Peripheral Teflon catheters: factors determining incidence of phlebitis and duration of cannulation

Peripheral intravenous catheter infection and failure: A systematic review and meta-analysis

BACKGROUND

Peripheral intravenous catheters are the most frequently used invasive device in nursing practice, yet are commonly associated with complications. We performed a systematic review to determine the prevalence of peripheral intravenous catheter infection and all-cause failure.

METHODS

The Cochrane Library, PubMed, CINAHL, and EMBASE were searched for observational studies and randomised controlled trials that reported peripheral intravenous catheter related infections or failure. The review was limited to English language and articles published from the year 2000. Pooled estimates were calculated with random-effects models. Meta-analysis of observation studies in epidemiology guidelines and the Cochrane process for randomised controlled trials were used to guide the review. Prospero registration number: CRD42022349956.

FINDINGS

Our search retrieved 34,725 studies. Of these, 41 observational studies and 28 randomised controlled trials (478,586 peripheral intravenous catheters) met inclusion criteria. The pooled proportion of catheter-associated bloodstream infections was 0.028 % (95 % confidence interval (CI): 0.009-0.081; 38 studies), or 4.40 catheter-associated bloodstream infections per 100,000 catheter-days (20 studies, 95 % CI: 3.47-5.58). Local infection was reported in 0.150 % of peripheral intravenous catheters (95 % CI: 0.047-0.479, 30 studies) with an incidence rate of 65.1 per 100,000 catheter-days (16 studies; 95 % CI: 49.2-86.2). All cause peripheral intravenous catheter failure before treatment completion occurred in 36.4 % of catheters (95 % CI: 31.7-41.3, 53 studies) with an overall incidence rate of 4.42 per 100 catheter days (78,891 catheter days; 19 studies; 95 % CI: 4.27-4.57).

INTERPRETATION

Peripheral intravenous catheter failure is a significant worldwide problem, affecting one in three catheters. Per peripheral intravenous catheter, infection occurrence was low, however, with over two billion catheters used globally each year, the absolute number of infections and associated burden remains high. Substantial and systemwide efforts are needed to address peripheral intravenous catheter infection and failure and the sequelae of treatment disruption, increased health costs and poor patient outcomes.

Study on incidence of phlebitis following the use of pherpheral intravenous catheter

Context:

Peripheral vein cannulation is commonly performed for rapid and accurate administration of medications. Phlebitis is one of the commonest complications that develop after intravenous catheter application.

Aims:

This study aims to investigate the incidence of phlebitis and to evaluate factors contributing to the development of phlebitis.

Settings and Design:

This was a prospective observational study conducted on patients admitted at 4 Air Force Hospital Kalaikunda.

Methods:

Study conducted on 150 patients who were admitted to the medical and surgical division of the hospital during the period from July 2018 to April 2019. The factors studied were age, gender, site of insertion, place of insertion, cannula size, IV medications, and blood products used. Phlebitis was graded using Visual Infusion Phlebitis Score.

Statistical Analysis Used:

The incidence of phlebitis was expressed in percentage and odds ratio was calculated to estimate the effects of suspected risk factors.

Results:

Incidence of phlebitis was found to be 31.4% from our study. The increased incidence rate of phlebitis was seen in the female gender, age less than 60 years, insertion in the lower limb, large catheter size, catheters inserted in emergency situations, and IV drugs administration.

Conclusion:

Phlebitis is an important on-going problem in present-day clinical practice. Avoiding of preventable risk factors, proper nursing care, and daily inspection of catheters needed for prevention of phlebitis.

The incidence and risk of infusion phlebitis with peripheral intravenous catheters: A meta-analysis

Introduction:

Phlebitis is a common complication associated with the use of peripheral intravenous catheters. The aim of this study was to estimate the incidence of phlebitis with peripheral intravenous catheter use and to identify risk factors for phlebitis development.

Method:

Literature survey was conducted in electronic databases (CINAHL, Embase, Google Scholar, Ovid, and PubMed), and studies were included if they used peripheral intravenous catheter for therapeutic or volumetric infusion and reported phlebitis incidence rates. Random effects meta-analyses were performed to obtain overall and subgroup phlebitis incidence rates and odds ratio between males and females in phlebitis incidence.

Results:

Thirty-five studies were included (20,697 catheters used for 15,791 patients; age 57.1 years (95% confidence interval: 55.0, 59.2); 53.9% males (95% confidence interval: 42.3, 65.5)). Incidence of phlebitis was 30.7 per 100 catheters (95% confidence interval: 27.2, 34.2). Incidence of severe phlebitis was 3.6% (95% confidence interval: 2.7%, 4.6%). Incidence of phlebitis was higher in non-intervened (30% (95% confidence interval: 27%, 33%)) than in intervened (21% (95% confidence interval: 15%, 27%)) groups, and with Teflon (33% (95% confidence interval: 25%, 41%)) than Vialon (27% (95% confidence interval: 21%, 32%)) cannula use. Odds of developing phlebitis was significantly higher in females (odds ratio = 1.42 (95% confidence interval: 1.05, 1.93); p = 0.02). Longer dwelling time, antibiotics infusion, female gender, forearm insertion, infectious disease, and Teflon catheter are important risk factors for phlebitis development identified by the included studies.

