How to cite this article: Buenfil-Vargas MA, Espinosa-Vital GJ, Rodriguez-Sing R, Miranda-Novales MG. Incidence of adverse events associated to the use of short peripheral venous catheters. Rev Med Inst Mex Seguro Soc. 2015;53 Suppl 3:S30-5.
Received: August 4th 2014
Accepted: September st 2015
Miguel Armando Buenfil-Vargas,a Guadalupe Judith Espinosa-Vital,b Roberta Rodriguez-Sing,b María Guadalupe Miranda-Novalesc
aServicio de Infectología
bDivisión de Epidemiología Hospitalaria
cUnidad de Investigación en Epidemiología Hospitalaria, Coordinación de Investigación en Salud
a,bHospital de Pediatría
Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Distrito Federal, México
Communication with: María Guadalupe Miranda-Novales
Telephone: (55) 5627 6900, extensiones 22507 y 207
Background: surveillance of adverse events associated to the use of short peripheral venous catheters (SPVC) is an indicator of quality of service. The objective was to report the incidence and risk factors associated to adverse events in SPVC.
Methods: Prospective cohort study. All patients with a SPVC for more than 48 hours were included. The outcome variables were dysfunction, chemical phlebitis and bacterial phlebitis. The data registered were age, sex, underlying diseases, nutritional status, site of placement, skin condition, administered intravenous fluids, and catheter dressing. Regarding statistical analysis, incidence rate for each adverse event was calculated per 100 catheters and per 1000 catheter-days. Univariate and multivariate analysis of risk factors were performed.
Results: 410 catheters were analyzed. Median of SPVC use was of three days. There was no evidence of infectious complications: 47 (11.4 %) presented chemical phlebitis and 231 (56.3 %) mechanical malfunction; the incidence rate was 35.6 and 175 per 1000 catheter-days, respectively. In the multivariate analysis, the risk factors associated to chemical phlebitis were skin lesions (p = 0.001, RR 3.479), and additional dressing use (p = 0.007, RR 4.025); for mechanical malfunction the only risk factor was the administration of intravenous chemotherapy (p = 0.026, RR 4.293).
Keywords: Catheters, Phlebitis, Adverse effects.
The use of intravascular devices has been of great clinical utility, allowing quick and safe access to the bloodstream; however, these devices are not without risk.1,2 Intravenous infusion (II) or short peripheral venous catheter is the resource most frequently used in hospitalized patients. The most frequently reported complications or adverse events are: chemical phlebitis, between 13 and 55%; infiltration, between 11 and 58%; obstruction, between 19.5 and 23%; and accidental release, between 6 and 15%. Bacterial phlebitis has received more attention, because it can progress to cellulitis and sepsis; fortunately, frequency is low.3-4
A study conducted at the Hospital de Pediatría “Silvestre Frenk Freund” found that complications rose with increased time with the catheter in place, especially when time in place exceeded 48 hours.5 Other factors associated with phlebitis were the patient’s main disease (neoplasms, nephropathy, immunodeficiency) and the condition of neutropenia. In another pediatric hospital, it was reported that, out of 1032 II installed in 342 children, 903 II used stainless steel butterfly needle and 129 used Teflon catheters. The average duration was 29.9 ± 19.9 hours and 93.7% had no complications. The complications in the rest were: phlebitis, residual tubing, infiltration, and obstruction.6 In Brazil a randomized controlled trial was done in children aged 0-12 years to assess the fixation used. The control group included peripheral intravenous catheters fixed with tape, Group I used sterile gauze, and Group II sterile transparent film.7 Regarding the presence of phlebitis and the type of material used, there was no statistically significant difference among the three groups. The sterile gauze showed a better performance compared to the other groups studied.
To reduce the risk of phlebitis associated with II use, different strategies have been employed: filters for capturing precipitated proteins and microcrystals of drugs, sterile transparent plastic film to cover the insertion site, the establishment of a nursing team specially trained to install and care for catheters, and changing every 96 hours for adult patients, but there are no recommendations for pediatric patients.8-10 A randomized clinical trial evaluated routine versus clinically indicated II replacement in adults. Routine change took place every 72 hours, and in the experimental group the catheter was changed only with an adverse event. There was no difference in the rate of phlebitis, infiltration, occlusion, or accidental withdrawal.11
Most studies on infections related to the use of intravascular devices focus on the use of central venous catheters, and few record side effects related to peripheral intravenous catheters, so the objective of this study was to report the incidence and risk factors for adverse events associated with the placement of short peripheral venous catheters.
This is a prospective cohort study. It included patients hospitalized in the Hospital de Pediatría del Centro Médico Nacional Siglo XXI who had II in place for at least 48 hours and remained in the hospital at least 48 hours after removal of the peripheral venous line. Patients were discarded who were discharged within 48 hours of withdrawal of the device, who could not make the final evaluation. The outcome variables were: mechanical dysfunction, bacterial or chemical phlebitis, and cellulitis. Researchers recorded for each patient: age, sex, underlying disease, nutritional status, site and place of placement, skin quality, type of solutions administered, antibiotics administered, chemotherapy, blood products, and type of fixation (splint, adhesive tape, gauze, sterile transparent film). The placement site and II conditions were assessed daily. At least two participants in the protocol described the event as adverse.
