Design, development and preliminary assessment in a porcine model of a novel peripheral intravenous catheter aimed at reducing early failure rates

BACKGROUND

Peripheral intravenous catheters (PIVCs) are the most commonly used invasive medical device, yet despite best efforts by end-users, PIVCs experience unacceptably high early failure rates. We aimed to design a new PIVC that reduces the early failure rate of in-dwelling PIVCs and we conducted preliminary tests to assess its efficacy and safety in a porcine model of intravenous access.

METHODS

We used computer-aided design and simulation to create a PIVC with a ramped tip geometry, which directs the infused fluid away from the vein wall; we called the design the FloRamp™. We created FloRamp prototypes (test device) and tested them against a market-leading device (BD Insyte™; control device) in a highly-controlled setting with five insertion sites per device in four pigs. We measured resistance to infusion and visual infusion phlebitis (VIP) every 6 h and terminated the experiment at 48 h. Veins were harvested for histology and seven pathological markers were assessed.

RESULTS

Computer simulations showed that the optimum FloRamp tip reduced maximum endothelial shear stress by 60%, from 12.7 Pa to 5.1 Pa, compared to a typical PIVC tip and improved the infusion dynamics of saline in the blood stream. In the animal study, we found that 2/5 of the control devices were occluded after 24 h, whereas all test devices remained patent and functional. The FloRamp created less resistance to infusion (0.73 ± 0.81 vs 0.47 ± 0.50, p = 0.06) and lower VIP scores (0.60 ± 0.93 vs 0.31 ± 0.70, p = 0.09) than the control device, although neither findings were significantly different. Histopathology revealed that 5/7 of the assessed markers were lower in veins with the FloRamp.

CONCLUSIONS

Herein we report preliminary assessment of a novel PIVC design, which could be advantageous in clinical settings through decreased device occlusion and reduced early failure rates.

Impact of an interventional bundle on complications associated with peripheral venous catheters in elderly patients

PURPOSE

Elderly patients admitted to geriatrics departments often require peripheral venous catheters (PVC), which should be inserted and maintained following a series of preventive recommendations. Our objective was to evaluate the impact of a training bundle comprising measures aimed at reducing complications associated with the use of PVC in elderly patients admitted to a tertiary teaching hospital.

METHODS

We performed a prospective study of patients who received a PVC within 24 h of admission to a geriatrics department. After a 10-month pre-interventional period, we implemented an educational and interventional bundle over a 9-month period. Follow-up was until catheter withdrawal. We analyzed and compared clinical and microbiological data between both study periods.

RESULTS

A total of 344 patients (475 PVC) were included (pre-intervention period, 204 patients (285 PVC); post-intervention period, 140 patients (190 PVC)). No statistically significant differences in demographic characteristics were observed between the study periods. The colonization and phlebitis rates per 1000 admissions in both periods were, respectively, 36.7 vs. 24.3 (p = 0.198) and 81.5 vs. 65.1 (p = 0.457). The main reason for catheter withdrawal was obstruction/malfunctioning (33.3%). Obstruction rate was higher for those inserted in the hand than for those inserted at other sites (55.7% vs. 44.3%, p = 0.045).

CONCLUSIONS

We found no statistically significant differences regarding phlebitis and catheter tip colonization rates. It is necessary to carry out randomized studies assessing the most cost-effective measure to reduce complications associated with PVC.

Comparison of the physicochemical properties of branded and generic glucose-added maintenance hypotonic infusion fluids to assess the potential for phlebitis and incompatibility with other drugs

In Japan, the switch from branded to generic infusion fluids has been promoted as a national policy. Recently, as generic products have been in short supply, the switch from generic to branded infusion fluids has increased. However, certain additives for injectable infusion fluids, such as nonvolatile acids like acetic acid and hydrochloric acid, are not required to be listed in the package insert. We hypothesized that the addition of nonvolatile acids may be one of the reasons for the differences in physicochemical properties between the branded and generic infusion fluids. We have previously reported that in other types of electrolyte infusion fluids, a variation in pH can cause incompatibility with other drugs, and variation in titratable acidity and osmolality can lead to phlebitis. Glucose-added maintenance hypotonic infusion fluid (listed as type-3G) is commonly used as a maintenance solution when energy support is needed. However, nonvolatile acid is added to prevent the caramelization of glucose, resulting in higher osmolality and titratable acidity and lower pH. Therefore, we hypothesized that both phlebitis and incompatibility with other drugs are likely to occur; hence, we measured and evaluated the physicochemical properties of branded and generic type-3G infusion fluids. We show that the osmolality, pH, and titratable acidity of all evaluated branded and generic products differed significantly and that these properties should be evaluated together to avoid phlebitis and incompatibility with other drugs when switching between branded and generic type-3G infusion fluids.

Phlebitis in Medical-Surgical Units: A Case-Control Study in a Brazilian Hospital

The most commonly used vascular access is the peripheral intravenous catheter (PIVC). However, it can trigger complications and the occurrence of adverse events, such as phlebitis. This study evaluated the variables that are associated with the occurrence of phlebitis in medical and surgical inpatient units. This is an observational, retrospective, case-control study in medical and surgical hospitalization units of a private general hospital in the city of São Paulo. Participants were an average age of 66.3 years, and 71% were hospitalized in medical units. The risk variables associated with phlebitis were medical hospitalization (odds ratio [OR] = 4.36; P = .002), presence of comorbidity (OR = 10.73; P < .001), and having 5 or more PIVCs (OR = 53.79; P = .001). Regarding intravenous therapy, the use of contrast was a risk variable (OR = 2.23; P = .072). On the other hand, patient education regarding PIVCs was a protective measure against the development of phlebitis. The nursing team plays an essential role in the care of patients with PIVCs, inpatient guidance, planning, and device choice, taking into account the risk factors for phlebitis to maintain the preservation of vascular health and reduce adverse events.

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.

A safe and effective winged peripheral intravenous cannula for use in clinical practice

Vascular access continues to be a key factor for the reliable and safe delivery of intravenous (IV) therapy to patients in any healthcare setting. Clinical guidelines advocate for the right vascular access device selection, in order to reduce avoidable complications, eg multiple stabs, phlebitis, thrombophlebitis, insertion site infection, and blood stream infection, while improving efficiency and reducing costs. Peripheral intravenous catheters or cannulas (PIVCs) remain widely used for gaining vascular access in all clinical settings, with both adults and children, because they provide a relatively cheap and simple way to provide blood sampling and the prompt administration of IV medications. Although safe and easy to insert, PIVCs present with associated risks that can be costly to the organisation. The case studies included with this article introduce Nipro's Safetouch Cath Winged with Injection Port as a new cost-effective choice of PIVC, which is now available from NHS Supply Chain.

Length of hospitalization, APPLE score, and number of intravenous catheters placed at admission are associated with increased odds of peripheral intravenous catheter complications in dogs

OBJECTIVE

To identify risk factors associated with peripheral intravenous catheter (PIVC) complications in dogs hospitalized in the critical care unit (CCU).

ANIMALS

107 dogs admitted to the CCU between October 2022 and March 2023.

METHODS

This prospective, observational clinical trial was performed at a single veterinary teaching hospital. Dogs hospitalized in the CCU for at least 24 hours were evaluated for enrollment. PIVC were placed following a standardized protocol and monitored for complications. PIVC complications were classified as extravasation, phlebitis, dislodgement, occlusion, line breakage, or patient removal.

RESULTS

Median PIVC dwell time was 46.50 hours (range, 24.25 to 159.25 hours). Overall PIVC complication rate was 12.1% (13/107), with phlebitis (4/107 [3.7%]) and extravasation (4/107 [3.7%]) being the most frequently recorded complications. Multivariable analysis identified increasing length of hospitalization (LOH; OR, 1.43; 95% CI, 1.04 to 1.97; P = .029), an acute patient physiologic and laboratory evaluation full (APPLEFULL) score > 35 (OR, 4.66; 95% CI, 1.09 to 19.90; P = .038), and having 2 PIVCs placed at admission (OR, 10.92; 95% CI, 1.96 to 60.73; P = .006) as risk factors for PIVC complication.

