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

Best practice in the use of peripheral venous catheters: A consensus from French experts

BACKGROUND

Peripheral intravenous catheters (PIVCs) are the most commonly used invasive medical devices in healthcare. While they are often perceived as innocuous because they are common, this perception does not match their risk factors. In France, 16% of intravenous device-associated bacteremia are due to PIVCs. This consensus document reports the French experience in PIVC management, issues arising from their complications, and a proposed path toward improved PIVC care.

METHODS

A panel of five French experts discussed this topic based on evidence and personal experience. A consensus process was applied to highlight the issues in need of increased awareness and to suggest possible improvements. PIVC topics were organized as General Statements, Indication, Preparation, Insertion, Maintenance, and Removal. An electronic survey was used to record agreement or disagreement; to expand the dataset, five additional French experts also answered the questions.

RESULTS

Out of 67 statements, 62 reached a consensus (the 80% agreement threshold was exceeded). Experts are increasingly aware that PIVCs are a significant source of complications, including local and bloodstream infections. Practices need to progress to improve patient outcomes, which will require better education for all personnel involved with the insertion and maintenance of PIVCs.

CONCLUSIONS

Current practice around PIVCs does not always comply with the recommendations issued. A new surveillance network targeting catheter-related healthcare-associated infections is now in place in France. Simplified, standardized, bundled solutions are needed to reduce avoidable harm from PIVCs. Healthcare practice has changed over time and new educational tools are needed to adapt to increased workload and time constraints.

Comparison of complication rates between midline catheters and peripherally inserted central catheters: a systematic review and meta-analysis of randomized controlled trials

Midline catheters (MCs) and peripherally inserted central catheters (PICCs) are essential for reliable vascular access in patients. Despite their prevalent use, comparative risk assessments of these catheters, particularly from randomized controlled trials (RCTs), remain scarce. This meta-analysis primarily focuses on RCTs to evaluate and compare the incidence of complications associated with MCs and PICCs. We conducted a comprehensive search of databases including the Cochrane Library, PubMed, Embase, Web of Science, ScienceDirect, Scopus and ProQuest, up to April 2024. The primary outcomes analysed were total complications and catheter-related bloodstream infections (CRBSIs), while secondary outcomes included catheter dwell time and thrombosis incidence. Meta-analyses were performed using a random-effects model. Of 831 initially identified articles, five trials involving 608 patients met the inclusion criteria. MCs exhibited a significantly higher rate of total complications compared with PICCs (relative risk = 1.95, 95% confidence interval = 1.23-3.08, P=0.005, I2= 0%). MCs also had shorter dwell times and a higher incidence of premature removal. However, no significant differences were observed in the rates of CRBSIs or thrombosis between MCs and PICCs. PICCs are associated with fewer total complications and longer dwell times compared with MCs, which tend to be more often removed prematurely. Thrombosis rates were similar between the two catheter types, underscoring the need for careful catheter selection based on specific patient conditions and treatment duration. Further research, particularly additional RCTs, is necessary to confirm these findings and guide optimal catheter selection in clinical practice.

Aligning peripheral intravenous catheter quality with nursing culture-A mixed method study

AIM

To explore barriers and facilitators that influence adherence to evidence-based guidelines for peripheral intravenous catheter care in different hospital wards.

DESIGN

Sequential explanatory mixedmethod study design, with qualitative data used to elaborate on quantitative findings.

METHOD

Data were collected between March 2021 and March 2022 using the previously validated Peripheral Intravenous Catheter mini questionnaire (PIVC-miniQ) on each ward in a tertiary hospital in Norway. Survey completion was followed by individual interviews with nurses from selected wards. The Pillar Integration Process was used to integrate and analyse the quantitative and qualitative findings.

RESULTS

The PIVC-miniQ screening assessed 566 peripheral intravenous catheters in 448 patients in 41 wards, and we found variation between wards in the quality of care. Based on the quantitative variation, we interviewed 24 nurses on wards with either excellent or not as good quality. The integration of the quantitative and qualitative findings in the study enabled an understanding of factors that influence nurses' adherence to the care of peripheral venous catheters. One main theme and four subthemes emerged. The main finding was that ward culture affects education practice, and this was evident from four subthemes: (1) Deviation from best practice, (2) Gaps in education and clinical training, (3) Quality variation between wards and (4) The importance of supportive leadership.

CONCLUSION

This mixed method study is the first study to explore reasons for variability in peripheral intravenous catheter quality across hospital wards. We found that ward culture was central to catheter quality, with evidence of deviations from best practice correlating with observed catheter complications. Ward culture also impacted nursing education, with the main responsibility for learning peripheral intravenous catheter management left to students' clinical training placements. Addressing this educational gap and fostering supportive leadership, including champions, will likely improve peripheral intravenous catheter care and patient safety.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Nurses learn good peripheral intravenous catheter care in wards with supportive leaders and champions. This implies that the quality of nursing practice and patient outcomes are situational. Nurses need a strengthened emphasis on peripheral catheter quality in the undergraduate curriculum, and nurse leaders must emphasize the quality of catheter care in their wards.

IMPACT

The study findings impact nurse leaders who must commit to quality and safety outcomes by appointing and supporting local ward champions for promoting peripheral intravenous catheter care. This also impacts nursing education providers, as the emphasis on catheter care must be strengthened in the undergraduate nursing curriculum and continually reinforced in the hospital environment, particularly when guidelines are updated.

REPORTING METHOD

The study adhered to the Good Reporting of A Mixed Method Study (GRAMM).

PATIENT OR PUBLIC CONTRIBUTION

A patient representative has been involved in planning this study.

Cost effectiveness of ultrasound-guided long peripheral catheters in difficult vascular access patients

OBJECTIVE

Peripheral intravenous catheter (PIVC) placement is a routinely performed invasive procedure in hospital settings with an unacceptably high failure rate that can result in significant costs. This investigation aimed to determine the cost-effectiveness of using long peripheral catheters (LPC) versus standard short peripheral catheters (SPC) in the difficult vascular access (DVA) population.

METHODS

A secondary analysis was performed of a randomized control trial that compared a 20-gauge 4.78 cm SPC to a 20-gauge 6.35 cm SPC for the endpoint of survival. This study assessed cost-effectiveness of the comparative interventions. Costs associated with increased hospitalization length of stay due to PIVC failure, including labor, materials, equipment, and treatment delays were estimated by utilizing healthcare resource utilization data. Cost-effectiveness of the LPC was analyzed through the incremental cost-effectiveness ratio, the cost-effectiveness acceptability curve, and the incremental net benefit. A sensitivity analysis was conducted to evaluate the robustness of the results during the time interval of PIVC insertion.

RESULTS

Among the 257 patients, the average total cost for therapy was lower in the LPC group compared to the SPC group ($400 vs $521; mean difference -$121, 95% bootstrapped CI -$461 to $225). A marginally significant absolute difference of complication averted was found for LPC versus SPC (10.8%, p = 0.07). The estimated incremental cost-effectiveness ratio (ICER) for LPC as compared with SPC was -$1123 (95% bootstrapped CI -$8652 to $5964) per complication averted. In a willingness to pay (WTP) analysis, as WTP = $0, the incremental net benefit (INB) $121 was positive, indicating LPC was less costly. Analysis of PIVCs that survived ⩽48 h (n = 134) demonstrated a lower average total cost for therapy among the LPC group ($418 vs $531; mean difference -$113, 95% bootstrapped CI -$507 to $282). Forty-seven of 66 (71.2%) LPCs did not experience a complication, compared with 37 of 68 (54.4%) SPCs, resulting in a significant absolute difference of complication adverted of 16.8% (p = 0.04). In addition, with a positive slope, the INB $113 was positive as WTP = $0, indicating LPC was estimated to be cost-effective.

CONCLUSIONS

When using ultrasound guidance for vascular access, LPCs are potentially a cost-effective strategy for reducing PIVC complications in DVA patients compared to SPCs. Given this finding, ultrasound-guided LPCs should be routinely considered as first-line among the DVA population in order to improve their overall care and wellbeing.

Effectiveness and Safety of Measures to Prevent Infections and Other Complications Associated With Peripheral Intravenous Catheters: A Systematic Review and Meta-analysis

BACKGROUND

Peripheral intravenous catheters (PIVCs) contribute substantially to the global burden of infections. This systematic review assessed 24 infection prevention and control (IPC) interventions to prevent PIVC-associated infections and other complications.

