Relationship between peripheral intravenous catheter Dwell time and the development of phlebitis and infiltration

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.

Short peripheral intravenous catheter securement with cyanoacrylate glue compared to conventional dressing: A randomized controlled trial

BACKGROUND

Short peripheral intravenous catheters (PIVCs) fail prior to completion of therapy in up to 63% of hospitalizations. This unacceptably high rate of failure has become the norm for the most common invasive procedure in all of medicine. Securement strategies may improve PIVC survival.

METHODS

We conducted a prospective, single-site, parallel, two-arm randomized controlled investigation with a primary outcome of catheter failure comparing securement with standard semi-permeable dressing and clear tape (SPD) to standard semipermeable dressing and clear tape with cyanoacrylate glue (SPD + CG). Adult emergency department patients with a short PIVC and anticipated hospital duration ⩾ 48 h were enrolled and followed until IV failure or completion of therapy for up to 7 days. Secondary outcomes included complications and cost comparisons between groups. Primary outcome was assessed by intention to treat and per protocol analyses.

FINDINGS

350 patients were enrolled between November 2019 and October 2020. PIVC survival for SPD + CG was similar to SPD group with the absolute risk difference of IV failure in the intention-to-treat (-5.8%, p = 0.065) population and improved in the per protocol (-8.1%, p = 0.04) population, respectively. Kaplan-Meier survival analysis indicated there was a significant benefit of the SPD + CG at greater than 2 days of hospitalization (p = 0.04). Prior to 48 h, there was no survival enhancement to either group (p = 0.98) in the intention to treat population. In a multivariable analysis with piecewise Cox regression, when the IV was functional greater than 48 h, the risk of IV failure in the SPD + CG was 43% less than the SPD group (adjusted hazard ratio [HR] 0.57, 95% confidence interval [CI] 0.34 to 0.97; p = 0.04). Cumulative cost related to IV during hospitalization was similar between groups with a lower incremental rescue cost in the SPD + CG group.

INTERPRETATION

SPD combined with cyanoacrylate glue provides similar benefit to patients compared to SPD alone and potentially improves short PIVC survival when the IV was inserted >48 h. As this strategy is cost neutral, it could be considered in admitted patients, particularly those with longer anticipated hospital durations.

Intravenous antimicrobial administration through peripheral venous catheters - establishing risk profiles from an analysis of 5252 devices

INTRODUCTION

Peripheral venous catheters (PVCs) are used to administer antimicrobials, but many fail prior to completion of therapy. While some antimicrobials are known to increase the PVC failure rate, risk profiles for many are unclear.

OBJECTIVE

To synthesize data from prospective PVC studies conducted between 2013 and 2019 to determine associations between common antimicrobials and PVC failure.

METHODS

A secondary analysis was undertaken of seven randomized controlled trials and two prospective cohort studies from three quaternary hospitals (two adult and one paediatric) in Australia between 2013 and 2019. The primary outcome was PVC failure due to vessel injury (occlusion, infiltration or extravasation) or irritation (pain or phlebitis). Associations between antimicrobial use and PVC failure were explored using multi-variable Cox regression.

RESULTS

In total, 5252 PVCs (4478 patients) were analysed; vessel injury and irritations occurred in 19% and 11% of all PVCs, respectively. Vessel injury was significantly associated with cefepime hydrochloride [hazard ratio (HR) 2.50; 95% confidence interval (CI) 1.44-4.34], ceftazidime pentahydrate (HR 1.91, 95% CI 1.11-3.31), flucloxacillin sodium (HR 1.84, 95% CI 1.45-2.33), lincomycin hydrochloride (HR 1.67, 95% CI 1.10-2.52) and vancomycin hydrochloride (HR 1.73, 95% CI 1.25-2.40). Irritation was significantly associated with flucloxacillin sodium (HR 2.58, 95% CI 1.96-3.40).

