Management of peripheral intravascular devices by wia20667


									                                                                                                                                      Volume 12
                                                                                                                                         Issue 5
                                                                                                                                ISSN: 1329-1874

                                                                     Management of
                                                    peripheral intravascular devices
• Healthcare professionals will need ongoing         Information Source
  education, training and assessment                 This Best Practice information sheet, which    This scenario leads to increased patient
  regarding the insertion and management of          updates and supersedes the JBI information     illness, length of stay and care costs.
  peripheral intravascular devices; preferably,      sheet of the same title published in 1998,1    Empirical evidence suggests that >50% of
  designate trained personnel to insert and          has been derived from updated guidelines       such infections are preventable.
  maintain intravascular devices (Grade A)           developed by the Centres for Disease           While peripheral venous catheters (PICs)
• Vigilance in handwashing and aseptic               Control (2002)2,3 and two systematic reviews   are rarely associated with bloodstream
  technique is vital, particularly for palpating,    published in 2005-2006,4,5 and an economic     infections (BSI) they are commonly
  inserting, replacing or dressing an                evaluation published in 2007.6                 associated with phlebitis, a condition that
  intravascular device (Grade A)                                                                    is mainly a physiochemical or mechanical

• Choose catheters based on intended
                                                     Background                                     phenomenon rather than infectious.2 A

                                                     Intravenous devices are an important and       number of factors influence the risk of
  purpose and duration of use, known
                                                     common aspect of hospital practice for the     contracting phlebitis: type of catheter
  complications and experience – Teflon,
                                                     administration of medications, nutrients,      material; catheter size; type of infusate;
  silicone elastomer or polyurethane catheters
                                                     fluid, blood products and to monitor the       and patient’s own risk. When phlebitis
  are safer than polyethylene, polyvinyl
                                                     haemodynamic status of a person.      2-5      does occur the risk of developing a local
  chloride or steel needles, which may cause
                                                     However, intravascular devices such as         catheter-related infection may increase.3
  necrosis if extravasation occurs (Grade A)
                                                     peripheral venous catheters, can be            The pathogenesis of catheter-related
• It is necessary to remove any intravascular
                                                     affected by a variety of local or systemic     infections is complex but most appear to
  device as soon as its clinical use is no
                                                     infectious events. For example, catheter-      result from skin organisms at the catheter
  longer justified (Grade A)
                                                     related infections such as bloodstream         insertion site migrating into the catheter
• Replace IV tubing, including piggyback                                                            tract, that eventually colonise the catheter
                                                     infections (BSI) are linked to increased
  tubing, no more frequently than at 72 hour                                                        tip. Contamination of the catheter hub may
                                                     morbidity, death and prolonged
  intervals, unless clinically indicated or                                                         also contribute to the colonisation of
                                                     hospitalisation (costs ranging from
  advised (Grade B)
                                                     US$4000 to US$56,000 per episode). In
• Routinely flush peripheral venous cannula          the United States alone, catheter-related
                                                                                                    Grades of Recommendation
  bungs with normal saline solution, unless          bloodstream infections (CR-BSI) occur at       These Grades of Recommendation have been
                                                                                                    based on the JBI-developed 2006 Grades of
  they are used to obtain blood specimens, in        an average rate of 5 per 1,000 days in
  which case a dilute heparin flush solution         ICUs, resulting in 80,000 episodes of CR-
  should be used (Grade B)                           BSI each year.6 Intravascular devices are      Grade A Strong support that merits application

• It is advised to use transparent dressing or       now the most important cause of
                                                                                                    Grade B Moderate support that warrants
  sterile gauze to cover the catheter site           healthcare-associated BSI, with an
                                                                                                            consideration of application
  (Grade B)                                          estimated 250,000-500,000 cases
                                                     occurring each year in the United States.6     Grade C Not supported