CLINICAL RELEVANCE

Increasing LOH, an APPLEFULL score > 35 and having 2 PIVCs placed at admission were associated with increased odds for PIVC complication in this study. Although these are independent risk factors for PIVC complication, the combination of increasing LOH, an APPLEFULL score > 35, and having 2 PIVCs placed at admission may represent a more severely ill population, drawing attention to a vulnerable group of dogs at risk for PIVC complication.

Phlebitis in Takayasu arteritis: A case-based literature review

Takayasu arteritis (TAK) is the main type of large vessel arteritis in young adults, which mainly affects the aorta and its main branches, leading to clinical manifestations such as syncope, intermittent limb claudication, hypertension, and abdominal pain. Among them, venous involvement is rarely reported. Here we show a case of TAK presenting as phlebitis. This was a 27-year-old woman, who initially admitted to our hospital with myalgia of the upper and lower extremities and night sweats. She was diagnosed as TAK according to the 1990 American College of Rheumatology TAK criteria. Surprisingly, vascular ultrasonography revealed wall thickening as indicated by macaroni sign of the multiple veins. TAK phlebitis appeared at the active phase, while disappearing rapidly at remission. Phlebitis might have a close relationship with disease activity. By retrospective study in our department, the estimated incidence rate of phlebitis might be 9.1% in TAK. With the literature review, it revealed that phlebitis might be an ignored manifestation in active TAK. However, due to the smaller sample size, it should be noted that a direct cause-effect relationship cannot be established.

The effect of warm moist compresses in peripheral intravenous catheter-related phlebitis

PURPOSE

Phlebitis is a common complication in palliative patients. There are limited nursing practices in phlebitis care. The study was conducted to determine the effect of warm moist compresses in patients with peripheral intravenous catheter-related phlebitis.

METHODS

70 patients (35 control and 35 experimental) with phlebitis symptoms who were hospitalized in the palliative clinic of a training and research hospital were recruited for the study. The phlebitis site of the patients in the control and experimental groups were followed for three days. While the control group received routine nursing care, the experimental group received a warm moist compresses at 28 °C for 15 min three times a day for three days in addition to routine nursing care.

RESULTS

According to the results, there was a decrease in the initial and final phlebitis grades between the control and experimental groups, but the difference was not statistically significant (p = 0.957, p = 0.078). In the final evaluation of the phlebitis site, a statistically significant difference was observed in redness, edema width, and pain intensity between the control and experimental groups in favor of the experimental group (p˂0.001, p = 0.006, p˂0.001, respectively).

CONCLUSIONS

It was determined that applying warm water compresses three times a day in phlebitis care had a positive effect on healing.

Care bundle for the prevention of peripheral venous catheter blood stream infections at a secondary care university hospital: Implementation and results

BACKGROUND

Venous catheterization for diagnostic and therapeutic purposes is part of routine hospital practice, as approximately 70% of hospitalized patients have a peripheral venous catheter (PVC). This practice, however, can lead to both local complications, (e.g., chemical, mechanical and infectious phlebitis) and systemic complications (e.g., PVC-related bloodstream infections [PVC-BSIs]). Surveillance data and activities are central to preventing nosocomial infections, phlebitis and improving patient care and safety. The aim of this study was to evaluate the impact of a care bundle on reducing PVC-BSI rates and phlebitis at a secondary care hospital in Mallorca, Spain.

METHODS

Three-phase intervention study targeting hospitalized patients with a PVC. The VINCat criteria were used to define PVC-BSIs and calculate incidence. In phase I (August-December 2015), we retrospectively analyzed baseline PVC-BSI rates at our hospital. In phase II (2016-2017), we conducted safety rounds and developed a care bundle with the goal of reducing PVC-BSI rates. In phase III (2018), we expanded the PVC-BSI bundle to prevent phlebitis and analyzed its impact.

RESULTS

The incidence of PVC-BSIs decreased from 0.48 episodes per 1000 patient-days in 2015 to 0.17 episodes per 1000 patient-days in 2018. The 2017 safety rounds also detected a reduction in phlebitis (from 4.6% of 2.6%). Overall, 680 healthcare professionals were trained in catheter care and five safety rounds were conducted to assess bedside care.

CONCLUSION

Implementation of a care bundle significantly reduced PVC-BSI rates and phlebitis at our hospital. Continuous surveillance programs are needed to adapt measures to improve patient care and guarantee safety.

Implementation of Evidence-Based Practice in Peripheral Intravenous Catheter Care

BACKGROUND

Inserting a peripheral intravenous (PIV) catheter is a common health care procedure; however, risks include phlebitis, extravasation, and accidental dislodgement. Using evidence-based practices (EBPs) can reduce these risks.

PURPOSE

The purpose of this study was to implement an evidence-based PIV catheter care bundle and a decision-making algorithm.

METHODS

A quasi-experimental study design was used. A care bundle and an evidence-based decision-making algorithm were implemented on a medical unit. Outcomes included length of PIV catheter dwell time, phlebitis and other complications, and health professionals' adherence to the interventions.

RESULTS

A total of 364 PIV catheters were assessed. PIV catheter dwell time decreased from 3.6 to 2.9 days ( P < .001), and phlebitis rates decreased from 14.8% to 4.9% ( P < .05). Health professionals' adherence increased from 84.3% to 91.8%.

CONCLUSIONS

Implementing EBPs can improve care provided to patients with PIV catheters.

Analysis of influencing factors on the duration of pediatric peripheral intravenous catheter

BACKGROUND

The application of peripheral intravenous catheter has been an effective guarantee for the success of pediatric therapy. We aimed to investigate the correlative factors that impacting the duration of pediatric peripheral intravenous catheter.

METHODS

From January 2017 to October 2017, 370 cases of pediatric patients in the First Hospital of Hunan University of Chinese Medicine were collected as the research object. Based on the indwelling time, the collected cases were divided into two groups, namely long time group (>72 h) and short time group (<72 h). The general data and laboratory test results of two groups were collected, and the correlation factors of indwelling time were analyzed by single factor and Logistic multiple factors.

RESULTS

As the results revealed that compared with short time group, patients in long time group had statistically significant differences in puncture site, phlebitis, extravasation of blood vessels, hemoglobin, white blood cells, platelets, and 75% ethanol sterilization (p < 0.05). Logistic multivariate analysis indicated that scalp puncture was the independent protective factors that affecting the duration of pediatric peripheral intravenous catheter. Moreover, phlebitis represented the independent risk factor that influencing the indwelling time of pediatric peripheral intravenous catheter. And the differences were statistically significant (p < 0.05).

CONCLUSIONS

Analyze factors influencing indwelling time of pediatric peripheral intravenous catheter and enhance the management of relevant factors are of great significance to prolong the indwelling time, reduce the pain of pediatric patients, and facilitate the clinical medication.

Fracture of an Intravenous Cannula in the Hand: A Case Report

BACKGROUND

Intravenous cannula insertion is important, given that it is the most common invasive procedure in the emergency department for blood sampling, fluid resuscitation, and intravenous drug administration. Complications of intravenous catheterization include pain, phlebitis, extravasation, inflammation, and embolization. Fracture of an intravenous cannula is rare, but delayed removal may result in secondary damage, such as vasculitis or embolization, with critical consequences. Here, we report a case of intravenous cannula fracture that occurred in our emergency department.

CASE PRESENTATION

A 63-year-old woman with a history of left ovarian cancer visited our emergency department owing to poor oral intake and general weakness. Intravenous catheterization using an 18 gauge cannula was attempted for intravenous fluid administration by a skilled operator, but it failed owing to collapsed veins and poor skin condition. After several attempts, a vein in the patient's hand was ruptured, and the patient complained of severe pain. The cannula was removed, but one-third of the cannula tip could not be seen. X-ray imaging was performed to locate the fragment of the cannula, and venotomy was performed for removal of the foreign body in the emergency department.

