There is no need to change PIVs every hours. Instead, symptom triggered removal and replacement, based on phlebitis, pain or malfunction are better triggers for changing PIVs. These results are in line with the major change in central venous catheters insertion and removal that resulted from a major study in the NEJM 20 years ago as well as several smaller studies in children.
In addition to saving potential pain and suffering associated with repeated attempts at PIV insertion, this study suggests that adopting an as needed approach to changing PIVs may save healthcare dollars as well as nursing and physician time.
In addition, hospitals should consider revising their guidelines regarding the duration PIVs can stay in place. Rickard CM et al. Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial.
Lancet Sep 22; This case therefore highlights the serious costs—both clinical and economic—that can be associated with peripheral IV catheter infections. 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. 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.
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. 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.
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. 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. 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.
Efforts should be directed toward enhancing expertise in IV catheter insertion and maintenance, rather than focusing on the replacement schedule. To reduce the risk of peripheral IV catheter—related infectious complications, the following are the best evidence-based practices:. 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. An epidemiologic study of the risks associated with peripheral intravenous catheters. Am J Epidemiol. Maki DG, Ringer M. Risk factors for infusion-related phlebitis with small peripheral venous catheters.
A randomized controlled trial. Ann Intern Med. Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database Syst Rev. Soft tissue infections related to peripheral intravenous catheters in hospitalised patients: a case-control study. J Hosp Infect. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of published prospective studies.
Mayo Clin Proc. Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis. Draw the required volume into the syringe and prime the rest of the neonatal transfusion set. Label the syringe with both patient and blood product identification details including expiry date and time of blood product. If rapid transfusion of small volumes is required, draw the required volume into a syringe through a to micron filter.
Burettes should not be used for transfusion of blood products. Sterile 0. This must be prescribed as a medication. The optimal volume used for intermittent injections or infusions is unclear. The literature suggests the volume of flush should equal at least twice the volume of the catheter and add on devices and a minimum of 2mL normal saline flush is recommended. Use 10ml syringe for flushing to avoid excessive pressure and catheter rupture.
Syringes with an internal diameter smaller than that of a 10mL syringe can produce higher pressure in the lumen and rupture the catheter. If resistance is felt during flushing and force is applied this may result in extravasation Use aseptic non touch techniques including cleaning the access port scrub the hub with a dual disinfectant agent e.
Flush in a pulsatile push-pause motion. Flush catheters: Immediately after placement Prior to and after fluid infusion as an empty fluid container lacks infusion pressure and will allow blood reflux into the catheter lumen from normal venous pressure or injection. Prior to and after blood drawing.
The dressing must be kept secure, clean dry and intact. Indications for dressing change: when it becomes insecure or if there is blood or fluid leakage under the dressing.
Determine the need for an assistant considering patient age, developmental level and family participation prior to the procedure. If patient is allergic to transparent film dressings, use sterile film dressing to be used and changed daily.
Carefully remove the old dressing, holding the cannula in place at all times Take the opportunity to thoroughly inspect the site of entry of the cannula for any sign of infection. Cleanse the area around the catheter insertion site including under the hub using a pattern which will ensure entire area is covered.
Allow skin preparation to air dry prior to applying any dressing, this allows the disinfectant to work. Consider placing a small piece of sterile cotton wool ball or gauze underneath the hub of the cannula to reduce pressure.
If desired, place sterile tape over the hub of the device before placing the transparent dressing. Cover the cannula insertion site with sterile transparent semipermeable, occlusive dressing e. Tegadermtm, IV tm placed using an aseptic non touch technique over the catheter. This will allow continuous observation of the site and to help stabilise and secure the catheter.
This will adequately immobilize the joint and minimise the risk of venous damage resulting from flexion. When using Splints, ensure these are positioned and strapped with the limb and digits in a neutral position to prevent injury from restricting blood or nerve supply and to prevent pressure sores Inspect the splint at least daily and change if soiled by blood or fluid leakage.
Cover with non-compression tubular bandage. Ensure there is a clear window where the cannula enters the skin- insertion site, so the site can be regularly viewed. In Summary, when dressing a peripheral IV cannula ensure: it is secure the site is visible the child can't injure themselves, or be injured by the connections the child can't remove or dislodge the cannula tapes are not too tight or restrictive.
Change of Extension sets Extension sets are to be changed when the access device is changed or immediately upon suspected contamination or when any break in integrity. Extension sets are to be primed and attached to the cannula at the time of IV insertion using an aseptic non touch technique When exiting the flushing of extension set you must use a positive pressure clamping technique. The label must be placed on the front of the fluid bag ensuring the fluid name, batch number, expiry date and graduations remain visible link to national standard.
Labels on syringes should be placed parallel to the long axis of the syringe barrel with the top edge of the label flush with but not covering the graduations link to national standard. Label IV line if multiple lines are running: label close to the fluid bag or syringe or below the drip chamber. If additives are added to infusion, please label the bag or syringe driver with additives added. Approved label can be generated by the EMR.
Fluid bag and infusion changes: Fluid bags and syringes with nil additives are changed at least every 7 days. Fluid bags and infusions with additives are changed every 24 hours.
Fresh blood products and lipid containing solutions; both the bag, syringe, giving set and lines should be removed or changed at conclusion of infusion or at least every 24 hours. Line changes Infusion lines are replaced at least every 7 days using standard aseptic technique. Administration sets that have been disconnected either accidentally or planned are no longer sterile and to be discarded and replaced.
If using fresh blood or fresh blood products replace line s at the end of the infusion. Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database of Systematic Reviews , Issue 8. DOI: The epic3 recommendation that clinically indicated replacement of peripheral venous catheters is safe and cost-saving: how much would the NHS save?
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