Low-Angled Peripheral Intravenous Catheter Tip Placement Decreases Phlebitis

Predictors of ultrasound-guided peripheral intravenous catheter failure: A secondary analysis of existing trial data

OBJECTIVES

Ultrasound-guided (US) peripheral intravenous catheters (PIVC) have a high failure rate with many failing prior to completion of therapy. Risk factors associated with catheter failure are poorly delineated. This study aimed to assess risk factors related to catheter failure including patient, procedure, catheter, and vein characteristics to further elucidate which variables may impact catheter longevity.

METHODS

This was a secondary analysis using an existing trial dataset that primarily compared survival of two catheters: a standard long (SL) and an ultra-long (UL) US PIVC. Adult emergency room patients with difficult intravenous access at a tertiary care suburban academic center were study participants. Kaplan-Meier was employed to estimate the median catheter survival time. Cox regression univariable and multivariable analyses were used to evaluate the primary outcome of catheter survival.

RESULTS

Among 257 subjects, 63% of PIVCs survived until completion of therapy. In a multivariable Cox regression model, length of catheter in vein >2.75 cm (adjusted hazard ratio [aHR] 0.58, 95% confidence interval [CI] 0.37-0.90, p = 0.01) was associated with improved survival. First stick success decreased the risk of catheter failure (aHR 0.68, 95% CI 0.44-1.06, p = 0.09) but was not statistically significant. Factors associated with the increased risk of catheter failure included: depth of vein >1.2 cm (aHR 1.68, 95% CI 1.06-2.66, p = 0.03) and PIVC placement in right extremity (aHR 1.64, 95% CI 1.07-2.51, p = 0.02).

CONCLUSIONS

This study demonstrated that catheter length in vein (>2.75 cm) was associated with improved US PIVC survival highlighting the value of longer catheters in US PIVC survival. Choosing targets in the non-dominant extremity with shallower depths (⩽1.2 cm) may also increase catheter survival.

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.

Operation STICK: A vascular access specialty program for the generalist emergency medicine clinician

OBJECTIVE

Comprehensive education and training programs are urgently needed to improve vascular access outcomes in the emergency department (ED). This study aimed to demonstrate the success of a formalized vascular access program in developing competent ED clinicians in traditional and ultrasound-guided insertion methods.

METHODS

This was a retrospective observational study exploring the success of trainees in obtaining competency in peripheral vascular access at an academic suburban ED with 120,000 annual visits. Eligible participants included healthcare workers that enrolled in the Operation STICK vascular access program and perform vascular access procedures as an aspect of their clinical practice. Competency in vascular access included both traditional and ultrasound-guided (US) peripheral intravenous catheter (PIVC) insertions. Competency was defined as demonstration of successful insertion of one traditional and one US PIVC in compliance with checklist. The primary objective was competency. Secondary objectives included trainee time to competency, trainee number of line encounters, and changes in program competency achievements over time.

RESULTS

From October 15, 2021, to April 15, 2023, 141 clinicians participated in peripheral vascular access training via the Operation STICK model, which included 72 (51.1%) nurses, 52 (36.9%) ED technicians, and 17 (12.0%) healthcare personnel with other medical training. Clinicians overall reported an average of 5.6 years of experience inserting peripheral intravenous catheters (PIVCs) and 23 (16.3%) had experience with using ultrasound. About 122 (86.5%) clinicians successfully completed the program and demonstrated competency in traditional and ultrasound-guided techniques. Time to competency varied over time, with a median of 124 days in the early phase, 32.5 days middle phase, and 10.6 h over 9.5 days in the later phase of the program (p < 0.001).

CONCLUSIONS

Achieving competency in PIVC insertion necessitates a focused effort on refining and systematizing education and training approaches. Recognizing the inherent challenges present in ED settings, it is feasible to effectively and efficiently train emergency clinicians to be expert in both basic and advanced PIVC placement techniques through participation in a well-organized vascular access training program.

