Lynelle Foster, RN, BN, MN

Marianne Wallis, RN, BSc(Hons), PhD

Barbara Paterson, RN, EM, NICC, BEd
Heather James, RN, BN, MN

A Descriptive Study of Peripheral

Intravenous Catheters in Patients
Admitted to a Pediatric Unit in One
Australian Hospital

indications for use, dwell time, and reasons for

Abstract
• • • •
Over a 5-month period, 496 peripheral
intravenous catheters (PIVs) inserted into
neonates, infants, and children were
prospectively studied. Data were collected on
demographic patient characteristics, PIV
removal, together with nursing actions. The
results showed that most PIVs were removed
within 72 hours. In 6.6% of cases, some degree
of phlebitis was present at PIV removal. The
risk of phlebitis increased when the PIV
remained in place longer, the child was younger,
or medication was administered. The greatest
risk was age, with neonates being 51/2 times
more likely to have some degree of phlebitis
than non-neonates.

Lynelle Foster has worked in the field of infusion therapy since 1992 and is the Clinical Nurse Consultant of Parenteral Therapy at
Gold Coast Hospital in Queensland, Australia.
Marianne Wallis has been the Chair of Clinical Nursing Research at Gold Coast Health Services District and Griffith University,
Queensland, Australia since January 2000.
Barbara Paterson has worked in the field of pediatrics for more than 20 years. She is the Nurse Educator in the Paediatric Unit,
Gold Coast Hospital in Queensland, Australia.
Heather James has been an Associate Lecturer in the School of Nursing, Griffith University, Queensland, Australia since 1999.
Address correspondence to: Lynelle Foster, Parental Therapy Department, Gold Coast Hospital, Office 18, 1st Floor, Southport,
Queensland, QLD 4215 (e-mail: Lynelle_Foster@health.qld.gov.au).

Vol. 25, No. 3, May/June 2002 159


• BACKGROUND TO THE STUDY
T
he setting used for this study was the pediatric
unit at the Gold Coast Hospital (GCH), Aus-
tralia. This pediatric unit admits approximately
3,700 patients each year, including neonates,
infants, and children. Neonates are defined as babies
younger than 28 days. Infants are in the first year of life,
and children are defined as 1 to 16 years of age. All
pediatric medical and nursing services are offered at
GCH except chemotherapy initiation, long-term venti-
lation, and cardiac surgery.
The Infusion Nursing Standard of Practice, estab-
lished by the Infusion Nurses Society (INS)1 and Guide-
line for Prevention of Intravascular Device-Related
Infection, Centers for Disease Control and Prevention
([CDC]. Atlanta, Ga: US Department of Health and
Human Services; 1996) are used to guide clinical infu-
sion practice at GCH. The issue of frequency of replace-
ment of peripheral intravenous catheters (PIVs) in
children is, however, unresolved with both INS and the
CDC. The pediatric nursing staff at GCH identified a
number of issues related to PIV insertion, use, and dwell
time that required further exploration.
• LITERATURE REVIEW
The epidemiology of intravascular device complications
is less well described for pediatrics than for adults, and
there are limitations to the existing data. First, a thor-
ough search of the literature, the Cochrane Collabora-
tion, and the Joanna Briggs Institute failed to identify
any systematic reviews of pediatric PIV use. Second,
most identified studies were uncontrolled and either ret-
rospective or prospective. Third, most of the available
data were gathered only in neonatal or pediatric inten-
sive care units and not in general pediatric wards.2-6
Research studies investigating issues related to com-
plications of peripheral intravenous therapy have
focused on infection control practices,7-12 types of
PIVs,13,14 PIV dwell times and patency maintenance,15-20
IV administration set changes, the use of add-on IV
devices,21,22 and the use of IV nursing teams.23,24 These
are considered individually in the following discussion.
• INFECTION CONTROL PRACTICES
Adherence to handwashing and aseptic technique are
accepted worldwide as the cornerstone for prevention
of IV catheter-related infection. Although this alone
160
may seem adequate for preventing infections associated
with PIVs, issues such as the appropriate use of an anti-
septic to prepare the skin before PIV insertion and the
maintenance of the dressing on the PIV exit site also are
implicated.9,10
An antiseptic skin solution should always be used
before insertion of a PIV. A prospective randomized
trial of agents used for cutaneous antisepsis demon-
strated that 2% aqueous chlorhexidine was superior to
either 10% povidone iodine or 70% alcohol in prevent-
ing catheter-related infection.9 However, the 2% aque-
ous chlorhexidine solution is not yet available in
Australia. Direct comparisons of aqueous and alcoholic
solutions of chlorhexidine have not been undertaken.
However, an alcoholic chlorhexidine solution combines
the benefits of rapid action and excellent residual
antimicrobial activity.25 To maintain skin integrity and
prevent chlorhexidine absorption in neonates, it is sug-
gested that after the solution has been allowed to dry
for 30 seconds, it should be removed completely using
sterile saline solution.10
The most common dressing type used for PIV exit
sites in adults is a sterile, transparent, semipermeable
membrane dressing. This dressing is popular because it
reliably secures the catheter, permits continuous visual
inspection of the exit site, and repels water.9,11 However,
it is not uncommon in the pediatric population to use
unsterile tape to secure PIVs.12,26,27 Infection control prac-
tices together with the type of catheter play an important
role in the prevention of complications with PIVs.
• TYPE OF PERIPHERAL INTRAVENOUS
CATHETER
The guidelines for choosing the appropriate PIV gauge
are the same for children as for adults. That is, the
smallest device possible should be used to deliver the
prescribed therapy.28 Manufacturers market a number
of peripheral devices, and although personal preference
is a consideration, the clinician should consider other
factors such as type and duration of therapy when mak-
ing a selection. The winged-steel (scalp and butterfly)
needles were designed specifically for pediatric use, but
because of the risk for dislodgement and subsequent
injury, they have been replaced by over-the-needle
PIVs.29 These devices consist of a catheter over an inter-
nal stylet. The original catheters were made from
Teflon, a stiff, fluorine-based plastic that can kink.
Recent improvements in the quality and properties of
polyurethane have resulted in a softer, high-strength
material patented as Vialon, which becomes pliable
once inside the vein.6,14 Catheter type, dwell time, and
patency maintenance have been implicated in PIV com-
plications.
Journal of Infusion Nursing