                                                                    JBI Management of peripheral intravascular devices Best Practice 12(5) 2008 | 1
    catheter lumens, especially in long-term            long-term catheters. The important pathogenic
                                                                                                            sites, and hand veins have a lower risk for
    catheters.2,3,6 Another common complication         determinants of infection are: the material of
                                                                                                            phlebitis than veins on the upper arm or wrist.
    in paediatric patients who have peripheral          the device; and the infecting organism’s
                                                                                                            Other factors that need to be assessed when
    venous catheters is extravasation.                  intrinsic virulence. Catheters made of Teflon,
                                                                                                            choosing the catheter insertion site are:
                                                        silicone elastomer or polyurethane are more
    To improve patient outcome and reduce                                                                   patient-specific considerations, for example
                                                        resistant to the adherence of micro-organisms
    healthcare costs, sound management                                                                      pre-existing catheters, anatomic deformity
                                                        than catheters made from polyethylene,
    practices of peripheral intravenous devices                                                             and bleeding diathesis.
                                                        polyvinyl chloride or steel.2,3 Steel needles for
    should be implemented to improve patient
                                                        peripheral venous access can be                     When choosing a site for a short peripheral
    outcome, reduce healthcare costs and
                                                        compromised by infiltration of intravenous          intravenous cannula avoid the inner aspect of
    reduce the occurrence of infections. A
                                                        fluids into the subcutaneous tissues.      2        the wrist within a 5cm radius as this will
    multidisciplinary approach is preferred
                                                        Catheters with surface irregularities accelerate    decrease the risk of damage to the radial,
    involving: a designated team of IV therapy
                                                        the microbial adherence of certain organisms,       median and ulnar nerves which are cellulitis,
    nurses who maintain intravascular catheters;
                                                        such as Acinetobacter calcoaceticus and             arteriovenous fistulae, skin grafts, fractures,
    healthcare managers who allocate
                                                        coagulase-negative staphylococci.      3            stroke, planned limb surgery and previous
    resources; and patients who can assist in the
                                                        Furthermore, certain catheter materials are         cannulations. Avoid high friction sites such as
    care of their catheters.
                                                        more thrombogenic than others, a trait that can     the cubital fossa or wrist. However, if these
                                                        predispose to catheter colonisation and             sites must be used adequate splinting will
    Objectives                                          catheter-related infection. This has                help to reduce the risk of thrombus formation,
    The purpose of this Best Practice information       emphasised the importance of preventing             tissue infiltration and dislodgement.2,3
    sheet is to provide summarised evidence on          catheter-related thrombus in the overall            Generally, the smallest gauge cannula
    managing peripherally inserted intravascular        management of CR-BSI.                               should be selected for the prescribed therapy
    devices in order to reduce the risk of infection.                                                       in order to minimise contact irritation and
                                                        Strategies for Prevention of                        prevent damage to the vessel intima and
    Quality of the research                             Catheter-Related Infection                          promote greater haemodilution. If the
                                                                                                            cannula is to large for the vein, blood flow is
    Due to the limited research evidence the            Reports have consistently shown that risk of
                                                                                                            impeded and irritant drugs may remain in
    following preventive strategies are based on:       infection declines following standardisation of
                                                                                                            prolonged contact with the vessel intima,
    firstly, the 2002 Guidelines for the Prevention     aseptic care, proper handwashing and
                                                                                                            resulting in mechanical thrombophlebitis.
    of Intravascular Catheter-Related Infections,       having specialised ‘IV teams’ maintain
                                                                                                            Veins with ample blood flow should be
    which still represent the latest update of          intravascular catheters rather than
                                                                                                            selected for infusion of hypertonic solutions
    evidence-based guidelines; and conclusions          inexperienced staff.   2,3,6
                                                                                       Such teams have
                                                                                                            or solutions containing irritant drugs.2,3 Drugs
    raised in systematic reviews that focused on        unequivocally been effective in reducing
                                                                                                            implicated include antibiotics such as:
    central venous catheters (CVCs) with                infection incidents and healthcare costs. It is
                                                                                                            amphotericin; cephalosporins; erythromycin;
    implications for peripheral intravascular           vital that all intravascular devices are
                                                                                                            metronidazole; tetracyclines; vancomycin;
    catheters. Quality was variable in terms of         removed as soon as their use is no longer
                                                                                                            cytotoxic agents; electrolytes such as
    the number of studies included or the degree        clinically indicated. Good hand
                                                                                                            calcium salts and potassium chloride; acidic
    to which they fulfilled selection criteria.         hygiene/washing before and attention to
                                                                                                            drug solutions; and hypertonic drug
                                                        aseptic technique during insertion of short
                                                                                                            solutions, eg. ionic contrast media, glucose-
    Types of Intervention -                             peripheral venous catheters provides
                                                                                                            containing solutions >5%.2
    Preventive Strategies                               protection against infection. It is advised to
                                                        use either a waterless, alcohol-based               Skin cleansing/antisepsis of the insertion site
    Pathogenesis                                        product or an antibacterial soap and water          is very important in preventing catheter-
                                                        with thorough rinsing. Disposable non-sterile       related infections. A few studies have
    The most common method of infection for
                                                        gloves are standard precautions to prevent          evaluated the effectiveness of different
    peripherally inserted, short-term catheters is
                                                        blood-borne pathogen exposure.2,3                   preparations and it appears that
    the migration of skin organisms at the insertion
                                                                                                            chlorhexidine, does prevent peripheral IV
    site into the cutaneous catheter tract with         The site of catheter insertion influences the
                                                                                                            colonisation compared to povidone iodine.2
    colonisation of the catheter tip.
                                                        risk of infection and phlebitis. For adults,
    Contamination of the catheter hub contributes       lower extremity insertion sites are linked to a     Transparent, semi-permeable polyurethane
    substantially to intraluminal colonisation in       higher risk of infection than upper extremity       dressings are widely used for dressing