CONCLUSIONS

This study identified several antimicrobials associated with increased PVC failure, including some that were already known to be associated and some that had not been identified previously. Research is needed urgently to determine superior modes of delivery (e.g. dilution, infusion time, device type) that may prevent PVC failure.

Vascular access care in patients with multimorbidity

BACKGROUND

More than half of patients with multimorbidity require intravenous therapy during their hospital stay. The aims of this study are to describe difficult intravenous access (DIVA) and vascular access care provided to this patient population and to explore the differences between easy and DIVA groups.

METHODS

A cohort study was conducted in patients with multimorbidity admitted to 2 hospitals between March and November 2013. The variables used to describe vascular care included choice and placement of devices, catheter swell time, and occurrence of adverse events. The incidence of adverse events was expressed as number cases per 1000 catheter days and χ², Student's t, or Mann-Whitney U tests were used to compare the care provided between both groups. Odds rates were calculated to determine the risk of complications associated with DIVA.

RESULTS

We recruited 135 patients, of whom 34.8% were women. Overall, 59.3% had DIVA. A total of 224 catheters were inserted, patients with difficult access requiring a mean of 1.71 catheters and those with easy access 1.58 catheters. Two or more attempts were required to place catheters in 23% of cases in the difficult access group versus 2.50% in the easy access group. Mean catheter dwell time was 3.84 days and 3.99 days, and the adverse event rate was 111/1000 and 83.6/1000 catheter days, respectively. The odds ratio for complications was 1.596.

CONCLUSIONS

Multimorbid patients with DIVA have a higher rate of complications as well as requiring more catheters and more placement attempts.

Impact of Physician Inspection in the Detection of Phlebitis and Factors Contributing to it in Admitted Children of a Tertiary Care Hospital: A Prospective Study

OBJECTIVE

To determine whether additional dedicated observations by a doctor would increase the pickup rate of phlebitis and related complications due to intravenous cannulation. Also, to identify the common demographic and clinical factors predisposing to phlebitis in children.

METHODS

This prospective study was conducted from January 2019 through December 2019. A total of 184 children with 341 cannulations were enrolled. The authors added dedicated inspection of cannula by the physician during rounds in attempt to increase the detection of phlebitis. The difference in detection rates of thrombophlebitis by physician and routine observation along with the demographic and clinical variables contributing to thrombophlebitis in hospitalized children were studied.

RESULTS

Total incidence of thrombophlebitis was 35/341 (10.3%), which included 2 extravasations. Nineteen events (55%) were picked up by routine nursing observations and an additional 16 (45%) by the physician. Among the factors contributing to phlebitis, maternal education status <12th standard (41.7% vs. 15.1% P = 0.018), cannula located on forearm (p value 0.008), bigger cannula size (18% vs. 8.6% P = 0.008), non-splinted cannula (14.4% vs. 7.7% P = 0.046) intravenous fluid containing potassium (15.4% vs. 2.9%, P = 0.001) and concentrated infusions in particular aminophylline and magnesium sulphate (26.3% vs. 9.3%, P = 0.018) were found to be significantly associated with the development of phlebitis.

CONCLUSIONS

Physician inspection during rounds can improve phlebitis detection and will also increase the sensitivity of nursing observation.

Quality Improvement Initiative to Reduce Intravenous Line-related Infiltration and Phlebitis Incidence in Pediatric Emergency Room

Aim and objective

To reduce the incidence of infiltration and phlebitis by 50% over 2 months among children admitted to the emergency room (ER) of a tertiary care hospital.

Materials and methods

The study was conducted in the pediatric ER of a tertiary care hospital in North India. All children aged >28 days, receiving intravenous (IV) medication and/or fluids, were enrolled between June (2017) and September (2017). Existing practices of IV line insertion and maintenance were observed and recorded. The visual infusion phlebitis score and infiltration assessment scale were to grade the extent of two. The intervention classified as “IV line insertion and maintenance bundle” included the introduction of low-cost mobile sterile compartment trays, audit and feedback, organizational change, introduction of infection control nurse and quality improvement (QI) team formations were implement in different Plan-Do-Study-Act (PDSA) cycles. Reduction in the “incidence of phlebitis and infiltration” was outcome measures while “scores on checklist of IV line insertion and IV line maintenance and administration of drugs” were process measures.