METHODS

We searched Ovid MEDLINE, Embase, Cochrane Library, WHO Global Index Medicus, CINAHL, and reference lists for controlled studies from 1 January 1980-16 March 2023. We dually selected studies, assessed risk of bias, extracted data, and rated the certainty of evidence (COE). For outcomes with 3 or more trials, we conducted Bayesian random-effects meta-analyses.

RESULTS

105 studies met our prespecified eligibility criteria, addressing 16 of the 24 research questions; no studies were identified for 8 research questions. Based on findings of low to high COE, wearing gloves reduced the risk of overall adverse events related to insertion compared with no gloves (1 non-randomized controlled trial [non-RCT]; adjusted risk ratio [RR], .52; 95% CI, .33-.85), and catheter removal based on defined schedules potentially resulted in a lower phlebitis/thrombophlebitis incidence (10 RCTs; RR, 0.74, 95% credible interval, .49-1.01) compared with clinically indicated removal in adults. In neonates, chlorhexidine reduced the phlebitis score compared with non-chlorhexidine-containing disinfection (1 RCT; 0.14 vs 0.68; P = .003). No statistically significant differences were found for other measures.

CONCLUSIONS

Despite their frequent use and concern about PIVC-associated complications, this review underscores the urgent need for more high-quality studies on effective IPC methods regarding safe PIVC management. In the absence of valid evidence, adherence to standard precaution measures and documentation remain the most important principles to curb PIVC complications.

CLINICAL TRIALS REGISTRATION

The protocol was registered in the Open Science Framework (https://osf.io/exdb4).

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.

Safety and Efficacy of Midline vs Peripherally Inserted Central Catheters Among Adults Receiving IV Therapy: A Randomized Clinical Trial

Importance

Midline catheters (MCs) are widely used, but safety and efficacy compared with peripherally inserted central catheters (PICCs) has not been adequately evaluated.

Objective

To compare the safety and efficacy of MCs with PICCs among adult patients with an anticipated intravenous therapy lasting from 5 to 28 days.

Design, Setting, and Participants

This parallel, 2-group, open-label, randomized clinical trial (RCT) was conducted in Denmark from October 2018 to February 2022 at a single academic tertiary care center. Adult inpatients and outpatients were consecutively randomized.

Intervention

Patients were randomized in a 1:1 ratio to either the MC group or the PICC control group.

Main Outcomes and Measures

The primary outcome was catheter-related bloodstream infection (CRBSI), analyzed using the Fisher exact test. Secondary outcomes were symptomatic catheter-related thrombosis and catheter failure, including mechanical cause, phlebitis, infiltration, pain in relation to drug or fluid administration, and leaking from the puncture site. Incidence rate ratios (IRRs) were calculated to assess between-group failure rates over device dwell time using Poisson regression. An intention-to-treat analysis was performed.

Results

A total of 304 patients (mean [SD] age, 64.6 [13.5] years; 130 [42.8%] female) were included in the analysis, and 152 patients were allocated to each catheter group. The incidence of CRBSI was low, with 0 in the MC group and 1 in the PICC control group (P > .99). The MC group had a higher catheter-related complication rate (20 [13.2%] vs 11 [7.2%]), and an IRR of 2.37 (95% CI, 1.12-5.02; P = .02) for complications compared with the PICC control group. In a post hoc analysis stratified by catheter dwell time, no significant difference in complication rate (IRR, 1.16; 95% CI, 0.50-2.68; P = .73) was found between the 2 groups for catheters used less than 16 days.

Conclusions and Relevance

In this RCT with patients who received medium- to long-term intravenous therapy, the incidence of CRBSI was low, with no difference between MCs and PICCs. The use of MCs resulted in a higher incidence of catheter-related complications compared with use of PICCs. This finding should be balanced in the decision of type of catheter used at the individual patient level.

Trial Registration

ClinicalTrials.gov Identifier: NCT04140916.

Ultrasonographic Findings of Catheter-Related Bloodstream Infection in Pediatric Patients

BACKGROUND

Catheter removal is essential for treating catheter-related bloodstream infection (CRBSI); however, clinicians are sometimes hesitant to remove catheters in pediatric patients due to the difficulty of securing vascular access. Confirming the diagnosis of CRBSI is important to justify catheter removal. The purpose of this study was to describe the sonographic findings of CRBSI.

MATERIALS AND METHODS

We included patients with a central venous catheter (CVC) or peripherally inserted central catheter (PICC) who had a positive blood culture and underwent ultrasound. The patients were classified as with or without CRBSI. Sonographic findings, such as the presence/absence of thrombus, venous wall thickening, hyperechogenicity, and fluid collection around the vein were compared using Fisher's exact test.

RESULTS

Of the 58 patients, 38 (66%) were diagnosed with CRBSI. The presence of thrombus (19/38 vs 3/20, P = .011); and hyperechogenicity around the vein (14/38 vs 2/20, P = .035) differed significantly, but There was no significant difference in the presence of venous wall thickening (10/38 vs 1/20, P = .077), and fluid collection around the vein (5/38 vs 0/20, P = .153), did not differ significantly in patients with and without CRBSI, respectively. One-third of patients with CRBSI, including 11 (42.3%) patients with CVC, and 2 (16.7%) patients with PICC, did not have abnormal sonographic findings.

CONCLUSION

Ultrasound findings are useful for diagnosing CRBSI. However, the sensitivity of sonographic findings is low and abnormal sonographic findings are sometimes absent in children with CRBSI; therefore, physicians should not rule out CRBSI based on normal sonographic findings, especially in patients a CVC and a positive blood culture.

Reduction in the incidence of infusion-related phlebitis in a pediatric critical care unit of Eastern India: A quality improvement initiative

Background

Phlebitis is one of the most common complications of the peripheral venous catheter (PVC) and adversely impacts future venous access, and bacterial phlebitis may lead to bloodstream infection. The objective of the study was to reduce the to reduce the incidence of infusion-related phlebitis in children admitted to the pediatric critical care unit.

Methods

This Quality Initiative was implemented in the pediatric critical care unit of a tertiary care hospital between November 2019 and April 2020. Five interventions were identified (hand hygiene, use of transparent dressing, use of extension lines with PVCs, use of hard cardboard splints for joint immobilization, use of heparinized flush after medication administration) and were introduced sequentially. Over the next five weeks, a new intervention was introduced weekly while continuing the previous ones, if found to be working well as per improvement parameter, the phlebitis rate. From the sixth week onwards, all five interventions were applied together as a bundle.

Results

Total seven hundred eighteen PVCs were sited in 284 (Male: female 1.58:1) patients during study period and a total of 56 incidences of phlebitis were observed. Mean baseline phlebitis rate was 48.5%. In the next 5 weeks when interventions were implemented as planned, phlebitis rate was 35.7% (n = 10), 16.6% (n = 03), 21.6% (n = 8), 10% (n = 05), and 13.3% (n = 2) respectively. Implementation of all five interventions together as a bundle led to reduction in phlebitis rate below 5 % consistently over the next 18 weeks (n = 8).

Conclusion

A consistent reduction in PVC-related phlebitis can be achieved by the implementation of evidence-based interventions for the prevention of phlebitis, as a bundle.

Mono- and bi-plane sonographic approach for difficult accesses in the emergency department - A randomized trial

BACKGROUND

The insertion of peripheral intravenous (PIV) catheters is one of the most performed invasive procedures in acute healthcare settings. However, peripheral difficult vascular access (PDVA) is not uncommon and can lead to delays in administering essential medications. Ultrasound (US) has emerged as a valuable tool for facilitating PIV cannulation. Advancements in technology have introduced a technique known as bi-plane imaging, allowing the simultaneous display of both longitudinal and transverse views of vessels. We aimed to investigate whether the utilization of bi-plane imaging, as opposed to the single-plane approach, would yield superior results for PDVA in the emergency department (ED).

METHODS

This study was a single-center randomized controlled trial. We included adult patients admitted to the ED who required PIV cannulation. Patients were randomly assigned to undergo cannulation using either the mono-plane or bi-plane approach, both performed by skilled providers. The primary outcome of the study was to compare the first attempt success rates between the two techniques.

RESULTS

A total of 442 patients were enrolled, with 221 undergoing cannulation attempts using the mono-plane approach. Successful placement of a functioning PIV catheter was achieved in a single attempt for 313 out of 442 patients (70.8%). There was no significant difference in the success rates between the two study groups: 68.3% in the mono-plane group and 73.3% in the bi-plane group (p = 0.395). The median time required for a successful attempt differed between the groups, with 45 s (range 18-600) in the mono-plane group and 35 s (range 20-600) in the bi-plane group (p = 0.03).