Evaluating the impact of external forces on peripheral intravenous catheter movement using ultrasound: A randomized pilot study

BACKGROUND

A major contributor to peripheral intravenous catheter (PIVC) failure may be related to PIVC movement within the vein which is associated with vein wall damage. The magnitude of PIVC movement against the vein wall has not previously been quantified. This study aimed to examine PIVC movement within the vein when minor forces were applied to the PIVC.

METHODS

This was a prospective, pilot trial including healthy volunteers in an outpatient research laboratory. The primary objective was to examine the in movement (millimeters) of the PIVC using ultrasound with external pull forces (4, 5, and 6 lbs; 1.8, 2.3, and 2.7 kg, respectively) applied to the PIVC in random order.

RESULTS

Participants (N = 11) were aged 40.36 ± 16.10 years with 54.55% being Male. Mean ± SD PIVC movement for 4, 5, and 6 lbs of force was 4.65 ± 1.88, 3.88 ± 2.28, and 5.25 ± 2.06 mm, respectively. There was substantial PIVC movement when a force was applied to the PIVC, but no statistically significant difference between 4, 5, and 6 lb forces (p > 0.05).

CONCLUSION

When external pull forces were applied to the PIVC, substantial PIVC movement within the vein occurred in a healthy population. Strategies that reduce PIVC movement and/or remove or limit external pull forces from the PIVC are needed. Future studies on hospitalized patients are warranted to quantify vein wall injury and PIVC failure due to PIVC movement from various pull forces.

Investigative study of hemodilution ratio: 4Vs for vein diameter, valve, velocity, and volumetric blood flow as factors for optimal forearm vein selection for intravenous infusion

BACKGROUND

Multimodal research and guidelines recognize veins in the forearm used for peripheral intravenous catheter (PIVC) insertion can optimize dwell time. Yet, many PIVCs are still placed in areas of flexion or suboptimal locations such as the back of the hand causing premature failure of >50%. This study identified characteristics of the forearm cephalic vein that make the anatomical location highly successful for PIVC insertion. The goal was to increase the understanding of the human vasculature in association with fluid mechanics in veins above the wrist and below the antecubital fossa.

METHODOLOGY

A prospective in-vivo study with 10 consented healthy human volunteers (HHVs) was performed with Color Pulse Wave Doppler Ultrasound that captured high-resolution video and images of vein diameter, velocity of blood flow, and location of venous valves in the forearm.

RESULTS

Forearm vein diameter was not directly correlated with higher or lower Velocity of Blood Flow (0.58 cm = 3.0 cm/s). However, Volumetric Blood Flow rates tended to be lower (2.51-8.28 mL/min) with Vein Diameters smaller than 0.29 cm. Ultrasound assessments and Volumetric Blood Flow calculations confirmed natural turbulence in blood and retrograde blood reflux correlated with venous valves opening and closing. Areas of turbulence, with pulse flushing, created backflow with retrograde blood flow around and into the catheter.

CONCLUSIONS

Placement of long PIVCs in the cephalic veins of the upper forearm yield adequate flow and hemodilution capacity for veins with at least a 3 to 1 hemodilution ratio. The data from this study, along with previous research, suggest that PIVC placement in the cephalic vein, based on selection criteria, may help to reduce or eliminate intravenous complications such as chemical or mechanical thrombophlebitis causing premature catheter failure. Application of these investigational principles may result in better outcomes and catheter longevity for patients who require intravenous infusions.

Predictive Factors for Infusion Site Induration After Outpatient Chemotherapy in Japan: A Secondary Analysis

PURPOSE

Even in the absence of extravasation, some patients develop induration at the peripheral intravenous catheterization site prior to the next day's treatment. Infusion site induration commonly affects patients who undergo repeated chemotherapy administrations. Vessel health is crucial for the continuation of chemotherapy. However, there is no effective method to prevent induration. Hence, this study aimed to investigate the factors that could cause induration for preventing its occurrence.