Result

The process measures, for IV line insertion, maintenance and administration of drugs through IV line, revealed an increase in scores on the checklist. There was a significant decrease in the incidence of infiltration and phlebitis from 82.9 and 96.1% to 45 and 55%, respectively, postimplementation of all PDSA cycles.

Conclusion

Multifaceted QI IV line insertion and maintenance bundle reduced the incidence of infiltration and phlebitis. These interventions when integrated into daily work bundles along with continuous education and motivation help in sustaining the goal and attaining long-term success.

How to cite this article

Singh N, Kalyan G, Kaur S, Jayashree M, Ghai S. Quality Improvement Initiative to Reduce Intravenous Line-related Infiltration and Phlebitis Incidence in Pediatric Emergency Room. Indian J Crit Care Med 2021;25(5):557–565.

Effectiveness of transparent film dressing for peripheral intravenous catheter

BACKGROUND

The intravenous applications are the most common type of such interventions. It is underlined that in cases where the peripheral intravenous catheter is not properly secured in place, even a minor movement inside the vein would result in injury of vein.

OBJECTIVE

The insertion of peripheral intravenous catheter is a common practice. This is a randomized controlled prospective study aiming at investigating the effectiveness of use of transparent film dressing for peripheral intravenous catheter.

METHODS

The universe of this study included inpatients in the Internal Diseases clinic of a University Hospital, and the sample included a total of 110 peripheral intravenous catheters that were calculated by power analysis. The patient identification form, the peripheral venous catheter and treatment information form, and the visual infusion phlebitis identification scale were used to collect data. The forms were completed by the investigators on the basis of daily observations. The data were assessed by the percentage, chi-square test, and logistic regression analysis via the software SPSS 20.00.

RESULTS

The individuals in the study group and the control group included in the sample are comparable in terms of gender, having/not having a chronic disease, the site of peripheral intravenous catheter, use of antibiotics, intravenous fluid therapy, and mean age. There were no statistically significant differences between the groups. There was a significant relationship between the dwell time for the catheter and development of any complications and the groups.

CONCLUSION

The use of transparent film dressing for insertion of peripheral intravenous catheter can be recommended as it increases the dwell time for the catheter and reduces incidence of complications.

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.

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.

Novel short peripheral catheter design for prevention of thrombophlebitis

Essentials Phlebitis is one of the most frequent complications related to short peripheral catheters (SPC). A new SPC design, aimed for minimizing mechanical phlebitis, was tested in vivo in swine. MRI analysis revealed 40% less inflammation with the new SPC design compared to commercial SPC. The results confirm that our SPC biomechanical design approach can minimize phlebitis rates. SUMMARY: Background Short peripheral catheters (SPCs) are the most common intravenous device in today's medical practice. Short peripheral catheter thrombophlebitis (SPCT) occurs in up to 80% of hospitalized patients. Symptoms appear on average 3 days after catheter insertion and can lead to extended hospitalization and increased related costs. Here we introduce a novel SPC, named very short peripheral catheter (VSPC), that was designed to minimize biomechanical irritation and improve blood flow. Objective The goal was to test the performance of the novel catheter in vivo for reduction of thrombophlebitis. Methods Very short peripheral catheter prototypes were inserted into swine ear veins (n = 12). Verification of the catheter conformation in situ and blood perfusion was performed using Echo-Doppler. The SPCT development rate was measured using magnetic resonance imaging (MRI), 4 and 12 days after catheter insertion, and analyzed by means of edema and inflammation intensities. Blind histopathology analysis was performed on the veins postmortem. Clinically available SPC was used as a reference. Results Operation of the VSPC devices did not require any special skills over those used for the clinically available SPC. Echo-Doppler imaging confirmed that in contrast to the traditional SPC, the VSPC avoided contact with the vein wall and allowed better blood perfusion. The MRI analysis revealed 2-fold inflammation and edema rates (~80%) in the veins cannulated with the commercial SPC, whereas rates of only ~40% were seen with the novel VSPC. A similar trend was noticed in the histopathology analysis. Conclusions The results indicate that the novel catheter design significantly reduced SPCT rates and demonstrated proof of concept for our biomechanical approach.

