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Peripheral venous catheter, a dangerous weapon. Key points to improve its use
Catéter venoso periférico, un arma peligrosa. Puntos clave para mejorar su uso
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Casademont" "autores" => array:1 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Casademont" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256517302187?idApp=WRCEE" "url" => "/00142565/0000021700000008/v1_201710301405/S0014256517302187/v1_201710301405/es/main.assets" ] "en" => array:18 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>" "titulo" => "Peripheral venous catheter, a dangerous weapon. Key points to improve its use" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "464" "paginaFinal" => "467" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A. Capdevila-Reniu, J.A. Capdevila" "autores" => array:2 [ 0 => array:3 [ "nombre" => "A." 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Puntos clave para mejorar su uso" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Catheter-related bacteremia (CRB) is an important cause of nosocomial infection, associated with high morbidity and mortality rates and a considerable economic burden.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">1,2</span></a> In 2006, Maki et al. graded the risk of bloodstream infection in adults with various intravascular devices,<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">3</span></a> concluding that the risk is higher in patients with large central venous catheters (CVCs) than in those with short peripheral venous catheters (PVCs), according to the number of days the catheter is in place.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Standard recommendations for prevention of catheter-related infection based on the best available evidence are periodically published by scientific societies.<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">4–6</span></a> This has contributed to reducing the infection risk of venous catheterization, mainly in intensive care units (ICU) where CVCs are commonly used. However, there is scant information about prevention in relation to PVCs. Recently, an expert consensus document was published on the prevention, diagnosis, and treatment of short-term PVC-related infection in adults.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">7</span></a> The aim of this article is to present and discuss the key points that can contribute to better use of short-term PVCs in hospital wards.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">The magnitude of the problem</span><p id="par0015" class="elsevierStylePara elsevierViewall">A recent prevalence study showed that 81.9% of patients admitted to Internal Medicine departments have one or more catheters inserted, among which 95% were short-term PVCs.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">8</span></a> PVC use is much more extensive than the use of CVCs. For example, in one community hospital in our setting, 60 PVCs were placed for each CVC (unpublished data from Mataro Hospital; Mataro, Spain).</p><p id="par0020" class="elsevierStylePara elsevierViewall">In the laboratory-based surveillance registry of hospital-acquired CRB in Catalonia (northeast Spain) during 2007–2010, which included 2977 CRB episodes from 40 hospitals, 1 out of 5 episodes was caused by a PVC.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">9</span></a> Analysis of data from outside the ICU has shown that PVC infection is even more relevant in this setting. In one university-affiliated hospital, 150 CRB episodes were detected in non-intensive care patients over a 12-month period: 77 were PVC-related and 73 CVC-related.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">10</span></a> Furthermore, <span class="elsevierStyleItalic">Staphylococcus aureus</span> was more commonly the cause of PVC episodes than CVC episodes (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.01) and this led to a higher rate of infectious complications, including nosocomial endocarditis, in patients with PVCs. Mortality was similar in the two groups. A study carried out in a community hospital<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">11</span></a> also showed the importance of <span class="elsevierStyleItalic">S. aureus</span> as a cause of PVC bacteremia; the complication rate and related mortality were not inferior to those of CVC bacteremia. These data underscore the relevance of PVCs and their high associated risk of nosocomial bacteremia.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">12</span></a> Clearly, preventive measures focusing on the management of peripheral lines should be implemented and adopted in clinical practice.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">State of the art</span><p id="par0025" class="elsevierStylePara elsevierViewall">A prevalence survey about PVCs management was carried out in 47 Internal Medicine departments (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2090 patients).<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">8</span></a> It included an interview with the head nurses using a standardized questionnaire to assess local policies and practices for daily care of intravenous catheters as compared to international standards. The results showed a huge need for improvement regarding catheter use and care. It was estimated that 19% of the catheters in place were no longer necessary. A daily record of the need for a catheter was available in only 40.6% of cases.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">8</span></a> In addition, several observational studies have shown that there is a lack of knowledge on how to use PVCs by attending staff and great differences in the handling of these devices.