2 | JBI Management of peripheral intravascular devices Best Practice 12(5) 2008
catheter insertion sites. They secure the         incidence of thrombophlebitis and bacterial
device and allow continuous visual inspection     colonisation of catheters increases after they
                                                                                                       administration sets no more frequently than
and necessitate less frequent changes than        have been in situ for more than 72 hours.2
                                                                                                       72 hours after initiation of use is cost
standard gauze and tape dressings.                Therefore to reduce this risk, short peripheral
                                                                                                       effective and safe.4 In fact, the findings
However, while such transparent dressings         catheters are usually resited at 48-72 hours.
                                                                                                       below do support the recommendations
save personnel time the findings from studies     Catheters should be removed at the first sign
                                                                                                       made by the Centres for Disease Control
comparing them to gauze dressings are             of phlebitis (eg. patient discomfort), if they
                                                                                                       that administration sets should not be
ambiguous in that the risk of CR-BSIs did not     have been inserted in emergency scenarios
                                                                                                       changed more frequently than at 72-hour
differ between the groups.2                       and when no longer needed. Midline
                                                                                                       intervals.2,4 Three studies published in 2001
Antimicrobial/antiseptic ointments have been      catheters, which are longer peripheral
                                                                                                       suggested that when a fluid that provokes
applied to catheter site at insertion and         catheters inserted via the antecubital fossa
                                                                                                       microbial growth is infused (eg. lipid
during dressing of the site. Certain catheters    but do not enter the central veins, are
                                                                                                       emulsions and blood products), more
that are coated or impregnated with               associated with lower rates of phlebitis and
                                                                                                       frequent changes of administration sets are
antimicrobial or antiseptic agents can lessen     infection than short peripheral catheters.2,3
                                                                                                       indicated, since these products are identified
the risk of CR-BSI and consequently the           A systematic review investigating 3 small            as independent risk factors for CR-BSI.4
hospital costs associated with treating CR-       RCTs (two trials including patients on total         Furthermore, one systematic review based
BSIs. Two meta-analyses (1999, 2000)              parenteral nutrition and the other with              on 13 RCTs and examining the frequency of
demonstrated that peripheral catheters            patients on crystalloid and drugs), has              intravenous administration set replacement
coated with chlorhexidine/silver sulfadiazine     suggested that elective replacement of               (for both central and peripheral catheters),
on the external luminal surface reduced the       peripheral intravenous catheters in adults can       concluded that changing sets not containing
risk of CR-BSI compared to standard non-          reduce the incidence and severity of                 lipids, blood or blood products at an interval
coated catheters.2 Such impregnated               thrombophlebitis. However, the appropriate           of up to 96 hours, did not affect the risk of
catheters may be more expensive but in the        intervals for catheter replacement were not          infuse-related BSI or cather-related BSI in
long-term they lead to cost savings and may       sufficiently investigated.5 Furthermore,             participants.4
prove cost effective in ICU patients, burns       hospital staff may view elective replacement
                                                                                                       Finally, ‘piggyback’ systems appear safer
patients, or neutropenic patients wherein the     without signs of complications as an
                                                                                                       than stopcocks (used for injecting
infection rate exceeds 3.3 per 1,000 catheter     unnecessary routine that creates more work.
                                                                                                       medications, collecting blood samples,
days.3 Evidence regarding the prophylactic        However, 1 study concluded that elective
                                                                                                       administering IV infusions), which are prone
administration of antimicrobials to reduce        replacement of catheters every 48 hours did
                                                                                                       to contamination in 45-50% of cases. It is
BSIs remains inconclusive due to the lack of      not statistically significantly increase the total
                                                                                                       essential to ensure in piggyback systems that
controlled or randomised trials.                  number of catheters utilised.5
                                                                                                       the device entering the rubber membrane of
Studies suggest that anticoagulants such as       Routine replacement of IV administration             an injection port is not exposed to air or
heparin in the form of flush solutions may        sets was explored in 3 well-controlled               comes into direct contact with non-sterile
play a key role in preventing CR-BSI because      studies, revealing that replacing                    tape used to fix the needle to the port.2
thrombi and fibrin deposits on catheters may
serve as a nidus for microbial colonisation of    Conclusions
intravascular catheters. Flushing catheters       The guidelines that were published in 2002 are still current. They recognise the importance of
aims to stop thrombosis rather than infection,    peripheral intravascular devices and recommend a number of strategies to reduce or prevent
but it has been shown that heparin and saline     and manage the incidence of catheter-related infections. Strategies need to change and
are equally effective in maintaining catheter     develop to reflect advances in technology and delivery of healthcare. It should be noted that
patency and reducing phlebitis.2                  the patient plays an important role in the decision to insert, and in the location of intravascular
The prevention of peripheral intravascular        devices. At the very least they should be informed about the reasons for insertion. Patients
device-related infections has been greatly        need to be encouraged to report any discomfort such as pain, burning, swelling or bleeding.
assisted by the policy of replacing catheters.2   Patient comfort can be managed during insertion by using topical local anaesthetic agents, and
Routine or scheduled replacement is advised       by avoiding multiple attempts at cannulation. To ensure patient safety it is advised to maintain
as a method of preventing phlebitis and other     accurate documentation and record keeping for auditing purposes and equally importantly,
infections. Studies of short peripheral venous    track any outbreaks of infection. Such documentation should include: date and time of
catheters have consistently shown that the        insertion; and when filters, tubing, and intravenous solutions were replaced.