Conclusion:

Incidence of phlebitis with the use of peripheral intravenous catheters during infusion is 31%. Severe phlebitis develops in 4% of all patients. Risk of phlebitis development can be reduced by adapting appropriate interventions.

Use of infrared thermography in the detection of superficial phlebitis in adult intensive care unit patients: A prospective single-center observational study

Common methods to detect phlebitis may not be sufficient for patients in the intensive care unit (ICU). The goal of this study was to investigate the feasibility of infrared (IR) thermography to objectively detect phlebitis in adult ICU patients. We included a total of 128 adult ICU-patients in a pilot and subsequent validation study. Median [interquartile range] age was 62 [54–71] years and 88 (69%) patients were male. Severity of phlebitis was scored using the visual infusion phlebitis (VIP)-score, ranging from 0 (no phlebitis) to 5 (thrombophlebitis). The temperature difference (ΔT) between the insertion site and a proximal reference point was measured with IR thermography. In 78 (34%) catheters early phlebitis and onset of moderate phlebitis was observed (VIP-score of 1–3). In both the pilot and the validation study groups ΔT was significantly higher when the VIP-score was ≥1 compared to a VIP-score of 0 (p<0.01 and p<0.001, respectively). Multivariate analysis identified ΔT (p<0.001) and peripheral venous catheter (PVC) dwell time (p = 0.001) as significantly associated with phlebitis. IR thermography may be a promising technique to identify phlebitis in the ICU. An increased ΔT as determined with thermography may be a risk factor for phlebitis.

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.

Clinically-indicated replacement versus routine replacement of peripheral venous catheters

BACKGROUND

US Centers for Disease Control guidelines recommend replacement of peripheral intravenous catheters (PIVC) 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 or infection. Costs associated with routine replacement may be considerable. This is the third update of a review first published in 2010.

OBJECTIVES

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

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 18 April 2018. We also undertook reference checking, and contacted researchers and manufacturers to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials that compared routine removal of PIVC 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 reviewed trials for inclusion, extracted data, and assessed risk of bias using Cochrane methods. We used GRADE to assess the overall evidence certainty.

MAIN RESULTS

This update contains two new trials, taking the total to nine included studies with 7412 participants. Eight trials were conducted in acute hospitals and one in a community setting. We rated the overall certainty of evidence as moderate for most outcomes, due to serious risk of bias for unblinded outcome assessment or imprecision, or both. Because outcome assessment was unblinded in all of the trials, none met our criteria for high methodological quality.Primary outcomesSeven trials (7323 participants), assessed catheter-related bloodstream infection (CRBSI). There is no clear difference in the incidence of CRBSI between the clinically indicated (1/3590) and routine change (2/3733) groups (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.08 to 4.68), low-certainty evidence (downgraded twice for serious imprecision).All trials reported incidence of thrombophlebitis and we combined the results from seven of these in the analysis (7323 participants). We excluded two studies in the meta-analysis because they contributed to high heterogeneity. There is no clear difference in the incidence of thrombophlebitis whether catheters were changed according to clinical indication or routinely (RR 1.07, 95% CI 0.93 to 1.25; clinically indicated 317/3590; 3-day change 307/3733, moderate-certainty evidence, downgraded once for serious risk of bias). The result was unaffected by whether the infusion was continuous or intermittent. Six trials provided thrombophlebitis rates by number of device days (32,709 device days). There is no clear difference between groups (RR 0.90, 95% CI 0.76 to 1.08; clinically indicated 248/17,251; 3-day change 236/15,458; moderate-certainty evidence, downgraded once for serious risk of bias).One trial (3283 participants), assessed all-cause blood stream infection (BSI). We found no clear difference in the all-cause BSI rate between the two groups (RR 0.47, 95% CI 0.15 to 1.53; clinically indicated: 4/1593 (0.02%); routine change 9/1690 (0.05%); moderate-certainty evidence, downgraded one level for serious imprecision).Three trials (4244 participants), investigated costs; clinically indicated removal probably reduces device-related costs by approximately AUD 7.00 compared with routine removal (MD -6.96, 95% CI -9.05 to -4.86; moderate-certainty evidence, downgraded once for serious risk of bias).Secondary outcomesSix trials assessed infiltration (7123 participants). Routine replacement probably reduces infiltration of fluid into surrounding tissues compared with a clinically indicated change (RR 1.16 (95% CI 1.06 to 1.26; routine replacement 747/3638 (20.5%); clinically indicated 834/3485 (23.9%); moderate-certainty evidence, downgraded once for serious risk of bias).Meta-analysis of seven trials (7323 participants), found that rates of catheter failure due to blockage were probably lower in the routine-replacement group compared to the clinically indicated group (RR 1.14, 95% CI 1.01 to 1.29; routine-replacement 519/3733 (13.9%); clinically indicated 560/3590 (15.6%); moderate-certainty evidence, downgraded once for serious risk of bias).Four studies (4606 participants), reported local infection rates. It is uncertain if there are differences between groups (RR 4.96, 95% CI 0.24 to 102.98; clinically indicated 2/2260 (0.09%); routine replacement 0/2346 (0.0%); very low-certainty evidence, downgraded one level for serious risk of bias and two levels for very serious imprecision).One trial (3283 participants), found no clear difference in the incidence of mortality when clinically indicated removal was compared with routine removal (RR 1.06, 95% CI 0.27 to 4.23; low-certainty evidence, downgraded two levels for very serious imprecision).One small trial (198 participants) reported no clear difference in device-related pain between clinically indicated and routine removal groups (MD -0.60, 95% CI -1.44 to 0.24; low-certainty evidence, downgraded one level for serious risk of bias and one level for serious imprecision).The pre-planned outcomes 'number of catheter re-sites per patient', and 'satisfaction' were not reported by any studies included in this review.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence of no clear difference in rates of CRBSI, thrombophlebitis, all-cause BSI, mortality and pain between clinically indicated or routine replacement of PIVC. We are uncertain if local infection is reduced or increased when catheters are changed when clinically indicated. There is moderate-certainty evidence that infiltration and catheter blockage is probably lower when PIVC are changed routinely; and moderate-certainty evidence that clinically indicated removal probably reduces device-related costs. The addition of two new trials for this update found no further evidence to support changing catheters every 72 to 96 hours. Healthcare organisations may consider changing to a policy whereby catheters are changed only if there is a clinical indication to do so, for example, if there were signs of infection, blockage or infiltration. This would provide significant cost savings, spare patients the unnecessary pain of routine re-sites in the absence of clinical indications and would reduce time spent by busy clinicians on this intervention. To minimise PIVC-related complications, staff should inspect the insertion site at each shift change and remove the catheter if signs of inflammation, infiltration, occlusion, infection or blockage are present, or if the catheter is no longer needed for therapy.

