How Safe Are Peripherally Inserted Intra-Vascular Devices (IV Cannula)?

By Dr Kadiyali M Srivatsa Abstract
Winchester and Eastleigh Healthcare NHS Trust (UK) begun prescribing the insertion of intra-vascular device (cannula) and reduced MRSA infection by 100%. This work proves beyond doubt the association of intra-vascular device with increased infection rate in hospitals. Multiple punctures put patients at risk for local and systemic infectious complications, including local site infection. IVD can now be classified similar to a classified drug as its use can result in serious harm to the patients. This may result in the introduction the organism present on the skin, resulting in severe toxemia & shock, and possible death. As doctors we must respect our ethics and ask this question “Is this cannula safe?” How do we defend our action ?

Introduction
Winchester and Eastleigh Healthcare NHS Trust (UK) (BBC News, 8th May 2008) begun prescribing the insertion of intra-vascular device (cannula). Doctors were able to monitor the tubes more closely for signs of infection. Since the introduction of this protocol last November there have been no new cases of MRSA infections. This figure covers all forms of MRSA, including bacteraemia and wound infections. This compares to 2007/08 when there was 11 reported bloodstream infections. This work proves beyond doubt the association of intra-vascular device with increased infection rate in hospitals. The emergence of new epidemic strains of CA-MRSA in the community, among patients without established MRSA risk factors, may present new challenges to MRSA control in healthcare settings(1). Klevens RM et al; reported Invasive MRSA is a major public health problem primarily related to health care but no longer confined to intensive care units, acute care hospitals, or any health care institution (2). Chhadia, AM et al; published the result of their study CA-MRSA Hand Infections in an Urban Setting, claiming 73% of healthy adults are said to carry this organism on their hands(3)

Doctors, patients and healthcare workers must look carefully at various procedures carried out in hospitals. We have been taking a close look at the most common procedures performed in modern-day medical practice is insertion of intravenous cannulation – is hated by all. As house officers claim the success of inserting a cannula is the first attempt is about 60% and rate improved to 90% as seniors doctor (4) Multiple punctures put patients at risk for local and systemic infectious complications, including local site infection. Peripheral venous catheters / cannulae are the devices most frequently used for vascular access. Although the incidence of local or bloodstream infections (BSIs) associated with peripheral venous catheters was said to be low. Now due to serious infectious complications produce considerable annual morbidity because of the frequency with which such catheters are used. PVCs inserted in the emergency department caused the highest number of episodes and had a shorter duration to bacteraemia than those inserted in other hospital areas. This is probably due to the fact that in the emergency department, PVCs are used excessively and are frequently inserted under poor aseptic conditions (5). Unsuccessful attempts not only cause distress to the patient and make cannulation more difficult, but each unnecessary puncture wound provides an access route for MRSA or other drug-resistant organisms into the bloodstream. The CDC and the UK Department of Health have addressed this issue by recommending that all PVCs inserted in emergency situations must be removed or changed on hospital wards within the first 48 h of admission and every 72 h irrespective of the presence of infection.(6). Ward nurses are, however, highly reluctant to change recently inserted vascular catheters. Furthermore, other studies have been unable to demonstrate an increased risk of complications after three days of peripheral vascular catheterisation and have questioned the CDC recommendation for the routine replacement of PVCs. (7) The various guidelines advise healthcare professionals to use the hand to place an intravascular device. Avoid the routine use of the veins of the lower extremities due to the increased risk of embolism, thrombophlebitis of and infection (8). These studies were carried out in intensive care settings and were based on central venous catheters (CVC). CDC has published their guidelines on hand hygiene in health care in their website, and this will soon need updating based on the present information. In September 2007, Spanish doctors published a paper and concluded the incidence of bacteria associated staphylococcus infection of blood is more common in patients having an Intra-venous Device (IVD) administered in ER and said to occur within 48 hours (5). Crnich, CJ et al assessed the risk of bloodstream

Infection in adults with different intravascular devices and published their result in Mayo Clinic Proceedings: The results show that all types of IVDs pose a risk of bloodstream infection (BSI) and can be used for benchmarking rates of infection caused by the various types of IVDs in use at the present time (9). Since almost all the national effort and progress to date to reduce the risk of IVD-related infection has focused on short-term no cuffed IVD as used in hospitals; infection control programs must now strive to consistently apply essential control measures and preventive technologies with all types of IVD’s. There are very convincing reports from respected institutions that will make doctors feel very uncomfortable in introducing cannulae in healthy adults. IVD can now be classified similar to a classified drug as its use can result in serious harm to the patients. The cleaning solution may not be as effective as claimed. This may result in the introduction the organism present on the skin, resulting in severe toxemia & shock, and possible death of the patients within 48 hours. As doctors we must respect our ethics and ask this question “Is this cannula safe?” How do we defend our action when a patient dies from an ICUacquired infection related to methicillin-resistant Staphylococcus aureus (10)? We have identified several potential causes that need updating. Use of non-sterile or sterile gloves, use of ported cannula, problems with cleaning solutions, introduction techniques, failure rates and fixation of devices to be the important factors requiring further assessment.

REFERENCE 1. Siegel JD; Rhinehart E; Jackson M; Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006. Healthcare Infection Control Practices Advisory Committee. Centres for Disease Control and Prevention.

2. Klevens RM; Morrison; Nadle J; Petit S, et al; Invasive Methicillin-Resistant Staphylococcus aureus Infections in the United States. JAMA, October 17, 2007-Vol 298, No. 15 1763-1771 3. Chhadia AM; Gonzalez MH; Rudy K, et al; Community Associated Methicillin-Resistant Staphylococcus aureus Hand Infections in an Urban Setting; The Journal of Hand Surgery, March 2007. 4. Lilantha Wedisinghe; Painless intravenous cannulation for 16p; GMC Today; Issue 11 January 2007 5. Pujol M; Hornero A; Saballs M, et al, Clinical epidemiology and outcomes of peripheral venous catheter-related bloodstream infections at a university-affiliated hospital. Journal of Hospital Infection (2007) 67, 22-29 6. Soifer NE, Borzak S, Edlin BR, Weinstein RA. Prevention of peripheral venous catheter complications with an intravenous therapy team. A randomized controlled trial. Arch Intern Med 1998; 158:473-477. 7. Bregenzer T, Conen D, Sakmann P, Widmer A. Is routine replacement of peripheral intravenous catheters necessary? Arch Intern Med 1998; 158:151-156.

8. Tagalakis, V., Kahn, S. R., Libman, M., & Blostein, M. (2002). The epidemiology of peripheral vein infusion thrombophlebitis: A critical review. The American Journal of Medicine, 113, 146-151.

9. Jean-Louis V; Brun-Buisson C et al. Ethics roundtable debate: A patient dies from an
ICU-acquired infection related to methicillin-resistant Staphylococcus aureus – how do you defend your case and your team? Critical Care 2005, 9:5-9:10.1186. 10. Crnich, Christopher J; Kluger, Daniel M; Maki, Dennis G; The Risk of Bloodstream Infection in Adults With Different Intravascular Devices: A Systematic Review of 200 Published Prospective Studies. Mayo Clinic Proceedings, September 1, 2006 11. Parienti JJ, Thibon P, Heller R et al. Hand-rubbing with an aqueous alcoholic solution vs traditional surgical hand-scrubbing and 30-day surgical site infection rates. A randomised equivalence study. JAMA 2002; 288:722-27.