Can We Really Use Super Glue Instead of Suture?
The Real Scoop on the Use of Tissue Adhesive for Wound Closure
For several years there has been increasing interest in the
midwife Super Glue" types of adhesives for
wound closure. Midwives who have done a little
research have found that the
cyanoacrylate glue (Super Glue) sold over-the-counter and medical cyanoacrylate glues are apparently identical in
composition and rumored to the be same as the
tissue adhesive used extensively during the
Vietnam War. Some midwives have even used over-the-counter
Super Glue (
Krazy Glue) successfully in lieu of suture to close the
perineum.
In readying in the 5th edition of Healing Passage: A Midwife's Guide to the
Care and
Repair of the Tissues Involved in
Birth, I felt it was important to address this issue. This article offers an expanded version of the information you will also find in the new edition.
History and
development:
In
1959, a variety of cyanoacrylate adhesives were developed, some types of which are now used for
surgical purposes in
Canada and
Europe. These glues polymerize on contact with basic substances such as
water or
blood to form a strong bond. The first glue developed was
methyl cyanoacrylate, which was studied extensively for its potential medical
applications and was
rejected due to its potential tissue
toxicity such as
inflammation or local
foreign body reactions. Methyl
alcohol has a short molecular chain which contributes to these complications.
Further
research revealed that by changing the type of alcohol in the
compound to one with a longer molecular chain, the tissue toxicity was much
reduced. All the medical grade tissue adhesives currently available for human use contain
butyl-esters, which are costlier to produce.
In
1964, the
Tennessee Eastman lab submitted its first application for new drug approval to the
FDA. The
military learned of this new glue and became extremely interested in its potential for use in field
hospitals.
MASH units in Vietnam were overloaded. Many
soldiers were dying from
chest and
abdominal wounds, despite the best efforts of medics. In 1966 a special surgical team was flown to
Vietnam, trained and equipped to use cyanoacrylate adhesive. A quick
spray over the wounds stopped
bleeding and
bought time until
conventional surgery could be performed. The possibilities were immediately seized by the medical communities of
Europe and the
Far East. Meanwhile the
FDA changed standards and kept requesting additional data until Eastman was reluctantly forced to withdraw his application. (Jueneman, 1981)
Histoacryl
Blue (n-butyl cyanoacrylate) has been used extensively in Europe since the
1970s for a variety of surgical applications including
middle ear surgery,
bone and
cartilage grafts,
repair of
cerebrospinal fluid leaks, and
skin closure. It has been available in
Canada through Davis & Geck Canada, with no adverse effects reported to date. Further, laboratory studies have been done which concluded that it has no
carcinogenic potential. Tissue toxicity has only been noted when the adhesive is introduced deep in highly vascular areas (the
perineum qualifies). While I always take claims of harmlessness with
a grain of salt, if used as directed, these adhesives appear to be basically
safe.
(Quinn & Kissick, 1994) Current use: Although not labeled as such, over-the-counter Super Glue products contain methyl alcohol, because it is inexpensive to produce. Cyanoacrylates cure by a chemical reaction called polymerization, which produces
heat. Methyl alcohol has a pronounced heating action when it contacts
tissue and may even produce
burns if the glue contacts a large enough area of tissue. Rapid curing may also lead to tissue
necrosis. Midwives have not noted such reactions because minimal amounts are being used for perineal repair. Nevertheless, with a greater toxic potential, over-the-counter products are inappropriate for use in wound closure. (Quinn & Kissick, 1994)
Medical grade products currently available contain either butyl, isobutyl or octyl esters. They are bacteriostatic and
painless to
apply when used as directed, produce minimal thermal reaction when applied to dry skin and break down harmlessly in tissue. They are essentially inert once dry. Butyl products are rigid when dry, but provide a strong bond. Available octyl products are more flexible when dry, but produce a weaker bond.
