Safety of prolonging peripheral cannula and i.v. tubing use from 72 hours to 96 hours

Microorganism colonization of peripheral venous catheters in a small animal clinical setting

OBJECTIVE

To compare the incidence of microorganism colonization of peripheral venous catheters (PVCs) placed in the Emergency Department (ED) to those placed in a routine preoperative setting. The relationship between catheter tip colonization and patient urgency (as assessed by triage priority) was also evaluated.

DESIGN

Prospective, observational study from January 2021 to October 2021.

SETTING

Emergency room and clinical areas of a large, urban, tertiary referral center.

ANIMALS

Three hundred dogs and 94 cats with a PVC in place for a minimum of 24 hours were enrolled in the study.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Two hundred and eighty-eight PVCs were placed in the ED and 106 were placed preoperatively. The overall colonization rate was 10.4% (41/394). Sixteen bacterial and 1 fungal genera were cultured. Eight of these bacterial genera (25/51 [49%] bacterial isolates) were resistant to at least 1 antimicrobial class. Twenty-nine of 288 (10.1%) catheters positive for colonization were placed in the ED, whereas 12 of 106 (11.3%) were placed preoperatively. There was no association between microorganism growth on catheters and clinical area of catheter placement. There was also no association between ED patient urgency and positive catheter tip culture. No significant risk factors were identified predisposing to colonization of PVCs.

CONCLUSIONS

The overall incidence of microorganism colonization of PVCs in this study population was equivalent to, or lower than, previously reported in veterinary literature. There was no statistical difference between the catheters placed in the ED and those placed for routine surgical procedures. Patient urgency did not affect the incidence of positivity of peripheral catheter tip cultures.

Determination of pain experienced by children during intravenous bolus treatments and its causes

OBJECTIVE

The present study aimed to determine the pain experienced by children during intravenous bolus treatment and to identify what causes it.

METHOD

In the first stage of the study, the first 40 observations were performed by two researchers. The study was continued by a single observer after the Kappa test was performed. In this study, 101 drug treatments were administered by intravenous bolus in patients aged between 1 month and 6 years. The pain experienced during treatment was assessed using pain scales according to the age group the patient was in.

RESULTS

Pain was observed in 63.4% (n = 64) of the treatments. There was a significant relationship between the type of medication administered and pain experienced during drug administration. There was also a significant correlation between the age of the children and their pain experiences. Given the location of the catheter, there was no significant difference among the children who experienced pain during intravenous treatment.

CONCLUSION

Intravenous drug therapy may cause pain in children. To minimize such pain, it is recommended to determine the drugs that cause pain during intravenous treatment and to develop application protocols to minimize pain caused by these drugs.

Prevalence of and risk factors for intravenous catheter infection in hospitalized cattle, goats, and sheep

BACKGROUND

Intravenous catheter (IVC) use in hospitalized ruminants is a common procedure. Limited information is available describing complications associated with IVCs.

HYPOTHESES

Prevalence of IVC infections in hospitalized ruminants is >50%. Intravenous catheters maintained for >5 days are more likely to be infected than those maintained for <5 days. Intravenous catheters placed non-aseptically have a higher risk for infection than those placed aseptically.

ANIMALS

Thirty-four cattle, 39 goats, and 33 sheep were hospitalized in a university teaching hospital.

METHODS

Prospective observational study. The IVCs from cattle, goats, and sheep admitted for medical and surgical procedures were randomly selected and submitted for bacteriological culture and susceptibility testing.

RESULTS

Prevalence values (95% confidence interval) of infected catheters were 61.8 (45.5, 78.1), 51.3 (35.3, 66.7), and 42.4% (25.2, 58.8) in cattle, goats, and sheep, respectively. Coagulase-negative Staphylococcus spp was the most frequently isolated bacterium. Catheter type/placement technique was a significant (P = .03) predictor of IVC infection in goats but not in cattle (P = .65) and sheep (P = .47). Antibiotic use and reason for catheter placement were not significant predictors of IVC infection in all species. Catheters maintained for >4 days had a higher likelihood of being infected than those maintained for <4 days in all species.

CONCLUSIONS AND CLINICAL IMPORTANCE

Clinicians should consider replacing catheters maintained for >4 days to reduce IVC infection.

