Peripheral IV in Too Long

SPOTLIGHT CASE

Commentary by Chi-Tai Fang, MD, PhD

Case Objectives

Case & Commentary—Part 1:

A 75-year-old man with a history of coronary artery disease and congestive heart failure (CHF) was admitted to the hospital with a CHF exacerbation. He was given intravenous (IV) diuretics and improved over the first 4 days in the hospital. At this medical center, there was a standard protocol that called for all peripheral IV catheters to be replaced after 4 days to prevent infection. Because of edema in his extremities, placing a new peripheral IV was going to be difficult. The bedside nurse asked the covering physician if the peripheral IV could be extended for an additional day or two. The physician was planning on discharging the patient the next day, so the extension was approved.

There has been substantial focus on the risks associated with central venous catheters including catheter-related bloodstream infections. Yet, peripheral intravenous (IV) catheters are much more common in modern hospitals and also have associated risks. This case provides one example of the hazards of this seemingly benign medical device.

Peripheral IV catheters allow reliable and convenient delivery of life-saving medications for hospitalized patients. Placement of a peripheral IV catheter, however, is often a painful experience for patients. For staff with limited experience in placing peripheral IV catheters, multiple attempts may be required, especially for those with difficult venous access. So the decision to extend the peripheral IV catheter by the covering physician in the present case is perfectly understandable.

Nevertheless, peripheral IVs can be associated with multiple complications. Phlebitis (inflammation of the vein where the IV is placed) complicates IV therapy in 2.3%–60% of cases in different series.(1-3) The typical clinical presentation is pain and redness at the IV site. While most cases of phlebitis are noninfectious (just inflammation of the vein), this can progress to suppurative soft tissue infections (cellulitis, abscess, or tissue necrosis). Although rare (incidence rate: 0.06 cases per 1000 bed-days), this complication can cause serious morbidity.(4) Another serious complication is peripheral IV catheter–related bacteremia, which occurs in 0.1% cases (0.5 per 1000 IV catheter-day), although the frequency is lower than that of central line–associated bacteremia (4.4%, 2.7 per 1000 catheter-day).(1,5)

In an effort to decrease the risk of catheter-related infections, scheduled replacement of peripheral IV catheters every 48–72 hours or every 72–96 hours has been widely used.(3,6-8) Despite the popularity of this practice, there is no strong evidence supporting it.(3,7,9) Based on findings that rate of phlebitis is not significantly different between peripheral IV catheters left in place for 72 hours versus 96 hours (10), the Centers for Disease Control and Prevention (CDC) recommends against replacing the peripheral IV catheter more frequently than every 72–96 hours.(6)

On the other hand, it should also be kept in mind that once peripheral IV catheter–related infectious complications do occur, infected catheters should be removed as soon as possible to prevent them from becoming a source of bloodstream infection. After inserting IV catheters, the site should be inspected daily, either at the time of changing dressing or by palpation through an intact dressing.(6,11) Erythema, tenderness, or other evidence of local inflammation should prompt the removal of the IV catheter.(6) In any case, it is imperative for the attending physician to inspect the IV catheter site to make sure that no early signs of phlebitis go unrecognized (4) before making the decision to extend the peripheral IV catheter.

In the case above, if the IV were functioning and the site lacked evidence of inflammation, it seems reasonable to extend the IV to 96 hours, particularly in light of the difficulty of placing a new IV and the potential pain to the patient.

Case & Commentary—Part 2:

The next day the patient was worse and required ongoing hospitalization. The peripheral IV was kept in place for 2 more days. On hospital day 6, the patient developed erythema around the IV site. With concerns for infection, the IV was removed and a new peripheral IV was placed. Later that day, the patient developed fever and chills. Blood cultures drawn at the time grew methicillin-resistant Staphylococcus aureus (MRSA), most likely secondary to the infected peripheral IV catheter. Subsequently, the patient complained of back pain and a magnetic resonance imaging (MRI) of the spine revealed an epidural abscess, which on aspiration grew MRSA. He required 6 weeks of IV antibiotics for the MRSA bacteremia and epidural abscess. The patient ultimately recovered and was discharged to home.

There is no mention whether the physician or the nurse inspected this patient's catheter site at 96 hours, but by 144 hours, cellulitis had developed at the catheter site. Sadly, the unexplained clinical deterioration of this patient—who was scheduled to be discharged—was likely caused by peripheral IV catheter infection. The local soft tissue infection led to MRSA bacteremia and then to an epidural abscess. Fortunately, after aggressive therapy and a prolonged course, the patient eventually recovered. The extra cost of MRI, imaging-guided aspiration of epidural abscesses, 6-week IV antimicrobial therapy, as well as the prolonged hospitalization, is likely to be in the hundreds of thousands of dollars, not to mention the patient dissatisfaction and potential for litigation. This case therefore highlights the serious costs—both clinical and economic—that can be associated with peripheral IV catheter infections.

Case & Commentary—Part 3:

In response to this event, the medical center involved developed a strict policy under which peripheral IVs must be changed every 3 days. They can be extended for 1 additional day with a physician's order but no longer. In addition, the medical center changed some of the nursing documentation to include the date of peripheral IV insertion and a description of the site during each shift.

