Peripheral Intravenous Catheterisation in Obstetric Patients in the Hand or Forearm Vein: A Randomised Trial

Peripheral intravenous catheter management in childbirth (PICMIC): A multi-centre, prospective cohort study

BACKGROUND

Childbirth is a normal, physiological process, yet intervention is common. Arguably the most common intervention is the insertion of a peripheral intravenous catheter; however, there are few studies guiding best practice. This study aimed to describe current intravenous catheter insertion practice, explore clinician decision-making during insertion and perceptions of women.

METHODS

This prospective, observational cohort study recruited 101 women and clinicians from two Australian regional hospitals. Data collection incorporated non-participant observation, brief interview and chart review. Variables measured included pain score, insertion attempts, catheter gauge and dwell time.

RESULTS

Childbearing women were, on average, aged 31 with body mass index (BMI) above 28. Women reported a mean pain score of 3.3/10 at 24 h for catheter insertion and 12% reported bruising. An 18-gauge catheter was considered more painful than a 16-gauge, and multiple attempts did not increase perceived average pain score. Association between failed first attempts and higher BMI was not established. Participant clinicians were predominantly midwives, who selected and placed 18-gauge catheters mostly in hand or wrist (66%). Decision-making about site, catheter gauge, dressing and attempts varied. Thirty-four per cent attempted two to three times, despite regular practise. Confidence to reliably insert determined catheter gauge and almost half clinician participants cited hospital policy and preferred non-dominant arm as key reasons for the location of PIVC.

CONCLUSIONS

Regular use of a large-gauge catheter is counter intuitive when placed in the small veins of the hand with extension tubing. More research is needed to promote best practice around gauge selection, site and women's experience.

Techniques to select site of insertion for a peripheral intravenous catheter with vessel locating devices using light, sounds or tactile actions (or palpations)

BACKGROUND

Approximately 80% of patients admitted to acute hospitals have at least one peripheral intravenous catheter inserted during their admission, for the administration of fluids and medicines, and/or diagnostic tests, so the failure rate is concerning. New technology may decrease these rates even when used by inexperienced inserters. The choice of insertion site for an intravenous catheter is a known predictor of catheter failure. Therefore, the objective for this study was to evaluate the utility of vessel locating devices for novice clinicians to select catheter insertion sites in the forearm.

METHODS

An inter-subject incomplete counterbalanced research design was employed with healthy volunteers. Novice clinicians used either a vessel locating device using light or sound waves or they used palpation to identify relatively superficial veins in the forearm. This was compared to site selection performed by an expert clinician using palpation method only. Measurements of differences were analysed from photos of chosen sites. Bland-Altman agreement analysis was used to plot novice expert agreement. The STROBE checklist was followed in reporting this study (Techniques to select site of insertion for a peripheral intravenous catheter with vessel locating devices (Appendix S1)).

RESULTS

A total of 32 novice clinicians used three vessel locating devices and a palpation technique. Novice clinicians did not choose more veins for optimum catheter placement when assisted with vessel locating devices compared to palpation techniques. All methods had a similar mean difference between novice and expert measurements and a similar percentage difference in distance from the expert choice. Bland-Altman agreement analysis did not identify any advantage for the novice with vessel locating devices over palpation.

CONCLUSION

Vessel locating devices do not enhance the ability of novice clinicians any greater than palpation when selecting suitable forearm veins. If vessel locating device approaches are to be adopted in clinical practice to support better insertion outcomes then current PIVC teaching techniques should include structured vessel locating devices theory and practice.

RELEVANCE TO CLINICAL PRACTICE

Successful insertion of a peripheral intravenous catheter (PIVC) on the first attempt is a challenging procedure for nurses. Careful consideration of the selected site of insertion could modify this risk factor for catheter failure. The choice of PIVC insertion site by a novice clinician compared to an expert does not necessarily improve with the use of vein locating technology. While there is a range of technological devices available to assist with locating vessels, there needs to be more emphasis from educators on how to select an appropriate insertion site for intravenous therapy.

The best vein to be accessed based on descriptive study of dorsal metacarpal vein

It is well known that the most common sites for venous access are the superficial veins of the upper limb, particularly dorsal metacarpal veins and median cubital vein. Although dorsal metacarpal veins are the first choice for venous cannulation, there is scarce information about their anatomic variation. Hence, detailed anatomical information about these veins will improve the anatomic knowledge of the health care providers. Subsequently, this study was designed to study the dorsal metacarpal veins and to determine the most prominent dorsal metacarpal vein. A cross sectional study of 402 subjects (804 hands), was prepared to study the superficial veins on the dorsum of the hand among Jordanian students and staff of one of the major governmental medical colleges in Jordan, by using infrared illumination system. The obtained data was analyzed according to sex, sidedness, and handedness. Six locations of the most prominent dorsal metacarpal veins were identified. There was a significant relation between both females and males and the most prominent dorsal metacarpal vein (P=0.01). For the first time this study identified the most common location of the most prominent dorsal metacarpal vein in the fourth intermetacarpal space.

Clinically-indicated replacement versus routine replacement of peripheral venous catheters

BACKGROUND

US Centers for Disease Control guidelines recommend replacement of peripheral intravenous catheters (PIVC) no more frequently than every 72 to 96 hours. Routine replacement is thought to reduce the risk of phlebitis and bloodstream infection. Catheter insertion is an unpleasant experience for patients and replacement may be unnecessary if the catheter remains functional and there are no signs of inflammation or infection. Costs associated with routine replacement may be considerable. This is the third update of a review first published in 2010.

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

We included randomised controlled trials that compared routine removal of PIVC with removal only when clinically indicated, in hospitalised or community-dwelling patients receiving continuous or intermittent infusions.

DATA COLLECTION AND ANALYSIS

Three review authors independently reviewed trials for inclusion, extracted data, and assessed risk of bias using Cochrane methods. We used GRADE to assess the overall evidence certainty.

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Dorsal metacarpal veins: anatomic variation and potential clinical implications

The dorsal metacarpal veins are frequently cannulated. Cannulation success is determined by several variable anatomic features. The objective of this study is to classify, for the first time, the anatomic variants of the dorsal metacarpal veins. In this cross-sectional study, 520 university students and staff were conveniently recruited. The dorsal metacarpal veins in 1040 hands were studied. Venous visibility was enhanced by either tourniquet application or near-infrared illumination. Variant patterns of the dorsal metacarpal veins were classified. The final analysis included 726 hands, for an exclusion rate of 30 %. Eight pattern types were identified. Three anatomic features informed the variation. Bilateral symmetry of the dorsal metacarpal veins was present in 352 participants (83 % of the total). The overall frequency distribution of variants in both hands was similar (P = 0.8). The frequency distribution of variants was subject to sexual dimorphism (P = 0.001), ethnic variation (P < 0.001), and technical variation (P < 0.001). The anatomic variants of the dorsal metacarpal veins were sorted into decreasingly frequent primary, secondary, and tertiary groups. The groups may signify a progressive increase in difficulty of peripheral cannulation, in the mentioned order. As such, primary patterns are the most common and likely the easiest to cannulate, while tertiary patterns are the least common and likely the most difficult to cannulate. The preceding premise, in tandem with the bilateral asymmetry of the veins, is clinically significant. With cannulation difficulty likely signifying an underlying tertiary pattern, the contralateral dorsal metacarpal veins are probabilistically characterized by a primary pattern and are, as such, the easier option for peripheral venous cannulation.