Incidence and risk factors of peripheral venous catheter-related adverse events in cardiology department of a Tunisian university hospital: A prospective observational study

AIM

The purpose of our study was to determine the incidence and risk factors of Peripheral Venous Catheter-Related Adverse Events (PVCAEs) in a cardiology department of a university hospital.

PATIENTS AND METHODS

We carried out a prospective observational study from Mars 2017 to May 2017 in the cardiology department of the University Hospital of Farhat Hached in Sousse, Tunisia. During this period, we actively followed-up all inserted PVCs (every 12hours) from insertion up to 48hours after removal. Regression analyses were applied and significance limits were set at P<0.05.

RESULTS

Data were analysed for 210 PVCs (794 PVC-days) in 148 patients. The incidence of PVCAEs was 33.33% with density of incidence of 8.81/1000 PVC-days. PVCAEs were mainly pain (50%) and mechanical events (31.42%). Infections accounted for 11.42%. The most frequent mechanical PVCAEs, was haematoma (15.71%). Multivariate analysis revealed as independent factors for the occurrence of PVCAEs: the hydro electrolytic nature of the injected product (OR=13.42, P<10-3), the medicinal nature of the injected product (OR=5.08, P=0.003), bad cutaneous state (OR=8.08, P=0.003), admission during nightshift (OR=3.76; P=0.014) and advanced age (OR=1.04, P=0.042).

CONCLUSION

Multicenter studies would be very useful to better analyze risk factors associated with PVCAEs.

Short-term Peripheral Venous Catheter-Related Bloodstream Infections: A Systematic Review

Short-term peripheral venous catheters (PVCs) are commonly used in healthcare settings. To determine the magnitude of bloodstream infections (BSIs) related to their use, PubMed, article bibliographies, and the authors' library were searched for pertinent articles. The incidence of PVC-related BSIs was 0.18% among 85063 PVCs. Short-term PVCs accounted for a mean of 6.3% and 23% of nosocomial BSIs and nosocomial catheter-related BSIs, respectively. Prolonged dwell time and catheter insertion under emergent conditions increased risk of PVC-related bloodstream infection (PVCR-BSI). If approximately 200 million PVCs are successfully inserted into adult patients each year in the United States, there may be many PVCR-BSIs occurring yearly. Clinicians should obtain blood cultures in patients with evidence of PVC infection and systemic symptomatology such as fever, carefully inspect the PVC insertion site in bacteremic or fungemic patients, and remove PVCs associated with localized infection with or without associated BSI.

Incidence of phlebitis associated with the use of peripheral IV catheter and following catheter removal

Objective:

to investigate the incidence of phlebitis and its association with risk factors when using peripheral IV catheters (PIC) and following their removal - (post-infusion phlebitis) in hospitalized adults.

Method:

a cohort study of 171 patients using PIC, totaling 361 punctures. Sociodemographic variables and variables associated with the catheter were collected. Descriptive and analytical statistical analyses were performed.

Results:

average patient age was 56.96 and 51.5% of the sample population was male. The incidence of phlebitis was 1.25% while using PIC, and 1.38% post-infusion. The incidence of phlebitis while using PIC was associated with the length of time the catheter remained in place, whereas post-infusion phlebitis was associated with puncture in the forearm. Ceftriaxone, Clarithromycin and Oxacillin are associated with post-infusion phlebitis.

Conclusions:

this study made it possible to investigate the association between risk factors and phlebitis during catheter use and following its removal. The frequency of post-infusion phlebitis was larger than the incidence of phlebitis with the catheter in place, with Phlebitis Grade III and II being the most frequently found in each of these situations, respectively. Aspects related to post-infusion phlebitis can be explained, given the limited number of studies addressing this theme from this perspective.