CONCLUSION

Emergency physicians and nurses should be vigilant about potential risk factors that can cause fracture of an intravenous cannula, and after the fracture is discovered, rapid removal of the cannula tip should be performed in the emergency department.

Incidence and type of peripheral intravenous catheter complications documented in hospitalised dogs

OBJECTIVE

To report the incidence and type of peripheral intravenous catheter complications in hospitalised dogs.

METHODS

A prospective, observational trial was performed. Peripheral intravenous catheters were monitored for complications. Complications were documented and classified as extravasation, phlebitis, dislodgement, occlusion and line breakage. If phlebitis was present, the Visual Infusion Phlebitis Scale was used to assign a grade (0 to 5). Fisher's exact test was used to compare the type of complications between the critical care unit and the intermediate care unit. A univariate logistic model was used to compare the incidence of complications between the critical care unit and the intermediate care unit and adjusted odds ratios were used to compare the groups.

RESULTS

The incidence of peripheral intravenous catheter complications was 24.2% in the Critical Care Unit and 13.1% in the Intermediate Care Unit, with an overall incidence of 19.9%. Phlebitis was the most common peripheral intravenous catheter complication in the Critical Care Unit, and line breakage was the most common complication in the Intermediate Care Unit. Length of hospitalisation and weight had a significant effect on the likelihood of complication. In a multivariable logistic regression model, the odds of a peripheral intravenous catheter complication was not significantly higher in CCU than IMCU, accounting for length of hospitalisation and weight (adjusted odds ratio, 1.84; 95% confidence interval, 0.98 to 3.48).

CLINICAL SIGNIFICANCE

Peripheral intravenous catheter complications are common in hospitalised dogs and may result in an increased expense for owners, failure to deliver prescribed treatments, venous depletion (lack of peripheral vessels for intravenous catheter placement) and pain experienced by the patient. Techniques to reduce peripheral intravenous catheter complications should be further evaluated and may include the use of peripheral intravenous catheter placement and maintenance checklists, use of force-activated separation devices, or patient sedation.

Integrated versus nonintegrated peripheral intravenous catheter in hospitalized adults (OPTIMUM): A randomized controlled trial

BACKGROUND

One-third of peripheral intravenous catheters (PIVCs) fail from inflammatory or infectious complications, causing substantial treatment interruption and replacement procedures.

OBJECTIVES

We aimed to compare complications between integrated PIVCs (inbuilt extension sets, wings, and flattened bases) and traditional nonintegrated PIVCs.

DESIGNS, SETTINGS AND PARTICIPANTS

A centrally randomized, controlled, superiority trial (with allocation concealment until study entry) was conducted in three Australian hospitals. Medical-surgical patients (one PIVC each) requiring intravenous therapy for >24 h were studied.

MAIN OUTCOME MEASURES

The primary outcome was device failure (composite: occlusion, infiltration, phlebitis, dislodgement, local, or bloodstream infection). Infection endpoints were assessor-masked. The secondary outcomes were: failure type, first-time insertion success, tip colonization, insertion pain, dwell time, mortality, costs, health-related quality of life, clinician, and patient satisfaction.

RESULTS

Out of 1759 patients randomized (integrated PIVC, n = 881; nonintegrated PIVC, n = 878), 1710 (97%) received a PIVC and were in the modified intention-to-treat analysis (2269 PIVC-days integrated; 2073 PIVC-days nonintegrated). Device failure incidence was 35% (145 per 1000 device-days) nonintegrated, and 33% (124 per 1000 device-days) integrated PIVCs.

INTERVENTION

Integrated PIVCs had a significantly lower failure risk (adjusted [sex, infection, setting, site, gauge] hazard ratio [HR]: 0.82 [95% confidence interval, CI: 0.69-0.96], p = .015). The per-protocol analysis was consistent (adjusted HR: 0.80 [95% CI: 0.68-0.95], p = .010). Integrated PIVCs had significantly longer dwell (top quartile ≥ 95 vs. ≥84 h). Mean per-patient costs were not statistically different.

CONCLUSIONS

PIVC failure is common and complex. Significant risk factors include sex, infection at baseline, care setting, insertion site, catheter gauge, and catheter type. Integrated PIVCs can significantly reduce the burden of PIVC failure on patients and the health system.

Intravenous cannula induced phlebitis in a tertiary care referral hospital: A prospective observational study with implication from patient's feedback system

BACKGROUND

Medicines delivered directly to systemic circulation have saved many lives from life-threatening conditions, but also can impart undesirable effects.

MATERIALS AND METHODS

A prospective observational study was performed for 10 months in the tertiary care hospital to identify and evaluate cannula induced phlebitis in our study population. The data collection form retrieved demographic details, diseases and cannulation particulars of each patient. Moreover, a patient feedback questionnaire (Cronbach's alpha=0.70) retrieved their concerns toward cannulation.

RESULTS

Phlebitis was identified in 96 patients out of 146 subjects enrolled in the study; 52% had the first sign of phlebitis. Female patients were more prone, and the complication occurred irrespective of age (p>0.05). On the other hand, those on IV cefoperazone-sulbactam (n=13, 13.5%) followed by amoxicillin clavulanic acid (n=6, 6%) had significant cannulation complication (p<0.01). The cannula indwells time (p=0.001) and vein assessment (p=0.001) were statistically associated with incidence of phlebitis. Half of our samples had pain lasting about five minutes (χ²=9.2, p<0.05). Nevertheless, limited patients (n = 35, 36.5%) were prescribed topical Heparin Benzyl Nitrate, and none preferred to self-medicate nor opted for other home remedies.

CONCLUSIONS

The study depicted high prevalence of phlebitis factored in by poor vein assessment and increase in indwelling time. We recommend proper awareness with on-site skill improvement program for health professionals on administration techniques and monitoring principles in order to lower cannulation related complications.

Complications of peripheral intravenous catheters and risk factors for infiltration and phlebitis in children

AIM

This study aimed to identify the types of complications of peripheral intravenous catheters (PIVCs) in hospitalised children and possible risk factors for the development of extravasation, infiltration and phlebitis.

METHOD

The study was conducted in the largest children's hospital in a region of Turkey, with a bed capacity of 354 and 1400 employees, which provides care only to paediatric patients aged from newborn to 18 years old. In this 5-month prospective study, the complications of PIVCs in hospitalised children and risk factors leading to the development of extravasation, infiltration and phlebitis were recorded. During morning and afternoon daily visits, the researcher examined catheter sites for complications and indications for removal.

RESULTS

The study covered 244 patients aged from 1 month to 17 years, 575 PIVCs and 1600 catheter days. The rates of infiltration and phlebitis observed in children with PIVCs were 8.7 % and 15.8% respectively. Logistic regression revealed that using 22- and 24-gauge catheters, hospitalisation in the surgery ward and continuous infusion were significant independent risk factors for the development of infiltration (P<0.001). Direct logistic regression revealed that age in months, hospitalisation in a surgery ward and placement of the catheter in the veins of the antecubital fossa were significant independent risk factors for the development of phlebitis (P<0.001).

CONCLUSION

Catheter size, hospitalisation in the surgery ward and continuous infusion contributed to the development of infiltration. Age, hospitalisation in the surgery ward and catheter placement in the antecubital vein contributed to the development of phlebitis.

Peripheral intravenous catheter failure: A secondary analysis of risks from 11,830 catheters

BACKGROUND

Peripheral intravenous catheters are an essential medical device which are prone to complications and failure.

OBJECTIVES

Identify patient, provider and device risk factors associated with all-cause peripheral intravenous catheter failure as well as individual complications: phlebitis, infiltration/occlusion, and dislodgement to improve patient outcomes.

DESIGN

Secondary analysis of twelve prospective studies performed between 2008 and 2020.