METHODS

This study was a secondary analysis of a prospective observational study. All participants were undergoing outpatient chemotherapy. Participant characteristics and related catheterization data were collected on the treatment day as baseline, and induration incidence was recorded on the subsequent treatment day. Receiver operating characteristic (ROC) analysis was performed to determine the sensitivity and specificity of cutoff points of the vein and catheter diameter ratios for distinguishing between developed induration and not developed induration. Additionally, cox regression analysis with multiple imputation was used to investigate the factors that predicted induration.

RESULTS

Seventy-one patients participated in the study. The cutoff point of the vein/catheter diameter ratio calculated using ROC analysis was ≥3.7. The ratio of larger-diameter veins to catheter diameter of ≥3.7 times was negatively associated with induration in both complete case analysis (HR: 0.11; p = 0.034) and multiple imputation analysis (HR: 0.12; p = .049).

CONCLUSIONS

Selecting the vein with 3.7 times higher diameter than the catheter diameter for the catheterization site may help prevent induration on the next treatment day.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

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.

Risk factors for peripheral venous catheter-related phlebitis stratified by body mass index in critically ill patients: A post-hoc analysis of the AMOR-VENUS study

Introduction

Phlebitis is an important complication in patients with peripheral intravascular catheters (PIVCs). Although an association between body mass index (BMI) and phlebitis has been suggested, the risk of phlebitis according to BMI has not been well elucidated. Therefore, in this study, we analyzed the risk of phlebitis according to BMI in patients in the intensive care unit (ICU).

Materials and methods

This study undertook a secondary analysis of the data from a prospective multicenter observational study assessing the epidemiology of phlebitis at 23 ICUs in Japan. Patients admitted into the ICU aged ≥18 years with a new PIVC inserted after ICU admission were consecutively enrolled and stratified into the following groups based on BMI: Underweight (BMI &lt; 18.5 kg/m2), normal weight (18.5 ≤ BMI &lt; 25.0 kg/m2), and overweight/obese (BMI ≥ 25.0 kg/m2). The primary outcome was phlebitis. The risk factors for phlebitis in each BMI-based group were investigated using a marginal Cox regression model. In addition, hazard ratios and 95% confidence intervals were calculated.

Results

A total of 1,357 patients and 3,425 PIVCs were included in the analysis. The mean BMI for all included patients was 22.8 (standard deviation 4.3) kg/m2. Among the eligible PIVCs, 455; 2,041; and 929 were categorized as underweight, normal weight, and overweight/obese, respectively. In the underweight group, catheter size ≥ 18 G and amiodarone administration were independently associated with the incidence of phlebitis. Drug administration standardization was associated with the reduction of phlebitis. In the normal weight group, elective surgery as a reason for ICU admission, and nicardipine, noradrenaline, and levetiracetam administration were independently associated with the incidence of phlebitis. Heparin administration was associated with the reduction of phlebitis. In the overweight/obese group, the Charlson comorbidity index, catheter size ≥ 18 G, and levetiracetam administration were independently associated with the incidence of phlebitis. Catheters made from PEU-Vialon (polyetherurethane without leachable additives) and tetrafluoroethylene were associated with the reduction of phlebitis.

Conclusion

We investigated the risk factors for peripheral phlebitis according to BMI in ICU and observed different risk factors in groups stratified by BMI. For example, in underweight or overweight patients, large size PIVCs could be avoided. Focusing on the various risk factors for phlebitis according to patients’ BMIs may aid the prevention of phlebitis.

Safety verification of a new peripheral intravenous catheter placed in the upper arm vein for administration of drugs with high irritant potential

Despite the widespread use of peripheral intravenous catheters, unscheduled catheter failure before completion of treatment occurs frequently. If a large vein is selected, catheter failures may be prevented despite administering a highly irritant drug. In this study, we attempted to use a catheter that can be placed in a large upper arm vein. The new catheter was 88 mm long but had no guidewire to reduce contamination risk. This study aimed to evaluate the safety of the first-in-human trial for the new catheter with the administration of highly irritant drugs. This study was conducted at a university hospital in Tokyo, Japan. Eight Japanese adults were hospitalized adults with planned administration of non-cancer drugs with high irritant potential using a peripheral catheter. A trained nurse catheterized with the new catheter in the upper arm using ultrasonography. The catheterization site was monitored by staff and a research nurse once every 24 hours for up to 7 days. No adverse events or catheter failure occurred and the catheter placement success rate was 100%. In two patients, a temporary occlusion alarm of the infusion pump occurred, possibly due to the flexion of the catheter base. The new peripheral intravenous catheter did not interrupt medical treatments as is common after placement, but safety administered the irritant drugs. However, because this catheter may be easily affected by the contraction of the muscle at the fixation position, the position and method of catheter fixation in the upper arm need to be carefully considered.