CONCLUSIONS

Our study confirms that US is a highly effective tool for facilitating PIV cannulation in patients with PDVA presenting to the ED. However, our investigation into the use of bi-plane imaging did not reveal a significant improvement when compared to mono-plane imaging.

Effectiveness of short peripheral intravenous catheter educational programmes to improve clinical outcomes protocol for a systematic review

The placement of a short peripheral intravenous catheter (sPIVC) is the most common invasive clinical procedure for patients requiring fluid infusion and multiple blood draws. Phlebitis and infiltration represent the most common catheter-related complications. Occlusions, dislocations, and infections are less frequent. Insufficient knowledge and skills may increase the risk of these complications. This review aims to evaluate the effectiveness of training programmes to reduce sPIVC failure amongst hospitalised patients. We will search PubMed, Embase, CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Vascular Specialized Register through the Cochrane Register of Studies, and Google Scholar. We defined the search query using the PICO framework (Participants: health professionals; Intervention: training programme; Comparison: No training programme; Outcomes: all-cause catheter failure). We will include experimental studies evaluating an educational programme to reduce early sPIVC failure amongst hospitalised patients. Two reviewers will independently screen studies for inclusion, extract data, and perform the risk of bias assessment using the Cochrane Effective Practice and Organisation of Care Risk of Bias tool for randomised controlled trials. This review will highlight important perspectives for future studies on the effectiveness of educational programmes focused on reducing the rate of sPIVC complications.

Midline Compared With Peripheral Intravenous Catheters for Therapy of 4 Days or Longer in Pediatric Patients: A Randomized Clinical Trial

Importance

Peripheral intravenous catheters (PIVCs) frequently fail during treatment causing therapy interruption, pain, recatheterization, and additional health care costs. Midline catheters (MCs) may improve functional dwell time and reduce failure compared with traditional PIVCs.

Objective

To compare device failure of MCs with PIVCs.

Design, Setting, and Participants

This was a pragmatic, randomized clinical superiority trial with an embedded internal pilot study conducted from July 2020 to May 2022. The study took place in a quaternary pediatric hospital in Brisbane, Queensland, Australia. Inclusion criteria were patients aged 1 to 18 years requiring peripherally compatible intravenous therapy for 4 days or longer.

Interventions

Patients were randomly assigned 1:1 to receive a PIVC or MC, stratified by age (≤5 years, >5 years). One catheter was studied per patient.

Main Outcomes and Measures

The primary outcome was all-cause device failure, defined as premature cessation of device function. Secondary outcomes included number of insertion attempts, insertion failure, pain (on insertion), procedural time, patient/parent satisfaction (with insertion), device dwell time, device complications during dwell time, additional vascular access devices required to complete treatment, clinician satisfaction (at removal), and health care costs.

Results

Of the 128 patients randomly assigned to study groups, 127 patients (median [IQR] age, 7 [2-13] years; 71 male [56%]) had a device inserted, with 65 (51.2%) in the PIVC group and 62 (48.8%) in the MC group. All patients were included in the intention-to-treat analysis. Device failure was lower in patients in the MC group (10 [16.1%]) compared with those in the PIVC group (30 [46.2%]; odds ratio [OR], 0.22; 95% CI, 0.10-0.52; P <.001). MCs were associated with fewer insertion attempts (mean difference [MD], -0.3; 95% CI, -0.5 to 0; P = .04), increased dwell time (MD, 66.9 hours; 95% CI, 36.2-97.5 hours; P <.001), and fewer patients required additional vascular access devices to complete treatment in the MC group (4 [6.5%]) and PIVC group (19 [29.2%]; OR, 0.17; 95% CI, 0.05-0.52; P = .002). Compared with PIVCs, use of MCs was associated with greater patient (9.0 vs 7.1 of 10; P = .002) and parent (9.1 vs 8.2 of 10; P = .02) satisfaction and lower health care costs (AUS -$151.67 [US -$101.13] per person; 95% credible interval, AUS -$171.45 to -$131.90 [US -$114.20 to -$87.95]).

Conclusions and Relevance

Findings suggest that MC insertion for patients requiring peripherally compatible intravenous therapy for 4 days or longer should be prioritized to reduce the resource intensive, expensive, and burdensome sequelae of device failure.

Trial Registration

Australia New Zealand Clinical Trials Registry, ACTRN12620000724976.

A guide to cannulation in adults

This article provides clinical guidance on performing cannulation on an adult. The site, equipment selection and aseptic non-touch technique will be discussed. The clinical procedural technique of cannulation will be explained and the article will also provide an awareness of the dangers and complications of this invasive technique for both the patient and the health professional.

Determinants of Intravenous Infusion Longevity and Infusion Failure via a Nonlinear Model Analysis of Smart Pump Event Logs: Retrospective Study

BACKGROUND

Infusion failure may have severe consequences for patients receiving critical, short-half-life infusions. Continued interruptions to infusions can lead to subtherapeutic therapy.

OBJECTIVE

This study aims to identify and rank determinants of the longevity of continuous infusions administered through syringe drivers, using nonlinear predictive models. Additionally, this study aims to evaluate key factors influencing infusion longevity and develop and test a model for predicting the likelihood of achieving successful infusion longevity.

METHODS

Data were extracted from the event logs of smart pumps containing information on care profiles, medication types and concentrations, occlusion alarm settings, and the final infusion cessation cause. These data were then used to fit 5 nonlinear models and evaluate the best explanatory model.

RESULTS

Random forest was the best-fit predictor, with an F1-score of 80.42, compared to 5 other models (mean F1-score 75.06; range 67.48-79.63). When applied to infusion data in an individual syringe driver data set, the predictor model found that the final medication concentration and medication type were of less significance to infusion longevity compared to the rate and care unit. For low-rate infusions, rates ranging from 2 to 2.8 mL/hr performed best for achieving a balance between infusion longevity and fluid load per infusion, with an occlusion versus no-occlusion ratio of 0.553. Rates between 0.8 and 1.2 mL/hr exhibited the poorest performance with a ratio of 1.604. Higher rates, up to 4 mL/hr, performed better in terms of occlusion versus no-occlusion ratios.

CONCLUSIONS

This study provides clinicians with insights into the specific types of infusion that warrant more intense observation or proactive management of intravenous access; additionally, it can offer valuable information regarding the average duration of uninterrupted infusions that can be expected in these care areas. Optimizing rate settings to improve infusion longevity for continuous infusions, achieved through compounding to create customized concentrations for individual patients, may be possible in light of the study's outcomes. The study also highlights the potential of machine learning nonlinear models in predicting outcomes and life spans of specific therapies delivered via medical devices.

Comparative localization of the courses of superficial veins in rabbits' limbs using latex and VeinViewer systems

The purpose of this study; It is to reveal whether the veinviewer device, which we have not encountered in animals, can be visualized in rabbits for thoracic and pelvic limb superficial veins. Therefore, the latex method was used as a "gold test" to verify VeinViewer precision. For this purpose, the project was designed with two stages. In the first stage, the extremities of 15 New Zealand white rabbits were imaged using the VeinViewer device, and the results were recorded. In the second stage, the latex injection method was applied to the same animals, the cadavers were dissected, and the obtained results were comparatively analysed. In the rabbits, it was determined that v. cephalica originated from v. jugularis or v. brachialis in the proximity of the insertion of m. omotransversarius and anastomosed with v. mediana at the middle 1/3 level of the antebrachium. It was found that the superficial venous circulation of the pelvic limbs was provided by the branches of v. iliaca externa and v. iliaca interna. The vena saphena medialis was determined to be present in pairs in 80% of the cadavers. All cadavers showed the presence of the ramus anastomoticus cum vena saphena mediali. Additionally, the superficial veins of both the thoracic limbs and pelvic limbs of the rabbits were imaged with the VeinViewer device, which provided results parallel with the results of the latex injection method. Considering that the findings obtained with the latex injection method and the VeinViewer device were compatible, the usage of this device can potentially be considered as an alternative to visualizing superficial veins in animals. Further morphological and clinical studies can prove that the method is applicable.