Assessing nursing students' knowledge of evidence-based guidelines on the management of peripheral venous catheters: A multicentre cross-sectional study

BACKGROUND

Inserting Peripheral Venous Catheters (PVCs) is one of the most routinely performed invasive procedures in nursing care and, if not well managed, it could expose patients to bloodstream-related infections. Knowledge of guidelines for the management of PVCs is fundamental to arise nurses and nursing students (NSs)' awareness on the importance of recommendations' adherence for clinical practice improvement.

OBJECTIVE

To determine NSs' theoretical knowledge of evidence-based guidelines for management of PVCs and investigate potential predictive factors associated to recommendations' adherence.

DESIGN

Cross-sectional.

SETTINGS

The study was carried out (March-September 2015) in seven Universities of three Regions of Italy (Marche, Abruzzo, Emilia Romagna).

PARTICIPANTS

A convenience sample of NSs (n = 1056) was involved.

METHODS

We collected data using a 10-items validated questionnaire assessing: knowledge of NSs' PVC guidelines and socio-demographic characteristics of the sample.

RESULTS

Most participants were female (74.8%), mean age: 22.4 years (DS = 3.9); attending the first, second and third year of Bachelor in Nursing (34.8%; 32.9%; 32.3%, respectively); with at least one year of training experience (32.1%). Most of incorrect answers given by NSs concerned the right way to wash hands before CVPs insertion (33.5%); the replacement of administration set <24 h when neither lipid emulsions nor blood products have been infused (79.7%); the choice of dressing to cover insertion site (59.3%); the use of steel needles to administer drugs (60.9%); the use of antibiotic ointment (68.7%); the correct concentration of chlorhexidine before PVCs' insertion (70.7%). In multivariate analysis, a higher level of education and an increased number of years of training experience and wards attended, were associated with better test scores. "Infusionset removal after 24 h when lipids or blood products are administered" (75.4%).

CONCLUSIONS

NSs' overall level of knowledge to some recommendations is inadequate. Nurse educators should emphasize on the importance of Evidence-based guidelines' knowledge in order to promote the translation of theory into practice of NSs.

Primary Intravenous Set Consumption Across 3 Branded Infusion Pumps

Supplemental Digital Content is Available in the Text.

This retrospective study of 6426 hip replacement, coronary artery bypass graft, and colectomy surgeries across 23 US hospitals found that intravenous (IV) set designs that can be interchanged for use both in gravity-fed and automated pump delivery systems are replaced less frequently than IV sets designed for use primarily by one delivery method. Semistructured interviews with nurses highlighted the impact of set design on nursing workflow when moving between gravity-fed and pump-based administration. Use of interchangeable, single-design IV sets across gravity and automated infusions minimizes disruptions to closed systems, may reduce nurses being distracted from patients' clinical needs when replacing sets, and may yield supply cost savings.

Peripheral venous catheter-related bloodstream infection is associated with severe complications and potential death: a retrospective observational study

BACKGROUND

The purpose of this study was to identify the clinical characteristics and outcomes of peripheral vascular catheter-related bloodstream infections (PVC-BSIs) and determine the risk of severe complications or death.

METHODS

We performed a retrospective observational study from June 2010 to April 2015 at two regional university-affiliated hospitals in Tokyo. We studied the clinical manifestations, underlying diseases, laboratory results, treatment methods, recurrence rates, and complications in 62 hospitalized patients diagnosed with PVC-BSIs by positive blood cultures.

RESULTS

The median time from admission to bacteremia was 17 days (range, 3-142 days) and that from catheter insertion to bacteremia diagnosis was 6 days (range, 2-15 days). Catheter insertion sites were in the arm in 48 (77.4%) patients, in the foot in 3 (4.8%) patients, and in an unrecorded location in 11 (17.7%) patients. Additionally, the causative pathogens were Gram-positive microorganisms in 58.0% of cases, Gram-negative microorganisms in 35.8% of cases, Candida spp. in 6.2% of cases, and polymicrobials in 25.8% of cases. Eight (12.9%) patients died within 30 days of their blood culture becoming positive. Patients who died of PVC-BSIs had a higher proportion of Staphylococcus aureus infection than patients who survived (odds ratio, 8.33; p = 0.004).

CONCLUSIONS

PVC-BSIs are a significant cause of health care-associated infection. We observed cases of severe PVC-BSI requiring intensive and long-term care along with lengthy durations of antibiotic treatment due to hematogenous complications, and some patients died. For patients with PVC-BSIs, S. aureus bacteremia remains a major problem that may influence the prognosis.

A Comparison of Two Commonly Used Methods for Securing Intravenous Cannulas

BACKGROUND

There is a wide variety of techniques to secure intravenous cannulas but little objective evidence to support their relative efficacy. This study compares the security of the two most common methods used within a major Australian Emergency Department.