SETTINGS

Australian metropolitan and regional hospitals including one paediatric hospital.

PARTICIPANTS

Participants were from medical, surgical, haematology, and oncology units.

METHODS

Multilevel mixed-effects parametric survival regression was used to identify factors associated with all-cause peripheral intravenous catheter failure, phlebitis, occlusion/infiltration, and dislodgement. We studied patient (e.g., age, gender), device (e.g., gauge), and provider (e.g., inserting clinician) variables. Stepwise regression involved clinically and p<0.20 significant variables entered into the multivariable model. Results were expressed as hazard ratios (HRs) and 95% confidence intervals (CI); p<0.01 was considered statistically significant.

RESULTS

Of 11,830 peripheral intravenous catheters (8,200 participants) failure occurred in 36% (n = 4,263). Occlusion/infiltration incidence was 23% (n = 2,767), phlebitis 12% (n = 1,421), and dislodgement 7% (n = 779) of catheters. Patient factors significantly associated with failure and complications were: female gender (phlebitis; (HR 1.98, 95% CI 1.72-2.27), (infiltration/occlusion; HR 1.45, 95% CI 1.33-1.58), (failure; HR 1.36, 95% CI 1.26-1.46); and each year increase in age (phlebitis; 0.99 HR, 95% CI 0.98-0.99), (failure; 0.99 HR, 95% CI 0.99-0.99). The strongest provider risk factor was intravenous antibiotics (infiltration/occlusion; HR 1.40, 95% CI 1.27-1.53), (phlebitis; HR 1.36, 95% CI 1.18-1.56), (failure; HR 1.26, 95% CI 1.17-1.36). Catheters inserted by vascular access teams were less likely to dislodge (HR 0.53, 95% CI 0.42-0.67). Device risk factors most associated with all-cause failure were wrist/hand (HR 1.34, 95% CI 1.23-1.46), antecubital fossa peripheral intravenous catheters (HR 1.29, 95% CI 1.16-1.44) and 22/24 gauge (HR 1.27, 95% CI 1.12-1.45) catheters.

CONCLUSION

Factors identified, including the protective aspect of vascular access team insertion, and high catheter failure associated with intravenous antibiotic administration, will allow targeted updates of peripheral intravenous catheter guidelines and models of care.

Multimodal intervention for preventing peripheral intravenous catheter failure in adults (PREBACP): a multicentre, cluster-randomised, controlled trial

BACKGROUND

2 billion peripheral intravenous catheters (PIVC) are inserted into inpatients worldwide each year. Almost one in two PIVCs fail before completion of intravenous therapy. We aimed to determine the efficacy and costs of a multimodal intervention to reduce PIVC failure among hospitalised patients.

METHODS

PREBACP was a cluster-randomised, controlled trial done at seven public hospitals in Spain. Clusters (hospital wards) had at least 70% permanent staff and data were collected from patients aged 18 years and older with one or more PIVCs at the start of intravenous therapy. Clusters were randomly assigned (1:1) to the multimodal intervention or control group using a centralised, web-based randomisation software, and stratified by type of setting. We concealed randomisation to allocation, without masking patients or professionals to the intervention. An intervention using a multimodal model and dissemination of protocols, education for health-care professionals and patients, and feedback on performance was implemented for 12 months in the intervention group. The control group received usual care. The primary outcome was all-cause PIVC failure at 12 months (phlebitis, extravasation, obstruction, or infections). Subsequently, through an amendment to the protocol approved on July 25, 2021, we included dislodgement as part of PIVC failure. Analysis was by modified intention to treat, which included all randomly assigned hospital wards for whom data on the primary endpoint were available. This trial is registered with the ISRCTN Registry, ISRCTN10438530.

FINDINGS

Between Jan 1, 2019, and March 1, 2020, we randomly assigned 22 eligible clusters to receive the multimodal intervention (n=11 clusters; 2196 patients, 2235 PIVCs, and 131 nurses) or usual practice in the control group (n=11 clusters; 2282 patients, 2330 PIVCs, and 138 nurses). At 12 months, the proportion of PIVC failures was lower in the intervention group than in the control group (37·10% [SD 1·32], HR 0·81 [95% CI 0·72 to 0·92] vs 46·49% [2·59], HR 1·23 [1·04 to 1·39]; mean difference -9·39% [95% CI -11·22 to -7·57]; p<0·0001). Per-protocol-prespecified analysis of the primary outcome excluding dislodgement also showed the intervention significantly reduced PIVC failure compared with the control group at 12 months (33·47% [SD 2·98], HR 0·85 [95% CI 0·75 to 0·96] vs 41·06% [4·62], HR 1·18 [1·04 to 1·33]; mean difference -7·59% [95% CI -11·05 to -4·13]; p<0·0001).

INTERPRETATION

A multimodal intervention reduced PIVC failure, thereby reducing potentially serious complications for hospitalised patients. The findings of PREBACP enabled a deeper understanding of decision making, knowledge mobilisation, and sense making in routine clinical practice.

FUNDING

The College of Nurses of the Balearic Islands.

TRANSLATION

For the Spanish translation of the abstract see Supplementary Materials section.

Enterocolic lymphocytic phlebitis: a rare pathology in children

Enterocolic lymphocytic phlebitis (ELP) is a rare pathology, usually seen in the adult population. The condition affects the venous vasculature of the intestine sparing the arteries and lymphatics. It is commonly identified histologically after surgical resection making the preoperative diagnosis a clinical challenge. As the condition can lead to intestinal ischaemia and necrosis, surgical resection of the affected segment is the treatment of choice. We report the case of a 9-year-old girl who presented with a 2-day history of lower abdominal pain and anorexia. The initial diagnosis of appendicitis was made clinically and the patient underwent a diagnostic laparoscopy . The appendix was macroscopically normal and there were no other obvious intra-abdominal pathologies to account for her presenting complaints . The appendix was removed, as per the preoperative discussion and consent from parents. She recovered well and was discharged home the following day. The histological examination of the appendix demonstrated ELP. We describe this rare clinical entity in a child especially in view of the scarce published literature in the paediatric population.

Applicability of TIVAP versus PICC in non-hematological malignancies patients: A meta-analysis and systematic review

BACKGROUND

Applicability of totally implantable venous access port (TIVAP) and peripherally inserted central venous catheter (PICC) in non-hematological malignancies patients remains controversial.

METHODS

A systematic studies search in the public databases PubMed, EMBASE, Wan Fang, CNKI (China National Knowledge Infrastructure), the Cochrane Library and Google Scholar (updated to May 1, 2020) was performed to identify eligible researches. All statistical tests in this meta-analysis were performed using Stata 12.0 software (Stata Corp, College Station, TX). A P value less than 0.05 was considered statistically significant.

RESULTS

Thirteen studies were included in this final meta-analysis. The pooled data showed that compared with PICC, TIVAP was associated with a higher first-puncture success rate (OR:2.028, 95%CI:1.25-3.289, P<0.05), a lower accidental removal rate (OR:0.447, 95%CI:0.225-0.889, P<0.05) and lower complication rates, including infection (OR:0.570, 95%CI: 0.383-0.850, P<0.05), occlusion (OR:0.172, 95%CI:0.092-0.324, P<0.05), malposition (OR:0.279, 95%CI:0.128-0.608, P<0.05), thrombosis (OR:0.191, 95%CI, 0.111-0.329, P<0.05), phlebitis (OR:0.102, 95%CI, 0.038-0.273, P<0.05), allergy (OR:0.155, 95%CI:0.035-0.696, P<0.05). However, no difference was found in catheter life span (P>0.05) and extravasation (P>0.05). Moreover, TIVAP is more expensive compared with PICC in six-month use (weighted mean difference:3.132, 95%CI:2.434-3.83, P<0.05), but is much similar in 12 months use (P>0.05).

CONCLUSION

For the patients with non-hematological malignancies, TIVAP was superior to PICC in the data related to placement and the incidence of complications. Meanwhile, TIVAP is more expensive compared with PICC in six-month use, but it is much similar in twelve-month use.