Ultrasound-guided PIVC insertion: a randomised controlled trial protocol

Ultrasound-guided insertion of peripheral intravenous catheters (PIVCs) is an alternative to traditional anatomical landmark-based insertion. However, data on its performance in paediatric patients of varying levels of difficult intravenous access are limited. The researchers hypothesise that ultrasound-guided PIVC insertion will increase first-attempt success compared with landmark technique. This randomised, parallel-group, single-centre, superiority trial commenced recruiting in July 2021, including hospitalised children (aged 0 (>37 weeks gestation) to 18 years) requiring a PIVC. It will recruit 180 children, stratified by degree of perceived difficulty, and centrally randomised into two groups (ratio 1:1). The primary outcome is first-attempt PIVC insertion success. Secondary outcomes include total number of PIVC insertion attempts, PIVC insertion failure, post-insertion complications, dwell time, patient/parent satisfaction, and healthcare costs. The current study will inform the superiority of ultrasound-guided PIVC insertion in comparison with landmark technique. Adoption by healthcare facilities might improve patient outcomes and decrease healthcare costs.

Best practice in the use of peripheral venous catheters: A scoping review and expert consensus

Background

Peripheral intravenous catheters (PIVCs) are the most commonly used invasive medical device in health care with an overall failure rate of 35-50%. Most complications are non-infectious, but local site and bloodstream infections can also occur. Even if PIVC-related infections are rare, the total number of affected patients and the preponderance of Staphylococcus aureus as related pathogen due to the frequent use of these devices are relevant arguments to implement preventive strategies. The aim of this document is to raise awareness that infections caused by PIVCs are a relevant problem that can be reduced by practice change.

Methods

A panel of experts discussed this topic based on evidence and proposed practice points by consensus.

Discussion

Despite published evidence-based guidelines, current practice concerning aseptic techniques during insertion and care of PIVCs often are substandard. These devices have become commonplace and tend to be perceived as safe. An overall lack of awareness about the true risks associated with the use of PIVCs results in limited surveillance and prevention efforts.

Conclusion

Successful insertion and maintenance bundles in central venous lines are a blueprint to the implementation of adapted bundle strategies in the prevention of PIVC-associated infections. There is a need for studies to specifically investigate infection prevention in PIVCs and to agree on effective and implementable bundles.

Needle-Based Electrical Impedance Imaging Technology for Needle Navigation

Needle insertion is a common procedure in modern healthcare practices, such as blood sampling, tissue biopsy, and cancer treatment. Various guidance systems have been developed to reduce the risk of incorrect needle positioning. While ultrasound imaging is considered the gold standard, it has limitations such as a lack of spatial resolution and subjective interpretation of 2D images. As an alternative to conventional imaging techniques, we have developed a needle-based electrical impedance imaging system. The system involves the classification of different tissue types using impedance measurements taken with a modified needle and the visualization in a MATLAB Graphical User Interface (GUI) based on the spatial sensitivity distribution of the needle. The needle was equipped with 12 stainless steel wire electrodes, and the sensitive volumes were determined using Finite Element Method (FEM) simulation. A k-Nearest Neighbors (k-NN) algorithm was used to classify different types of tissue phantoms with an average success rate of 70.56% for individual tissue phantoms. The results showed that the classification of the fat tissue phantom was the most successful (60 out of 60 attempts correct), while the success rate decreased for layered tissue structures. The measurement can be controlled in the GUI, and the identified tissues around the needle are displayed in 3D. The average latency between measurement and visualization was 112.1 ms. This work demonstrates the feasibility of using needle-based electrical impedance imaging as an alternative to conventional imaging techniques. Further improvements to the hardware and the algorithm as well as usability testing are required to evaluate the effectiveness of the needle navigation system.

Does longer peripheral intravenous catheter length optimise antimicrobial delivery? Protocol for the LEADER study

BACKGROUND

Hospitalised patients receiving intravenous antimicrobial therapy require a reliable device through which this is delivered. Short peripheral intravenous catheters (PIVCs) are the default device for antimicrobial therapy but up to half fail before therapy completion, leading to suboptimal drug dosing, patient distress from repeated insertions, and increased healthcare costs. This study will investigate the use of long PIVCs to determine if they are more reliable at delivering antimicrobial therapy.

METHODS

A two-arm, parallel randomised controlled trial of hospitalised adults requiring at least 3 days of peripherally compatible intravenous antimicrobials. Participants will be randomised to a short (<4 cm) or long (4.5-6.4 cm) PIVC. After interim analysis ( n=70) for feasibility and safety, 192 participants will be recruited. Primary outcome is disruption to antimicrobial administration from all-cause PIVC failure. Secondary outcomes include: number of devices to complete therapy, patient-reported pain and satisfaction, and a cost analysis. Ethical and regulatory approvals have been received.

Relationship between indwelling site and peripheral venous catheter-related complications in adult hospitalized patients: A systematic review and meta-analysis

AIMS AND OBJECTIVES

This systematic review and meta-analysis aimed to compare the incidence of PVC-related complications between catheterisation in the forearm and back of the hand in adult patients.

BACKGROUND

A peripheral intravenous catheter (PVC) is often inserted as part of care during patients' hospitalisation. The catheter is typically inserted in the forearm or at the back of the hand in usual practice. Studies have not yet reached a consensus on the optimal insertion site in any clinical setting.

DESIGN

We performed a systematic review and meta-analysis based on PRISMA guidelines.

METHODS

We searched the following electronic databases: PubMed, Cochrane Library, Embase, and CINAHL. Randomised controlled trials, cohort studies, case-control studies and cross-sectional studies from inception to July 2021 reporting the incidence of PVC-related complications at the forearm and back of the hand were included. Fixed-effects models and random-effects models were used to derive the pooled risk ratios.

RESULTS

Twenty-four studies involving 16562 PVCs met our inclusion criteria. The meta-analysis showed that compared with PVC placement in the back of the hand, placement in the forearm was associated with a higher incidence of total complications and infiltration/extravasation. However, the differences between the PVC indwelling sites were not significant (total complications: P = 0.43; phlebitis: P = 0.35; infiltration/extravasation: P = 0.51). Both incidence of total complications and infiltration/extravasation analyses showed high heterogeneity (total complications: I2  = 60%; infiltration/extravasation: I2  = 58%).

CONCLUSION

Available evidence suggests that there is no significant difference between PVC placement in the forearm and at the back of the hand in terms of the incidence of complications, thus making both approaches suitable.

RELEVANCE TO CLINICAL PRACTICE

For patients who need indwelling PVC, medical staff can choose the best indwelling site, and both forearm and back of the hand are suitable.

Verification study on the catheterization of an upper arm vein using the new long peripheral intravenous catheter to reduce catheter failure incidence: A randomized controlled trial

Intravenous infusion using a peripheral intravenous catheter (PIVC) is often complicated by catheter failure (CF). We hypothesized that catheterization of an upper arm vein instead of a forearm vein may help prevent CF. This study was designed to compare the incidence of CF in patients receiving hyper-stimulant drugs when catheters are placed in the forearm using short PIVCs (SPCs) with that when catheters are placed in the upper arm using the new long PIVCs. Patients admitted to a university hospital in Tokyo, Japan were enrolled in this study and were assigned to the SPC or the new long PIVC group. The primary outcome was the incidence of CF until 7 days. The secondary outcomes were the number of CFs per 1,000 days, the duration of the indwelling catheter, and the presence of thrombi and subcutaneous edema. Forty-seven patients were analyzed (median age, 67.0 years). The incidence of CF was 0% in the new long PIVCs and 32.0% (8 catheters) in the SPCs (p = 0.007), and the number of CF per 1,000 days was 0/1,000 and 81.7/1,000 days, respectively (p = 0.001). A significant difference in the duration of the indwelling catheter until CF occurrence was observed between the two groups (p = 0.004). Thrombi and subcutaneous edema were observed more frequently in the SPC group (p < 0.001). Catheterization of an upper arm vein using the new long PIVC to administer a hyper-stimulant drug might reduce CF compared with catheterization of a forearm vein using SPC.

Observational study of peripheral intravenous catheter outcomes in an internal medicine department

BACKGROUND

In elderly patients hospitalised in internal medicine departments, risk factors, preferable placement area and methods of securement of short peripheral venous catheters (SPVC) a unclear.

AIM

To determine the incidence and risk factors of adverse events using a transparent bordered dressing for securement in the dorsum of the hand or cubital fossa in consecutive patients hospitalised in an internal medicine department.