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.

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.

Damage to subcutaneous tissue at the catheterization site during chemotherapy: A prospective observational study using ultrasonography

PURPOSE

Chemotherapy administration can affect subcutaneous tissue at the catheterization site with no macroscopic signs or subjective symptoms. Yet clinical studies about the impact of chemotherapy on tissue at the catheterization site, except for apparent extravasation cases, are limited. This study aimed to investigate subcutaneous tissue changes in nonmacroscopically damaged catheterization sites after chemotherapy administration.

METHODS

Participants were people with cancer receiving outpatient chemotherapy. Ultrasonographic images were used to assess the condition of subcutaneous tissues, including the vein, at the catheterization site before catheterization, immediately after chemotherapy, and on the next scheduled treatment day. Data on macroscopic inspection, palpation, and subjective symptoms were also collected and analyzed.

RESULTS

Data from 41 participants were analyzed. All had normal subcutaneous tissues before catheterization. After treatment, 16 (39.0%) manifested abnormalities such as subcutaneous edema, vessel wall thickening, and/or thrombosis; there was no extravasation immediately after treatment. On the next treatment day, 15 (36.6.%) showed persistent or new onset of abnormalities, including subcutaneous edema. Eight of the 15 did not exhibit any subjective symptoms or macroscopic or palpation findings.

CONCLUSION

After chemotherapy administration via peripheral intravenous catheters, it was found that this damage, which was difficult to detect by the conventional assessment method, persisted. Ultrasonography can provide useful information to avoid reusing damaged sites for chemotherapy administration.

A prospective sonographic evaluation of peripheral intravenous catheter associated thrombophlebitis

OBJECTIVE

Thrombophlebitis associated with peripheral intravenous catheters (PIVCs) is a poorly described complication in the literature. Given limited accuracy of current assessment tools and poor documentation in the medical record, the true incidence and relevance of this complication is misrepresented. We aimed to identify risk factors in the development of thrombophlebitis using an objective methodology coupling serial diagnostic ultrasound and clinical assessment.

METHODS

We conducted a single-site, prospective observational cohort study. Adult patients presenting to the emergency department that underwent traditionally placed PIVC insertion and were being hospitalized with an anticipated length of stay greater than 2 days were eligible participants. Using serial, daily ultrasound evaluations and clinical assessments via the phlebitis scale, we identified patients with asymptomatic and symptomatic thrombosis. The primary goal was to identify demographic, clinical, and IV related risk factors associated with thrombophlebitis. Univariate and multivariate analyses were employed to identify risk factors for thrombophlebitis.

RESULTS

A total of 62 PIVCs were included between July and August 2020. About 54 (87.10%) developed catheter-related thrombosis with 22 (40.74%) of the thrombosed catheters were characterized as symptomatic. Multivariate cox regression demonstrated that catheter diameter relative to vein diameter greater than one-third [AHR = 5.41 (1.91, 15.4) p = 0.0015] and angle of distal tip of catheter against vein wall ⩾5° [AHR = 4.39 (1.39, 13.8) p = 0.0116] were associated with increased likelihood of thrombophlebitis.

CONCLUSIONS

Our study found that the increased proportion of catheter relative to vein size and steeper catheter tip angle increased the risk of thrombophlebitis. Catheter size relative to vein size is a modifiable factor that should be considered when inserting PIVCs. Additional larger prospective investigations using objective methodologies are needed to further characterize complications in PIVCs.

[The use of venous catheter : Which ones to choose, how to prevent their complications?]