Effects of a Clinically Indicated Peripheral Intravenous Replacement on Indwelling Time and Complications of Peripheral Intravenous Catheters in Pediatric Patients: A Randomized Controlled Trial

Peripheral intravenous catheters (PVCs) are common treatment modalities for pediatric patients, and may cause infection, infiltration, occlusion, and phlebitis. The purpose of this study was to evaluate the effect of a clinically indicated peripheral intravenous replacement (CIPIR) on PVC indwelling time and complication rates in pediatric patients. This study used a randomized, pre- and post-repeated measures design. A total of 283 participants were randomly assigned to an experimental group (n = 140) and a control group (n = 143). The experimental group received CIPIR and the control group received usual care with routine PVC replacement every three days. The insert sites of PVC were assessed every day until the signs of infiltration, occlusion, or phlebitis were presented. Patients in the experimental group had significantly longer PVC indwelling times compared to those in the control group (t = −18.447, p < 0.001). No significant differences were noted between groups in infiltration (χ² = 2.193, p = 0.139), occlusion (χ² = 0.498, p = 0.481), or phlebitis (χ² = 3.865, p = 0.050). CIPIR can prolong the PVC indwelling time in pediatric patients with no increase in the rate of adverse events.

Standardization and Chemical Characterization of Intravenous Therapy in Adult Patients: A Step Further in Medication Safety

BACKGROUND

Intravenous drug administration is associated with potential complications, such as phlebitis. The physiochemical characteristics of the infusate play a very important role in some of these problems.

AIM

The aim of this study was to standardize the dilutions of intravenous drugs most commonly used in hospitalized adult patients and to characterize their pH, osmolarity and cytotoxic nature to better guide the selection of the most appropriate vascular access.

METHODS

The project was conducted in three phases: (i) standardization of intravenous therapy, which was conducted using a modified double-round Delphi method; (ii) characterization of the dilutions agreed on in the previous phase by means of determining the osmolarity and pH of each of the agreed concentrations, and recording the vesicant nature based on the information in literature; and (iii) algorithm proposal for selecting the most appropriate vascular access, taking into account the information gathered in the previous phases.

RESULTS

In total, 112 drugs were standardized and 307 different admixtures were assessed for pH, osmolarity and vesicant nature. Of these, 123 admixtures (40%), had osmolarity values >600 mOsm/L, pH < 4 or > 9, or were classified as vesicants. In these cases, selection of the most suitable route of infusion and vascular access device is crucial to minimize the risk of phlebitis-type complications.

CONCLUSIONS

Increasing safety of intravenous therapy should be a priority in the healthcare settings. Knowing the characteristics of drugs to assess the risk involved in their administration related to their physicochemical nature may be useful to guide decision making regarding the most appropriate vascular access and devices.

Randomized clinical trial analyzing maintenance of peripheral venous catheters in an internal medicine unit: Heparin vs. saline

Background

Peripheral venous catheters (PVCs) require adequate maintenance based on heparin or saline locks in order to prevent complications. Heparin has proven effective in central venous catheters, although its use in PVCs remains controversial. Our hypothesis was that saline locks are as effective as heparin locks in preventing problems with PVCs. The objective of the present study was to compare phlebitis and catheter tip colonization rates between PVCs locked with saline and those locked with heparin in patients admitted to an internal medicine department (IMD).

Methods

We performed a 19-month prospective, controlled, open-label, randomized clinical study of patients with at least 1 PVC admitted to the IMD of our hospital. The patients were randomized to receive saline solution (PosiFlush^®, group A) or heparin (Fibrilin^®, group B) for daily maintenance of the PVC. Clinical and microbiological data were monitored to investigate the frequency of phlebitis, catheter tip colonization, and catheter-related bloodstream infection (C-RBSI), as well as crude mortality, days of hospital stay, and days of antimicrobial treatment.

Results

We assessed 339 PVCs (241 patients), of which 192 (56.6%) were locked with saline (group A) and 147 (43.4%) with heparin (group B). The main demographic characteristics of the patients were distributed equally between the 2 study groups. The median (IQR) catheter days was 5 (3–8) for both groups (p = 0.64). The frequency of phlebitis was 17.7% for group A and 13.3% for group B (p = 0.30). The frequency of colonization of PVC tips was 14.6% and 12.2% in groups A and B, respectively (p = 0.63). Only 2 episodes of C-RBSI were detected (1 patient in group A). Saline lock was not an independent factor for phlebitis or catheter colonization.

Conclusions

Our study revealed no statistically significant differences in the frequency of phlebitis and catheter tip colonization between PVCs locked with saline and PVCs locked with heparin. We suggest that PVC can be maintained with saline solution, as it is safer and cheaper than heparin.

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.

Observation for clinical effect of phellodendron wet compress in treating the phlebitis caused by infusion

Aim of the study was to observe and analyze the clinical effect of phellodendron wet compress in treating the phlebitis caused by infusion. The research objects were 600 cases of phlebitis caused by infusion, all of which were treated in our hospital from June 2013 to June 2016. All patients were entitled to the right to know. They were randomly divided into the research group and the control group. Patients in the control group were treated with magnesium sulfate solution wet compress, while patients in the research group were treated with phellodendron wet compress. The effects in these two groups were observed and compared. Compared with the control group, the research group has better overall treatment efficiency, p<0.05; shorter average onset of action, p<0.05; less time in relieving red swelling and pain, p<0.05. Phellodendron wet compress shows a beneficial effect in treating the phlebitis caused by infusion. It can not only obviously shorten the onset of action, but also level up the overall treatment efficiency that helps patients to recover.

Transdermal Glyceryl Trinitrate to Allow Peripheral Total Parenteral Nutrition: A Double-Blind Placebo Controlled Feasibility Study

Seventy-two consecutive patients requiring total parenteral nutrition (TPN) were randomized to two groups. Group A received daily a peripheral intravenous regimen which provided 10 g nitrogen and 1400 non-nitrogen kcal (5.9 MJ). Group B received daily a peripheral intravenous regimen which delivered 9.4 g nitrogen and 1900 non-nitrogen kcal (8.0 MJ). Each group was further randomized to receive a self-adhesive patch of transdermal glyceryl trinitrate (GTN) or an identical placebo. Infusion survival was the main end-point. For group A, the median time of infusion survival was 74 h (range: 58–100) in the control group compared with 108 h (range: 68–156) in the group that received transdermal GTN (P < 0.001). For group B, the median infusion survival was 67 h (range: 46–92) in the control group compared with 103 h (range: 66–151) in the treatment group (P < 0.001). TPN is feasible via peripheral veins and the incidence of infusion failure can be effectively reduced by transdermal GTN.

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.

Evaluation on inflammatory states of peripheral veins connected with cannulation /

INTRODUCTION

Peripheral veins cannulation is one of the most frequently executed medical procedures. Primary blood infections which might be the result of peripheral veins cannulation are serious issue that medical care centers all over the world must consider. Medical personnel can choose the area of cannulation thanks to the availability of peripheral veins. Duration of cannulation longer than 72 – 96 hours can cause peripheral veins inflammation.

AIM OF THE STUDY

Assay of observation sheets of peripheral cannulation.

MATERIAL AND METHODS

The study included 14926 patients, who were hospitalized in 2016 in the Municipal Hospital in Zabrze. Observations of each cannulation were recorded in observation sheets for peripheral veins cannulation. Patients age median and duration of cannulation median were calculated basing on 782 observation sheets with registered inflammation of the area of cannulation.

RESULTS

Right forearm was area where the most (19%) of vein inflammation occurred. First level of veins inflammation according to criteria of veins inflammation intensity evaluation was the most frequent (90,7%). Duration of venous cannulation median indicated that most of the catheters were removed on the second day. When veins inflammation was diagnosed, the most frequent action was to remove the catheter. During 12 hours 697 observations of cannulation were proceeded. 548 observations of intravenous cannulation were proceeded once for 24 hours.

