Description of the condition
A peripheral venous catheter (PVC), often referred to as an intravenous cannula, is a flexible, hollow, plastic tube that is inserted in a peripheral vein, most commonly the metacarpal vein of the hand, and alternatively, either the cephalic or basilic vein of the lower forearm (Tagalakis 2002; Dougherty 2008; O'Grady 2011). It is typically used for short-term delivery of intravascular fluids and medications. It is an essential element of modern medicine and the most frequent invasive procedure performed in hospital, with over 60% of all hospitalised patients requiring peripheral venous catheterisation (Wilson 2006). It has been conservatively reported that patients have a PVC for 15% to 20% of the total time they spend in an acute care hospital. (Zingg 2009). In the United States, an estimated 330 million PVC are sold each year (Hadaway 2012).
The Infusion Nurses Society Standards recommend that PVCs be re-sited when clinically indicated, and that decisions about when to re-site should be based on an assessment of the patient's PVC site, including: skin and vein integrity, type of intravenous (IV) therapy prescribed, the treatment setting, and patency of the PVC and securing dressing or stabilisation device (INS 2011). PVCs often fail before intravenous treatment is completed. Reported failure rates, or unscheduled restarts, range from 33% to 69% (Harwood 1992; Royer 2003; Smith 2006; Rickard 2010; Bolton 2010). PVCs fail for a wide range of reasons; the most commonly identified causes of failure are partial dislodgement or accidental removal, phlebitis (irritation or inflammation to the vein wall), occlusion/infiltration (blockage/moving into surrounding tissue) leakage and infection (Webster 2008; Bolton 2010; Rickard 2010).
Dislodgement and accidental removal
Inadequate catheter stabilisation or securement can lead to poor attachment of the PVC to the skin, allowing movement of the catheter out of the vein, and resulting in partial or complete dislodgement. PVC dislodgement rates have been reported to range from 6% to as high as 20% of PVC insertions (Wood 1997; Royer 2003; Dillon 2008; Rickard 2010).
Intravenous therapy can be disrupted by phlebitis, which is the irritation and inflammation to a vein wall caused by the presence of an intravenous device (IVD) (Monreal 1999; Tagalakis 2002). Phlebitis can be categorised as chemical (caused by infusates or medication), bacterial (caused by contamination of the site, catheter, tubing or IV solution), or mechanical (caused by the action of the catheter in the vessel) (Macklin 2003). An improperly secured IVD (intravascular device) allows micro-movement of the catheter within the vein; this can irritate the vein wall and lead to mechanical phlebitis (Sheppard 1999; Gallant 2006). Phlebitis is characterised by the presence of any combination of tenderness, pain, erythema (redness), oedema (swelling), warmth, palpable cord (hard, thickened vein), or purulent (pus) drainage ( Maki 1991; Tagalakis 2002; Gallant 2006). Phlebitis rates range from 2.6% to 67.2% depending on the authors' definition, study design, study population and the duration of follow-up period (Catney 2001; White 2001; Karadeniz 2003; Malach 2006; Webster 2008; Rickard 2010; Rickard 2012).
Occlusion/infiltration and leakage
A poorly-stabilised PVC within a vein can damage the vessel wall, instigating the release of thromboplastic substances and platelets that promote blood clotting (Gabriel 2010). This process may cause narrowing or occlusion of the catheterised vein, which then forces the backflow and potential leakage of IV fluids from the PVC insertion site, or their infiltration into the surrounding tissues, and restricts future venous access in the limb (Royer 2003; Gabriel 2010). Recent studies show PVC failure due to infiltration occur in 12% to 36% of patients (Homer 1998; Catney 2001; Tagalakis 2002; Webster 2008; Rickard 2010).
Poor catheter stabilisation, particularly if it leads to unscheduled PVC re-siting, may increase a patient's risk of infection. In order to be sited, a PVC must be inserted through the patient's skin, which normally acts as a protective barrier against bacteria that might otherwise access the body. Consequently the catheter may be contaminated during initial insertion or subsequent re-sitings with a new PVC (Gabriel 2008). The most common cause of catheter-related bloodstream infection (CRBSI) in short-term catheters occurs when the skin has been broken. Micro-organisms can cause local infection and may track along the surface of the PVC to contaminate the catheter tip, and then the bloodstream (Morris 2008; O'Grady 2011). Micro-motion while the PVC is in place may also encourage microbial entry via the PVC wound (Frey 2006). However, CRBSI occur less frequently in PVC than in other intravascular devices (0.1% per PVC, 0.5 per 1000 PVC-days) (Maki 2006).
Improper securement of a PVC to the skin allows the catheter to move within the vein, which increases the incidence of PVC dislodgement, mechanical phlebitis, infiltration, leakage and infection (Royer 2003; Bolton 2010; Gabriel 2010). This movement results in PVC failure, an interruption to intravenous therapy and the need to re-site the PVC. Repeated re-siting of PVC can lead to venous access difficulties, including the need for more frequent PVC re-sites or for a central venous catheter, and causing interruption to the delivery of IV therapy and a potential increase in the duration of hospital stay and healthcare costs (Monreal 1999;Tagalakis 2002; Dillon 2008).