Descriptive statistics were used for statistical analysis. Incidence density was calculated for the outcome variables per 100 catheters per 1000 catheter days. Univariate analysis and multivariate logistic regression were performed to assess the factors associated with adverse events. The analysis was done using SPSS version 20.0
Regarding ethics, the study was without risk, in accordance with Article 17 of the Reglamento en Materia de Investigación of the Ley General de Salud. All data collected were handled confidentially. No deviations were detected when checking the infusion that would put the patient at risk. The study was approved by the Local Research Committee under number R-2014-3603-6.
410 short peripheral catheters placed in 211 children were included in the study. Of these, 46.3% were female and 53.7% male. The mean weight was 10.7 kg. An average of 1.9 II were placed per patient, distributed as follows: 1 II in 57.8%, two catheters in 19.4%, three catheters in 9%, four catheters in 5.2%, five catheters in 5.7%, six catheters in 1.4%, seven catheters in 0.5%, and eight catheters (the highest number) in 1%. Of all II, 350 (85.4%) were placed in hospitalization, 45 (11%) in continuous admission, and 15 (3.6%) in the operating room. In addition, 141 II (34.4%) were placed in patients with some degree of malnutrition, 34 (8.3%) in obese patients, and 235 (57.3%) in patients with appropriate weight for their age.
The median days with II in place was three days; 24 II (5.8%) had one day in place; 100 catheters (24.4%) two days; 130 (31.7%) three days in place; 100 catheters (24.4%) four days; 39 (9.5%) five days; ten (2.5%) six days; five (1.2%) seven days; and two catheters remained eight days (0.5%).
Within the study period no patient presented infectious phlebitis, and 47 (out of 211) (22.2%) presented chemical phlebitis. The largest number of events was recorded in the first 72 hours of II installation: the first day there were five (10.6%), the second day 14 (29.7%), the third day 13 (27.6%), the fourth day eight (17%), the fifth day six (12.7%), and the seventh day one event (2.1%) (Figure 1).
Figure 1 Distribution of chemical phlebitis events in patients with short catheters by day of presentation
Table I shows the distribution and characteristics of chemical phlebitis and dysfunction events. Both events occurred more frequently in children under two years and in patients receiving antibiotics. Most chemical phlebitis events occurred in patients with moderate to severe malnutrition.
II fixation was performed with adhesive tape on microporous fabric; 252 (61.4%) had transparent film placed, 134 (32.8%) had an airplane splint placed, and 24 (5.8%) had a diaper placed by way of protection. Of the patients who had chemical phlebitis, the following was found: 33 (70.2%) had only transparent film placed, nine (19.2%) were covered with a diaper, and five (10.6%) used a splint. For events that presented dysfunction, 132 (out of 231) (57.2%) had semi-transparent film placed, 17 (7.4%) were covered with a diaper, and 82 (35.4%) used a splint.
|Table I Distribution and characteristics of chemical phlebitis and catheter dysfunction events|
(n = 47)
|< 2 years||32||68||146||63.2|
|> 2 years||15||32||85||36.8|
|Appropriate weight for age||12||25.5||128||55.4|
|Moderate to severe malnutrition||32||68||91||39.4|
|Quality of skin|
|Erythema and petechiae||17||36.2||41||17.7|
|Hematoma and lacerations||1||2||1||0.5|
|Intravenous solutions and medications||6||12.8||50||21.8|
Univariate analysis was performed for both adverse events found. For mechanical dysfunction, antibiotic use was found to be a statistically significant risk factor (RR 3.128, 95% CI: 2.082-4.730, p < 0.001), and administration of only solutions and other medications (except for antibiotics, chemotherapeutics, and blood products) was found to be a protective factor (RR 0.361, 95% CI: 0.138-0.711, p = 0.004). For chemical phlebitis, associated risk factors were skin lesions (RR 4.605, 95% CI: 2.359-8.988, p = 0.003), use of diaper as an extra covering (RR 5.887, 95% CI: 2.389-14.507, p < 0.001), and antibiotics (RR 4.526, 95% CI: 1.975-10.373, p = 0.005). Management with only solutions was found to be a protective factor (RR 0.288, 95% CI: 0.119-0.697, p = 0.006).