METHODS

The plastic sheaths of four needle-less intravenous cannulas were secured to the skin surface (not intravenously) of 40 volunteers using two different taping styles, an "under and over" method with one of the tapes applied to the posterior surface of the hub then crossed anteriorly to adhere to the opposite skin surface or "horizontal" taping with the tapes applied horizontally across the anterior surface of the hub. The peak force required to dislodge the taped cannulas using each of these different methods was then measured in both an anterograde and retrograde direction of force using a force transducer.

RESULTS

The force required to dislodge a cannula taped in an 'under and over' taping style was significantly higher than that required for the horizontal taping in both anterograde and retrograde directions of force (p < 0.001).

CONCLUSIONS

The results of this study suggest that the "under and over" taping technique offers significantly more security than "horizontal" taping and should be considered as a more effective method for securing intravenous cannulas.

A survey of 554 peripheral intravenous catheters: infection, duration of cannulation and documentation issues

The purpose of this survey was to improve nursing care of patients with peripheral intravenous catheters (PVCs), focusing on duration of cannulation. The survey was conducted in 20 general wards recording data on the duration of cannulation, site-infection, dating of PVC dressing and documentation in nursing notes. Nursing staff were interviewed on duration of the PVC and a documentation form was introduced during the survey.

A total of 554 PVCs in 397 patients were surveyed. Duration of cannulation ranged from one to ten days, with 402 (73%) of PVCs removed by day three. The site-infection rate was 28 (5%) with no cases of blood stream infection. Most site infection (20 of 28 (71%)) occurred within the first three days.

The duration of cannulation, from interview, was known by nurses in 416 (75%) of cases and documented in 208 (40%) of cases. Eighteen months after its introduction, the PVC documentation form was in use in 19 of 20 wards for 60 (76%) PVCs.

While the infection rate was low and nurses were generally aware of the duration of cannulation, inadequate documentation by nursing and medical staff was a cause for concern. Information on PVCs should be included in standard documentation on all wards and in relevant departments to assist nurses and others in the provision of quality care to patients.

Inter-rater agreement on PIVC-associated phlebitis signs, symptoms and scales

RATIONALE, AIMS AND OBJECTIVES

Many peripheral intravenous catheter (PIVC) infusion phlebitis scales and definitions are used internationally, although no existing scale has demonstrated comprehensive reliability and validity. We examined inter-rater agreement between registered nurses on signs, symptoms and scales commonly used in phlebitis assessment.

METHODS

Seven PIVC-associated phlebitis signs/symptoms (pain, tenderness, swelling, erythema, palpable venous cord, purulent discharge and warmth) were observed daily by two raters (a research nurse and registered nurse). These data were modelled into phlebitis scores using 10 different tools. Proportions of agreement (e.g. positive, negative), observed and expected agreements, Cohen's kappa, the maximum achievable kappa, prevalence- and bias-adjusted kappa were calculated.

RESULTS

Two hundred ten patients were recruited across three hospitals, with 247 sets of paired observations undertaken. The second rater was blinded to the first's findings. The Catney and Rittenberg scales were the most sensitive (phlebitis in >20% of observations), whereas the Curran, Lanbeck and Rickard scales were the most restrictive (≤2% phlebitis). Only tenderness and the Catney (one of pain, tenderness, erythema or palpable cord) and Rittenberg scales (one of erythema, swelling, tenderness or pain) had acceptable (more than two-thirds, 66.7%) levels of inter-rater agreement.

CONCLUSIONS

Inter-rater agreement for phlebitis assessment signs/symptoms and scales is low. This likely contributes to the high degree of variability in phlebitis rates in literature. We recommend further research into assessment of infrequent signs/symptoms and the Catney or Rittenberg scales. New approaches to evaluating vein irritation that are valid, reliable and based on their ability to predict complications need exploration.

Clinically-indicated replacement versus routine replacement of peripheral venous catheters

BACKGROUND

US Centers for Disease Control guidelines recommend replacement of peripheral intravenous (IV) catheters no more frequently than every 72 to 96 hours. Routine replacement is thought to reduce the risk of phlebitis and bloodstream infection. Catheter insertion is an unpleasant experience for patients and replacement may be unnecessary if the catheter remains functional and there are no signs of inflammation. Costs associated with routine replacement may be considerable. This is an update of a review first published in 2010.