Intravenous catheters are multiple and essential for daily practice. They are also responsible for high morbidity and mortality. Simple or echo-guided peripheral venous catheters, midlines, PICCline, tunneled or non-tunneled central venous catheters, and implantable venous access device are currently at our disposal. Thus, catheter selection, duration and indications for use, and prevention and treatment of complications vary according to the situation. The objective of this update is to provide the clinician with an overview of knowledge and rules of good practice on the use of catheters.

Evaluation of a thermosensitive liquid crystal film for catheterization site assessment immediately following chemotherapy administration: An observational study

PURPOSE

Extravasation incidence is exceptionally low; however, ulceration or necrosis occurs in severe cases, possibly requiring surgical treatment. Early extravasation signs and symptoms are not always evident on treatment day, and inflammation, which leads to ulceration or necrosis, may appear several days later. Therefore, to minimize damage, identification of high-risk groups is required. This study aims to investigate the relationship between subcutaneous edema which is an early extravasation sign, and skin surface temperature using a thermosensitive liquid crystal film.

METHODS

Patients receiving chemotherapy through a peripheral intravenous catheter were recruited. Subcutaneous tissue around the catheterization site was observed for the presence of subcutaneous edema by ultrasonography. During chemotherapy initiation, a thermosensitive liquid crystal film was placed on the catheterization site. Color changes of the film were observed, and each case was classified according to low-temperature distribution patterns. To investigate the factors associated with temperature distribution pattern, logistic regression analysis was performed using clinically selected independent variables.

RESULTS

Data from 63 patients were analyzed. No obvious extravasation was observed. Film analysis revealed 34 cases of broadening low-temperature area from the vein and 23 cases of non-broadening low-temperature area from the vein. Subcutaneous edema was observed in 18 patients: 17 with broadening low-temperature area from the vein and 1 with non-broadening low-temperature area from the vein. Subcutaneous edema was positively correlated with broadening low-temperature area from the vein.

CONCLUSION

Catheter site skin temperature distribution pattern during chemotherapy was associated with subcutaneous edema which is the early extravasation sign immediately after chemotherapy.

Peripheral venous access using devices over needles with and without extension: costs and outcomes

OBJECTIVES

to analyze the mean direct cost and peripheral venous access length outcomes using devices over needle with and without extension.

METHODS

quantitative, exploratory-descriptive research. Venous punctures and length of the devices were followed. The mean direct cost was calculated by multiplying the time (timed) spent by nursing professionals by the unit cost of labor, adding to the cost of materials.

RESULTS

the total mean direct cost of using devices "with extension" (US$ 9.37) was 2.9 times the cost of using devices "without extension" (US$ 4.50), US$ 7.71 and US$ 2.66, respectively. Totaling 96 hours of stay, the "device over needle with extension" showed a lower occurrence of accidental loss.

CONCLUSIONS

the use of the "device over needle with extension", despite its higher mean direct cost, was more effective in favoring adequate length of peripheral venous access.

Evaluation of the risk factors on time to phlebitis- and nonphlebitis-related failure when peripheral venous catheters were replaced as clinically indicated

BACKGROUND

This study aimed to determine the frequency of peripheral venous catheter-related complications and the risk factors that have an impact on the time of peripheral venous catheter failure when they were replaced as clinically indicated.

METHODS

This was a prospective observational study. The demographic and clinical characteristics of the patients, as well as the catheter specifications, were recorded. All the catheters were followed-up at 12-h intervals for the development of complications. Two different peripheral venous catheters were used in the study. The catheter dwell times were estimated using Kaplan-Meier analysis. The logrank test was utilized to investigate the catheter dwell times by univariate analyses. Variables with a significance level of less than 0.20 were taken into Cox regression analysis.

RESULTS

Our results revealed that phlebitis and nonphlebitis complications occurred more frequently within the first 96 h. No significant difference was observed in the occurrence time of phlebitis, nonphlebitis, and composite failures. The use of a locally manufactured catheter, unsuccessful first attempt, poor skin integrity, after-hours' insertion, the use of sterile gauze dressing were all associated with shorter catheter survival rates.