Upon multivariate analysis, only two factors were independently associated with the presentation of chemical phlebitis: skin lesions (RR 3.479, 95% CI: 1.688-11.863, p = 0.001), and use of diaper as covering (RR 4.025, 95% CI: 1.474-11.039, p = 0.007) (Table II).
|Table II Multivariate analysis of risk factors for chemical phlebitis|
|Use of diaper as covering||4.025||1.474||11.039||0.007|
|Place of installation||0.917||0.330||2.551||0.868|
|> 3 catheter days||0.936||0.460||1.903||0.854|
|Administration of antibiotics||4.885||0.395||60.464||0.217|
|Administration of chemotherapy||1.531||0.117||20.083||0.931|
|Intravenous solutions and other drugs*||1.373||0.106||17.780||0.809|
|*Administration of intravenous solutions and medications (except antibiotics and chemotherapeutics)
RR = risk ratio; 95% CI = 95% confidence interval
For mechanical malfunction, it was found that chemotherapy was a statistically significant risk factor (RR 4.293, 95% CI: 1.188-15.545, p = 0.026), and administration of solutions and other medicines was found to be a protective factor (RR 0.216, 95% CI: 0.062-0.763, p = 0.017) (Table III).
|Table III Multivariate analysis of risk factors for mechanical dysfunction|
|Use of diaper as covering||2.056||0.746||5.668||0.163|
|Place of installation||1.283||0.703||2.341||0.417|
|> 3 catheter days||1.029||0.657||1.612||0.899|
|Administration of antibiotics||0.723||0.239||2.803||0.609|
|Administration of chemotherapy||4.293||1.188||15.545||0.026|
|Administration of blood products||0.877||0.222||3.456||0.883|
|Solutions and other drugs*||0.218||0.062||0.763||0.017|
|* Administration of intravenous solutions and medications (except antibiotics and chemotherapeutics)
RR = risk ratio
The incidence density for chemical phlebitis was 35.6 and for mechanical dysfunction 175 x1000 catheter days.
No infectious complications associated with peripheral venous catheter use were recorded in the study. This information contrasts with that reported in the literature, and can be explained by the duration of catheter use in the patients included. It has previously been shown that with longer time in place, the frequency of colonization is higher and the risk of infection increases;12 however, the patients included in the study had a median II time in place of three days, so the infectious complications reported by other authors did not present themselves. Several studies have shown that continuous training of health personnel and the implementation of guidelines for venous access care decrease the frequency of adverse events associated with the use of both peripheral and central catheters.13-17 The clinical practice guideline serves as a basis for the manuals used in medical units depending on staff and type of patient. While a smaller group of patients had the II in place for more than 72 hours, no records were found of infection, reflecting the work of the nursing staff. Notably, no bacteremia events were found either, which are not only related to the development of infectious phlebitis and cellulitis, but also to the contamination of parenteral solutions.18
The recommendation to routinely change short catheters to reduce the frequency of complications, especially infections, has recently been questioned. Systematic reviews have found no differences in favor of routine change versus change upon clinical indication.11,19 These studies have not included pediatric patients, and the only recommendation mentioned in the guidelines is that the catheter can be kept for as long as it works properly. This study cannot make a conclusion about the maximum time of II use in the absence of infectious complications.
The incidence density of adverse events was high compared to reports from the literature. Especially for the dysfunction outcome, which necessitates the removal of the catheter, and explains the short duration of the device. Chemotherapy was the only factor independently associated with dysfunction. Denisia de Brito et al.20 conducted an evaluation of the literature on the use of peripheral catheters versus central catheters for use in chemotherapy, but found no data to support that one was superior to the other. As expected, if the patient is not given antibiotics, chemotherapy, or blood products, the risk of dysfunction decreases. Drug management protocols must be strengthened in order to preserve the II for longer, reduce the number of punctures, maintain skin integrity, and avoid installing a central venous catheter in the medium term.21,22
Recent years have seen an increased number of studies on the importance and care of peripheral catheters, percutaneous installation of central catheters, and the utility of administering parenteral nutrition even in newborns.23 The main reason for peripheral catheter removal in this study was dysfunction; extravasation was the main reason in the study of Barria et al.24 The second cause of removal was chemical phlebitis. Factors associated with statistical significance were skin lesions and using a diaper as covering or protection to prevent accidental removal of the catheter. Regarding the skin, it is necessary to identify the best place to install the II: although most of the patients included had healthy skin at the time of installation, the few who had lesions were those who presented phlebitis. Moreover, there is no recommendation in the guidelines to use different materials for splints, microporous tape, adhesive tape, or transparent film for fixing the catheter. Machado et al. found no difference with different fixation methods,7 but a material that completely covers the insertion site and increases local heat promotes moisture and hinders proper check of the installed catheter.
This study has several limitations. The first is that there were no infectious events, so it is necessary to increase the number of catheters monitored. Nor was it possible to evaluate the number of punctures made by installing the catheter.
In summary, this study cannot establish recommendations on the maximum duration of short peripheral venous catheter. Dysfunction rate is very high and the only independent risk factor was chemotherapy, which cannot be changed; although statistically significant, the use of additional covering, in this case a diaper to prevent accidental removal, increases the risk for both dysfunction and chemical phlebitis, so it should be avoided.
Conflict of interest statement: The authors have completed and submitted the form translated into Spanish for the declaration of potential conflicts of interest of the International Committee of Medical Journal Editors, and none were reported in relation to this article.