OBJECTIVES

To assess the effects of removing peripheral IV catheters when clinically indicated compared with removing and re-siting the catheter routinely.

SEARCH METHODS

For this update the Cochrane Vascular Trials Search Co-ordinator searched the Cochrane Vascular Specialised Register (March 2015) and CENTRAL (2015, Issue 3). We also searched clinical trials registries (April 2015).

SELECTION CRITERIA

Randomised controlled trials that compared routine removal of peripheral IV catheters with removal only when clinically indicated in hospitalised or community dwelling patients receiving continuous or intermittent infusions.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data.

MAIN RESULTS

Seven trials with a total of 4895 patients were included in the review. The quality of the evidence was high for most outcomes but was downgraded to moderate for the outcome catheter-related bloodstream infection (CRBSI). The downgrade was due to wide confidence intervals, which created a high level of uncertainty around the effect estimate. CRBSI was assessed in five trials (4806 patients). There was no significant between group difference in the CRBSI rate (clinically-indicated 1/2365; routine change 2/2441). The risk ratio (RR) was 0.61 (95% CI 0.08 to 4.68; P = 0.64). No difference in phlebitis rates was found whether catheters were changed according to clinical indications or routinely (clinically-indicated 186/2365; 3-day change 166/2441; RR 1.14, 95% CI 0.93 to 1.39). This result was unaffected by whether infusion through the catheter was continuous or intermittent. We also analysed the data by number of device days and again no differences between groups were observed (RR 1.03, 95% CI 0.84 to 1.27; P = 0.75). One trial assessed all-cause bloodstream infection. There was no difference in this outcome between the two groups (clinically-indicated 4/1593 (0.02%); routine change 9/1690 (0.05%); P = 0.21). Cannulation costs were lower by approximately AUD 7.00 in the clinically-indicated group (mean difference (MD) -6.96, 95% CI -9.05 to -4.86; P ≤ 0.00001).

AUTHORS' CONCLUSIONS

The review found no evidence to support changing catheters every 72 to 96 hours. Consequently, healthcare organisations may consider changing to a policy whereby catheters are changed only if clinically indicated. This would provide significant cost savings and would spare patients the unnecessary pain of routine re-sites in the absence of clinical indications. To minimise peripheral catheter-related complications, the insertion site should be inspected at each shift change and the catheter removed if signs of inflammation, infiltration, or blockage are present.

The Effectiveness of Clinically Indicated Replacement of Peripheral Intravenous Catheters: An Evidence Review With Implications for Clinical Practice

BACKGROUND

Current clinical guidelines from the Centers for Disease Control and Prevention (CDC; 2011) state that peripheral intravenous catheters are to be replaced every 72-96 hr to prevent infection and phlebitis in the adult patient. It is unclear whether this practice reduces the incidence of phlebitis or other infections.

AIM

The aim of this study was to examine levels I and II evidence to determine if replacing peripheral intravenous catheters only when clinically indicated compared to every 72-96 hr increases the adult patient's risk for infection or phlebitis.

METHODS

The following patient or population, intervention, comparison, outcome question was used to search the literature databases PubMed, ClinicalKey, ProQuest, Ovid SP, and CINAHL: In the adult patient requiring a peripheral vascular catheter (P), does replacing the catheter only when clinically indicated (I) compared to replacing the catheter every 72-96 hr (C) increase the occurrence of phlebitis and infection (O)? A set of specific search criteria along with critical appraisal tools was used to identify relative studies.

RESULTS

Four level II randomized controlled trials with no less than 155 subjects, and two level I meta-analyses reviewing a total of 13 research studies indicated that the replacement of peripheral intravenous catheters only when clinically indicated does not increase patient risk of phlebitis or infection when compared to the current practice of routine replacement between 72 and 96 hr in the adult patient population.

LINKING EVIDENCE TO ACTION

The current practice of replacing peripheral intravenous catheters every 72-96 hr does not decrease the incidence of phlebitis or infection when compared to replacing catheters when clinically indicated in the adult population. By translating this research into current practice, healthcare costs and nursing care time will decrease, and unnecessary invasive procedures would be eliminated thereby increasing patient safety and satisfaction.

Outpatient parenteral antimicrobial therapy (OPAT) in patients with cystic fibrosis

Background

To determine complications during outpatient parenteral antimicrobial therapy (OPAT) administrated through a peripheral venous line, PICC-line or PORT-A-CATH (PAC).

Methods

Catheter related complications in patients with cystic fibrosis during OPAT were identified through a retrospective review of patient files supplemented by an interview.