Accepted but Unacceptable: Peripheral IV Catheter Failure

Peripheral intravenous (IV) catheter insertion, the most common invasive hospital procedure performed worldwide, is associated with a variety of complications and an unacceptably high overall failure rate of 35% to 50% in even the best of hands. Catheter failure is costly to patients, caregivers, and the health care system. Although advances have been made, analysis of the mechanisms underlying the persistent high rate of peripheral IV failure reveals opportunities for improvement.

Observational Study of Peripheral Intravenous Catheter Outcomes in Adult Hospitalized Patients: A Multivariable Analysis of Peripheral Intravenous Catheter Failure

BACKGROUND

Almost 70% of hospitalized patients require a peripheral intravenous catheter (PIV), yet up to 69% of PIVs fail prior to completion of therapy.

OBJECTIVE

To identify risk factors associated with PIV failure.

DESIGN

A single center, prospective, cohort study.

SETTING

Medical and surgical wards of a tertiary hospital located in Queensland, Australia.

PARTICIPANTS

Adult patients requiring a PIV.

MEASUREMENTS

Demographic, clinical, and potential PIV risk factors were collected. Failure occurred if the catheter had complications at removal.

RESULTS

We recruited 1000 patients. Catheter failure occurred in 512 (32%) of 1578 PIVs. Occlusion/infiltration risk factors included intravenous (IV) flucloxacillin (hazard ratio [HR], 1.98; 95% confidence interval [CI], 1.19-3.31), 22-gauge PIVs (HR, 1.43; 95% CI, 1.02-2.00), and female patients (HR, 1.48; 95% CI, 1.10-2.00). Phlebitis was associated with female patients (HR, 1.81; 95% CI, 1.40-2.35), bruised insertion sites (HR, 2.16; 95% CI, 1.26-3.71), IV flucloxacillin (HR, 2.01; 95% CI, 1.26-3.21), and dominant side insertion (HR, 1.39; 95% CI, 1.09-1.77). Dislodgement risks were a paramedic insertion (HR, 1.78; 95% CI, 1.03-3.06).Each increase by 1 in the average number of daily PIV accesses was associated (HR 1.11, 95% CI 1.03-1.20)-(HR 1.14, 95% CI 1.08-1.21) with occlusion/infiltration, phlebitis and dislodgement. Additional securement products were associated with less (HR 0.32, 95% C-0.46)-(HR 0.63, 95% CI 0.48-0.82) occlusion/infiltration, phlebitis and dislodgement.

CONCLUSION

Modifiable risk factors should inform education and inserter skill development to reduce the currently high rate of PIV failure.

INFLUENCE OF LONG-TERM CYTOTOXIC CHEMOTHERAPY ON THE CONDITION OF PERIPHERAL VENOUS CHANNEL

The necessity of long-term venous access in cancer patients appears at frequent and long-term courses of cytotoxic therapy. Peripheral veins of forearms are most often used for these aims. The conditions of peripheral venous channel in 32 cancer patients, who underwent the long-term treatment with antitumor preparations were analyzed in the article on own investigatory material. The methods of dopplerography, morphological and immunohystochemical studies were used. The qualitative and quantitative dopplerographic changes in forearm veins in different terms after chemotherapy start were revealed in most patients. The conclusion was made about unsuitability of forearm peripheral veins for the long term administration of cytostatics and the necessity to create the alternative vascular access that would correspond to the criteria of safety, reliability and long-term exploitation.

