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PURLs Priority Updates from the Research Literature

from the Family Physicians Inquiries Network

Dionna Brown, MD;


Kate Rowland, MD, MS
The University of Chicago
Optimal timing for peripheral
PURLs Editor
Bernard Ewigman, MD,
IV replacement?
MSPH
The University of Chicago
Theres no downside to switching from routine to
clinically indicated replacement of peripheral IV
catheters. And your patients will appreciate having fewer
needlesticks.

PRACTICE CHANGER it is not necessary to replace peripheral IV


Replace peripheral IV catheters as needed, catheters in adults more than every 72 to
rather than on a routine basis.1 96 hours,3 but the CDC does not specify when
the catheters should be replaced. For adult
STRENGTH OF RECOMMENDATION patients, the recommendation that a cath-
A: Based on a randomized equivalence trial. eter be replaced only for clinical indications
Rickard CM, Webster J, Wallis MC, et al. Routine versus clinically indi- is an unresolved issue, according to the
cated replacement of peripheral intravenous catheters: a randomised
controlled equivalence trial. Lancet. 2012;380:1066-1074. guidelines. For children, however, replace-
ment only when clinically indicated is rec-
ommended by the CDC. Many hospitals have
Illustrative case protocols that require replacement of IV cath-
On Day 4 of her hospitalization for a wound eters every 72 to 96 hours, regardless of clini-
infection requiring IV antibiotics, a 45-year- cal indication.
old patient is told by her nurse that her IV zA 2008 study of 755 inpatients com-
catheter must be replaced. Its hospital policy, pared clinically indicated replacement of IV
the RN says, to replace the catheter every catheters with routine replacement and found
96 hours. The patient is afraid of needles and no significant differences in phlebitis and
is not eager to have her catheter replaced ev- infiltration rates between the 2 groups (38%
ery few days. Is it really necessary to replace vs 33%, respectively; relative risk [RR]=1.15;
the IV, she wants to know. 95% confidence interval [CI], 0.95-1.40).4
zA 2010 trial randomized 362 hospital-

E
ach year, nearly 200 million periph- ized patients to routine or clinically indicated
eral IV catheters are placed in patients replacement of peripheral IV lines, with me-
in hospitals throughout the United dian dwell times of 71 and 85 hours, respec-
States.2 Many of the catheters need to be re- tively. There was no significant difference in
placed due to phlebitis, infiltration, pain, or rates of phlebitis between the routine replace-
swelling at the IV site, but the rate of blood- ment (7%) and clinically indicated (10%)
stream infections associated with peripheral groups (RR=1.44; 95% CI, 0.71-2.89; P=.34).
IVs is just 0.5 per 1000 catheter days.2 No local infections or IV-related bloodstream
infections occurred in either group.5
Timing of replacement zA 2010 Cochrane review included
is unresolved 5 randomized controlled trials (with a total
The Centers for Disease Control and Pre- of 3408 patients) that compared rates of sus-
vention (CDC)s 2011 guidelines state that pected catheter-related phlebitis in patients