Results

In 64 treatment episodes with a peripheral venous line, 51 (79.7 %) used bolus injection and 13 (20.3 %) used infusion pump. 27 out of 51 (53.0 %) bolus injection episodes experienced complications, which required removal. None were observed for infusion pump treatments.

The infectious complications requiring removal of peripheral venous line were 9 out of 23 (39.1 %) for the PICC line and 11 out of 26 (42.3 %) for the PAC.

No anaphylaxis was observed during the OPAT treatments.

Conclusions

Our data indicate that using an infusion pump to administer the antibiotic treatment minimized peripheral venous line complications. The frequency of complications leading to removal of the catheter is about the same for PICC-lines and PACs, but the average life-time of the latter is much longer. Allergic reactions are not a major problem.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-015-1019-4) contains supplementary material, which is available to authorized users.

Establish a perioperative check forum for peripheral intravenous access to prevent the occurrence of phlebitis

The prevalence of intravenous (IV) catheter-related infections is 0.5 per 1000 device days, and these infections cause tenderness, erythema, swelling and phlebitis. Catheter-related bloodstream infections (CRBSI) may independently increase hospital costs and length of stay; the aim of the study was to set up a standard operating procedure (SOP) for the maintenance of peripheral vein catheter patency and the prevention of IV catheter-related complications. This is a retrospective study, enrolling patients who received anesthesia between April 2010 and January 2011. The study included 1 month of pretest phase, and 3 months each of "notification" phase, "observation" phase and "end" phase, respectively. The cannulations were set up by surgical ward nurses following the SOP on establishing peripheral intravenous catheter in our hospital. The cannulation sites were then examined before surgery and postoperatively by registered nurse anesthetists using the Baxter Scale. We also tried to set up a feedback circuit to let ward nurses know about the IV patency rate. As a result, 14,682 patients were enrolled in the study. The incidence of IV therapy-related adverse events was 0.78% in the notification phase, 0.43% in the observation phase, and 0.13% in the end phase. Overall IV therapy-related events declined significantly (p < 0.01), and the presence of phlebitis was associated with age (p < 0.05). An SOP established to assess IV patency through a checklist can reduce phlebitis and improve quality. The checklist increases ward nurses' and nurse anesthetists' awareness of IV patency, and the feedback circuit substantially reduces IV event rate.

Guidelines for the Prevention of Intravascular Catheter–Related Infections

Background:

Although many catheter-related blood-stream infections (CRBSIs) are preventable, measures to reduce these infections are not uniformly implemented.

Objective:

To update an existing evidenced-based guideline that promotes strategies to prevent CRBSIs.

Data Sources:

The MEDLINE database, conference proceedings, and bibliographies of review articles and book chapters were searched for relevant articles.

Studies Included:

Laboratory-based studies, controlled clinical trials, prospective interventional trials, and epidemiologic investigations.

Outcome Measures:

Reduction in CRBSI, catheter colonization, or catheter-related infection.

Synthesis:

The recommended preventive strategies with the strongest supportive evidence are education and training of healthcare providers who insert and maintain catheters; maximal sterile barrier precautions during central venous catheter insertion; use of a 2% chlorhexidine preparation for skin antisepsis; no routine replacement of central venous catheters for prevention of infection; and use of antiseptic/antibiotic-impregnated short-term central venous catheters if the rate of infection is high despite adherence to other strategies (ie, education and training, maximal sterile barrier precautions, and 2% chlorhexidine for skin antisepsis).

Conclusion:

Successful implementation of these evidence-based interventions can reduce the risk for serious catheter-related infection.

Routine Replacement versus Clinical Monitoring of Peripheral Intravenous Catheters in a Regional Hospital in the Home Program A Randomized Controlled Trial

This randomized, controlled trial involving 316 patients in the home setting found no difference in the rate of phlebitis and/or occlusion among patients for whom a peripheral intravenous catheter was routinely resited at 72-96 hours and those for whom it was replaced only on clinical indication (76.8 events per 1,000 device-days vs 87.3 events per 1,000 device-days; P = .71). There were no bloodstream infections.

Device-related infections in long-term healthcare facilities: the challenge of prevention

The world is aging and the number of elderly multimorbid patients is steadily increasing. The limited numbers of acute care beds in hospitals, in addition to the need to reduce costs, has led to the introduction of efficient discharge policies, which in turn have increased demand for beds in nursing homes and long-term care facilities (LTCFs). As a consequence, the number of postacute LTCF residents is rising, as is the number of residents requiring complex medical care delivered by use of indwelling medical devices. These devices place patients at a heightened risk for infection. Furthermore, infection control resources in LTCFs are often limited. This article reviews the preventive measures that should be taken in LTCFs to reduce the risk of device-related infections.