• PERIPHERAL INTRAVENOUS
CATHETER DWELL TIME AND
PATENCY MAINTENANCE
The recommendation to replace short PIVs in adults and
rotate insertion sites every 48 to 72 hours to minimize the
risk of phlebitis is well documented in the litera-
ture.9,11,15,16,28 However, the recommendation to replace
PIVs routinely in children remains unresolved.11,28
One comprehensive epidemiologic study30 of 3,094
adult patients with 5,161 total episodes of PIVs found an
overall phlebitis rate of 2.3% and a catheter-associated
bacteremia rate of 0.08%. The study concluded that the
current recommendation to replace adult PIVs every 48
to 72 hours seemed appropriate. However, a prospective
study of 303 critically ill children with 654 PIV inser-
tions2 established a phlebitis rate at 13%, yet concluded
that PIVs could be maintained safely up to 6 days.
Another pediatric study31 reviewed 525 patients with
642 PIVs and reported a phlebitis rate of 1.1%. The
findings indicated that the overall risk of complications
was extremely low and would not be reduced by routine
PIV replacements. It is difficult to compare these results
because no standardized scale was used to establish the
phlebitis rates.
Whether saline or heparin flush solution should be
used to maintain PIV patency and minimize infusion
phlebitis in children remains a matter of controversy.17
One pediatric study found no significant differences in
PIV patency or phlebitis between saline and heparin flush
solutions.18 However, another study of children with PIVs
demonstrated longer durations of patency in catheters
flushed with 10 U/ml heparin flush solution.19 When PIV
dwell time and patency maintenance are investigated, IV
administration set changes should be considered.
• INTRAVENOUS ADMINISTRATION
SET CHANGES AND USE
OF ADD-ON DEVICES
The frequency of IV administration set changes and the
number of times the catheter hub is exposed have an
impact on the potential for infection32-34: the more inter-
ruptions, the greater the potential for the entry of
microorganisms. The use of injection ports, three-way
taps, and needleless IV access systems all have been
examined in relation to potential risk of infection with
intravascular catheters.35,36 Several investigators have
shown that intrinsic contamination of unused intra-
venous fluid is rare. It has been estimated that the inci-
dence of catheter-related infection from contaminated
intravenous fluids is less than 1 per 1,000 infusions.9
Vol. 25, No. 3, May/June 2002
However, outbreaks have occurred, and after these out-
breaks it was recommended that IV administration sets
be replaced at 24-hour intervals.
Researchers currently investigating the frequency of
administration set changes recommend that 48 to 72
hours is the acceptable time between changes.11,28 As of
this writing, research projects are evaluating 96-hour set
changes.21 However, no available data specifically
relates to pediatric set changes. Whereas it is established
that more frequent PIV and subsequent administration
set manipulations are associated with a greater risk of
infection, the impact of an infusion team on PIV com-
plications also has been explored.
• INTRAVENOUS NURSING TEAMS
Although it has been demonstrated that infusion nurs-
ing teams reduce catheter-related complications in the
adult population, no studies were found that explored
this topic in the pediatric population. One prospective
controlled study showed a phlebitis rate of 32% in the
control group, as compared with a phlebitis rate of
15% in the group under the care of the infusion team.37
A randomized prospective controlled study24 also
showed a significant reduction in both local and bac-
teremic complications of PIVs. The control group was
reported to have an inflammation rate of 21.7%, as
compared with a rate of 7.9% for patients whose
catheters were maintained by an infusion team member.
Another study23 also established a 35% reduction in pri-
mary nosocomial bloodstream infections. However, all
these results should be interpreted cautiously because
the definitions for phlebitis and bacteremia varied.
According to one study, the use of infusion nurses for
insertion of PIVs in children is more cost effective than
the use of registered nurses or medical officers for pro-
vision of this service.38 Unfortunately, the outcomes in
this study were not measured in terms of infection pre-
vention.
Widely used in the pediatric population, PIVs pro-
vide the means for administering fluids, blood products,