CONCLUSION

We observed no difference on the time to phlebitis or nonphlebitis symptoms with clinically indicated replacement of peripheral venous catheters. We found a significant difference in survival rates between locally manufactured and imported peripheral venous catheters. Our identified risk factors should be taken into account to reduce peripheral venous catheter-related complications and to increase dwell time.

Preventing peripheral intravenous catheter failure by reducing mechanical irritation

Peripheral intravenous catheter failure is a significant concern in the clinical setting. We investigated the effectiveness of care protocols, including an ultrasonographic “pre-scan” for selecting a large-diameter vein before catheterization, a “post-scan” for confirming the catheter tip position after catheterization with ultrasonography, and the use of a flexible polyurethane catheter to reduce the mechanical irritation that contributes to the incidence of catheter failure. This intervention study was a non-randomized controlled trial to investigate the effectiveness of the abovementioned care protocols, the effects of which were compared to the outcomes in the control group, which received conventional care. For both groups, participants were selected from patients in two wards at the University of Tokyo in Japan between July and November 2017. Inverse probability score-based weighted methods (IPW) using propensity score were used to estimate the effectiveness of care protocols. The primary outcome was catheter failure, which was defined as accidental and unplanned catheter removal. We used Kaplan-Meier survival curves to compare rates of time until catheter failure. We analysed 189 and 233 catheters in the intervention and control groups, respectively. In the control group, 68 catheters (29.2%) were determined to have failed, whereas, in the intervention group, only 21 catheters (11.1%) failed. There was a significant difference between each group regarding the ratio of catheter failure adjusted according to IPW (p = 0.003). The relative risk reduction of the intervention for catheter failure was 0.60 (95% CI: 0.47–0.71). Care protocols, including assessment of vein diameter, vein depth, and catheter tip location using ultrasound examination for reducing mechanical irritation is a promising method to reduce catheter failure incidence.

Catheter tips are a possible resource for biological study on catheter failure

Few studies have investigated the molecular mechanisms of catheter failure (CF). Herein, we performed histological and molecular biological analyses of the catheter tip to demonstrate its potential as a resource for biological investigation. Additionally, we searched for risk factors for the development of inflammation and coagulation, which are pathological conditions clarified by biological analysis. The CF group included 30 failed catheters involving thrombus and subcutaneous edema identified by ultrasonography. The No-CF group included 26 catheters with no complications. The removed catheter tips were fixed for hematoxylin-eosin (HE) staining with the application of a real-time reverse transcriptase polymerase chain reaction for eukaryotic 18S ribosomal RNA (rRNA), interleukin 1β, tumor necrosis factor α, tissue plasminogen activator, and plasminogen activator inhibitor 1 (SERPINE1). HE staining identified attached nuclear cells on the inner surfaces of both CF and No-CF catheters. The 18S rRNA was amplified in all samples. The expression level of SERPINE1 was significantly higher in the CF group than in the No-CF group (p = 0.01), whereas the expression levels of other genes did not differ between the groups. Symptoms of CF associated with the expression of SERPINE1 were analyzed. The catheter being in contact with blood vessels during placement was a suggested factor related to the high expression of SERPINE1 (p = 0.04). Catheter tips are a potential resource for biological investigation, and expression analysis of the attached cells can reflect the pathological condition of the catheterized tissue. Further studies using catheter tips are required to elucidate the molecular mechanisms of CF.

Vascular endothelium damage from catheter-induced mechanical stimulation causes catheter sleeve formation in a rabbit model

BACKGROUND

Intravenous catheters are widely used but are often removed due to complications associated with catheter sleeve formation. A catheter sleeve can develop from a thrombus, and catheter-induced vascular endothelium damage may be a critical factor for thrombus formation. We investigated the effect of catheter-induced mechanical stimulation on venous endothelial cells and catheter sleeve formation and the efficacy of anti-thrombogenic technology for preventing catheter sleeve formation in vivo.