200 The Journal of Family Prac tice | Apr i l 2 0 1 3 | V o l 6 2 , N o 4


whose catheters were routinely replaced with had a catheter-related bloodstream infection;
those in the clinically indicated group. The re- no one in the clinically indicated group did.
viewers found no significant increase in phle- The mortality rate for each group was <1%.
bitis in the clinically indicated group (9%) vs
the routine replacement group (7.2%) (odds
ratio=1.24; 95% CI, 0.97-1.60; P=.09).6 Whats new
Each of these studies had either a rela- We can order clinically indicated
tively small sample size or wide confidence IV replacement with confidence
intervals, raising the possibility of missing a The findings of this equivalence trial support
real increase in infection due to inadequate prior studies and add greater statistical power.
statistical power. The study summarized here The results suggest that we can recommend
addressed these concerns. clinically indicated replacement of periph-
eral IV catheters without increasing the rate of
phlebitis. Implementing clinically indicated
Study summary replacement of IVs could decrease hospital
Forgoing routine replacement costs and improve patient satisfaction.
does not increase risk
Rickard et al1 conducted a multicenter, non-
blinded randomized equivalence trial to Caveats
determine whether routine or clinically indi- Findings do not apply Nine patients
cated removal reduced rates of infection. In to patients with bacteremia in the routine
the routine group, catheters were replaced Patients with known bacteremia were exclud- replacement
every 72 to 96 hours. In the clinically indi- ed from this study, and the results are there- group
cated group, catheters were replaced in in- fore not generalizable to this population. developed
stances of phlebitis, infiltration, occlusion, The nonblinded nature of this trial raises bloodstream
accidental removal, or suspected infection the possibility of observer and reporting bias. infections,
related to the catheter. However, measures were taken to minimize vs 4 patients
Participants (N=3283) were inpatients the potential for bias. A structured outcome in the clinically
on medical and surgical units who had IV assessment was used to standardize report- indicated group.
catheters in place and were expected to ing of signs of phlebitis. Both patients pain
need treatment for at least 4 days. Individu- scores and nurses assessments of the IV sites
als whose IV catheters had been placed in an were used to determine whether an infec-
emergency were excluded, as were those who tion was present, and the investigators and
had a known bloodstream infection or who research nurses were not involved in the re-
were not expected to have the IV in place for moval of the IV catheters.
at least 24 hours. Follow-up data were avail- This study did not report on the daily
able for all participants. maintenance protocols the investigators used
The primary outcome was phlebitis, with for the peripheral IVs. The study was conduct-
a prespecified equivalence margin of 3%. In ed in hospitals in Australia, and we dont know
both groups, phlebitis occurred in 7% of pa- whether the protocols used in that country are
tients (RR=1.06; 95% CI, 0.83-1.36; P=.64). similar to standard protocols in US hospitals.
The absolute risk difference was 0.41% (95%
CI, -1.33 to 2.15), which was within the equiv-
alence margin. Challenges to Implementation
The mean IV catheter dwell time was Changing hospital protocols
70 hours in the routine replacement group wont be easy
and 99 hours in the clinically indicated group. Implementing the findings of this study will
Nine patients in the routine replacement require that physicians work with the nursing
group developed bloodstream infections, vs staff and administrators to create and imple-
4 patients in the clinically indicated group ment new protocols for assessing peripheral
(hazard ratio=0.46; 95% CI, 0.14-1.48; P=.19). IV catheters in hospitals with routine IV re-
One patient in the routine placement group placement policies already in place. It would

jfponline.com Vol 62, No 4 | April 2013 | The Journal of Family Practice 201
PURLs

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be necessary to ensure that all clinicians
who place peripheral IV catheters are
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taught the clinical signs of phlebitis and
are using a standardized protocol. That
said, we think that this is a worthwhile
change to achieve the long-term ben-
efits of fewer unnecessary IV catheter N
 ew concussion
replacements. JFP
guideline dispenses
Acknowledgement with grading system
The PURLs Surveillance System was supported in part
by Grant Number UL1RR024999 from the National
Christopher C. Giza, MD, UCLA
Center for Research Resources, a Clinical Translational Brain Injury Research Center
Science Award to the University of Chicago. The con-
tent is solely the responsibility of the authors and
does not necessarily represent the official views of Asthma still
the National Center for Research Resources or the Na-
tional Institutes of Health. uncontrolled? Try
Copyright 2013. Family Physicians Inquiries
these troubleshooting
Network. tips
Jennie Broders, PharmD, BCPS
References UPMC St. Margaret, Pittsburgh
1. Rickard CM, Webster J, Wallis MC, et al. Routine versus .
clinically indicated replacement of peripheral intrave-
nous catheters: a randomised controlled equivalence
2 ways to listen to these audiocasts:
trial. Lancet. 2012;380:1066-1074. 1. Go to jfponline.com
2. Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream
infection in adults with different intravascular devices: a 2. Scan the QR codes
systematic review of 200 published prospective studies.
Mayo Clin Proc. 2006;81:1159-1171.
3. Centers for Disease Control and Prevention. 2011 guide-
lines for the prevention of intravascular catheter-related
See how the Neers and
infections. Available at: http://www.cdc.gov/hicpac/
BSI/references-BSI-guidelines-2011.html. Accessed
Hawkins tests are done
March 13, 2013. Courtesy of: Christopher Faubel,
4. Webster J, Clarke S, Paterson D, et al. Routine care of MD, ThePainSource.com
peripheral intravenous catheters versus clinically indi-
cated replacement: randomised controlled trial. BMJ.
2008;337:a339.
5. Rickard CM, McCann D, Munnings J, et al. Routine resite
of peripheral intravenous devices every 3 days did not
INSTANT poll
reduce complications compared with clinically indi-
cated resite: a randomised controlled trial. BMC Med.
With what frequency do you encounter
2010;8:53. adverse effects when prescribing
6. Webster J, Osborne S, Rickard C, et al. Clinically-indi-
cated replacement versus routine replacement of pe-
fluoroquinolones?
ripheral venous catheters. Cochrane Database Syst Rev.
2010;(3):CD007798.
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