antibiotics, opioids, and other medications. However,
serious complications are associated with the insertion
and management of these devices. Infectious complica-
tions are the most serious.
• PHLEBITIS
Phlebitis is a condition in which inflammation of the
intima of the vein occurs. It is characterized by pain and
tenderness along the course of the vein, erythema, and
inflammatory swelling with a feeling of warmth at the
161
site. It can be associated with the administration of
chemicals (chemical phlebitis), misplacement of the
catheter (mechanical phlebitis), or proliferation of bac-
teria (bacterial phlebitis).38
Postinfusion phlebitis also is commonly reported.
This condition becomes evident 48 to 96 hours after
catheter removal.39 Phlebitis is considered important
because it may indicate bacterial colonization, which in
turn can lead to catheter-related bloodstream infection
(CR-BSI).39,40 The final consequences can be prolonged
hospitalization, costly treatment, loss of necessary
access, and sometimes even death. Although guidelines
and standards for PIV indications, care, and manage-
ment are readily available for the adult population, staff
of the pediatric unit at GCH believe these cannot be
generalized to children. This issue prompted the authors
to investigate peripheral intravenous practices in the
pediatric unit at their facility.
• METHOD
A convenience sample of 496 PIVs was studied prospec-
tively over a 5-month period from June to October
2000. At the time of this study, PIVs were inserted by
the pediatric medical registrars, remaining in place until
the catheter dislodged, infiltrated, or was no longer
required. At GCH, Insyte catheters (BD Medical Sys-
tems, Franklin Lakes, NJ) and a needleless IV access
system, Interlink (BD Medical Systems), are the stan-
dard items used for both adults and children.
Standard IV medical and nursing practice was main-
tained throughout the period of data collection. This
involved applying a dermal anesthetic eutectic mixture
of local anesthetic cream at least 60 minutes before PIV
insertion in most children older than 2 years, cleansing
the skin with a 70% isopropyl alcohol and 1%
chlorhexidine swab, and allowing the area to dry. After
insertion of the PIV, unsterile zinc oxide tape 1 cm wide
was placed in a chevron around the catheter. The area
approximately 20 to 30 mm distal to the catheter exit
site, where the tip of the catheter was estimated to
reside in the vein, was left exposed to facilitate regular
observation. An arm board then was splinted to the
limb with wide adhesive tape to immobilize it. There
was no dressing covering the PIV exit site. The limb dis-
tal to the PIV exit site was observed hourly.
• DATA COLLECTION
Members of the research team, in consultation with
clinicians, developed the data collection instrument.
Data were collected on demographic variables such as
162
age, gender, and diagnosis; factors related to insertion
such as site and time of insertion; uses of the catheter;
reasons for and timing of removal; adverse events and
nursing actions after removal.
The INS scale for phlebitis was designed for use with
adults because it includes subjective assessment of
pain.28 One problem encountered by the research team
was that pain could not be assessed accurately in pre-
verbal children when data were collected by multiple
nursing staff rather than one trained research assistant.
Consequently, the registered nurse removing the
catheter was asked to observe the site and check a vari-
ety of boxes on a data collection instrument, which
included erythema, swelling, pain, streak, and palpable
cord. The researchers then classified the degree of
phlebitis on the scale depicted in Table 1.
Retrospectively, the clinical nurse who administered
parenteral therapy, electronically accessed all the posi-
tive pediatric blood culture results from AUSLAB
(Pathology and Scientific Services Information System)
during the study period. The purpose of this examina-
tion was to investigate whether any of these blood-
stream infections were possibly PIV related.
• PROCEDURE
All pediatric PIVs inserted during the study period were
eligible for inclusion in the study. Data collection forms
were kept with the admission paperwork, and all regis-
tered nurses were asked to complete a form for each PIV
inserted into each patient. The form was completed by
the registered nurse caring for the patient with the PIV.