METHODS

We surgically implanted poly(2-methoxyethyl acrylate)-coated and uncoated catheters with and without a stylet into the right external jugular vein of a rabbit model for 14 days. Catheter sleeve formation and the ratio of residual venous endothelial cells were compared using histological examination and immunostaining with an anti-CD31 antibody, respectively.

RESULTS

Stiffening an uncoated catheter with a stylet induced catheter sleeve formation along more than two-thirds of the length of the catheter. The ratios of residual venous endothelial cells at the tip of uncoated catheters with and without a stylet were 3% and 36%, respectively. While poly(2-methoxyethyl acrylate) coating also reduced the ratio of venous endothelial cells at the tip of the stiffened catheter (12%), it prevented external thrombus and catheter sleeve formation.

CONCLUSION

High levels of mechanical stimulation can affect catheter-related thrombosis and promote catheter sleeve formation, and anti-thrombogenic technology such as a poly(2-methoxyethyl acrylate) coating reduces thrombus formation and can prevent catheter sleeve formation on stiffened catheters. Further studies are required to determine the maximum degree of venous endothelial cell damage before catheter sleeve formation and to compare other anti-thrombogenic technologies with poly(2-methoxyethyl acrylate) for preventing catheter sleeve formation.

The incidence and risk of infusion phlebitis with peripheral intravenous catheters: A meta-analysis

Introduction:

Phlebitis is a common complication associated with the use of peripheral intravenous catheters. The aim of this study was to estimate the incidence of phlebitis with peripheral intravenous catheter use and to identify risk factors for phlebitis development.

Method:

Literature survey was conducted in electronic databases (CINAHL, Embase, Google Scholar, Ovid, and PubMed), and studies were included if they used peripheral intravenous catheter for therapeutic or volumetric infusion and reported phlebitis incidence rates. Random effects meta-analyses were performed to obtain overall and subgroup phlebitis incidence rates and odds ratio between males and females in phlebitis incidence.

Results:

Thirty-five studies were included (20,697 catheters used for 15,791 patients; age 57.1 years (95% confidence interval: 55.0, 59.2); 53.9% males (95% confidence interval: 42.3, 65.5)). Incidence of phlebitis was 30.7 per 100 catheters (95% confidence interval: 27.2, 34.2). Incidence of severe phlebitis was 3.6% (95% confidence interval: 2.7%, 4.6%). Incidence of phlebitis was higher in non-intervened (30% (95% confidence interval: 27%, 33%)) than in intervened (21% (95% confidence interval: 15%, 27%)) groups, and with Teflon (33% (95% confidence interval: 25%, 41%)) than Vialon (27% (95% confidence interval: 21%, 32%)) cannula use. Odds of developing phlebitis was significantly higher in females (odds ratio = 1.42 (95% confidence interval: 1.05, 1.93); p = 0.02). Longer dwelling time, antibiotics infusion, female gender, forearm insertion, infectious disease, and Teflon catheter are important risk factors for phlebitis development identified by the included studies.

Conclusion:

Incidence of phlebitis with the use of peripheral intravenous catheters during infusion is 31%. Severe phlebitis develops in 4% of all patients. Risk of phlebitis development can be reduced by adapting appropriate interventions.

Left Brachiocephalic Vein Stenosis due to the Insertion of a Temporal Right Subclavian Hemodialysis Catheter

Central vein stenosis/occlusion is a common well-described sequel to the placement of hemodialysis catheters in the central venous system. The precise mechanisms by which central vein stenosis occurs are not well known. Current concepts in central vein stenosis pathophysiology focus on the response to vessel injury model, emphasizing the process of trauma. A case of left brachiocephalic vein stenosis due to the insertion and function of a temporary right subclavian hemodialysis catheter is presented. The purpose of the manuscript is to emphasize that, with the introduction of a temporary subclavian hemodialysis catheter via the right subclavian vein apart from causing concurrent stenosis/infarction of the right subclavian and right brachiocephalic vein, it is also possible to cause stenosis of the left brachiocephalic vein (close to its contribution to the superior vena cava) although the catheter tip is placed in the correct anatomical position in the superior vena cava.