Clinically-indicated replacement versus routine replacement of peripheral venous catheters

BACKGROUND

US Centers for Disease Control guidelines recommend replacement of peripheral intravenous (IV) catheters no more frequently than every 72 to 96 hours. Routine replacement is thought to reduce the risk of phlebitis and bloodstream infection. Catheter insertion is an unpleasant experience for patients and replacement may be unnecessary if the catheter remains functional and there are no signs of inflammation. Costs associated with routine replacement may be considerable. This is an update of a review first published in 2010.

OBJECTIVES

To assess the effects of removing peripheral IV catheters when clinically indicated compared with removing and re-siting the catheter routinely.

SEARCH METHODS

For this update the Cochrane Peripheral Vascular Diseases (PVD) Group Trials Search Co-ordinator searched the PVD Specialised Register (December 2012) and CENTRAL (2012, Issue 11). We also searched MEDLINE (last searched October 2012) and clinical trials registries.

SELECTION CRITERIA

Randomised controlled trials that compared routine removal of peripheral IV catheters with removal only when clinically indicated in hospitalised or community dwelling patients receiving continuous or intermittent infusions.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data.

MAIN RESULTS

Seven trials with a total of 4895 patients were included in the review. Catheter-related bloodstream infection (CRBSI) was assessed in five trials (4806 patients). There was no significant between group difference in the CRBSI rate (clinically-indicated 1/2365; routine change 2/2441). The risk ratio (RR) was 0.61 but the confidence interval (CI) was wide, creating uncertainty around the estimate (95% CI 0.08 to 4.68; P = 0.64). No difference in phlebitis rates was found whether catheters were changed according to clinical indications or routinely (clinically-indicated 186/2365; 3-day change 166/2441; RR 1.14, 95% CI 0.93 to 1.39). This result was unaffected by whether infusion through the catheter was continuous or intermittent. We also analysed the data by number of device days and again no differences between groups were observed (RR 1.03, 95% CI 0.84 to 1.27; P = 0.75). One trial assessed all-cause bloodstream infection. There was no difference in this outcome between the two groups (clinically-indicated 4/1593 (0.02%); routine change 9/1690 (0.05%); P = 0.21). Cannulation costs were lower by approximately AUD 7.00 in the clinically-indicated group (mean difference (MD) -6.96, 95% CI -9.05 to -4.86; P ≤ 0.00001).

AUTHORS' CONCLUSIONS

The review found no evidence to support changing catheters every 72 to 96 hours. Consequently, healthcare organisations may consider changing to a policy whereby catheters are changed only if clinically indicated. This would provide significant cost savings and would spare patients the unnecessary pain of routine re-sites in the absence of clinical indications. To minimise peripheral catheter-related complications, the insertion site should be inspected at each shift change and the catheter removed if signs of inflammation, infiltration, or blockage are present.

Fungal infections in severe acute pancreatitis

Severe acute pancreatitis (SAP) is associated with significant morbidity and mortality. The majority of deaths related to SAP are the result of infectious complications. Although bacterial infections are most commonly encountered, fungal infections are increasingly being recognized. Candida is the most common fungal infection. The occurrence of fungal infection in patients with acute pancreatitis adversely affects the clinical course, leading to a higher incidence of systemic complications, and possibly mortality as well. Important risk factors for fungal infection in patients with acute pancreatitis include broad-spectrum antibiotics, prolonged hospitalization and surgical/endoscopic interventions, use of total parenteral nutrition, and mechanical ventilation. Patients with higher severity of pancreatitis are at a greater risk. The pathogenesis of fungal infection in patients with acute pancreatitis is multifactorial. Translocation of microorganisms across the gut epithelium, lymphocyte dysfunction, and the virulence of the invading microorganisms play important roles. Histological demonstration of fungi remains the gold standard of diagnosis, but a positive biopsy is rarely obtained. The role of biomarkers in the diagnosis is being investigated. As early diagnosis and treatment can lead to improved outcome, a high index of suspicion is required for prompt diagnosis. Limiting the use of broad-spectrum antibiotics, early introduction of enteral nutrition, and timely change of vascular catheters are important preventive strategies. The role of antifungal prophylaxis remains controversial. Surgical necrosectomy with antifungal therapy is the most widely used treatment approach. Clinical trials on antifungal prophylaxis are needed, and indications for surgical intervention need to be clearly defined.

