Decision base for re-siting peripheral intravenous cannulae

Thinking about the decision base for re-siting a peripheral intravenous cannula. Should it be based on time or clinical indications?

Insertion of peripheral intravenous cannulae (PIVC) is the most common vascular access procedure performed in hospitals [1]. Limm and colleagues have highlighted the prevalence of the “just in case” PIVC in Australia with Goddard and Thomas revealing a similar occurrence in the UK [2-5].

While we may have an unknown rationale for the insertion of PIVC, we also have an issue with the dwell time of PIVC. If we can’t resist inserting PIVCs, we also can’t resist taking a functioning PIVC out only to re-insert another. Considering the time, vessel health (reduced peripheral vein options) operator success and potential infection this is a clinical procedure that one really wants performed on as few occasions where possible.

Much debate surrounds the optimum dwell time of the PIVC. Over the past 50 years this has ranged from clinical indication to 24hrs to 96hrs. Clinical indication for removal includes pain, erythema/redness, induration, infiltration/extravasation, or an abnormal phlebitis score. If the device is not required for intravenous therapy it should be removed.

Questions for your hospitals vascular access team/ interest groups/ policy authors.

  • Is removing a functioning cannula without a clinical indication at 72hrs or 96hrs doing a disservice to your patient population?
  • Is leaving it until clinical indication to risk potential bacteraemia wise?
  • What evidence is this based on?
  • What is your departmental/hospital policy on PIVC removal?
  • Is there any high level evidence for this?

Discussion and debate over PIVC removal indications

At the 2013 Association for Vascular Access Scientific Meeting the Australian Vascular Access Research & Teaching (AVATaR) group presented a variety of vascular access studies. The Director of AVATaR Prof Claire Rickard delivered a keynote speech based in part on her recent Lancet publication “Routine versus clinically indicated replacement of PIVC” [5]

The FOAMed community now has the opportunity to add to this discussion and debate with Peter Carr (PhD student and advocate for vascular access teams) and Prof Claire Rickard both active on twitter…

Current AVATaR Research

  • The OMG Study - One Million Global catheters PIVC worldwide prevalence study
  • The RSVP Trial - Intravascular device administration sets: Replacement after Standard Versus Prolonged use.  A multi-centre, randomised controlled trial.
  • The SAVE Trial - Securing All intraVenous devices Effectively in hospitals. A randomised controlled trial.

References

  1. O’Grady, N.P., et al., Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis, 2011. 52(9): p. e162-93. [PMID 21460264]
  2. Goddard, L., et al., The ‘just-in-case venflon’: effect of surveillance and feedback on prevalence of peripherally inserted intravascular devices. The Journal of hospital infection, 2006. 64(4): p. 401-2. [PMID 17046109]
  3. Thomas, A., et al., Venflons: why can’t we resist putting them in? Journal of Hospital Infection, 2006. 63(1): p. 108-109. [PMID 16517008]
  4. Limm, E.I., et al., Half of All Peripheral Intravenous Lines in an Australian Tertiary Emergency Department Are Unused: Pain With No Gain? Annals of emergency medicine, 2013. [PMID 23623052]
  5. Loveday HP et al., epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection Volume 86, Supplement 1 , Pages S1-S70, January 2014 [PMID 24330862]
  6. Rickard CM et al., Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial. Lancet. 2012 Sep 22;380(9847):1066-74 [PMID 22998716]
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Comments

  1. says

    This is a great topic. There is lots of hub bub about placing the PIV in the first place after ACEP this year indicated these ‘just in case’ lines are more invasive and costly than beneficial. One potential road that may smooth the removal question is emergency nurses become competent at placing mid lines. The folks needing mid lines are going to be long term admits getting big antibiotics and they will be obvious patient groups for the most part. Mid lines are great in that they are still peripheral, relatively easy to place with ultrasound, have extended dwell times and have a lower infection rate than any other access device except a mediport. I look forward to the evolution of this topic.

  2. Pete Carr says

    It is a great topic Brian. Not so sure adding a skill to the ED nurse with multiple competing tasks is the way to go.

    What do you place next if the midline fails?

    We need to look at device avoidance, as you mention avoid the unnecessary device/ “just in case”. If one is required we need to place a vascular access device that is the most appropriate for the person’s treatment and empirical diagnosis. One that is placed by clinicians qualified to do so. It then needs to be maintained by the person (where possible with management advice) with the support of health care professionals educated and trained to do the same so that device failure does not occur. Elective re-sites based on time 24-48-72-96hrs means hospital staff are not trusted to manage these devices and this required attention.

    Pete

  3. says

    On a related topic, any of you being asked to get a consent form signed before placing an IV?

    Latest wizard-wheeze is to get consent forms for all ‘invasive procedures’. One would hope bunging in an IV doesn’t qualify -- but given the reported 1 in 4 failure rate of cannulas, perhaps a consent form SHOULD be signed?
    ;-/

  4. says

    Yes it should and should be prescribed too.
    The infusates need to be prescribed but not the device. Contradiction +/-?
    Until this changes the peripheral line will be inappropriately utilized “just in case” with financial waste (cost of insertion/ cost of failed ) and patient safety being the the “fall guy”
    The peripheral cannula “the bold boy in the good room”….nothing to see here etc etc the ultimate case of the medical device by-stander effect.

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