Accepted but unacceptable: peripheral IV catheter failure

Peripheral intravenous (IV) catheter insertion, the most common invasive hospital procedure performed worldwide, is associated with a variety of complications and an unacceptably high overall failure rate of 35% to 50% in even the best of hands. Catheter failure is costly to patients, caregivers, and the health care system. Although advances have been made, analysis of the mechanisms underlying the persistent high rate of peripheral IV failure reveals opportunities for improvement.

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.

Devices and dressings to secure peripheral venous catheters to prevent complications

BACKGROUND

A peripheral venous catheter (PVC) is typically used for short-term delivery of intravascular fluids and medications. It is an essential element of modern medicine and the most frequent invasive procedure performed in hospitals. However, PVCs often fail before intravenous treatment is completed: this can occur because the device is not adequately attached to the skin, allowing the PVC to fall out, leading to complications such as phlebitis (irritation or inflammation to the vein wall), infiltration (fluid leaking into surrounding tissues) or occlusion (blockage). An inadequately secured PVC also increases the risk of catheter-related bloodstream infection (CRBSI), as the pistoning action (moving back and forth in the vein) of the catheter can allow migration of organisms along the catheter and into the bloodstream. Despite the many dressings and securement devices available, the impact of different securement techniques for increasing PVC dwell time is still unclear; there is a need to provide guidance for clinicians by reviewing current studies systematically.

OBJECTIVES

To assess the effects of PVC dressings and securement devices on the incidence of PVC failure.

SEARCH METHODS

We searched the following electronic databases to identify reports of relevant randomised controlled trials (RCTs): the Cochrane Wounds Group Register (searched 08 April 2015): The Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 3), Ovid MEDLINE (1946 to March 7 2015); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, March 7 2015); Ovid EMBASE (1974 to March 7 2015); and EBSCO CINAHL (1982 to March 8 2015).

SELECTION CRITERIA

RCTs or cluster RCTs comparing different dressings or securement devices for the stabilisation of PVCs. Cross-over trials were ineligible for inclusion, unless data for the first treatment period could be obtained.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed trial quality and extracted data. We contacted study authors for missing information. We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included six RCTs (1539 participants) in this review. Trial sizes ranged from 50 to 703 participants. These six trials made four comparisons, namely: transparent dressings versus gauze; bordered transparent dressings versus a securement device; bordered transparent dressings versus tape; and transparent dressing versus sticking plaster. There is very low quality evidence of fewer catheter dislodgements or accidental removals with transparent dressings compared with gauze (two studies, 278 participants, RR 0.40; 95% CI 0.17 to 0.92, P = 0.03%). The relative effects of transparent dressings and gauze on phlebitis (RR 0.89; 95% CI 0.47 to 1.68) and infiltration (RR 0.80; 95% CI 0.48 to 1.33) are unclear. The relative effects on PVC failure of a bordered transparent dressing and a securement device have been assessed in only one small study and these were unclear. There was very low quality evidence from the same single study of less frequent dislodgement or accidental catheter removal with bordered transparent dressings than securement devices (RR 0.14, 95% CI 0.03 to 0.63) but more phlebitis with bordered dressings (RR 8.11, 95% CI 1.03 to 64.02) (very low quality evidence). A small single study compared bordered transparent dressings with tape and found very low quality evidence of more PVC failure with the bordered dressing (RR 1.84, 95% CI 1.08 to 3.11) but the relative effects on dislodgement were not clear (very low quality evidence). The relative effects of transparent dressings and a sticking plaster have only been compared in one small study and are unclear. More high quality RCTs are required to determine the relative effects of alternative PVC dressings and securement devices.

AUTHORS' CONCLUSIONS

It is not clear if any one dressing or securement device is better than any other in securing peripheral venous catheters. There is a need for further, independent high quality trials to evaluate the many traditional as well as the newer, high use products. Given the large cost differences between some different dressings and securement devices, future trials should include a robust cost-effectiveness analysis.

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.

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.