Risk Factors for Peripheral Intravenous Catheter Failure: A Multivariate Analysis of Data from a Randomized Controlled Trial

Objective.

To assess the relative importance of independent risk factors for peripheral intravenous catheter (PIVC) failure.

Methods.

Secondary data analysis from a randomized controlled trial of PIVC dwell time. The Prentice, Williams, and Peterson statistical model was used to identify and compare risk factors for phlebitis, occlusion, and accidental removal.

Setting.

Three acute care hospitals in Queensland, Australia.

Participants.

The trial included 3,283 adult medical and surgical patients (5,907 catheters) with a PIVC with greater than 4 days of expected use.

Results.

Modifiable risk factors for occlusion included hand, antecubital fossa, or upper arm insertion compared with forearm (hazard ratio [HR], 1.47 [95% confidence interval (CI), 1.28–1.68], 1.27 [95% CI, 1.08–1.49], and 1.25 [95% CI, 1.04–1.50], respectively); and for phlebitis, larger diameter PIVC (HR, 1.48 [95% CI, 1.08–2.03]). PIVCs inserted by the operating and radiology suite staff had lower occlusion risk than ward insertions (HR, 0.80 [95% CI, 0.67–0.94]). Modifiable risks for accidental removal included hand or antecubital fossa insertion compared with forearm (HR, 2.45 [95% CI, 1.93–3.10] and 1.65 [95% CI, 1.23–2.22], respectively), clinical staff insertion compared with intravenous service (HR, 1.69 [95% CI, 1.30–2.20]); and smaller PIVC diameter (HR, 1.29 [95% CI, 1.02–1.61]). Female sex was a nonmodifiable factor associated with an increased risk of both phlebitis (HR, 1.64 [95% CI, 1.28–2.09]) and occlusion (HR, 1.44 [95% CI, 1.30–1.61]).

Conclusions.

PIVC survival is improved by preferential forearm insertion, selection of appropriate PIVC diameter, and insertion by intravenous teams and other specialists.

Trial Registration.

The original randomized controlled trial on which this secondary analysis is based is registered with the Australian New Zealand Clinical Trials Registry (http://www.anzctr.org.au; ACTRN12608000445370).

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.

Intravascular device administration sets: replacement after standard versus prolonged use in hospitalised patients-a study protocol for a randomised controlled trial (The RSVP Trial)

INTRODUCTION

Vascular access devices (VADs), such as peripheral or central venous catheters, are vital across all medical and surgical specialties. To allow therapy or haemodynamic monitoring, VADs frequently require administration sets (AS) composed of infusion tubing, fluid containers, pressure-monitoring transducers and/or burettes. While VADs are replaced only when necessary, AS are routinely replaced every 3-4 days in the belief that this reduces infectious complications. Strong evidence supports AS use up to 4 days, but there is less evidence for AS use beyond 4 days. AS replacement twice weekly increases hospital costs and workload.

METHODS AND ANALYSIS

This is a pragmatic, multicentre, randomised controlled trial (RCT) of equivalence design comparing AS replacement at 4 (control) versus 7 (experimental) days. Randomisation is stratified by site and device, centrally allocated and concealed until enrolment. 6554 adult/paediatric patients with a central venous catheter, peripherally inserted central catheter or peripheral arterial catheter will be enrolled over 4 years. The primary outcome is VAD-related bloodstream infection (BSI) and secondary outcomes are VAD colonisation, AS colonisation, all-cause BSI, all-cause mortality, number of AS per patient, VAD time in situ and costs. Relative incidence rates of VAD-BSI per 100 devices and hazard rates per 1000 device days (95% CIs) will summarise the impact of 7-day relative to 4-day AS use and test equivalence. Kaplan-Meier survival curves (with log rank Mantel-Cox test) will compare VAD-BSI over time. Appropriate parametric or non-parametric techniques will be used to compare secondary end points. p Values of <0.05 will be considered significant.

ETHICS AND DISSEMINATION

Relevant ethical approvals have been received. CONSORT Statement recommendations will be used to guide preparation of any publication. Results will be presented at relevant conferences and sent to the major organisations with clinical practice guidelines for VAD care.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trial Registry (ACTRN 12610000505000).

Prospective study of incidence and predictors of peripheral intravenous catheter-induced complications

BACKGROUND

Although intravenous therapy is one of the most commonly performed procedures in hospitalized patients, it remains susceptible to infectious and noninfectious complications. Previous studies investigated peripheral intravenous catheter (PIVC) complications mainly in pediatrics, but apparently none were investigated among Saudi adult populations. The aim of this study was to assess the pattern and complications of PIVCs at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia.

METHODS

An observational prospective cohort study investigated PIVCs pattern and complications among adults with PIVCs, admitted to various wards at KAMC. PIVCs-related clinical outcomes (pain, phlebitis, leaking, and others) were recorded in 12-hour intervals, using the Visual Inspection Phlebitis scale. Density incidence (DI) and cumulative incidence (CI) of complications and their relative risks (RRs) were calculated. Regression analyses were applied and significance limits were set at P<0.05.