CONCLUSIONS

Right forearm was area where the most of cannulations occurred. Frequent observation of the area of peripheral venous cannulation allows quick inflammation symptoms detection.

INFECTION PREVENTION: PERIPHERAL INTRAVENOUS CATHETER ASSESSMENT AND CARE

Peripheral intravenous catheters are the most common device in hospital patients, but they do come with infection risks. Awareness of the complications and regular assessment can reduce risks and improve patient outcomes.

Peripheral Venous Catheter-Related Adverse Events: Evaluation from a Multicentre Epidemiological Study in France (the CATHEVAL Project)

Introduction

Peripheral venous catheters (PVC) are medical devices most frequently used during hospital care. Although the frequency of specific PVC-related adverse events (PVCAEs) has been reported, the global risk related to the insertion of this device is poorly estimated. The aim of this study is to determine the incidence of PVCAEs during the indwell time, after catheter removal, and to identify practice-mirroring risk factors.

Methods

A prospective observational study was conducted as a part of a research project, called CATHEVAL, in one surgery ward and four medicine wards from three public general tertiary care hospitals in Northern France that were invited to participate between June-2013 and June-2014. Each participating ward included during a two-month study period all patients older than 15 years carrying a PVC. All inserted PVCs were monitored from insertion of PVC to up to 48 hours after removal. Monitored data included several practice-mirroring items, as well as the occurrence of at least one PVCAE. A multivariate Cox proportional hazard model, based on a marginal risk approach, was used to identify factors associated with the occurrence of at least one PVCAE.

Results

Data were analysed for 815 PVCs (1964 PVC-days) in 573 patients. The incidence of PVCAE was 52.3/100 PVCs (21.9/100 PVC-days). PVCAEs were mainly clinical: phlebitis (20.1/100 PVCs), haematoma (17.7/100 PVCs) and liquid/blood escape (13.1/100 PVCs). Infections accounted for only 0.4/100 PVCs. The most frequent mechanical PVCAEs, was obstruction/occlusion of PVC (12.4/100 PVCs). The incidence of post-removal PVCAEs was 21.7/100 PVCs. Unstable PVC and unclean dressing were the two main risk factors.

Conclusion

Limitation of breaches in healthcare quality including post-removal monitoring should be reinforced to prevent PVC-related adverse events in hospital settings.

Complications of Peripherally Inserted Central Venous Catheters: A Retrospective Cohort Study

BACKGROUND AND AIM

The use of venous catheters is a widespread practice, especially in oncological and oncohematological units. The objective of this study was to evaluate the complications associated with peripherally inserted central catheters (PICCs) in a cohort of patients.

MATERIALS AND METHODS

In this retrospective cohort study, we included all patient carrying PICCs (n = 603) inserted at our institute between October 2010 and December 2013. The main variables collected were medical diagnosis, catheter care, location, duration of catheterization, reasons for catheter removal, complications, and nursing care. Complications were classified as infection, thrombosis, phlebitis, migration, edema, and/or ecchymosis.

RESULTS

All patients were treated according to the same "nursing care" protocol. The incidence rate of complications was two cases per 1000 days of catheter duration. The most relevant complications were infection and thrombosis, both with an incidence of 0.17 cases per 1000 days of the total catheterization period. The total average duration of catheterization was 170 days [SD 6.06]. Additionally to "end of treatment" (48.42%) and "exitus", (22.53%) the most frequent cause of removal was migration (displacement towards the exterior) of the catheter (5.80%).

CONCLUSIONS

PICCs are safe devices that allow the administration of long-term treatment and preserve the integrity of the venous system of the patient. Proper care of the catheter is very important to improve the quality life of patients with oncologic and hematologic conditions. Therefore, correct training of professionals and patients as well as following the latest scientific recommendations are particularly relevant.

Causes and nursing countermeasures in pediatric PICC catheter complications

To analyze the complications and nursing countermeasures of PICC (Peripherally Inserted Central Catheter) catheters using children PICC catheter technique 40 cases, complications were observed, and analyze the original causes, in order to propose a solution. There were 10 cases of catheter blockage, 5 cases of catheter infection, 6 cases of phlebitis, 5 cases of puncture difficulties, 2 cases of poor feeding tube, 2 cases of bleeding puncture site with the continuous exploration and research of nursing intervention, the production of clinical complications from PICC has been used in children were greatly reduced.

Peripheral IV Site Rotation Based on Clinical Assessment vs. Length of Time Since Insertion

The difference in complication rates for phlebitis and infiltration between peripheral intravenous site rotation based on clinical assessment versus length of time since insertion was evaluated. Evidence was generated for a policy change that will impact the quality of patient care.

Securing All intraVenous devices Effectively in hospitalised patients--the SAVE trial: study protocol for a multicentre randomised controlled trial

INTRODUCTION

Over 70% of all hospital admissions have a peripheral intravenous device (PIV) inserted; however, the failure rate of PIVs is unacceptably high, with up to 69% of these devices failing before treatment is complete. Failure can be due to dislodgement, phlebitis, occlusion/infiltration and/or infection. This results in interrupted medical therapy; painful phlebitis and reinsertions; increased hospital length of stay, morbidity and mortality from infections; and wasted medical/nursing time. Appropriate PIV dressing and securement may prevent many cases of PIV failure, but little comparative data exist regarding the efficacy of various PIV dressing and securement methods. This trial will investigate the clinical and cost-effectiveness of 4 methods of PIV dressing and securement in preventing PIV failure.

METHODS AND ANALYSIS

A multicentre, parallel group, superiority randomised controlled trial with 4 arms, 3 experimental groups (tissue adhesive, bordered polyurethane dressing, sutureless securement device) and 1 control (standard polyurethane dressing) is planned. There will be a 3-year recruitment of 1708 adult patients, with allocation concealment until randomisation by a centralised web-based service. The primary outcome is PIV failure which includes any of: dislodgement, occlusion/infiltration, phlebitis and infection. Secondary outcomes include: types of PIV failure, PIV dwell time, costs, device colonisation, skin colonisation, patient and staff satisfaction. Relative incidence rates of device failure per 100 devices and per 1000 device days with 95% CIs will summarise the impact of each dressing, and test differences between groups. Kaplan-Meier survival curves (with log-rank Mantel-Cox test) will compare device failure over time. p Values of <0.05 will be considered significant. Secondary end points will be compared between groups using parametric or non-parametric techniques appropriate to level of measurement.

ETHICS AND DISSEMINATION

Ethical approval has been received from Queensland Health (HREC/11/QRCH/152) and Griffith University (NRS/46/11/HREC). Results will be published according to the CONSORT statement and presented at relevant conferences.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trial Registry (ACTRN); 12611000769987.

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.

Graves' Disease Patients with Persistent Hyperthyroidism and Diffuse Lymphoplasmacytic Infiltration in the Thyroid Show No Histopathological Compatibility with IgG4-Related Disease

BACKGROUND

IgG4-related disease is a novel disease entity characterized by diffuse lymphoplasmacytic infiltration rich in IgG4-positive plasma cells and fibrosis into multiple organs. There is still controversy over whether some thyroid diseases are actually IgG4-related disease. The objective of this study was to elucidate the clinicopathological features of Graves' disease with diffuse lymphoplasmacytic infiltration in the thyroid.

PATIENTS AND METHODS

Among 1,484 Graves' disease patients who underwent thyroidectomy, we examined their histopathological findings including the degree of lymphoplasmacytic and fibrotic infiltration and levels of IgG4-positive plasma cells in the thyroid. Their clinical pictures were defined by laboratory and ultrasonographic evaluation.