If the data collected on a form were found to be
incomplete, a member of the research team audited the
medical record or interviewed the staff member involved
to maximize data collection. All staff gave informed con-
sent for these interviews. In a number of cases, it was not
possible to collect all the information related to patient
demographics or PIV characteristics. Therefore, in the
Results section of this article, the sample sizes will vary.
To facilitate follow-up evaluation of adverse events,
each form was identified with a code number. Only the
research team had access to the information linking the
patient to the data collected. This study was approved
by the Gold Coast Health Service District Human
Research Ethics Committee.
• DATA ANALYSIS
Once collected, data were entered into the Statistical
Package for the Social Sciences, version 10, computer
program (SPSS Inc., Chicago Ill). Descriptive analyses
Journal of Infusion Nursing
 TABLE 1
Phlebitis Scale
Grade Clinical Criteria
0 0 or 1 sign (erythema, swelling, pain)
1 2 signs
2 3 signs
3 2/3 signs plus streak formation
4 2/3 signs plus palpable cord
were conducted on the univariate data, which included
frequencies, percentages, and measures of central ten-
dency such as mean, standard deviation, and mode. The
chi-square test for comparison of proportions was used
to determine significant differences between categorical
variables. Odds ratios and the 95% confidence intervals
were calculated for a variety of variables to identify the
factors associated with phlebitis.
• LIMITATIONS OF THE METHOD
This study did not include prospective microbiologic
assays of PIV exit sites or PIV tips. According to the CDC,
isolation of the same organism from a semiquantitative or
quantitative culture of a catheter segment and from a
peripheral blood culture is required for diagnosis of CR-
BSI.11 In this study, these microbiologic assays were not
conducted prospectively because of funding limitations.
Therefore, the results related to CR-BSI are only estimates.
• RESULTS
Demographic Patient Characteristics
The sample consisted of 496 PIVs inserted into 436 pedi-
atric patients. No more than four different PIVs in any
patient were included in the study. Most patients had only
TABLE 2
Frequencies and Percentages for Catheter Insertion Sites
Veins Used
Metacarpal, dorsal venous arch, tributaries of cephalic and basilic
Cephalic, basilic, median antebrachial
Saphenous, median, marginal, dorsal arch
Total
Vol. 25, No. 3, May/June 2002
one PIV per admission. Of these PIVs, 152 (30.6%) were
inserted into infants (18.5% in neonates), and 344
(69.4%) into children. The mean age of the non-neonates
was 5.5 years (range, 1 month to 16 years; SD 4.88 years).
In this sample, 234 (47.6%) of the catheters were inserted
into girls and 258 (52.4%) into boys. Because this sample
was drawn from a general pediatric population, most of
the diagnostically related groupings were included.
Peripheral Intravenous Catheter
Characteristics
The most common PIVs inserted in this study were 22-
and 24-gauge catheters. As Table 2 shows, 241 PIVs
(49.8%) were inserted into veins of the left upper limb,
219 (45.2%) into veins of the right upper limb, and 23
(4.8%) into veins in the lower limbs.
The mean dwell time for PIVs was 42.35 (SD 29.22)
hours. However, the range was from 2.5 hours to 189.5
hours (7.89 days). Nearly 13% (12.9%; n = 63) of the
PIVs remained in place longer than 72 hours, and 5.7%
(n = 28) of the PIVs were in place more than 96 hours
(4 days).
In this study, 470 PIVs (98%) were used for the
administration of medications or fluids. Fluid replace-
ment therapy was administered through 451 PIVs
(91.3%). In addition, 273 PIVs (57.5%) were used for
medication administration, 49.8% for IV antibiotics,
and 8.2% for a wide variety of other IV medications
including opioids, corticosteroids, bronchodilators,
antiviral agents, insulin, sedatives, antiepileptics, diuret-
ics, antiemetics, and paralyzing agents.
Complications
The most common reason for the removal of a PIV was
that it was no longer required (74.6%; n = 370), either
because treatment had stopped or the patient was being
discharged from hospital. A total phlebitis score was
calculated for all the PIVs (Table 3).
Insertion Site Frequency (%)
Right hand 171 (35.3)
Left hand 216 (44.6)
Right arm 48 (9.9)
Left arm 25 (5.2)
Right foot 11 (2.3)
Left foot 12 (2.5)
Other 1 (0.2)
484 (100.0)
163
TABLE 3
Frequencies and Percentages of Phlebitis Scale Scores