RESULTS

During the study period, 359 adults were included, mounting to 842 PIVCs and 2,505 catheter days. The majority of patients, 276 (76.9%), had medical, chief admission complaints, whereas 83 (23.1%) were trauma/surgical and infectious cases. Complicated catheters were found in 141 (39.3%) patients, with 273 complications (32.4/100 catheters), in 190 complicated catheters (CI =22.56/100 catheters and DI =75.84/1,000 catheter days). Phlebitis ranked first among complications, 148 (CI =17.6%), followed by pain 64 (CI =7.6%), leaking 33 (CI =3.9%), dislodgement 20 (CI =2.4%), and extravasations and occlusion 4 (CI =0.5% each). Phlebitis was predicted with female sex (P<0.001), insertion in fore/upper arm (P=0.024), and infusion of medication (P=0.02). Removal time for PIVCs insertion was not a significant predictor of phlebitis (RR =1.46, P=0.08).

CONCLUSION

Incidence of complications in this study was significantly higher than rates in previous studies. Better insertion techniques may be sought to lower the incidences of PIVC complications, thus extending their onset beyond day 3. Changing catheters is recommended when clinically indicated rather than routinely post-72 hours.

Peripheral i.v. stabilization and the rate of complications in children: an exploratory study

Peripheral intravascular catheter insertion is the most common invasive procedure performed on the hospitalized child with a significant potential for complications. This study compared complication rates between a standard aseptic taping technique and a commercially-available adhesive anchoring device in 80 hospitalized children ages 2-17 years. Eighteen (18) participants (22.5%) experienced a complication with occlusion being the most common (n=8) followed by infiltration (n=4), leaking (n=3), and dislodgement (n=2). There were no differences in complication rates or types between the two groups. This study provides evidence that a stabilization device may not be necessary in short-duration PIVs in children.

epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England

National evidence-based guidelines for preventing healthcare-associated infections (HCAI) in National Health Service (NHS) hospitals in England were originally commissioned by the Department of Health and developed during 1998-2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were first published in January 2001(1) and updated in 2007.(2) A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identified, appraised and, if shown to be effective for the prevention of HCAI, incorporated into amended guidelines. Periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority. The Department of Health commissioned a review of new evidence and we have updated the evidence base for making infection prevention and control recommendations. A critical assessment of the updated evidence indicated that the epic2 guidelines published in 2007 remain robust, relevant and appropriate, but some guideline recommendations required adjustments to enhance clarity and a number of new recommendations were required. These have been clearly identified in the text. In addition, the synopses of evidence underpinning the guideline recommendations have been updated. These guidelines (epic3) provide comprehensive recommendations for preventing HCAI in hospital and other acute care settings based on the best currently available evidence. National evidence-based guidelines are broad principles of best practice that need to be integrated into local practice guidelines and audited to reduce variation in practice and maintain patient safety. Clinically effective infection prevention and control practice is an essential feature of patient protection. By incorporating these guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of health care in NHS hospitals in England can be minimised.

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.

Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial

BACKGROUND

The millions of peripheral intravenous catheters used each year are recommended for 72-96 h replacement in adults. This routine replacement increases health-care costs and staff workload and requires patients to undergo repeated invasive procedures. The effectiveness of the practice is not well established. Our hypothesis was that clinically indicated catheter replacement is of equal benefit to routine replacement.

METHODS

This multicentre, randomised, non-blinded equivalence trial recruited adults (≥18 years) with an intravenous catheter of expected use longer than 4 days from three hospitals in Queensland, Australia, between May 20, 2008, and Sept 9, 2009. Computer-generated random assignment (1:1 ratio, no blocking, stratified by hospital, concealed before allocation) was to clinically indicated replacement, or third daily routine replacement. Patients, clinical staff, and research nurses could not be masked after treatment allocation because of the nature of the intervention. The primary outcome was phlebitis during catheterisation or within 48 h after removal. The equivalence margin was set at 3%. Primary analysis was by intention to treat. Secondary endpoints were catheter-related bloodstream and local infections, all bloodstream infections, catheter tip colonisation, infusion failure, catheter numbers used, therapy duration, mortality, and costs. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12608000445370.

FINDINGS

All 3283 patients randomised (5907 catheters) were included in our analysis (1593 clinically indicated; 1690 routine replacement). Mean dwell time for catheters in situ on day 3 was 99 h (SD 54) when replaced as clinically indicated and 70 h (13) when routinely replaced. Phlebitis occurred in 114 of 1593 (7%) patients in the clinically indicated group and in 114 of 1690 (7%) patients in the routine replacement group, an absolute risk difference of 0·41% (95% CI -1·33 to 2·15%), which was within the prespecified 3% equivalence margin. No serious adverse events related to study interventions occurred.

INTERPRETATION

Peripheral intravenous catheters can be removed as clinically indicated; this policy will avoid millions of catheter insertions, associated discomfort, and substantial costs in both equipment and staff workload. Ongoing close monitoring should continue with timely treatment cessation and prompt removal for complications.

FUNDING

Australian National Health and Medical Research Council.