RESULTS

A total of 11 patients (0.74%) showed diffuse lymphoplasmacytic infiltration in the stroma of the thyroid gland. Meanwhile, other patients showed variable lymphoid infiltration ranging from absent to focally dense but no aggregation of plasma cells in the thyroid gland. Based on the diagnostic criteria of IgG4-related disease, 5 of the 11 subjects had specifically increased levels of IgG4-positive plasma cells in the thyroid. Fibrotic infiltration was present in only 1 patient developing hypothyroidism after anti-thyroid drug treatment for 4 years, but not in the other 10 patients with persistent hyperthyroidism. Obliterative phlebitis was not identified in any of the 11 subjects. Thyroid ultrasound examination showed 1 patient developing hypothyroidism who had diffuse hypoechogenicity, but the other hyperthyroid patients had a coarse echo texture.

CONCLUSIONS

In our study, Graves' disease patients with persistent hyperthyroidism who had diffuse lymphoplasmacytic infiltration rich in IgG4-positive plasma cells in the thyroid showed no concomitant fibrosis or obliterative phlebitis.

Central nervous system granulomastous phlebitis with limited extracranial involvement of the heart and lungs: An autopsy case

Primary angiitis of the central nervous system is a rare condition, usually with an insidious onset. There is a wide variety of histological types (granulomatous, lymphocytic or necrotizing vasculitis) and types of vessel involved (arteries, veins or both). Most cases are idiopathic. We describe a first case of idiopathic granulomatous central nervous system phlebitis with additional limited involvement of the heart and lung, exclusively affecting small and medium sized veins in a 22-year-old woman, presenting as a sub acute headache. The reasons for this peculiar limitation of inflammation to the veins and the involvement of the heart and lungs are unknown.

Detection of serum IgG4 levels in patients with IgG4-related disease and other disorders

Objective

Elevated serum IgG4 levels are an important hallmark for diagnosing IgG4-related disease (IgG4-RD), but can also be observed in other diseases. This study aimed to compare two different testing methods for IgG4: ELISA and nephelometric assay. Both assays were used to measure serum IgG4 concentrations, and to assess the prevalence of high serum IgG4 levels in both IgG4-RD and non-IgG4-RD diseases.

Methods

A total of 80 serum samples were tested using the nephelometric assay and ELISA method that we established. Serum IgG4 concentrations were determined by ELISA for 957 patients with distinct diseases, including 12 cases of IgG4-RD and 945 cases of non-IgG4-RD.

Results

IgG4 levels from 80 selected serum samples examined by ELISA were in agreement with those detected using the nephelometry assay. Meanwhile, the serum IgG4 concentrations measured by ELISA were also consistent with the clinical diagnoses of patients with IgG4-RD during the course of disease. The Elevated levels of serum IgG4 (>1.35 g/L) were detected in all IgG4-RD (12/12) patients, and the prevalence of high IgG4 serum levels was 3.39% in non-IgG4-RD cases. Among them, the positive rates of serum IgG4 were 2.06% in patients with carcinoma and 6.3% in patients with other non-IgG4 autoimmune diseases.

Conclusion

Our established ELISA method is a reliable and convenient technique, which could be extensively used in the clinic to measure serum IgG4 levels. High levels of IgG4 were observed in IgG4-RD. However, this phenomenon could also be observed in other diseases, such as carcinomas and other autoimmune diseases. Thus, a diagnosis of IgG4 disease cannot only be dependent on the detection of elevated serum IgG4 levels.

Post-insertion of poloxamer 188 strengthened liposomal membrane and reduced drug irritancy and in vivo precipitation, superior to PEGylation

The ultimate aim of this study was to develop asulacrine (ASL)-loaded long-circulating liposomes to prevent phlebitis during intravenous (i.v.) infusion for chemotherapy. Poly(ethylene)glycol (PEG) and poloxamer 188-modified liposomes (ASL-PEGL and ASL-P188L) were developed, and ASL was loaded using a remote loading method facilitated with a low concentration of sulfobutyl ether-β-cyclodextrin as a drug solubilizer. The liposomes were characterized in terms of morphology, size, release properties and stability. Pharmacokinetics and venous tissue tolerance of the formulations were simultaneously studied in rabbits following one-hour i.v. infusion via the ear vein. The irritancy was assessed using a rat paw-lift/lick model after subplantar injections. High drug loading 9.0% w/w was achieved with no drug leakage found from ASL-PEGL or ASL-P188L suspended in a 5% glucose solution at 30days. However, a rapid release (leakage) from ASL-PEGL was observed when PBS was used as release medium, partially related to the use of cyclodextrin in drug loading. Post-insertion of poloxamer 188 to the liposomes appeared to be able to restore the drug retention possibly by increasing the packing density of phospholipids in the membrane. In rabbits (n=5), ASL-P188L had a prolonged half-life with no drug precipitation or inflammation in the rabbit ear vein in contrast to ASL solution. Following subplantar (footpad) injections in rats ASL solution induced paw-lick/lift responses in all rats whereas ASL-P188L caused no response (n=8). PEGylation showed less benefit possibly due to the drug 'leakage'. In conclusion, drug precipitation in the vein and the drug mild irritancy may both contribute to the occurrence of phlebitis caused by the ASL solution, and could both be prevented by encapsulation of the drug in liposomes. Poloxamer 188 appeared to be able to 'seal' the liposomal membrane and enhance drug retention. The study also highlighted the importance of bio-relevant in vitro release study in formulation screening.

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).

[Effect of pharmacotherapy on course of postoperative period after endovenous thermal ablation]

The authors assessed the effect of a micronized purified flavonoid fraction (MPFF) on the course of the postoperative period after endovenous thermal ablation (EVTA). The patients of the Study Group matching by the main studied parameters to the Control Group patients were given the MPFF according to the suggested regimen for 7 days. The obtained results were analysed by means of questionnaires (CIVIQ, VCSS, VAS) and ultrasound angioscanning. The obtained findings were statistically processed by means of the program Statistica 6.0 and reliability of the results was assessed with the help of the Student t-test. Patients of the both groups showed complete stable obliteration of the target veins. No statistically significant differences of the items of the questionnaires CIVIQ and VCSS at the beginning of the study and at the last examination were revealed, differences were noted on days 2-14 after EVTA and were not statistically significant (p>0.05). Phlebotrophic therapy in the postoperative period after EVTA helps to decrease phlebitic alterations in the coagulated vein, to improve motor activity and mental psychoemotional state of the patients.

MULTIFOCAL RETINAL INFILTRATES WITH PHLEBITIS AND OPTIC NEUROPATHY IN AN HIV-POSITIVE PEDIATRIC PATIENT

PURPOSE

To describe an unusual presentation of bilateral HIV-associated multifocal retinal infiltrates with phlebitis and optic neuropathy in a pediatric patient from Zimbabwe, Africa.

METHODS

Retrospective case report of a 15-year-old boy from Zimbabwe, Africa.

RESULTS

The patient was found to have bilateral vitritis, multifocal retinitis with phlebitis, and optic neuropathy in the setting of previously unrecognized HIV infection. Vision improved and the clinical findings resolved after treatment with intravenous corticosteroids and highly active retroviral therapy (HAART).

CONCLUSION

The authors describe the occurrence and treatment of bilateral, HIV-associated multifocal retinal infiltrates with phlebitis and HIV-associated optic neuropathy in a pediatric patient from Zimbabwe, Africa.

[Incidence of adverse events associated to the use of short peripheral venous catheters]

BACKGROUND

Surveillance of adverse events associated to the use of short peripheral venous catheters (SPVC) is an indicator of quality of service. The objective was to report the incidence and risk factors associated to adverse events in SPVC.

METHODS

Prospective cohort study. All patients with a SPVC for more than 48 hours were included. The outcome variables were dysfunction, chemical phlebitis and bacterial phlebitis. The data registered were age, sex, underlying diseases, nutritional status, site of placement, skin condition, administered intravenous fluids, and catheter dressing. Regarding statistical analysis, incidence rate for each adverse event was calculated per 100 catheters and per 1000 catheter-days. Univariate and multivariate analysis of risk factors were performed.