<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">13–16</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Opportunities to improve</span><p id="par0030" class="elsevierStylePara elsevierViewall">Based on the results of observational studies and the evaluation of staff knowledge about the risk factors for infection and handling of PVCs, we think there are many opportunities to improve catheter use and care. Several guidelines and consensus documents are available on the prevention, diagnosis, and treatment of CVC-related infections, especially in the ICU, and these have contributed to reduce the risk of infection. However, these guidelines do not focus on peripheral lines.<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">4–6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In 2016, a panel of experts from the Spanish Societies of Internal Medicine (SEMI), Cardiovascular Infections (SEICAV), Chemotherapy (SEQ) and Thoracic and Cardiovascular Surgery (SECTCV) joined forces to establish recommendations based on the best available evidence for PVC management. Many recommendations had a low quality of evidence because of the lack of well-designed studies in this field.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">7</span></a> In the current article, we will discuss some recommendations that we believe are key points to improve PVC management, and that will contribute to reduce PVC bacteremia episodes.</p><p id="par0040" class="elsevierStylePara elsevierViewall">First, we should consider the need for a PVC. A venous line should not be placed as a routine act.<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">17</span></a> Many practitioners prefer to prescribe intravenous drugs, even though the patient's clinical condition would allow oral administration, and treatment alternatives with an equally effective pharmacokinetic profile are available. Prevalence studies have shown that almost 38% of PVCs are not necessary.<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">17,18</span></a> Avoiding unnecessary venous catheterization is obviously the main action to prevent catheter-related bacteremia. When an intravenous access is needed, it is mandatory to choose the catheter type in accordance with the expected duration of catheterization and the use for which it is required. Intravenous therapy planned for more than 6 days, or a catheter needed for major procedures such as hemodialysis, plasmapheresis, chemotherapy, parenteral nutrition, or monitoring fluid replacement therapy, among others, require the use of a central line rather than a peripheral one.<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">6,19</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Second, inserting a PVC into a central vein does not make much sense. If it is necessary, upper extremity veins are preferable to minimize the risk of infection. Insertion of a PVC does not require a sterile surgical field, as is mandatory for CVCs, but an aseptic technique is mandatory. The skin must be disinfected, and no differences have been seen between the use of alcoholic chlorhexidine or iodine. The insertion site should not be touched after disinfection. The caregiver inserting the PVC can wear clean single-use gloves instead of sterile ones, and the catheter must be handled from its proximal end. Additional measures of asepsis are not required. Nonetheless, when there are doubts about adherence to these basic rules, the catheter should be removed and replaced by another, if needed.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Third, the catheter and its use should be assessed daily, as the risk of phlebitis and infection increases gradually over time.<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">19–22</span></a> The insertion site should be carefully evaluated. Pain, tenderness, warmth, and/or local erythema are suspicious signs of initial phlebitis/infection that may prompt catheter removal. When the purpose of PVC use is completed, it is strongly recommended to remove it. Catheters in place more than 24<span class="elsevierStyleHsp" style=""></span>h out of use are prone to infection and should be removed.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Fourth, a causal relationship has been established between the time a PVC is in place and the risk of phlebitis.<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">19–22</span></a> For this reason, some authors have advocated for scheduled PVC replacement every 3 or 4 days.<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">20–23</span></a> However, this strategy involves the inconvenience of catheter replacement for both caregivers and patients, and it has not demonstrated a cost-benefit effect. Prospective randomized studies comparing PVC replacement at 72<span class="elsevierStyleHsp" style=""></span>h versus a clinically indicated time point, have not shown differences in outcomes.<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">24–32</span></a> A recent meta-analysis demonstrated that scheduled PVC removal is not supported by current scientific evidence if the catheter site is monitored daily.<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">33</span></a> However, it is not advisable to maintain PVCs in place beyond 5 days, mainly if they are not in use.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Fifth, the catheter should be removed under the following circumstances: end of therapy, clinical signs of phlebitis, suspicion of infection, malfunction, or inappropriate insertion or manipulation. Simple removal is performed with clean single-use gloves, and gauze dressing is applied thereafter. Removal for suspected infection implies sending the catheter tip (2–3<span class="elsevierStyleHsp" style=""></span>cm of the distal end) in a sterile container for microbiologic processing. In this case, sterile gloves and a sterile instrument must be used to cut the catheter, and clinical judgment is needed to obtain two sets of blood cultures to demonstrate CRB.