Intermittent flushing with heparin versus saline for maintenance of peripheral intravenous catheters in a medical department: a pragmatic cluster-randomized controlled study

BACKGROUND

Three meta-analyses conducted in the 1990s concluded that the effect of intermittent flushing with heparin at low concentration (10 U/mL) was equivalent to that of 0.9% sodium chloride flushes in preventing occlusion or superficial phlebitis. No firm conclusion was reached on the safety and efficacy of heparin concentrations of 100 U/mL used as an intermittent flush.

PURPOSE

To determine whether flushing peripheral intravenous catheters with 3 mL of a 100 U heparin/mL solution instead of saline improves the outcome of infusion devices.

METHODS

Cluster-randomized, controlled, two-arm, open trial, conducted in a research and teaching hospital in Northern Italy, involving 214 medical patients without contraindications to heparin: 107 randomly allocated to heparin and 107 to saline flushes (control group). Main outcome measure was catheter occlusion and catheter-related phlebitis.

RESULTS

Patients with either phlebitis or occlusion were 45 (42.1%) in the heparin group and 68 (63.6%) in the saline group (OR 0.41; 95% CI 0.24-0.72; p= 0.002); patients with occlusion alone were 23 (21.5%) and 47 (43.9%), respectively (p= 0.03); patients with phlebitis alone were 28 (26.2%) and 56 (52.6%) respectively (p= <0.001). Similar results were obtained when the analysis was based on catheters. No heparin severe side effects were identified.

LIMITATIONS

Lack of blinding, patient selection, cluster randomization of periods of treatment.

CONCLUSIONS

Heparin 100 U/mL in the maintenance of peripheral venous catheters was more effective than saline solution, in that it reduced the number of catheter-related phlebitis/occlusions and the number of catheters per patient, with potential advantages to both patients and the health system. It also appeared safe. However, subjects with platelet or coagulation defects were excluded, and, therefore, caution should be used when prescribing this type of catheter maintenance to patients at risk of bleeding.

Associação entre flebite e retirada de cateteres intravenosos periféricos

Estudo de coorte prospectivo, com objetivo de verificar a incidência de flebite em pacientes com cateter intravenoso periférico e identificar possíveis associações dessa complicação com variáveis relativas a estes cateteres. Foram avaliados 76 pacientes adultos internados em enfermaria de um hospital universitário, utilizando-se de uma ficha contendo variáveis relativas aos pacientes, ao cateter intravenoso periférico e à terapia farmacológica. A flebite foi avaliada segundo classificação proposta pela Infusion Nurses Society. Utilizou-se estatística descritiva e inferencial. Observou-se incidência de 25,8% de flebite, das quais 40% apresentaram manifestações clínicas de dor, com eritema e ou edema. Dentre os pacientes com flebite, 60% desenvolveram um episódio da complicação, e o tempo de permanência médio dos cateteres intravenosos periféricos com flebite foi de 3,10 dias. Constatou-se associação da flebite à retirada do cateter intravenoso periférico por ocorrência adversa (p<0,001). São necessárias ações educativas e capacitação da equipe de enfermagem para o manejo da terapia intravenosa, principalmente no que tange à detecção precoce da flebite.

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.

Factors that affect longevity of intravenous cannulas: a prospective study

BACKGROUND

Few guidelines exist to guide medical personnel on the most successful means of achieving sustained intravenous cannulation. This study examines the impact of gauge and site of intravenous cannulas (IC) on the longevity of ICs in hospitalized patients.

METHODS

A prospective study was conducted on 500 ICs inserted into patients of St Vincent's Private hospital from December 2005 to June 2006. Patients were followed until the IC had been removed or changed. Statistical analysis was performed using Cox proportional hazards.

RESULTS

Of the 500 ICs inserted, 37% were 18 g, 46% were 20 g and 18% were 22 g. Gauge of IC was the most significant predictor of increased longevity of IC (P = 0.0002, RR = 1.17, 95% CI 1.08-1.27). The median survival of 18, 20 and 22 g were 57 h (95% CI 49-72), 43 h (95% CI 36-48.5) and 29 h (95% CI 24-40.5), respectively. The site of IC placement influenced the longevity of ICs (P = 0.005, RR= 0.7, 95% CI 0.55-0.9), as did male gender (P = 0.03, RR = 0.76, 95% CI 0.6-0.97). However in subgroup analysis, the most marked effect on IC longevity was evident in those patients with 18 g placed in the forearm/wrist (median 72 h) with less marked changes in other site/gauge combinations. In contrast, 22 g ICs placed in the hand had a median lifespan of 29 h.

CONCLUSION

IC gauge and site of placement are important factors in determining IC longevity. 18 g ICs placed in the forearm/wrist can considerably increase the longevity of ICs and should be attempted in patients who require sustained cannulation.

Routine care of peripheral intravenous catheters versus clinically indicated replacement: randomised controlled trial

OBJECTIVE

To compare routine replacement of intravenous peripheral catheters with replacement only when clinically indicated.

DESIGN

Randomised controlled trial.

SETTING

Tertiary hospital in Australia.

PARTICIPANTS

755 medical and surgical patients: 379 allocated to catheter replacement only when clinically indicated and 376 allocated to routine care of catheter (control group).

MAIN OUTCOME MEASURE

A composite measure of catheter failure resulting from phlebitis or infiltration.