RESULTS

410 catheters were analyzed. Median of SPVC use was of three days. There was no evidence of infectious complications: 47 (11.4 %) presented chemical phlebitis and 231 (56.3 %) mechanical malfunction; the incidence rate was 35.6 and 175 per 1000 catheter-days, respectively. In the multivariate analysis, the risk factors associated to chemical phlebitis were skin lesions (p = 0.001, RR 3.479), and additional dressing use (p = 0.007, RR 4.025); for mechanical malfunction the only risk factor was the administration of intravenous chemotherapy (p = 0.026, RR 4.293).

CONCLUSIONS

The malfunction incidence rate was high; in consequence, the catheter was removed before 96 hours of use. This could explain the absence of infectious complications.

Aloe vera for prevention and treatment of infusion phlebitis

BACKGROUND

Up to 80% of hospitalised patients receive intravenous therapy at some point during their admission. About 20% to 70% of patients receiving intravenous therapy develop phlebitis. Infusion phlebitis has become one of the most common complications in patients with intravenous therapy. However, the effects of routine treatments such as external application of 75% alcohol or 50% to 75% magnesium sulphate (MgSO4) are unsatisfactory. Therefore, there is an urgent need to develop new methods to prevent and alleviate infusion phlebitis.

OBJECTIVES

To systematically assess the effects of external application of Aloe vera for the prevention and treatment of infusion phlebitis associated with the presence of an intravenous access device.

SEARCH METHODS

The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator (TSC) searched the Specialised Register (last searched February 2014) and CENTRAL (2014, Issue 1). In addition the TSC searched MEDLINE to week 5 January 2014, EMBASE to Week 6 2014 and AMED to February 2014. The authors searched the following Chinese databases until 28 February 2014: Chinese BioMedical Database; Traditional Chinese Medical Database System; China National Knowledge Infrastructure; Chinese VIP information; Chinese Medical Current Contents; Chinese Academic Conference Papers Database and Chinese Dissertation Database; and China Medical Academic Conference. Bibliographies of retrieved and relevant publications were searched. There were no restrictions on the basis of date or language of publication.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-randomised controlled trials (qRCTs) were included if they involved participants receiving topical Aloe vera or Aloe vera-derived products at the site of punctured skin, with or without routine treatment at the same site.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data on the study characteristics, description of methodology and outcomes of the eligible trials, and assessed study quality. Data were analysed using RevMan 5.1. For dichotomous outcomes, the effects were estimated by using risk ratio (RR) with its 95% confidence interval (CI). For continuous outcomes, mean differences (MD) with 95% CIs were used to estimate their effects.

MAIN RESULTS

A total of 43 trials (35 RCTs and eight qRCTs) with 7465 participants were identified. Twenty-two trials with 5546 participants were involved in prevention of Aloe vera for phlebitis, and a further 21 trials with 1919 participants were involved in the treatment of phlebitis. The included studies compared external application of Aloe vera alone or plus non-Aloe vera interventions with no treatment or the same non-Aloe vera interventions. The duration of the intervention lasted from one day to 15 days. Most of the included studies were of low methodological quality with concerns for selection bias, attrition bias, reporting bias and publication bias.The effects of external application of fresh Aloe vera on preventing total incidence of phlebitis varied across the studies and we did not combine the data. Aloe vera reduced the occurrence of third degree phlebitis (RR 0.06, 95% CI 0.03 to 0.11, P < 0.00001) and second degree phlebitis (RR 0.18, 95% CI 0.10 to 0.31, P < 0.00001) compared with no treatment. Compared with external application of 75% alcohol, or 33% MgSO4 alone, Aloe vera reduced the total incidence of phlebitis (RR 0.02, 95% CI 0.00 to 0.28, P = 0.004 and RR 0.43, 95% CI 0.24 to 0.78, P = 0.005 respectively) but there was no clear evidence of an effect when compared with 50% or 75% MgSO4 (total incidence of phlebitis RR 0.41, 95% CI 0.16 to 1.07, P = 0.07 and RR 1.10 95% CI 0.54 to 2.25, P = 0.79 respectively; third degree phlebitis (RR 0.28, 95% CI 0.07 to 1.02, P = 0.051 and RR 1.19, 95% CI 0.08 to 18.73, P = 0.9 respectively; second degree phlebitis RR 0.68, 95% CI 0.21 to 2.23, P = 0.53 compared to 75% MgSO4) except for a reduction in second degree phlebitis when Aloe vera was compared with 50% MgSO4 (RR 0.26, 95% CI 0.14 to 0.50, P < 0.0001).For the treatment of phlebitis, Aloe vera was more effective than 33% or 50% MgSO4 in terms of both any improvement (RR 1.16, 95% CI 1.09 to 1.24, P < 0.0001 and RR 1.22, 95% CI 1.16 to 1.28, P < 0.0001 respectively) and marked improvement of phlebitis (RR 1.97, 95% CI 1.44 to 2.70, P < 0.001 and RR 1.56, 95% CI 1.29 to 1.87, P = 0.0002 respectively). Compared with 50% MgSO4, Aloe vera also improved recovery rates from phlebitis (RR 1.42, 95% CI 1.24 to 1.61, P < 0.0001). Compared with routine treatments such as external application of hirudoid, sulphonic acid mucopolysaccharide and dexamethasone used alone, addition of Aloe vera improved recovery from phlebitis (RR 1.75, 95% CI 1.24 to 2.46, P = 0.001) and had a positive effect on overall improvement (marked improvement RR 1.26, 95% CI 1.09 to 1.47, P = 0.0003; any improvement RR 1.23, 95% CI 1.13 to 1.35, P < 0.0001). Aloe vera, either alone or in combination with routine treatment, was more effective than routine treatment alone for improving the symptoms of phlebitis including shortening the time of elimination of red swelling symptoms, time of pain relief at the location of the infusion vein and time of resolution of phlebitis. Other secondary outcomes including health-related quality of life and adverse effects were not reported in the included studies.

AUTHORS' CONCLUSIONS

There is no strong evidence for preventing or treating infusion phlebitis with external application of Aloe vera. The current available evidence is limited by the poor methodological quality and risk of selective outcome reporting of the included studies, and by variation in the size of effect across the studies. The positive effects observed with external application of Aloe vera in preventing or treating infusion phlebitis compared with no intervention or external application of 33% or 50% MgSO4 should therefore be viewed with caution.

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.

Cost-effectiveness analysis of clinically indicated versus routine replacement of peripheral intravenous catheters

BACKGROUND

Millions of peripheral intravenous catheters are used worldwide. The current guidelines recommend routine catheter replacement every 72-96 h. This practice requires increasing healthcare resource use. The clinically indicated catheter replacement strategy is proposed as an alternative.

OBJECTIVES

To assess the cost effectiveness of clinically indicated versus routine replacement of peripheral intravenous catheters.

METHODS

A cost-effectiveness analysis from the perspective of Queensland Health, Australia, was conducted alongside a randomized controlled trial. Adult patients with an intravenous catheter of expected use for longer than 4 days were randomly assigned to receive either clinically indicated replacement or third-day routine replacement. The primary outcome was phlebitis during catheterization or within 48 h after catheter removal. Resource use data were prospectively collected and valued (2010 prices). The incremental net monetary benefit was calculated with uncertainty characterized using bootstrap simulations. Additionally, value of information (VOI) and value of implementation analyses were performed.

RESULTS

The clinically indicated replacement strategy was associated with a cost saving per patient of AU$7.60 (95% confidence interval [CI] 4.96-10.62) and a non-significant difference in the phlebitis rate of 0.41% (95% CI -1.33 to 2.15). The incremental net monetary benefit was AU$7.60 (95% CI 4.96-10.62). The expected VOI was zero, whereas the expected value of perfect implementation of the clinically indicated replacement strategy was approximately AU$5 million over 5 years.

CONCLUSION

The clinically indicated catheter replacement strategy is cost saving compared with routine replacement. It is recommended that healthcare organizations consider changing to a policy whereby catheters are changed only if clinically indicated.