Peripheral venous catheters: an under-evaluated problem

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Abstract

Peripheral venous catheters (PVC) are the most frequently used invasive devices in hospitals. Up to 70% of patients require a peripheral venous line during their hospital stay, and conservative estimates suggest that PVC days account for 15ā€“20% of total patient days in acute care hospitals. Most published studies focus on thrombophlebitis and address the issue of scheduled catheter change, but there is still no consensus on the optimal time point for PVC change, or whether catheter replacement is required at all. Although PVC-associated catheter-related bloodstream infections (PVC-BSI) are far more serious than thrombophlebitis, few studies address this issue, and a large multicentre trial is lacking. Some studies on thrombophlebitis mention that no, or only a few, PVC-BSIs were identified, but such results must be interpreted with caution. Current data available on PVC-BSI suggest incidence density rates of 0.2ā€“0.7 episodes per 1000 device days, which appear low when compared with other catheters. However, some studies report absolute PVC-BSI numbers in the range of central line-associated infections. It remains unclear whether PVC-BSI should be considered a serious healthcare problem or simply a very rare event. More research is needed both to capture the dimension of the problem and to provide efficient control measures.

Introduction

Peripheral venous catheters (PVC) are the most frequently used invasive device in hospitals. It is estimated that 30ā€“80% of patients receive a peripheral line during their hospital stay [1, 2, 3, 4, 5, 6]. Despite the frequent use of this routine device, randomized studies investigating PVC-associated catheter-related bloodstream infections (PVC-BSI) are rare and focus on phlebitis, catheter colonization and catheter patency [7, 8, 9, 10]. Although there is abundant literature on catheter-associated bloodstream infection, it concerns mostly central-line devices. Indeed, data on this potentially serious complication can only be obtained from small studies, notably the exemplary report by Maki et al. [11]. We reviewed the literature to determine if complications arising from PVC use are under-evaluated and, in particular, whether the peer-reviewed literature appropriately reflects the wide use of this device, whether potentially harmful complications are well addressed, and the type of prevention and intervention measures proposed.

Section snippets

Epidemiology

A total of 150 million PVCs are used annually in the USA, and extrapolated catheter days reach 450 million, which is 15 times higher than the cumulative dwell time of central venous lines. At present there are no Europe-wide epidemiological data on PVC use. In 2006, the Swedish Council on Technology Assessment in Health Care conducted a country-wide review of annual PVC use and reported 5 million PVCs. PVC use is a routine procedure, but various studies estimate that 4ā€“28% of the PVCs are not

Thrombophlebitis

The best described, most frequent PVC complication is phlebitis, or thrombophlebitis when phlebitis is combined with thrombus formation. PVC-associated thrombophlebitis rates range from 2 to 80% [4, 5, 16, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37]. This remarkable variation results from distinct study settings and the use of individual rather than universally valid definitions of thrombophlebitis. While all definitions are based on clinical findings such as

Scheduled catheter change

There are many reports on scheduled catheter change for thrombophlebitis prevention. Based on early results the CDC suggested that PVCs should be replaced after 48ā€“72 h [5, 19]. The threshold of 3 days was subsequently challenged by various studies in which catheters were in place for 96 h or longer without detecting an increase in thrombophlebitis [17, 18, 26, 70, 71, 72, 73, 74]. Although the studies extending the dwell time to 96 h produced satisfying results, those suggesting that scheduled

Precautionary measures

Only a few studies have investigated clinical intervention strategies, and those that have done sowere mainly focuse donthrom-bophlebitis as the primary outcome parameter. Performance feedback reduced phlebitis rates from 8.5% to 5.4% in a before-after study among 37 surgical wards in the UK [20]. Feedback is a well-established intervention method in medicine, particularly in infection control [76, 77]. It has repeatedly been shown that performance feedback can be effective in improving

Conclusion

PVCs are the most frequently used, but at the same time abused, invasive devices in hospitals. The risks and benefits of PVCs are largely underevaluated in clinical medicine, and this is particularly true for PVC-BSI. Given that PVC-BSI is the most serious complication of catheterization in general, such a lack of information is regrettable. Compared with central venous lines, where many studies describe every single detail as well as the overall epidemiological picture, it is not known whether

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