Routine resite of peripheral intravenous devices every 3 days did not reduce complications compared with clinically indicated resite: a randomised controlled trial

BACKGROUND

Peripheral intravenous device (IVD) complications were traditionally thought to be reduced by limiting dwell time. Current recommendations are to resite IVDs by 96 hours with the exception of children and patients with poor veins. Recent evidence suggests routine resite is unnecessary, at least if devices are inserted by a specialised IV team. The aim of this study was to compare the impact of peripheral IVD 'routine resite' with 'removal on clinical indication' on IVD complications in a general hospital without an IV team.

METHODS

A randomised, controlled trial was conducted in a regional teaching hospital. After ethics approval, 362 patients (603 IVDs) were randomised to have IVDs replaced on clinical indication (185 patients) or routine change every 3 days (177 patients). IVDs were inserted and managed by the general hospital medical and nursing staff; there was no IV team. The primary endpoint was a composite of IVD complications: phlebitis, infiltration, occlusion, accidental removal, local infection, and device-related bloodstream infection.

RESULTS

IVD complication rates were 68 per 1,000 IVD days (clinically indicated) and 66 per 1,000 IVD days (routine replacement) (P = 0.86; HR 1.03; 95% CI, 0.74-1.43). Time to first complication per patient did not differ between groups (KM with log rank, P = 0.53). There were no local infections or IVD-related bloodstream infections in either group. IV therapy duration did not differ between groups (P = 0.22), but more (P = 0.004) IVDs were placed per patient in the routine replacement (mean, 1.8) than the clinical indication group (mean, 1.5), with significantly higher hospital costs per patient (P < 0.001).

CONCLUSIONS

Resite on clinical indication would allow one in two patients to have a single cannula per course of IV treatment, as opposed to one in five patients managed with routine resite; overall complication rates appear similar. Clinically indicated resite would achieve savings in equipment, staff time and patient discomfort. There is growing evidence to support the extended use of peripheral IVDs with removal only on clinical indication.

REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ANZCTR) Number ACTRN12608000421336.

Clinically-indicated replacement versus routine replacement of peripheral venous catheters

BACKGROUND

Centers for Disease Control Guidelines recommend replacement of peripheral intravenous (IV) catheters every 72 to 96 hours. Routine replacement is thought to reduce the risk of phlebitis and bacteraemia. Catheter insertion is an unpleasant experience for patients and replacement may be unnecessary if the catheter remains functional and there are no signs of inflammation. Costs associated with routine replacement may be considerable.

OBJECTIVES

To assess the effects of removing peripheral IV catheters when clinically indicated compared with removing and re-siting the catheter routinely.

SEARCH STRATEGY

The Cochrane Peripheral Vascular Diseases Group searched their Specialised Register (last searched October 2009) and the Cochrane Central Register of Controlled Trials (CENTRAL) (last searched Issue Issue 4, 2009). We also searched MEDLINE (last searched October 2009).

SELECTION CRITERIA

Randomised controlled trials that compared routine removal of peripheral IV catheters with removal only when clinically indicated in hospitalised or community dwelling patients receiving continuous or intermittent infusions.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trial quality and extracted data.

MAIN RESULTS

In five trials (3408 participants) there was a 44% reduction in suspected catheter-related bacteraemia in the clinically-indicated group (0.2 versus 0.4%) but this was not statistically significant (odds ratio (OR) 0.57; 95% confidence interval (CI) 0.17 to 1.94; P = 0.37). Phlebitis was assessed in six trials (3455 patients); there was a non-significant increase in phlebitis in the clinically-indicated group (9% versus 7.2%); the OR was 1.24 (95% CI 0.97 to 1.60; P = 0.09). We also measured phlebitis per 1000 device days using data from five trials, (8779 device days). No statistical differences in the incidence of phlebitis per 1,000 device days was found (clinically indicated 1.6 cases per 1,000 catheter days versus 1.5 cases per 1,000 catheter days in the routine-replacement group).The combined OR was 1.04 (95% CI 0.81 to 1.32; P = 0.77). Cost was measured in two trials (961 patients). Cannulation costs were significantly reduced in the clinically-indicated group (mean difference (MD) -6.21; 95% CI -9.32 to -3.11; P = < 0.000).

