Octylcyanoacrylate tissue adhesive in the repair of pediatric extremity lacerations. The American surgeon. 1999 May:65(5):470-2 [PubMed PMID: 10231221]
Kazzi MG, Silverberg M. Pediatric tongue laceration repair using 2-octyl cyanoacrylate (dermabond(®)). The Journal of emergency medicine. 2013 Dec:45(6):846-8. doi: 10.1016/j.jemermed.2013.05.004. Epub 2013 Jul 1 [PubMed PMID: 23827167]
Level 3 (low-level) evidenceKnott PD, Zins JE, Banbury J, Djohan R, Yetman RJ, Papay F. A comparison of dermabond tissue adhesive and sutures in the primary repair of the congenital cleft lip. Annals of plastic surgery. 2007 Feb:58(2):121-5 [PubMed PMID: 17245135]
Level 1 (high-level) evidenceMattick A. Use of tissue adhesives in the management of paediatric lacerations. Emergency medicine journal : EMJ. 2002 Sep:19(5):382-5 [PubMed PMID: 12204980]
Rushbrook JL, White G, Kidger L, Marsh P, Taggart TF. The antibacterial effect of 2-octyl cyanoacrylate (Dermabond®) skin adhesive. Journal of infection prevention. 2014 Nov:15(6):236-239. doi: 10.1177/1757177414551562. Epub 2014 Nov 30 [PubMed PMID: 28989390]
Bhende S, Rothenburger S, Spangler DJ, Dito M. In vitro assessment of microbial barrier properties of Dermabond topical skin adhesive. Surgical infections. 2002 Fall:3(3):251-7 [PubMed PMID: 12542926]
Quinn J, Wells G, Sutcliffe T, Jarmuske M, Maw J, Stiell I, Johns P. A randomized trial comparing octylcyanoacrylate tissue adhesive and sutures in the management of lacerations. JAMA. 1997 May 21:277(19):1527-30 [PubMed PMID: 9153366]
Level 1 (high-level) evidenceBruns TB, Robinson BS, Smith RJ, Kile DL, Davis TP, Sullivan KM, Quinn JV. A new tissue adhesive for laceration repair in children. The Journal of pediatrics. 1998 Jun:132(6):1067-70 [PubMed PMID: 9627610]
Level 1 (high-level) evidenceSinger AJ, Hollander JE, Valentine SM, Turque TW, McCuskey CF, Quinn JV. Prospective, randomized, controlled trial of tissue adhesive (2-octylcyanoacrylate) vs standard wound closure techniques for laceration repair. Stony Brook Octylcyanoacrylate Study Group. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 1998 Feb:5(2):94-9 [PubMed PMID: 9492126]
Level 1 (high-level) evidenceCoutts SJ, Sandhu R, Geh VS. Tissue glue and iatrogenic eyelid gluing in children. Pediatric emergency care. 2012 Aug:28(8):810-1. doi: 10.1097/PEC.0b013e31826288fa. Epub [PubMed PMID: 22863824]
Level 3 (low-level) evidence