Grade Clinical Criteria
0 0 or 1 sign (erythema, swelling, pain)
1 2 signs
2 3 signs
3 2/3 signs plus streak formation
4 2/3 signs plus palpable cord
Total
Some degree of phlebitis was present at the removal
of 33 PIVs (6.6%). Of this group, most (5.2%) were
associated with grade 1 phlebitis. Two PIVs (0.4%)
were associated with grade 2 phlebitis, and five PIVs
(1%) with grade 3 phlebitis. No palpable cord was doc-
umented as present for any patient. Because PIV
phlebitis has a demonstrated association with CR-
BSI,35,36 blood culture reports also were reviewed.
A retrospective review of positive blood cultures
from patients in the study reported via the AUSLAB sys-
tem during the study period showed that a source for
infection was not found in most cases. Each patient
from whom a blood culture was collected had a PIV in
place. The most common organism isolated was coagu-
lase-negative Staphylococcus (ie, normal skin flora).
This suggests a high rate of specimen contamination at
collection, but it also could imply that a PIV may have
been the source.
For this study, 29 positive blood cultures were ana-
lyzed. In two neonates, a CR-BSI may have developed
from a PIV. The first neonate, during a 32-day length of
stay in a special care nursery, had a PIV in place for 38
hours. This neonate was recorded as having grade 3
phlebitis, and coagulase-negative Staphylococcus was
isolated from the blood culture 3 days after PIV removal.
The second neonate had a 36-day length of stay in a spe-
cial care nursery. The PIV was in place for 24 hours.
Although this neonate scored zero on the phlebitis scale,
evidence in the medical record stated that the IV exit site
was pink. Coagulase-negative Staphylococcus also was
isolated from the blood 4 days after the PIV was
removed. In both cases, no other source of infection was
found. There was no record whether the clinical symp-
toms of infection resolved on removal of the PIV.
The odds ratios of risk factors associated with
phlebitis are shown in Table 4. These data suggest that
phlebitis is related to age, administration of medications
through the catheter, and PIV dwell time.
Neonates and infants, as compared with children
older than 1 year, had more than five times the risk of
phlebitis. Administration of IV medication means that
the patient had more than double the risk of phlebitis.
The data regarding dwell time is more complicated. If a
164
Frequency (%) Cumulative %
463 (93.4) 93.4
26 (5.2) 98.6
2 (0.4) 99.0
5 (1.0) 100.0
0 (0.0) 100.0
496 (100.0)
PIV was in place longer than 72 hours, the risk was
doubled. However, a PIV dwell time of 96 hours did not
increase the risk, and a dwell time less than 48 hours did
not reduce the risk.
Nursing Actions After Removal
Although it is clear that nurses observed signs of phlebitis
when removing the 33 PIVs, no exit site skin swabs or
PIV tips were collected to confirm whether these inci-
dences were related to bacteria. Although a specific item
on the form required nurses to record why a swab was
not sent for culture if a catheter exit site was red or
swollen, this item was completed only twice. The first of
these two completed items included the comment “did
not persist,” and the second included the comment “IV
infiltration with no obvious signs of infection.”
• DISCUSSION
The purpose of this study was to describe PIV use, man-
agement, and associated incidence of phlebitis in the
pediatric unit at GCH. The studied sample included
neonates, infants, and children. This study was con-
cerned with the use, management, and complications of
peripheral intravenous catheterization in a general pedi-
atric population. It is clear from the results that most
PIVs inserted into neonates, infants, and children are
used more frequently for fluid administration than for
drug administration. The most common drugs adminis-
tered are antibiotics, but a wide range of drugs may be
given occasionally via the PIV.
Whereas most catheters are inserted into the left
upper limb of the child, a large minority are inserted
into the right upper limb. Although handedness does
not develop until approximately the age of 3 years,41 a
large proportion of children older than 3 years still have
PIVs inserted into their dominant hand. This would
have implications for the play and learning experiences
in which children could engage during hospitalization.
Journal of Infusion Nursing
 TABLE 4
Univariate Analysis of Risk Factors for Phlebitis