AUTHORS' CONCLUSIONS

The review found no conclusive evidence of benefit in changing catheters every 72 to 96 hours. Consequently, health care organisations may consider changing to a policy whereby catheters are changed only if clinically indicated. This would provide significant cost savings and would also be welcomed by patients, who would be spared the unnecessary pain of routine re-sites in the absence of clinical indications.

Peripheral venous catheters: an under-evaluated problem

Peripheral venous catheters (PVC) are the most frequently used invasive devices in hospitals. Up to 70% of patients require a peripheral venous line during their hospital stay, and conservative estimates suggest that PVC days account for 15-20% of total patient days in acute care hospitals. Most published studies focus on thrombophlebitis and address the issue of scheduled catheter change, but there is still no consensus on the optimal time point for PVC change, or whether catheter replacement is required at all. Although PVC-associated catheter-related bloodstream infections (PVC-BSI) are far more serious than thrombophlebitis, few studies address this issue, and a large multicentre trial is lacking. Some studies on thrombophlebitis mention that no, or only a few, PVC-BSIs were identified, but such results must be interpreted with caution. Current data available on PVC-BSI suggest incidence density rates of 0.2-0.7 episodes per 1000 device days, which appear low when compared with other catheters. However, some studies report absolute PVC-BSI numbers in the range of central line-associated infections. It remains unclear whether PVC-BSI should be considered a serious healthcare problem or simply a very rare event. More research is needed both to capture the dimension of the problem and to provide efficient control measures.

Access technique and its problems in parenteral nutrition - Guidelines on Parenteral Nutrition, Chapter 9

Catheter type, access technique, and the catheter position should be selected considering to the anticipated duration of PN aiming at the lowest complication risks (infectious and non-infectious). Long-term (>7-10 days) parenteral nutrition (PN) requires central venous access whereas for PN <3 weeks percutaneously inserted catheters and for PN >3 weeks subcutaneous tunnelled catheters or port systems are appropriate. CVC (central venous catheter) should be flushed with isotonic NaCl solution before and after PN application and during CVC occlusions. Strict indications are required for central venous access placement and the catheter should be removed as soon as possible if not required any more. Blood samples should not to be taken from the CVC. If catheter infection is suspected, peripheral blood-culture samples and culture samples from each catheter lumen should be taken simultaneously. Removal of the CVC should be carried out immediately if there are pronounced signs of local infection at the insertion site and/or clinical suspicion of catheter-induced sepsis. In case PN is indicated for a short period (max. 7-10 days), a peripheral venous access can be used if no hyperosmolar solutions (>800 mosm/L) or solutions with a high titration acidity or alkalinity are used. A peripheral venous catheter (PVC) can remain in situ for as long as it is clinically required unless there are signs of inflammation at the insertion site.

Risk factors for peripheral intravenous catheter infection in hospitalized patients: a prospective study of 3165 patients

We conducted a prospective study of 6538 polyurethane peripheral intravenous (IV) catheters in 3165 hospitalized adult patients using semiquantitative culture techniques. We found that extending the scheduled catheter replacement interval from 48 to 72 hours to 72 to 96 hours was not a risk factor for local catheter infection, but that catheter insertion by personnel other than IV therapists and the use of continuous infusion to maintain catheter patency were 2 independent risk factors for infection.

COSMOS - a study comparing peripheral intravenous systems

In many areas of the world, safety peripheral intravenous systems have come into widespread use. The Madrid region was the first in Spain to adopt such an approach. These systems, though initially introduced to protect users from sharps injuries, have now evolved to include patient protection features as well. Patient protection, simply stated, means closing the system to pathogen entry. The authors' purpose was to investigate, in a prospective and randomized study, the clinical performance of a closed safe intravenous system versus an open system (COSMOS - Compact Closed System versus Mounted Open System). COSMOS is designed to provide definitive answers, from a nursing perspective, to many topics related to peripheral venous catheterization, which have important implications in intravenous therapy and which have not been validated scientifically. Furthermore, it forms pioneering research in that it is the first clinical trial on medical devices in a legislated environment carried out entirely by nurses and whose promoter and principal investigator is a nurse. The objectives of COSMOS are to compare the effectiveness (as defined by time of survival without complications) and rates of catheter-related complications, such as phlebitis, pain, extravasation, blockage and catheter-related infections. It also looks at rates of catheter colonization, the ease of handling of both systems and overall costs. This article outlines the authors' approach, both in preparing hospital units for such an evaluation as well as in the choice of parameters and their method of study. Further articles will detail the results and findings of the study.