                                                                     JBI Management of peripheral intravascular devices Best Practice 12(5) 2008 | 3
            Management of peripheral intravascular devices                                                                • Bridie Kent, School of Nursing, Faculty of Medical
                                                                                                                            and Health Sciences, University of Auckland, New
                                                                                      PIV insertion                         Zealand.

                                                                                                                          1. The Joanna Briggs Institute. Management of
                                                                                                                             Peripheral Intravascular Devices. Best Practice:
                                                                                                                             evidence-based practice information sheets for the
                                                                          IV Team
                                                                         available?                                          health professionals. 1998; 2(1): 1-6.

                                                                                                                          2. Guidelines for the Prevention of Intravascular Catheter-
                                                                                                                             Related Infections. Centres for Disease Control
                                                                                                                             Recommendations and Reports, August 9, 2002.
                                                                                    Collect equipment                     3. Pratt RJ, Pellowe CM, Wilson JA, Loveday HP, Harper
                                                                                Sterilise and prepare skin
                                                                                   Asceptic technique/                       PJ, Jones SRLJ, McDougall C, Wilcox MH. epic2:
                                                                                  proper handwashing
                                                                                                                             National Evidence-Based Guidelines for Preventing
                                                                                                                             Healthcare-Associated Infections in NHS Hospitals in
                                                                                                                             England. The Journal of Hospital Infection, 2007;
                                                                                      Choose upper
                                                                                      extremity vein                         65S:S1-S64.