Risk Factor Frequency of Phlebitis Unadjusted Odds Ratio (95% CI) P

Neonate
Non-neonate 16 1.0
Neonate 17 5.58 (2.70–11.55) ⬍ .0001
Age, y
ⱖ1 11 1.0
⬍1 22 5.12 (2.41–10.86) ⬍ .0001
Gender
Female 18 1.0
Male 15 0.74 (0.36–1.51) .515
Catheter size, g
ⱖ 22 28 1.0
⬍ 22 2 0.53 (0.12–2.27) .562
Catheter site
Catheter not in hand 7 1.0
Catheter in hand 26 0.926 (0.39–2.20) 1.000
Drug administration
No drugs 5 1.0
Drugs 28 4.5 (1.17–11.88) .002
Dwell, h
ⱕ 72 23 1.0
⬎ 72 9 2.91 (1.28–6.62) .017
ⱕ 96 30 1.0
⬎ 96 2 1.1 (0.25–4.86) 1.000
ⱕ 48 18 1.0
⬎ 48 14 0.50 (0.24–1.04) .092

CI, confidence interval.

One of the greatest difficulties in examining complica-
tions such as phlebitis associated with PIVs is the lack of
a common definition. The INS phlebitis scale,28 which
ranks degree of phlebitis by how many signs or symptoms
are present, did not function sufficiently with this popula-
tion because pain assessment in preverbal children is dif-
ficult. The scale developed by the authors of this study
seems to have utility for use with children. The overall
phlebitis rate determined by this instrument was 6.6%.
The risk of phlebitis increased according to how long the
PIV had been in place, how young the child was, and
whether medication had been administered. The greatest
risk was age. Neonates were 51/2 times more likely to have
some degree of phlebitis than non-neonates.
Although the phlebitis rate with the current sample
falls between results from other studies, it is difficult to
make comparisons because no standardized phlebitis
scale was used. One study31 in a general pediatric popu-
lation (excluding neonates) reported a 1.1% phlebitis
rate with PIVs. Another study conducted in a pediatric
intensive care unit reported a phlebitis rate of 13%.2
It is acknowledged that differentiating among
mechanical, chemical, and bacterial phlebitis can be
clinically difficult, but timely collection of microbio-
logic evidence can assist diagnosis. This study did not
prospectively assess CR-BSI. However, retrospective
analysis shows that CR-BSI may have developed in two
neonates from a PIV during the study period. Further-
more, it is necessary to educate healthcare professionals
regarding the possible infection risks associated with
PIVs, thereby increasing their awareness of the require-
ment to collect a PIV exit site skin swab and a PIV tip
for microbiologic culture when appropriate.
• RECOMMENDATIONS
FOR FUTURE RESEARCH
The first recommendation from this study is for the
development of a standard definition for phlebitis asso-
ciated with pediatric PIVs so that further epidemiologic

Vol. 25, No. 3, May/June 2002 165

studies may be accurately compared in this important
area of research. Second, randomized controlled trials
in this population are necessary to explore the link
between phlebitis and CR-BSI in the future.
ACKNOWLEDGMENT
The authors thank Tracy Bladen, Clinical Nurse, Par-
enteral Therapy, Gold Coast Hospital, Queensland,
Australia for her contribution to this article.
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