METHODS

In a prospective observational study of patients admitted to a regional hospital with a SPVC, the dependent variable was the need to replace the catheter because of an adverse event (phlebitis, accidental removal, infiltration/occlusion). The independent variables were age, gender, disorientation, placement area, intravenous antibiotic therapy and indwelling time. Risk factors were determined by Cox regression model analysis.

RESULTS

There were 709 catheters placed in 499 patients. Per catheter placed the mean age was 75 ± 17 years. Accidental removal, infiltration/obstruction and phlebitis occurred in 21.5, 16.2 and 15.0 events per 1000 days respectively. There was a significantly increased risk on Day 3 compared to Days 2 and 4. An older age, intravenous antibiotics and disorientation increased the hazard for accidental displacement, whereas phlebitis was associated only with intravenous antibiotics and occlusion/infiltration only with age.

CONCLUSIONS

The observed low rates of adverse events suggests that placement in the dorsum of the hand or cubital fossa secured by a transparent dressing is acceptable. It is important to consider the indwelling catheter time when studying adverse events, and elderly patients, disoriented patients and/or patients receiving intravenous antibiotics deserve special attention.

Integrated versus non-integrated peripheral intravenous catheters: a cross-sectional survey of nurse experiences

BACKGROUND

Integrated peripheral intravenous catheters (PIVCs) demonstrate clinical efficacy, however, device complexity and design differences may be a potential barrier to implementation.

AIMS

To assess nurse acceptability of integrated PIVC systems.

METHODS

A cross-sectional survey was nested within a multicentre randomised controlled trial. One hundred nurses caring for patients with integrated and non-integrated PIVCs completed a 17-item survey about key differences between devices (eg function and appearance, perceived patient comfort and skin injuries).

FINDINGS

Most nurses reported the integrated PIVC wings prevented device movement (80%), achieved patient comfort in areas of flexion (78%), and no patients developed skin injuries (100%). Nurses rated the ease of accessing and overall confidence using the integrated PIVC as significantly higher than the non-integrated design (P<0.001).

CONCLUSION

The integrated PIVC received positive feedback from nurses and had few barriers to implementation.

Asia-Pacific guidelines for standardization of appropriate selection, placement, and management of vascular access devices

Vascular access devices (VADs) are common and essential in the healthcare setting. However, several factors influence VAD selection and management. Wide variations in VAD practices and the degree of VAD awareness are noted across Asia-Pacific (APAC) countries. An international panel was convened that applied the ASA 2020 method to develop standard criteria for use of VADs in the APAC region. After a literature search, scenarios related to VAD use, care, and maintenance were developed according to the patient population, indication for insertion, and duration of use. These scenarios were rated on a scale of 1-5 (1 being strongly disagreed and 5 strongly agreed) by 11 expert members. A total of 48 clinical scenarios were developed: 23 in hospitalized patients, 3 in critical patients, 4 in cancer settings, 7 pertinent to VAD placement, and 11 for VAD maintenance. The multidisciplinary panel generated several recommendations for the use, care, and management of VADs across general hospitalized patients with or without difficult venous access, critically ill patients, patients with malignancy, patients with different stages of chronic kidney disease (CKD) with or without dialysis, and in other special populations through evidence-based standards. These recommendations may help in achieving uniformity in practice patterns and improving the quality of VAD care and quality of life of patients in APAC region.

Peripheral vascular catheter use in Latin America (the vascular study): A multinational cross-sectional study

Background

Peripheral intravenous catheter (PIVC) insertion is one of the most common clinical procedures worldwide, yet little data are available from Latin America. Our aim was to describe processes and practices regarding PIVC use in hospitalized patients related to hospital guidelines, characteristics of PIVC inserters, prevalence of PIVC complications, and idle PIVCs.

Methods

In 2019 we conducted a multinational, cross-sectional study of adult and pediatric patients with a PIVC in hospitals from five Latin American countries: Argentina, Brazil, Chile, Colombia, and Mexico. We used two data collection tools to collect hospital guidelines and patient-specific data on the day of the study. The vessel health and preservation (VHP) model guided synthesis of the study aims/questions and suggested opportunities for improvement.

Results

A total of 9,620 PIVCs in adult (86%) and pediatric inpatients in 132 hospitals were assessed. Routine replacement 8-72 hourly was recommended for adults in 22% of hospitals, rather than evidence-based clinical assessment-based durations, and 69% of hospitals allowed the use of non-sterile tape rather than the international standard of a sterile dressing. The majority (52%) of PIVCs were inserted by registered nurses (RNs), followed by nursing assistants/technicians (41%). Eight percent of PIVCs had pain, hyperemia, or edema, 6% had blood in the extension tubing/connector, and 3% had dried blood around the device. Most PIVCs had been inserted for intravenous medications (81%) or fluids (59%) in the previous 24 h, but 9% were redundant.

Conclusion

Given the variation in policies, processes and practices across countries and participating hospitals, clinical guidelines should be available in languages other than English to support clinician skills and knowledge to improve PIVC safety and quality. Existing and successful vascular access societies should be encouraged to expand their reach and encourage other countries to join in multinational communities of practice.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

Impact of the failure of initial insertion of a peripheral intravascular catheter on the development of adverse events in patients admitted to the intensive care unit from the emergency room: A post hoc analysis of the AMOR-VENUS study

Aim

To investigate an association between failure of initial peripheral intravascular catheter (PIVC) insertion and adverse events in patients admitted to the intensive care unit (ICU) from the emergency room (ER).

Methods

This study was a post hoc analysis of the AMOR-VENUS study, a multicenter cohort study that included 22 institutions and 23 ICUs in Japan between January and March of 2018. Study participants included consecutive adult patients admitted to the ICU with PIVCs inserted in ICU during the study period exclusively from the ER. The primary outcome was adverse events. Adverse events were composite of arterial puncture, hematoma, extravasation, nerve injury, tendon injury, compartment syndrome, pain, redness, bad location, and effusion. Multivariate logistic regression analyses were performed to assess the association between adverse events and the failure of initial PIVC insertion.

Results

In total, 363 patients and 1121 PIVCs were analyzed. Moreover, 199 catheters failed to insert properly, and 36 patients and 107 catheters experienced adverse events. After performing multivariate logistic regression analysis, there were statistically significant associations in the odds ratio (OR) and 95% confidence interval (CI) for the failure of initial insertion (OR, 1.66 [1.02-2.71]; p = 0.04).

Conclusion

Failure of initial insertion may be a risk factor for adverse events. We could potentially provide various interventions to avoid failure of initial PIVC insertion. For example, PIVC insertion could be performed by experienced practitioners.

Ultrasound assessment of peripheral intravenous catheters by nurses in the pediatric intensive care unit

OBJECTIVE

Establish the feasibility of pediatric intensive care unit (PICU) nurse-directed ultrasound assessment (UA) of peripheral intravenous (PIV) catheters, compare the results of UA to traditional assessment (TA), and determine PIV survival after UA.

DESIGN

Prospective observational cohort study.

SETTING

PICU within a children's hospital.

PATIENTS

PICU patients with a PIV.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Eight nurses performed UA on 131 PIVs in 85 patients. Median age was 3.0 years (IQR 1.0-13.8) and median weight was 15.0 kg (IQR 9.6-59.3). The most common PIV location was the arm (43%) and extravasation occurred in 15% of PIVs. Agreement between TA and UA was moderate with a Kappa of 0.47 (95% CI 0.28-0.66). Nursing confidence in the UA was significantly higher than TA (92% vs 21% very confident, p < 0.0001). In 106 PIVs with a UA that indicated the PIV was intravascular (i.e. negative UA), the median survival was 50.0 h (IQR 21.8-100.3).

CONCLUSIONS

Nurses can perform UA of PIV status in PICU patients and express greater confidence in the findings of UA than TA. Further study is necessary to determine the impact of UA on the rate of PIV complications.

Risk factors for peripheral venous catheter failure: A prospective cohort study of 5345 patients

PURPOSE

The objective of this study was to determine the independent risk factors associated with peripheral venous catheter (PVC) failure and develop a model that can predict PVC failure.

METHODS

This prospective, multicenter cohort study was carried out in nine tertiary hospitals in Suzhou, China between December 2017 and February 2018. Adult patients undergoing first-time insertion of a PVC were observed from catheter insertion to removal. Logistic regression was used to identify the independent risk factors predicting PVC failure.