Description of the intervention
The intervention of interest is the wound dressing(s) or securement device(s) used for PVC stabilisation. Following clinical practice protocols or clinician preference, two standard dressings are generally used to secure the PVC: either non sterile tape with gauze or bandage; or a transparent dressing (Gabriel 2010; O'Grady 2011). However, new products, such as antimicrobial-impregnated dressings and sutureless (stitch-less) securement devices that are designed to be used with the wound dressing to improve attachment of the PVC to the skin, have recently become available.
A combination of tape with bandage or gauze has been widely used to secure PVCs. This combination can range from non-sterile tape and sterile gauze assembled by clinicians using products such as Micropore® (3M) or Hypafix® (Smith & Nephew Healthcare Ltd), to commercially-available dressings that combine a sterile tape and gauze design, for example Primapore® (Smith & Nephew Healthcare Ltd). However, gauze needs to be removed so that the insertion site can be seen and this can potentially increase the chance of catheter dislodgement or movement, resulting in complications such as phlebitis, infiltration or occlusion (Campbell 1999). Furthermore, although gauze dressings are absorbant and can prevent the pooling of moisture at the insertion site, when wet they provide an ideal environment for the proliferation of infection-producing organisms (Campbell 1999; Gabriel 2010).
Transparent dressings have been in use since the early 1980s and offer clear visualisation of the PVC insertion site. The Opsite® (Smith & Nephew Healthcare Ltd) and Tegaderm® (3M) ranges of dressings are the most commonly used products (Webster 2011). An early systematic review that compared gauze dressings to transparent dressings for PVC securement found a significantly higher infection risk with transparent dressings (Hoffmann 1992). This was thought to be related to increased collection of moisture (Hoffmann 1992). As a result of these studies, modern transparent dressings were developed that claim to have greater moisture vapour permeability (MVP) (Wille 1993). A study comparing standard Opsite and Opsite IV3000 for dressing central venous catheters reported MVPs of 800 g/m2 and 3000 g/m2, respectively and no differences between the dressings for complications such as moisture accumulation, lifting of dressing or durability (Wille 1993). Recently, new versions of these products, with additional strongly-adhesive fabric borders, or additional sterile tapes to improve securement, have become available.
Antimicrobial dressings or impregnated discs have been developed to aid prevention of CRBSIs, for example Biopatch® (Johnson and Johnson) and Tegaderm CHG® (3M). The most common source of infection for CRBSI is colonisation of the skin surrounding the insertion site, so antimicrobial dressings aim to reduce colonisation, and thus decrease the incidence of CRBSI (Dainiels 2012). The Centers for Disease Control and Prevention recommend the use of a chlorhexidine-impregnated sponge for temporary short-term catheters (typically used in intensive care units) if the central line-associated bloodstream infection (CLABSI) rates, are unacceptably high and not decreasing despite the implementation of basic preventative measures (i.e. education and training, maximal sterile barrier precautions and >0.5% chlorhexidine in an alcoholic solution for skin antisepsis) (O'Grady 2011). However, there is no mention in the Guidelines of antimicrobial sponge/dressing use in conjunction with peripheral catheters.
Sutureless securement devices
Sutureless securement devices have incorporated anchor points, or clips, to hold the PVC in place more securely, for example Statlock® (Bard Medical), Grip-Lok® (Zefon International) or Hubguard ® (Centurion Medical Products). It is reported that the added attachment to the skin decreases catheter movement and reduces complications such as phlebitis, dislodgement, infiltration and vessel occlusion (Schears 2006). The Centers for Disease Control and Prevention has recommended use of sutureless securement devices to decrease the risk of infection (O'Grady 2011). The Infusion Nurses Society advises that a stabilisation device should be used in preference to tape or sutures when possible, to aid in maintaining device integrity and minimisation of movement at the catheter hub (INS 2011).
How the intervention might work
The aim of all PVC dressings and securement devices is to maintain a barrier to infection and to ensure that the device remains in the vein.This review aims to examine the different PVC protection and stabilisation methods; the impact they have on PVC dwell time and stabilisation-related complications such as dislodgement, phlebitis, occlusion/infiltration, leaking, and infection; and the costs involved with the different products.
Identification of the most effective securement method may help reduce stabilisation-related complications.
Why it is important to do this review
PVC insertion and IV therapy is a common procedure for hospitalised patients. Prevention of failure and unscheduled restarts of PVC therapy is an important patient outcome: failure interrupts prescribed therapy, and reinsertion can be distressing and painful. A PVC that is not securely attached to the skin has the potential to migrate externally and simply fall out, or cause complications such as phlebitis and infiltration. An inadequately secured PVC also increases the risk of CRBSI, as the pistoning action of the catheter can allow migration of organisms along the catheter and into the systemic circulation (Gabriel 2001; O'Grady 2011). These unnecessary complications can lead to delays in treatment and increases in length of hospital stay (Bolton 2010). These factors have an impact on health resources, as PVC replacement is time consuming, requires skilled clinicians and disposable sterile equipment, and CRBSIs cause significant increases in treatment costs (Bolton 2010; Gabriel 2010). Despite the many dressings and securement devices available, the impact of different securement techniques for increasing PVC dwell time is still unclear; there is a need to provide guidance for clinicians by reviewing current studies systematically.