                                                                                                                          4. Gillies D, O’Riordan L, Wallen M, Morrison A, Rankin
                                                                                                                             K and Nagy S. Optimal timing for intravenous
                                                                                Cover insertion site with
                                                                                 TAD or sterile gauze
                                                                                                                             administration set replacement (Review). Cochrane
                                                                                                                             Database of Systematic Review; 2005 Issue 4.

                                                                                                                          5. Idvall E and Gunningberg L. Evidence for elective
                                                                                                                             replacement of peripheral intravenous catheter to
                                                                                        required?                            prevent thrombophlebitis: a systematic review.
                                                                                                                             Journal of Advanced Nursing; 2002; 55(6): 715-722.
                                                                                                                          6. Halton K, Graves N. Economic Evaluation and
                                                                                                                             Catheter-related Bloodstream Infections. Emerging
                                                                                                       Remove                Infectious Diseases 2007; 13(6).
                                                                                                                          7. The Joanna Briggs Institute. Systematic reviews - the
                                                                                                                             review process, Levels of evidence. Accessed on-line
                                                                                          No                                 2006

                                                                                          Flush                           8. Pearson A, Wiechula R, Court A, Lockwood C. The
                                                           Observe for                                                       JBI Model of Evidence-Based Healthcare. Int J of
                                                                                                                             Evidence-Based Healthcare 2005; 3(8):207-215.

                                    Remove and replace                       Replace cannula
                                     peripheral catheter                       48-72 hours
                                                                         Replace IV administration
                                                                             sets 72-96 hours                             • The Joanna Briggs Institute
                                                                                                                            Royal Adelaide Hospital
                                                                                                                            North Terrace, South Australia, 5000
    Acknowledgments                                                  • Dr Carole Pellowe, Thames Valley Centre for 
                                                                       Evidence Based Nursing and Midwifery, Faculty of
    This Best Practice information sheet was developed by                                                                    ph: +61 8 8303 4880
                                                                       Health and Human Sciences, Thames Valley
    the Joanna Briggs Institute and the review and
                                                                       University, UK.                                       fax: +61 8 8303 4881
    guideline authors.
                                                                     • Chaweewan Thongchai, Thailand Centre for              email:
    In addition this Best Practice information sheet has
                                                                       Evidence Based Nursing and Midwifery, Faculty of
    been reviewed by nominees of International Joanna                                                                     • Published by
                                                                       Nursing, Chiang Mai University, Thailand.
    Briggs Collaborating Centres:                                                                                            Wiley-Blackwell
                                                                     • Judith Berry, CNAHS, Royal Adelaide Hospital,
    • Janita Chau, Hong Kong Centre EBN, Chinese                                                                          “The procedures described in Best Practice must only
                                                                       Adelaide, South Australia, Australia.
      University Hong Kong, Nethersole School of                                                                          be used by people who have appropriate expertise in
      Nursing, Ester Lee Building, Hong Kong Special                 • Emily Lannan, CNAHS, Royal Adelaide Hospital,      the field to which the procedure relates. The
      Administrative Region.                                           Adelaide, South Australia, Australia.              applicability of any information must be established
                                                                                                                          before relying on it. While care has been taken to
                                                                                                                          ensure that this edition of Best Practice summarises
                                                                                                                          available research and expert consensus, any loss,
                                                                                                                          damage, cost, expense or liability suffered or incurred
                       This Best Practice information sheet presents the best available evidence on this topic.
                                                                                                                          as a result of reliance on these procedures (whether
                       Implications for practice are made with an expectation that health professionals will
                                                                                                                          arising in contract, negligence or otherwise) is, to the
                       utilise this evidence with consideration of their context, their client’s preference and
                                                                                                                          extent permitted by law, excluded”.
                     their clinical judgement.6

4 | JBI Management of peripheral intravascular devices Best Practice 12(5) 2008

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