RESULTS

This study included 5345 patients. The PVC failure rate was 54.05% (n = 2889/5345), and the most common causes of PVC failure were phlebitis (16.3%) and infiltration/extravasation (13.8%). On multivariate analysis, age (45-59 years: OR, 1.295; 95% CI, 1.074-1.561; 60-74 years: OR, 1.375; 95% CI, 1.143-1.654; ⩾75 years: OR, 1.676; 95% CI, 1.355-2.073); department (surgery OR, 1.229; 95% CI, 1.062-1.423; emergency internal/surgical ward OR, 1.451; 95% CI, 1.082-1.945); history of venous puncture in the last week (OR, 1.298, 95% CI 1.130-1.491); insertion site, number of puncture attempts, irritant fluid infusion, daily infusion time, daily infusion volume, and type of sealing liquid were independent predictors of PVC failure. Receiver operating characteristic curve analysis indicated that a logistic regression model constructed using these variables had moderate accuracy for the prediction of PVC failure (area under the curve, 0.781). The Hosmer-Lemeshow goodness of fit test demonstrated that the model was correctly specified (χ² = 2.514, p = 0.961).

CONCLUSION

This study should raise awareness among healthcare providers of the risk factors for PVC failure. We recommend that healthcare providers use vascular access device selection tools to select a clinically appropriate device and for the timely detection of complications, and have a list of drugs classified as irritants or vesicants so they can monitor patients receiving fluid infusions containing these drugs more frequently.

Impact of Skin Disinfection on Cutaneous Microbiota, before and after Peripheral Venous Catheter Insertion

Introduction. Patients with invasive medical devices are at high risk for infection. Skin colonization is the initial stage of these infections, leading to the recommendation of practices requiring disinfection using antiseptics. Microbial communities playing a major role in skin health could be impacted by antiseptic procedures. Aim. To characterize and compare the bacterial communities of skin samples from patients before an antisepsis procedure, and after removal of the medical device itself, according to the nature of the antiseptic molecule (povidone iodine or chlorhexidine). Methods. The study focused on alterations in bacterial communities depending on the nature of the antiseptic procedure and type of intravascular device. After amplification of 16S rDNA, libraries (n = 498 samples) were sequenced using MiSeq platform. Results. Using an in-house pipeline (QIIME2 modules), while no alteration in skin microbiota diversity was associated with antiseptic procedure or PVC type, according to culture results (p < 0.05), alterations were at times associated with restricted diversity and higher dissimilarity (p < 0.05). Antiseptic procedures and PVC types were associated with the modification of specific bacterial representations with modulation of the Bacillota/Bacteroidota (Firmicutes/Bacteroidetes) ratio (modulation of C. acnes, Prevotella, Lagierella, and Actinomyces spp.) (p < 0.05). At baseline, the microbiota shows certain bacteria that are significantly associated with future PVC colonization and/or bacteremia (p < 0.05). All of these modulations were associated with altered expression of metabolic pathways (p < 0.05). Discussion. Finally, this work highlights the need to optimize the management of patients requiring intravascular devices, possibly by modulating the skin microbiota.

Comparison of clinically indicated replacement and routine replacement of peripheral intravenous catheters: A systematic review and meta-analysis of randomized controlled trials

Background

It is unknown whether clinically indicated replacement of peripheral intravenous catheters (PIVCs) increases the risks of PIVC-associated complications and infections compared to routine replacement of PIVCs.

Methods

We searched PubMed, the Web of Science, the Cochrane Library, Ovid MEDLINE, and Clinicaltrials.gov for randomized controlled trials (RCTs) that compare the safety outcomes of routine replacement and clinically indicated replacement of PIVCs were included for meta-analysis. The primary outcome was the incidence of phlebitis, and secondary outcomes included the risks of occlusion, local infection, infiltration, catheter-related bloodstream infection (CRBSI), and accidental removal of the PIVC.

Results

A total of 9 RCTs involving 10 973 patients were included in this meta-analysis, of whom 5,546 and 5,527 were assigned to the study group (clinically indicated replacement of PIVCs) and control group (routine replacement of PIVCs every 72–96 h), respectively. The incidence of phlebitis in the study group was significantly higher than that in the control group [risk ratio (RR), 1.20; 95% confidence interval (CI), 1.01–1.44, P = 0.04, I² = 49%]. In addition, the study group was associated with a higher risk of occlusion (RR, 1.45; 95% CI, 1.08–1.95, P = 0.01, I² = 82%) and infiltration (fluid leaks) (RR, 1.27; 95% CI, 1.06–1.53, P = 0.01, I² = 72%) than the control group. However, no significant differences were observed in the risks of local infection (RR, 1.75; 95% CI, 0.38–8.16, P = 0.48, I² = 0%) and CRBSI (RR, 0.61; 95% CI, 0.08–4.68, P = 0.64, I² = 0%) between the study and control groups.

Conclusion

The clinically indicated replacement of PIVCs may increase the risks of PIVC-associated phlebitis, infiltration, and occlusion compared to the routine replacement of PIVCs, but did not increase the risk of PIVC-associated infections. Based on these findings, routine replacement of PIVCs every 72–96 h maybe a preferred option than clinically indicated replacement of PIVCs.

Systematic review registration

[www.crd.york.ac.uk/prospero/], identifier [CRD42022302021].

Mapping progress in intravascular catheter quality surveillance: An Australian case study of electronic medical record data linkage

Background and significance

Intravascular (IV) catheters are the most invasive medical device in healthcare. Localized priority-setting related to IV catheter quality surveillance is a key objective of recent healthcare reform in Australia. We sought to determine the plausibility of using electronic health record (EHR) data for catheter surveillance by mapping currently available data across state-wide platforms. This work has identified barriers and facilitators to a state-wide EHR surveillance initiative.

Materials and methods

Data variables were generated and mapped from routinely used EHR sources across Queensland, Australia through a systematic search of gray literature and expert consultation with clinical information specialists. EHR systems were eligible for inclusion if they collected data related to IV catheter insertion, care, or outcomes of hospitalized patients. Generated variables were mapped against international recommendations for IV catheter surveillance, with data linkage and data export capacity narratively summarized.

Results

We identified five EHR systems, namely, iEMR, MetaVision ICU®, Multiprac, RiskMan, and the Nephrology Registry. Systems were used across jurisdictions and hospital wards. Data linkage was not evident across systems. Extraction processes for catheter data were not standardized, lacking clear and reliable extraction techniques. In combination, EHR systems collected 43/50 international variables recommended for catheter surveillance, however, individual systems collected a median of 24/50 (IQR 22, 30) variables. We did not identify integrated clinical analytic systems (incorporating machine learning) to support clinical decision making or for risk stratification (e.g., catheter-related infection).

Conclusion

Current data linkage across EHR systems limits the development of an IV catheter quality surveillance system to provide timely data related to catheter complications and harm. To facilitate reliable and timely surveillance of catheter outcomes using clinical informatics, substantial work is needed to overcome existing barriers and transform health surveillance.

Automatic vein measurement by ultrasonography to prevent peripheral intravenous catheter failure for clinical practice using artificial intelligence: development and evaluation study of an automatic detection method based on deep learning

OBJECTIVES

Complications due to peripheral intravenous catheters (PIVC) can be assessed using ultrasound imaging; however, it is not routinely conducted due to the need for training in image reading techniques. This study aimed to develop and validate a system that automatically measures blood vessel diameters on ultrasound images using artificial intelligence (AI) and provide recommendations for selecting an implantation site.

DESIGN

Pilot study.

SETTING

The University of Tokyo Hospital, Japan.

PRIMARY AND SECONDARY OUTCOME MEASURES

First, based on previous studies, the vessel diameter was calculated as the mean value of the maximum long diameter plus the maximum short diameter orthogonal to it. Second, the size of the PIVC to be recommended was evaluated based on previous studies. For the development and validation of an automatic detection tool, we used a fully convoluted network for automatic estimation of vein location and diameter. The agreement between manually generated correct data and automatically estimated data was assessed using Pearson's product correlation coefficient, systematic error was identified using the Bland-Altman plot, and agreement between catheter sizes recommended by the research nurse and those recommended by the system was evaluated.

RESULTS

Through supervised machine learning, automated determination was performed using 998 ultrasound images, of which 739 and 259 were used as the training and test data set, respectively. There were 24 false-negatives indicating no arteries detected and 178 true-positives indicating correct detection. Correlation of the results between the system and the nurse was calculated from the 178 images detected (r=0.843); no systematic error was identified. The agreement between the sizes of the PIVC recommended by the research nurse and the system was 70.2%; 7% were underestimated and 21.9% were overestimated.