RESULTS

Catheters were removed because of phlebitis or infiltration from 123 of 376 (33%) patients in the control group compared with 143 of 379 (38%) patients in the intervention group; the difference was not significant (relative risk 1.15, 95% confidence interval 0.95 to 1.40). When the analysis was based on failure per 1000 device days (number of failures divided by number of days catheterised, divided by 1000), no difference could be detected between the groups (relative risk 0.98, 0.78 to 1.24). Infusion related costs were higher in the control group (mean $A41.02; pound19.71; euro24.80; $38.55) than intervention group ($A36.40). The rate of phlebitis in both groups was low (4% in intervention group, 3% in control group).

CONCLUSION

Replacing peripheral intravenous catheters when clinically indicated has no effect on the incidence of failure, based on a composite measure of phlebitis or infiltration. Larger trials are needed to test this finding using phlebitis alone as a more clinically meaningful outcome.

REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry ACTRN12605000147684.

Developing a Research base for Intravenous Peripheral cannula re-sites (DRIP trial). A randomised controlled trial of hospital in-patients

BACKGROUND

There is currently no high grade evidence on which to base decisions about the frequency of intravenous cannula re-sites.

OBJECTIVE

To assess the safety of changing peripheral venous cannulas when clinically indicated.

DESIGN

Randomised controlled trial.

SETTING

A tertiary referral hospital in Brisbane, Australia.

PARTICIPANTS

Two hundred and six hospitalised patients from surgical, medical and orthopaedic wards.

INTERVENTIONS

Peripheral intravenous cannulas were re-sited only when complications occurred (intervention group) or every 3 days (control group).

MAIN OUTCOME MEASURES

The primary endpoint was any unplanned cannula removal, the secondary outcome was cost.

RESULTS

Forty six patients had unplanned removals in the intervention group compared with 41 in the control group [relative risk 1.12, 95% confidence interval 0.81-1.55 (p=0.286)], a non-significant difference. Total duration of peripheral cannulation was similar in both groups (mean 123.3h in the intervention group and 125.9h in the control group: P=0.82) but significantly more re-sites occurred in the control group (167 in intervention group, 202 in the control group: p=0.022). Cost of cannula replacements in the intervention group was AUD$3,183.62 and in the control group AUD$3,837.56 (p=0.006).

CONCLUSION

Re-siting peripheral venous cannulas when clinically indicated compared with changing them routinely every 3 days does not lead to more complications and reduces costs.

Evidence for elective replacement of peripheral intravenous catheter to prevent thrombophlebitis: a systematic review

AIM

This paper reports a review of the scientific evidence for elective replacement of peripheral intravenous catheters in adults in the absence of any clinical complications, with the aim being to reduce the incidence and severity of thrombophlebitis.

BACKGROUND

The incidence of thrombophlebitis associated with peripheral intravenous catheters has been reported to range from 5.3% to 77.5%. Many factors that increase the risk for thrombophlebitis have been reported, of which time in situ is one. In Sweden, the recommended guideline is elective replacement of peripheral intravenous catheters every 12-24 hours.

METHOD

A systematic literature review was carried out in 2005 using the Cochrane Library, OvidMedline and CINAHL databases and hand searching of reference lists and with keywords catheterization, peripheral, thrombophlebitis and parenteral nutrition. The review included randomized controlled trials of elective replacement of peripheral intravenous catheters in adults. Three reviewers assessed the data found according to predetermined criteria.

FINDING

Three randomized control trials met the inclusion criteria and were retrieved for critical appraisal. The samples in two of the trials included patients requiring total parenteral nutrition. Patients in the third trial were receiving crystalloid and drugs. Time intervals for elective replacement varied. Study quality and relevance were rated as 'medium' in two of the trials and as 'low' in the third trial.

CONCLUSION

Limited scientific evidence suggests that elective replacement of peripheral intravenous catheters reduces the incidence and severity of thrombophlebitis.

Audit of peripheral venous cannulae by members of an IV therapy forum

This article describes a clinical audit of peripheral venous cannulae (PVC) undertaken by members of a national intravenous therapy forum. PVC care was reviewed using the RCN 'Standards for Infusion Therapy' and the Department of Healh's 'Winning Ways' report, action area 2 (DH, 2003; RCN, 2003) to define best practice. Data were collected by members of the forum and submitted for analysis by the members' coordinator. The findings of the audit highlighted several areas for improvement in PVC care. The most significant finding was poor documentation of the insertion of the cannula. An additional concern was that the person who performed the cannulation could not be identified for 236 (37.7%) of PVC audited. Draft recommendations with strategies for implementation have been proposed and feedback sought from participants with plans to re-audit in 2007.

The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies

OBJECTIVE

To better understand the absolute and relative risks of bloodstream Infection (BSI) associated with the various types of intravascular devices (IVDs), we analyzed 200 published studies of adults In which every device in the study population was prospectively evaluated for evidence of associated infection and microbiologically based criteria were used to define IVD-related BSI.