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Sixth, it is mandatory to keep a daily record of the characteristics and conditions of the catheter. This registry should be a basic element of nosocomial bacteremia control in each hospital. Data about the catheter type, date, and anatomic location of insertion, results of daily inspection, removal date, and reason for removal should be included. Electronically supported registries can facilitate data collection and analysis. If catheter incidents are not recorded, we will be unaware of how the catheters are being used and what associated complications arise, which is an obstacle to establishing measures to improve catheter use and reduce nosocomial bacteremia.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Finally, continuous education is the best way to avoid misuse of catheters. Lack of a continuing education program leads to relaxation of the rules and abandonment of good clinical practices. On the other hand, specific, periodic educational programs have proven to be effective for reducing infection rates,<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">34–40</span></a> particularly if education is among peers, such as the staff engaged in catheter management.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0075" class="elsevierStylePara elsevierViewall">PVCs are an important resource for treating patients. However, abuse and misuse of these devices can lead to a considerable increase in treatment-related complications, particularly bacteremia. Responsible use and careful management of PVCs is essential to avoid these events. Obligatory daily recording of the characteristics and conditions of the catheter is the best way to prevent infection, and analysis of these data may provide information to be used by educational programs for continuous training and improvements in catheter use. It may be helpful to establish a checklist for appropriate manipulation of PVCs (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). If the simple rules for proper catheter management are not fulfilled, prompt removal of the device is advised.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Many of these recommendations are strong enough to be applied, but the quality of the available evidence is sometimes weak and based only on clinical experience. The paucity of robust evidence in this regard indicates a need for further research to achieve continuing improvements in PVC management.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflict of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres933383" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec907730" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres933384" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec907731" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "The magnitude of the problem" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "State of the art" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Opportunities to improve" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-03-22" "fechaAceptado" => "2017-04-22" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec907730" "palabras" => array:7 [ 0 => "Catheter-related infection" 1 => "Catheter-related bacteremia" 2 => "Nosocomial infection" 3 => "Prevention" 4 => "Peripheral venous catheter" 5 => "Phlebitis" 6 => "Bloodstream infection" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec907731" "palabras" => array:7 [ 0 => "Infección relacionada con catéteres" 1 => "Bacteriemia por catéter" 2 => "Infección nosocomial" 3 => "Prevención" 4 => "Catéter venoso periférico" 5 => "Flebitis" 6 => "Bacteremia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Catheter-related bacteremia is one of the most important causes of nosocomial infection. Is associated to high rates of morbidity and mortality, including an economic burden. Peripheral venous catheter bacteremia is a leading cause of nosocomial infection in internal medicine departments. In this article, we review some important key points to improve its use and avoid infections.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La bacteriemia relacionada con el uso de catéteres venosos es una de las principales causas de infección nosocomial que se asocia a importante morbilidad, mortalidad e incremento del gasto sanitario. El catéter venoso periférico es una causa importante de bacteriemia nosocomial en los servicios y/o unidades médicas. En este artículo revisamos los aspectos más importantes de su uso que pueden contribuir a prevenir la infección relacionada con estos catéteres periféricos.</p></span>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">PVC, peripheral venous catheter.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="6" align="left" valign="top">Insertion</td><td class="td" title="table-entry " align="left" valign="top">- Correct hand hygiene \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">- Field disinfection \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">- Use single-use clean gloves \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">- Do not touch the insertion site \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">- Do not touch the intravenous segment of the catheter \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">- Sterile dressing (gauze or transparent) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="4" align="left" valign="top">Manipulation</td><td class="td" title="table-entry " align="left" valign="top">- Daily assessment of the need for the PVC \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">- Daily inspection of the insertion site \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">- Daily assessment of the function of the catheter \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">- Adequate replacement of infusion sets \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Daily catheter and events registry \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1577487.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Checklist for an appropriate manipulation of peripheral catheters. 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