CONCLUSIONS

Our automated AI-based image processing system may aid nurses in assessing peripheral veins using ultrasound images for catheterisation; however, further studies are still warranted.t.

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.

Risk factors for peripheral intravascular catheter-related phlebitis in critically ill patients: analysis of 3429 catheters from 23 Japanese intensive care units

Background

Phlebitis is an important complication occurring in patients with peripheral intravascular catheters (PIVCs). The risk factors for phlebitis in the intensive care unit (ICU) was examined.

Methods

A secondary analysis of a prospective multicenter cohort study was conducted, involving 23 ICUs in Japan—the AMOR–VENUS study. Consecutive patients aged ≥ 18 years admitted to the ICU with newly inserted PIVCs after ICU admission were enrolled. Characteristics of the ICU, patients, PIVCs, and the drugs administered via PIVCs were recorded. A marginal Cox regression model was used to identify the risk factors associated with phlebitis.

Results

A total of 2741 consecutive patients from 23 ICUs were reviewed for eligibility, resulting in 1359 patients and 3429 PIVCs being included in the analysis population. The median dwell time was 46.2 h (95% confidence interval [CI], 21.3–82.9). Phlebitis occurred in 9.1% (95% CI, 8.2–10.1%) of catheters (3.5 cases/100 catheter days). The multivariate analysis revealed that the only factors that increased the risk of developing phlebitis were drugs administered intravenously. This study included 26 drugs, and 4 were associated with increased phlebitis: nicardipine (HR, 1.85; 95% CI, 1.29–2.66), noradrenaline (HR, 2.42; 95% CI, 1.40–4.20), amiodarone (HR, 3.67; 95% CI, 1.75–7.71) and levetiracetam (HR, 5.65; 95% CI, 2.80–11.4). Alternatively, factors significantly associated with a reduced risk of phlebitis were: standardized drug administration measures in the ICU (HR, 0.35; 95% CI, 0.17–0.76), 30≤ BMI (HR, 0.43; 95% CI, 0.20–0.95), catheter inserted by a doctor as nurse reference (HR, 0.55; 95% CI, 0.32–0.94), and upper arm insertion site as forearm reference (HR, 0.52; 95% CI, 0.32–0.85). The nitroglycerin was associated with a reduced phlebitis risk (HR, 0.22; 95% CI, 0.05–0.92).

Conclusion

Various factors are involved in the development of phlebitis caused by PIVCs in critically ill patients, including institutional, patient, catheter, and drug-induced factors, indicating the need for appropriate device selection or models of care in the ICU.

Trial registration: UMIN-CTR, the Japanese clinical trial registry (registration number: UMIN000028019, July 1, 2017).

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-01009-5.

Peripheral intravenous cannulation decision-making in emergency settings: a qualitative descriptive study

OBJECTIVES

Rates of unused ('idle') peripheral intravenous catheters (PIVCs) are high but can vary per setting. Understanding factors that influence the decision-making of doctors, nurses and paramedics in the emergency setting regarding PIVC insertion, and what factors may modify their decision is essential to identify opportunities to reduce unnecessary cannulations and improve patient-centred outcomes. This study aimed to understand factors associated with clinicians' decision-making on whether to insert or use a PIVC in the emergency care setting.

DESIGN

A qualitative descriptive study using in-depth semistructured interviews and thematic analysis.

SETTING

Gold Coast, Queensland, Australia, in a large tertiary level emergency department (ED) and local government ambulance service.

PARTICIPANTS

Participants recruited were ED clinicians (doctors, nurses) and paramedics who regularly insert PIVCs.

RESULTS

From the 15 clinicians interviewed 4 key themes: knowledge and experience, complicated and multifactorial, convenience, anticipated patient clinical course, and several subthemes emerged relating to clinician decision-making across all disciplines. The first two themes focused on decision-making to gather data and evidence, such as knowledge and experience, and decisions being complicated and multifactorial. The remaining two themes related to the actions clinicians took such as convenience and anticipated patient clinical course.

CONCLUSION

The decision to insert a PIVC is more complicated than clinicians, administrators and policy-makers may realise. When explored, clinician decisions were multifaceted with many factors influencing the decision to insert a PIVC. In actual practice, clinicians routinely insert PIVCs in most patients as a learnt reflex with little cognitive input. When considering PIVC insertion, more time needs to be devoted to the awareness of: (1) decision-making in the context of the clinician's own experience, (2) cognitive biases and (3) patient-centred factors. Such awareness will support an appropriate risk assessment which will benefit the patient, clinician and healthcare system.

Inflammatory, Mechanical and Infectious Complications Associated with Peripheral Intravenous Catheters in Dogs and Cats: A Risk Factor Analysis

The placement of peripheral intravenous catheters (PIVC) is potentially associated with complications that negatively impact healthcare. Our study investigated factors associated with the occurrence of PIVC-related complications in dogs and cats at a Veterinary Teaching Hospital. The second aim was to determine the prevalence of PIVC bacterial colonization. A total of 76 dogs and 40 cats with PIVCs were evaluated for the occurrence of phlebitis and mechanical complications. The devices were removed when they ceased to be functional or when complications occurred, and the content was submitted for bacterial cultures and antimicrobial susceptibility tests. Both multivariable linear regression models and ROC analysis were employed. Complications were recorded in 46.6% of cases, and 20.7% of catheters yielded a positive culture. Among the isolates, 45% were classified as multi-resistant. In dogs, a ≥36-h indwelling time was associated with an increased risk of complications. Male cats seem more prone to developing complications, while the insertion of PIVCs under sedation may represent a protective factor in this species. In conclusion, PIVC-associated complications were frequently observed, and the high rate of positive culture for PIVCs, together with the presence of multi-resistant isolates, is a cause of concern in a hospital setting.

Catheter failure in the administration of hyperosmotic drugs through a peripheral vein and vascular selection: A retrospective cohort study

This study aimed to determine whether the placement of a peripheral intravenous catheter (PIVC) in the cephalic vein of the forearm could prevent PIVC failure in patients receiving hyperosmotic drugs through the peripheral vein. This retrospective cohort study included patients aged ≥ 20 years who had received infusion therapy via a PIVC in our institution between July and November 2017. Patients were divided into groups according to PIVC insertion into the cephalic, basilic, and medial veins. PIVCs used to administer drugs with osmotic pressure ratios > 2.0 were included. The primary outcome was survival time to catheter failure. Catheter failure was defined as accidental and unplanned catheter removal. We set the cephalic vein and other veins, including the medial and basilic veins, in the forearm as cohort groups. We used the Kaplan-Meier survival curves to compare the time until catheter failure in the cohort groups. The Cox proportional hazard models were fitted, and the hazard ratios were calculated. A total of 46 catheters with hyperosmotic agents were included in the analysis. Catheter failure was observed in 25 (54.3%) cases. Time to catheter failure in patients receiving high-dose drugs via the cephalic vein was significantly longer than that in the other two groups (p < 0.01). Thus, the cephalic vein, which has a high blood flow, is the ideal site of PIVC insertion in patients receiving high drug concentrations to prevent catheter failure.

Routine replacement versus replacement as clinical indicated of peripheral intravenous catheters: A multisite randomised controlled trial

AIMS AND OBJECTIVES

To compare the safety of replacing peripheral intravenous catheter as clinically indicated versus routine replacement on patient outcomes in the Chinese context.

BACKGROUND

Some evidence from developed countries recommend replacing peripheral intravenous catheter as clinically indicated; however, there is limited evidence from developing countries.

DESIGN

A multisite randomised controlled trial.

METHODS

The 3050 participants from three hospitals in China were randomly assigned to clinically indicated or routine replacement groups. Patients in the clinically indicated group had the catheters kept in situ until any of the following clinical signs appeared: phlebitis, infiltration, occlusion, displacement, local infection and diagnosed catheter-related bloodstream infection. Patients in the routine replacement group had their peripheral intravenous catheters replaced every 96 hours. The outcomes of phlebitis, infiltration, occlusion, displacement; catheter-related bloodstream infection, all-cause bloodstream infection, and local infection were compared. CONSORT checklist was used to guide the reporting of this RCT.