METHODS

English-language reports of prospective studies of adults published between January 1, 1966, and July 1, 2005, were identified by MEDLINE search using the following general search strategy: bacteremla [Medical Subject Heading, MeSH] OR septicemia [MeSH] OR bloodstream Infection AND the specific type of intravascular device (e.g., central venous port). Mean rates of IVD-related BSI were calculated from pooled data for each type of device and expressed as BSIs per 100 IVDs (%) and per 1000 IVD days.

RESULTS

Point incidence rates of IVD-related BSI were lowest with peripheral Intravenous catheters (0.1%, 0.5 per 1000 IVD-days) and midline catheters (0.4%, 0.2 per 1000 catheter-days). Far higher rates were seen with short-term noncuffed and nonmedicated central venous catheters (CVCs) (4.4%, 2.7 per 1000 catheter-days). Arterial catheters used for hemodynamic monitoring (0.8%, 1.7 per 1000 catheter-days) and peripherally inserted central catheters used in hospitalized patients (2.4%, 2.1 per 1000 catheter-days) posed risks approaching those seen with short-term conventional CVCs used in the Intensive care unit. Surgically implanted long-term central venous devices--cuffed and tunneled catheters (22.5%, 1.6 per 1000 IVD-days) and central venous ports (3.6%, 0.1 per 1000 IVD-days)--appear to have high rates of Infection when risk Is expressed as BSIs per 100 IVDs but actually pose much lower risk when rates are expressed per 1000 IVD-days. The use of cuffed and tunneled dual lumen CVCs rather than noncuffed, nontunneled catheters for temporary hemodlalysis and novel preventive technologies, such as CVCs with anti-infective surfaces, was associated with considerably lower rates of catheter-related BSI.

CONCLUSIONS

Expressing risk of IVD-related BSI per 1000 IVD-days rather than BSIs per 100 IVDs allows for more meaningful estimates of risk. These data, based on prospective studies In which every IVD in the study cohort was analyzed for evidence of infection by microbiologically based criteria, show that all types of IVDs pose a risk of IVD-related BSI and can be used for benchmarking rates of infection caused by the various types of IVDs In use at the present time. Since almost all the national effort and progress to date to reduce the risk of IVD-related Infection have focused on short-term noncuffed CVCs used in Intensive care units, Infection control programs must now strive to consistently apply essential control measures and preventive technologies with all types of IVDs.

Midline Catheters

Evangelical Community Hospital at Lewisburg, Pennsylvania, is a small community hospital with 110 beds. This organization sought a device to bridge between the short peripheral catheter and the peripherally inserted central catheter. The midline catheter provided an answer to this dilemma. However, a literature search for midline catheters yielded only four published articles, and only one of these was related to outcomes. The drugs used and the type of patients treated at Evangelical Community Hospital provided a challenge for the infusion therapist. This article examines the management of the patients who fell into a midlength of stay, and for whom both the short peripheral catheter and the peripherally inserted central catheter were inappropriate.

Dicloxacillin: a higher risk than cloxacillin for infusion phlebitis

Ever since dicloxacillin and cloxacillin were introduced in the 1960s, it has been known that they are associated with a high incidence of infusion phlebitis. Some in vitro studies and clinical experience have indicated that dicloxacillin is the more vessel-irritating of the 2 drugs. In this prospective observational study on 39 patients with 111 peripheral venous catheters (PVCs), the incidence of infusion phlebitis was compared between these 2 drugs. The incidence of phlebitis was 38% with dicloxacillin and 21% with cloxacillin; which, compared by logistic regression with other risk factors as covariates, was significant [odds ratio 5.06, 95% confidence interval (95% CI) 1.45-17.60]. Since the duration of catheterization is also an important risk factor, Cox regression was performed, and the difference between the 2 drugs was still significant (proportional hazard rate 3.48, 95%, CI 1.64-7.38). The only other significant risk factor found in the study was the insertion site; the risk was higher in PVCs inserted in the forearm/antecubital fossa than in the hand/wrist. The infusion time and dilution of the infusate were not significant risk factors.

A survey of nurses' assessment of peripheral intravenous catheters

The purpose of this survey was to improve nursing care of patients with peripheral intravenous catheters (PVCs), focusing on assessment of the PVC site for infection. The survey was conducted in 20 wards by an infection control nurse (ICN), recording data on assessment, site infection and removal/resiting of PVCs. Nursing staff were interviewed on assessment of the PVC site and nursing interventions were recorded. A total of 554 PVCs in 397 patients were surveyed of which 28 (5%) had site infection. There was no related bloodstream infection (BSI). Overall, PVCs were assessed 450 (81%) times by nurses. Malfunction was reported 95 (17%) times, pain 28 (5%) times and pyrexia 10 (2%) times. Characteristics that showed significant difference between 28 infected and 526 non-infected PVCs included when nurses assessed PVCs as infected, and nurses' intervention for PVCs inserted for 1-3 days' duration. Other characteristics were resiting PVCs when associated with malfunction and also resiting because of pain. The involvement of the ICN was likely to have contributed to the low infection rate. While not conclusive this survey identified characteristics between infected and non-infected PVCs that may have been associated with this low infection rate, namely, nurses' overall intervention in PVC care and assessment that is focused on identifying infection, and resiting for malfunction and pain. These are simple assessment and intervention measures that should not require the assignment of a dedicated ICN, but which are within the capabilities of all healthcare workers entrusted with PVC care.