It appears the medical center took some steps to try to prevent future peripheral IV infections. But, are these the highest-yield interventions? What should be learned from this case and what should be changed?

In this case, there were multiple issues with the IV management. The process of insertion was probably a difficult one in the presence of edema in the extremities, and staff with limited experience may have been unable to maintain good aseptic technique. In addition, there was inadequate and delayed recognition of the catheter infection; by the time it was recognized on day 6, cellulitis and bloodstream infection had already developed. These may have been due to a lack of expertise in day-to-day management of IVs and IV sites.

Best Practices for Management of Peripheral IVs

There are system interventions that can help prevent IV catheter complications. A randomized controlled trial demonstrated that a dedicated IV therapy team of registered nurses specially trained for inserting IV catheters and inspecting catheter sites significantly reduced both local and bacteremic complications of peripheral IV catheters.(11) Moreover, a large prospective study of 3165 patients also showed that deployment of well-trained IV teams can effectively prevent peripheral IV catheter infection.(12)

The insertion site, method of insertion, catheter type, and maintenance protocol all seem to matter as well. In adults, upper extremities are the preferred site for catheter insertion.(6) Using an insertion site in lower extremity has been found to be an independent risk factor for catheter-related soft tissue infection.(4) For skin disinfection before the insertion of IV catheter, 2% alcoholic chlorhexidine is more effective than 10% povidone-iodine in the prevention of catheter-related infections.(13,14) Teflon or polyurethane catheters have fewer infectious complications than catheters made with polyvinyl chloride or polyethylene.(2,6) After placement of an IV catheter, the catheter site should be covered by either sterile gauze or a sterile transparent semipermeable dressing.(6,15) The use of a continuous infusion to maintain IV catheter patency is an independent risk factor for microbiologically-proven catheter infection (12) and catheter-related soft tissue infection.(4) The use of a closed intermittent infusion system with a plastic cap that can be cleansed before drug injection is safer. For IV catheters not used for infusion of blood product or lipid emulsions, the IV administration sets in continuous use, including secondary sets and add-on devices, should be changed no more frequently than every 96 hours, but at least every 7 days.(6,16) Adoption of the above-stated simple, inexpensive, and evidence-based practices is the best approach to prevent similar events in the future.

All of this brings us back to where we began: What is the optimal frequency to change peripheral IV catheters? As described above, there is no strong evidence in support of routinely changing catheters at 72 hours. We do know that longer (greater than 48 hours) catheter dwelling time is a risk factor for phlebitis.(1,2) In a prospective study of 3165 patients, however, the majority of phlebitis cases were culture-negative, suggesting the local inflammation was not caused by infection, and that extending the scheduled catheter replacement interval from 48–72 hours to 72–96 hours did not significantly increase the risk of microbiologically proven catheter infection.(12) A recent Cochrane review found no conclusive evidence of benefit in changing IV catheters every 72–96 hours in comparison with clinically indicated replacement in terms of the rates of IV catheter–related complications.(3,7,17) However, the two clinical trials reviewed were statistically underpowered for examining whether the risk of catheter-related bacteremia increases in clinically indicated replacement group.(6,10) A longer replacement schedule or clinical indicated replacement strategy has benefits in patient comfort and cost-savings, which need to be weighed against the potential harm of increased risk of catheter infection, especially bacteremia. In the absence of well-trained IV teams, replacement only when clinically indicated carries the risk of delayed recognition of catheter infection by inexperienced staff, until the development of serious consequences, as illustrated in the present case. In adult patients, replacement of peripheral IV catheters at 72–96 hour intervals is more comfortable for patients as well as less expensive than routine 48–72 hours exchanges, without significant increase in infection risk.(6)

The medical center attributed this adverse event to nonadherence to standard operating procedure, and in response, strictly enforced a scheduled replacement of peripheral IV catheters every 72–96 hours, which is consistent with the CDC recommendations.(6) This straightforward solution, although commendable, may not be enough to prevent future events. Efforts should be directed toward enhancing expertise in IV catheter insertion and maintenance, rather than focusing on the replacement schedule.(12) To ensure best practice, the institution should consider using well-trained IV teams (6,11,12), which is the most effective way to reduce peripheral IV catheter–related infectious complications.(8)

Take-Home Points

To reduce the risk of peripheral IV catheter–related infectious complications, the following are the best evidence-based practices:

Use IV therapist teams for peripheral IV catheter insertion and day-to-day management.
Place the IV catheter in upper extremities.
Use 2% alcoholic chlorhexidine for skin disinfection before the insertion of peripheral IV catheter.
Use intermittent flushing to maintain the peripheral IV catheter patency.
Replace peripheral IV catheters every 72–96 hours, but not more often, in adult patients.

Chi-Tai Fang, MD, PhD

Associate Professor

Institute of Epidemiology and Preventive Medicine

National Taiwan University

Faculty Disclosure: Dr. Fang has declared that neither he, nor any immediate member of his family, has a financial arrangement nor other relationship with the manufacturers of any commercial products discussed in this continuing medical education activity. The commentary does not include information regarding investigational or off-label use of pharmaceutical products or medical devices.

References

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