RESULTS

The risk of phlebitis, phlebitis per 1000 catheter days, occlusion, dislodgement, all bloodstream infections, local infection and mortality between the two groups were not significantly different. The risk of infiltration was increased in the clinically indicated group (HR 1.29). There was no catheter-related bloodstream infection reported in either group. Patients' first peripheral intravenous catheter dwelling time and cumulative indwelling time of all peripheral intravenous catheters in the clinically indicated group were significantly longer than the routine replacement group. There was no statistical significant difference in survival times from phlebitis between the two groups.

CONCLUSIONS

In the Chinese context, removing peripheral catheters as clinical indicated did not increase the risk of phlebitis, occlusion, catheter displacement and catheter infection; however, there was an increased infiltration incidence.

RELEVANCE TO CLINICAL PRACTICE

In developing countries, removing peripheral catheters as clinical indicated is feasible, but more frequent observations of infiltration are highly recommended.

Comparison of Routine Replacement With Clinically Indicated Replacement of Peripheral Intravenous Catheters

IMPORTANCE

Peripheral intravenous catheters (PVCs) are the most frequently used indwelling devices in hospitals worldwide. Peripheral intravenous catheter bloodstream infections (PVC-BSIs) are rare, but severe and preventable, adverse events.

OBJECTIVE

To investigate the incidence of PVC-BSIs after changing the policy of routine PVC replacement every 96 hours to clinically indicated replacement.

DESIGN, SETTING, AND PARTICIPANTS

This institution-wide, observational cohort study evaluated all patients hospitalized at a large university-affiliated hospital with 10 sites in Western Switzerland with a PVC insertion between January 1, 2016, and February 29, 2020.

EXPOSURES

Peripheral intravenous catheters were routinely replaced every 96 hours until March 31, 2018 (baseline period). Between April 1, 2018, and October 15, 2019, PVCs were replaced if clinically indicated (intervention period). From October 16, 2019, PVCs were again routinely replaced every 96 hours (reversion period).

MAIN OUTCOMES AND MEASURES

The PVC-BSI rates and PVC-BSI incidence rate ratios (IRRs) during each period.

RESULTS

A total of 412 631 PVCs with documented catheter duration were included (164 331 patients; median [interquartile range] patient age, 51 [33-72] years; 88 928 [54.1%] female): 241 432 PVCs at baseline, 130 779 at intervention, and 40 420 at reversion. Eleven PVC-BSIs were observed during the baseline period, 46 during the intervention, and 4 during the reversion period. Although the monthly number of PVC-days remained stable during all study periods, the number of monthly inserted PVCs decreased during the intervention period. The number of PVCs still in place more than 4 or more than 7 days was higher during the intervention period compared with the baseline and reversion periods. A significantly increased IRR of PVC-BSIs was observed for the intervention period (IRR, 7.20; 95% CI, 3.65-14.22; P < .001) compared with baseline, whereas during the reversion period there was no significant increase (IRR, 1.35; 95% CI, 0.30 6.17; P = .69).

CONCLUSIONS AND RELEVANCE

The results of this cohort study using a large, prospective surveillance database suggest that replacement of PVCs only when clinically indicated may be associated with an increased risk of PVC-BSI compared with routine replacement. Even if PVC-associated BSI is a rare event, the use of PVCs in most patients makes this outcome relevant.

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.

Safety and impact of peripheral parenteral nutrition on nutrient delivery in patients with nutrition risk: A prospective observational study

BACKGROUND

Malnutrition is common in hospitalized patients and strategies to improve energy and protein intake have a positive impact on outcome. Despite early evidence suggesting the usefulness of peripheral parenteral nutrition (PPN), its adoption has been hampered by concerns regarding safety and efficacy. This study addresses this issue.

METHODS

This prospective observational study was performed in medical and surgical inpatients in who were screened for nutrition risk and assessed using Subjective Global Assessment (SGA). Data captured included nutrition status, energy and protein requirements, intravenous access, indications for PPN, use of supplemental micronutrients, and disposition of patients on PPN.

RESULTS

Ninety-eight patients were recruited from two centers over 8 months. The average age was 61.5 years, the mean Charlson Comorbidity Index was 4.21 (±3.09), 52% were male, and 48% were admitted to medicine, whereas 52% were admitted to surgery. Thirty-three percent of patients were SGA C, 44% were SGA B, and 19% were SGA A. Twenty-seven percent of patients had cancer. The average length of hospital stay was 22 days. The main indications for PPN were gastrointestinal tract dysfunction (72%) and postsurgical status (16%). PPN provided an average of 1296 kcal (±191) and 46 g of protein (±7). Intravenous access complications in patients receiving PPN did not occur in excess of expected. Almost 40% of patients required transition to central PN.

CONCLUSIONS

PPN is a safe, effective way to deliver supplemental protein, energy, and micronutrients to malnourished patients and supports transition to other modes of nutrition care.

Microbiological colonization of peripheral venous catheters: a prospective observational study in a Swedish county hospital

Background

Most peripheral venous catheters (PVCs) used in Scandinavia are fitted with an injection port, creating an open PVC system. This port is difficult to disinfect, which may lead to the introduction of micro-organisms upon use.

Aim

To investigate the prevalence of microbiological colonization of the injection port and internal lumen of ported PVCs with a minimum dwell time of 48 h at sample collection.

Methods

Adult patients admitted to different medical and surgical departments and the intensive care unit were invited to participate in this prospective observational study. With the PVC in situ, the injection port and internal lumen were swabbed and cultured separately. Demographic and clinical data were collected to compare patients with colonized and non-colonized PVCs.

Findings

In total, 300 PVCs from 300 patients were analysed. Of these, 33 patients (11.0%) had at least one positive culture. The colonization locations were as follows: port only, 26 (8.7%); internal lumen only, 5 (1.7%); and port and internal lumen, 2 (0.7%). The colonization rate was significantly higher in the injection port than in the internal lumen (P<0.0001). A ported PVC inserted in the hand incurred a significant risk of colonization (P=0.03). The odds ratio for colonization among patients in the infectious diseases department was 0.1 (95% confidence interval 0.1–1; P<0.06) compared with patients in the medical department.

Conclusion

This study showed that 11% of ported PVCs were colonized by micro-organisms, with the vast majority (8.7%) of colonization occurring in the injection port.

Clinical trial registration

ClinicalTrials.gov; ID NCT03351725.

Idle peripheral intravenous cannulation: an observational cohort study of pre-hospital and emergency department practices

BACKGROUND

Unused ('idle') peripheral intravenous catheters (PIVC) are those not used within 24 hours of insertion. There is little data on cannulation practices and idle PIVC rates in emergency settings, especially the pre-hospital environment.

METHODS

This was an observational cohort study set in south-east Queensland, Australia using data from a large tertiary level emergency department (ED) and the local statutory ambulance service. Demographic, clinical and PIVC data were collected over two periods; 9 February-18 March 2017 and 5 January-4 February 2018. Adult patients were included if they were allocated an Australasian triage scale (ATS) category between 2 and 5, and had a PIVC inserted in the pre-hospital setting or ED. PIVC use was defined as idle if no fluids, medications or contrast were administered intravenously within 24 hours of insertion. Comparisons between pre-hospital and ED practice and idle PIVC status were undertaken using descriptive statistics and logistic regression.

RESULTS

A total of 1249 patients with a PIVC (372 pre-hospital; 877 ED) were included. Overall, 366 PIVCs (29.3%; 95% CI 26.9%-31.9%) remained idle at 24 hours. In the pre-hospital group, 147 (39.5%) PIVCs inserted were not used pre-hospital, and 74 (19.9%) remained idle. In comparison, 292 (33.3%) PIVCs placed in the ED remained idle. ED staff more frequently inserted PIVCs in the antecubital fossa than paramedics (65.5% vs. 49.7%), where forearm PIVC insertion was more common pre-hospital than in ED (13.7% vs. 7.4%). Nursing staff inserted idle PIVCs at a rate of (35.1%) compared to doctors (29.6%) and paramedics (19.9%). Having a PIVC inserted in the ED was the only factor significantly (p ≤ .001) predicting an idle outcome (Odds Ratio: 2.4; 95% CI 1.7-3.3).

CONCLUSION

One-third of PIVCs inserted within the emergency setting remained idle, suggesting unnecessary risk and costs. Pre-hospital and ED PIVC insertion practices differed, with idle PIVCs 2.4 times more prevalent if inserted in the ED than pre-hospital and with greater use of antecubital insertion. Reasons for these differences are not well understood and requires more targeted research.