Infusion phlebitis assessment measures: a systematic review

RATIONALE, AIMS AND OBJECTIVES

Phlebitis is a common and painful complication of peripheral intravenous cannulation. The aim of this review was to identify the measures used in infusion phlebitis assessment and evaluate evidence regarding their reliability, validity, responsiveness and feasibility.

METHOD

We conducted a systematic literature review of the Cochrane library, Ovid MEDLINE and EBSCO CINAHL until September 2013. All English-language studies (randomized controlled trials, prospective cohort and cross-sectional) that used an infusion phlebitis scale were retrieved and analysed to determine which symptoms were included in each scale and how these were measured. We evaluated studies that reported testing the psychometric properties of phlebitis assessment scales using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines.

RESULTS

Infusion phlebitis was the primary outcome measure in 233 studies. Fifty-three (23%) of these provided no actual definition of phlebitis. Of the 180 studies that reported measuring phlebitis incidence and/or severity, 101 (56%) used a scale and 79 (44%) used a definition alone. We identified 71 different phlebitis assessment scales. Three scales had undergone some psychometric analyses, but no scale had been rigorously tested.

CONCLUSION

Many phlebitis scales exist, but none has been thoroughly validated for use in clinical practice. A lack of consensus on phlebitis measures has likely contributed to disparities in reported phlebitis incidence, precluding meaningful comparison of phlebitis rates.

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.

A randomized controlled trial to compare the complications of 2 peripheral intravenous catheter-stabilization systems

An open-label, prospective, randomized, noninferiority study was conducted at a large academic, Magnet-designated, Level I trauma center to compare the peripheral intravenous catheter securement-related complication rates of 2 different stabilization systems. The control stabilization system included the StatLock device with a nonwinged catheter, and the investigational stabilization system included a closed catheter system with a specially designed Tegaderm dressing. Data from 302 subjects indicated that the investigational stabilization system was noninferior or similar to the control stabilization system with respect to the overall securement-related complications. The cost of the investigational stabilization system was approximately 75% of the cost for the control stabilization system.

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.

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.

Improving peripheral IV cannula care: implementing high-impact interventions

Infection prevention and control measures have been recognized as effective in minimizing the risk of infection from peripheral intravenous (IV) cannulas. However, this relies on health professionals' compliance with guidelines for the care of patients with IV catheters and at times it may be that practice is inconsistent with guidelines. This article discusses the care required for peripheral cannulas and shows how implementing the high-impact interventions can improve peripheral IV catheter care on insertion and its management afterwards.

Ultrasonography-guided peripheral intravenous catheter survival in ED patients with difficult access

OBJECTIVES

We determined the survival and complications of ultrasonography-guided peripheral intravenous (IV) catheters in emergency department (ED) patients with difficult peripheral access.

METHODS

This was a prospective, observational study conducted in an academic hospital from April to July of 2007. We included consecutive adult ED patients with difficult access who had ultrasonography-guided peripheral IVs placed. Operators completed data sheets and researchers examined admitted patients daily to assess outcomes. The primary outcome was IV survival >96 hours. As a secondary outcome, we recorded IV complications, including central line placement. We used descriptive statistics, univariate survival analysis with Kaplan Meier, and log-rank tests for data analysis.

RESULTS

Seventy-five patients were enrolled. The average age was 52 years. Fifty-three percent were male, 21% obese, and 13% had a history of injection drug use. The overall IV survival rate was 56% (95% confidence interval, 44%-67%) with a median survival of 26 hours (interquartile range [IQR], 8-61). Forty-seven percent of IVs failed within 24 hours, most commonly due to infiltration. Although 47 (63%) operators reported that a central line would have been required if peripheral access was unobtainable, only 5 (7%; 95% confidence interval, 2%-15%) patients underwent central venous catheterization. Only 1 central line was placed as a result of ultrasonography-guided IV failure. We observed no infectious or thrombotic complications.

CONCLUSION

Despite a high premature failure rate, ultrasonography-guided peripheral IVs appear to be an effective alternative to central line placement in ED patients with difficult access.

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.

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.