Reconsider routine change for peripheral IV catheters
Source: Bregenzer T, et al. Is routine replacement of peripheral catheters necessary? Arch Intern Med 1998; 158:151-156.
In order to determine the relationship between catheter-related complications and duration of peripheral catheter insertion, Bregenzer and colleagues conducted a prospective, observational study of all patients in whom peripheral cannulation was performed. Catheters were left in place for the duration of intravenous therapy or until a complication occurred; routine catheter changes at 72 hours were not performed. They entered 451 patients receiving 665 catheters into the study; a total of 609 were evaluable.
After catheter removal, the investigators cultured all catheters using the semi-quantitative method. Overall, 386 catheters were in place for three days or less, and 223 were in place for more than three days. Complications occurred in 156 catheterization episodes (25.6%), including 120 episodes of phlebitis (19.7%), 35 episodes of obstruction (5.7%), and 42 semi-quantitative cultures yielding 15 or more colonies per plate (6.9%).
Only four of the colonized catheters showed clinical evidence of phlebitis; there were no episodes of catheter-related bacteremia. Kaplan-Meier curves demonstrated a linear rate of occurrence of phlebitis, obstruction, and colonization to day 14. Day-specific risk did not increase for any adverse outcome after the second day.
Comment by Robert Muder, MD, hospital epidemiologist at the Pittsburgh VA Medical Center.
Studies of IV therapy performed in the 1970s demonstrated that a sharp increase in peripheral catheter infection occurred after 48 hours of catheterization. The Centers for Disease Control and Prevention in Atlanta, therefore, recommends that peripheral intravenous catheters be rotated to a new site at 48 to 72 hours. However, newer catheter materials, such as Teflon and polyurethane, appear to reduce the risk of phlebitis and bacteremia.1
The results reported by Bregenzer and colleagues suggest that routine rotation of peripheral catheters may not decrease the incidence of catheter-related complications, and that catheters could, in many patients, remain in place until a complication occurred or until the end of therapy, for as long as 14 days.
Controlled trials have clearly shown that such a strategy is effective in the management of central venous catheters.2 Reducing the need for rotation of peripheral catheters would clearly reduce the cost, effort, and patient discomfort associated with repeated needlesticks.
However, I believe it is premature to abandon the practice of routine peripheral catheter changes just yet. The current study involved only 223 catheters in place for more than three days; of these, only 82 were in place for six to 10 days and 26 for 11 to 15 days.
Finally, it should be noted that catheter care was standardized and meticulous during the conduct of this study. The importance of meticulous catheter insertion and care is supported by the observation that institution of a full-time IV therapy team is followed by a dramatic decrease in catheter-related infections.3
Bregenzer and co-authors make the appropriately restrained conclusion that their results support the conduct of a randomized clinical trial to definitively settle the issue of routine rotation of peripheral catheters. I agree.
References
1. Maki DG, Ringer M. Risk factors for infusion-related phlebitis with small peripheral venous catheters: A randomized controlled trial. Ann Intern Med 1991; 114:845-854.
2. Cobb DK, et al. A controlled trial of scheduled replacement of central venous and pulmonary-artery catheters. N Engl J Med 1992; 327:1,062-1,068.
3. Miller JM, et al. Reduction in nosocomial intrav en - ous device-related bacteremias following institution of an intravenous therapy team. J Intravenous Nurs 1996; 2:103-106.
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