When used for repair, ideally the wound to be
closed is
fresh,
clean, fairly
shallow, with
straight edges that lie together on their own. The glue is applied to
bridge over the closed edges; it should not be used within the wound (on
raw surfaces), where it will
impair epithelization. The only currently FDA approved adhesives suitable for use as suture alternatives are veterinary products; n-butyl- cyanoacrylate tissue adhesives Vetbond (
3M) and Nexaband liquid and octyl-based Nexaband S/C (intended for topical skin closure when deep sutures have been placed). Histoacryl Blue (butyl based) (Davis & Geck) and Tissu-Glu (isobutyl based) (Medi-West Pharmaceuticals) are sold in
Canada for human use. DMSO (dimethyl sulfoxide) or acetone serve as removers. (Helmstetter, 1995; Quinn & Kissick, 1994)
How to use tissue adhesive:
Although not specifically recommended for perineal repair, tissue adhesive has been successfully used by some midwives. However, Hisotcryl Blue was used in place of
interrupted or subcuticular stitches in a small study of the closure of the superficial layer in mediolaterial
clitorotomy (episiotomy). (Adoni & Anteby) In this study, the yoni (
vaginal) mucosa and subcutaneous layers were closed with conventional
suture techniques. It might be a good alternative to offer when women refuse conventional sutures. Tissue adhesive works best when the
wound is moderately shallow. Midwives report that extremely shallow wounds tend to pull apart as healing occurs and usually require no closure of any kind. The wound should also have no
pockets to collect
lochia and should not require other sutures. However, as the study mentioned above demonstrates, it can also be used instead of subcuticular sutures after placing basting
stitches.
Tissue
glue is only applied to outside
surfaces to bridge over
edges; do not apply it directly to raw surfaces. The wound edges should be straight and lie together naturally. Insert a
tampon, then clean and dry the skin thoroughly. Have your assistant stabilize the wound edges from top to bottom (be sure the edges are matched correctly). Insert your finger between the edges and pull it out to bring them forward slightly. This is to ensure that the wound edges are not rolled inward toward each other, but meet perfectly. It could also be accomplished with a tissue
forceps. Hold
gauze against the
area immediately below the
apex to catch and drips as you apply the glue. Apply tiny
dots of glue sparingly at
intervals where the wound edges meet. Or, apply a bead of tiny droplets to bridge the edges. (Thick applications do not enhance bonding and tend to crack and loosen prematurely.) Products dyed blue are easier to see. (If using Histoacryl Blue, attach a 27 g.
syringe needle to the ampoule hub to help control application.
After use, the needle should be discarded and replaced with a new needle that does not have glue within its lumen.) Be careful to apply the glue on where it is needed; glue removers should not the used in the
genital area. As long as no part of the tube tip or the attached needle contacts the tissue or bodily fluids, the tube can be reused.
Use a
hair dryer or
fan the area
dry, which takes about 30 seconds. Adhesive will
stiffen when dry. Women should observe the same precautions as those who have refused sutures entirely.
Bathing is not contraindicated but
prolonged soaking should be avoided. Expect the adhesive to flake off in 3 to 7 days.
Allergic reactions are very rare, but may include
inflammation and
swelling.
From: AFryeMidwf@aol.com (Anne Frye)
References
(Various midwives 1993-95)
Adoni, A., & Anteby, E., "The Use of Histoacryl for Episiotomy Repair," Br. J. of Ob Gyn, Vol. 98, May 1991, pp. 476-8. Heimstetter, G., personal communciation, Permabond Internat. Bridgewater, NJ, 1995.
Jueneman, F, "Stick it to um," Industrial Research & Dev. Aug. 1981, p. 19.
Quinn, J., & Kissack, J., "Tissue Adhesives for
Laceration Repair During Sporting Events," Clinical J. of Sports Med., Vol. 4 No. 4, 1994, p. 245.
Sources of tissue adhesives:
Animal Care Products, 3M Health Care, 3M Center Building 225 1N 07, St. Paul, MN 55144-1000, (612) 733-8477. 3M produces Vetbond Tissue Adhesive.
Veterinary Products Laboratory (800) 548- 2828 distributes Nexaband products which are manufactured by Tri-Point in Raleigh, NC (919) 790-1041. These products are restricted items sold and approved for veterinary use only.
Davis & Geck-
CANADA (905) 470-3647 distributes Histoacryl Blue, which is manufactured in
Germany by B. Braun.
Medi-West Pharmaceuticals markets Tissu-Glu.