NIHR DC Discover

Intravenous cannuale

NIHR Signal Routine replacement of intravenous cannulae is unnecessary and costly

Published on 28 January 2016

doi: 10.3310/signal-000188

Changing peripheral venous catheters (“cannulae”) according to clinical need is just as safe as doing it routinely every three to four days. Bloodstream infections from either approach were rare, less than about one per 1000 insertions. This Cochrane review found that if the catheter is functioning and there are no signs of inflammation around the point of insertion then replacement is not necessary. This practice is likely to be less painful for patients and cheaper.

This updated review looked for new high quality studies addressing this question and confirmed that catheter replacement by need is a better approach, on the balance of similar safety at reduced costs. A clinical need-based replacement schedule would rely on inspecting the point where the catheter enters the patient’s skin at least once per shift, as recommended in 2014 UK guidance.

Further dissemination of the review’s findings among health care professional networks may provide the reassurance needed for changing practice away from more cautious routine replacement.

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Why was this study needed?

Peripheral venous catheters – also known as intravenous drips or intravenous cannulae – are commonly used in hospital treatment to administer fluids or medication. In light of risks from ongoing placement, such as introducing infection to the bloodstream or irritating the vein, previous guideline recommendations were cautious, in favour of scheduled catheter replacement.

A Cochrane review in 2013 found no evidence that this was safer than changing according to clinical need, but practitioners have been reluctant to abandon the cautious, scheduled approach of former recommendations and these authors looked for any new research on the topic.

Repeatedly placing a tube into a vein is a painful process and changing the catheter according to a time schedule is potentially costly, due to the large number of patients and qualified health professionals involved. Confirming the evidence may provide the reassurance required to change practice.

What did this study do?

This Cochrane review updated the 2013 version by checking for relevant new trials published by March 2015. It included seven randomised controlled trials, covering 4,895 participants. Relevant trials compared routine removal of peripheral venous catheters with replacement when needed, for people receiving continuous or intermittent infusions for at least three days.

The main outcomes were catheter-related bloodstream infection, and inflammation of veins around the catheter. Secondary outcomes included catheter-related problems such as blockages, and costs of the procedures.

Cochrane reviews are carried out to a high standard. The overall quality of the evidence was rated as being high for most of the outcomes, except for catheter related blood stream infection, for which the evidence was moderate. 

What did it find?

  • No new trials were added to the review since the previous Cochrane review in 2013.
  • From five trials, there was no significant difference in frequency of catheter-related bloodstream infection between the groups where replacement was by clinical need 1/2,365 and the routine replacement after 72-96 hours group, 2/2,441 (risk ratio [RR] 0.61, 95% confidence interval [CI] 0.08 to 4.68). The confidence interval was very wide reflecting the small number of adverse events.
  • There was no difference in rates of vein inflammation between the two approaches (replacement by clinical need 186/2,365; changing after 72 hours, 166/2,441; RR 1.14, 95% CI 0.93 to 1.39).
  • From three trials in Australia, overall procedural costs were lower by approximately $AUS 7 (equivalent to £3.40 at January 2016 exchange rates) for catheter replacement by clinical need, compared with changing after 72-96 hours (mean difference -6.96, 95% CI -9.05 to -4.86).
  • There was no significant difference in frequency of catheter related problems (such as blockages) between the two approaches.

What does current guidance say on this issue?

UK guidance from 2014 recommends that peripheral vascular catheters should be re-sited when clinically indicated and not routinely, unless device specific recommendations from the manufacturer state otherwise. Peripheral vascular catheter insertion sites should be inspected at least each shift, as a minimum.

Updated guidance from the Royal College of Nursing on Intravenous therapy is expected in 2016.

What are the implications?

UK guidance published in 2014 is supported by evidence in the previous (2013) and current (2015) versions of this Cochrane review. However, practitioners report that cultural barriers still exist against changing to this practice.

Health care professional organisations may wish to promote the message that it is safe to adopt catheter change based on clinical need, for example using blogs such as Evidently Cochrane or professional TweetChats.

Further UK research on cost saving implications of the change in practice in the UK may also help practitioners change to clinical-need based catheter replacement.

Citation

Webster J, Osborne S, Rickard CM, et al. Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database Syst Rev. 2015;(8):CD007798.

Bibliography

Chapman, S. Getting evidence into nursing practice: replacing the routine. In: Evidently Cochrane [blog]. Cochrane Library; 21 November 2015.

Loveday H, Wilson J, Pratt R, et al. epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. Journal of Hospital Infection. 2014;86:S1-S70.

NICE. Intravenous fluid therapy in adults in hospital. CG174. London: National Institute for Health and Care Excellence; 2013.

RCN. Infusion therapy. London: Royal College of Nursing; 2008. Update due for publication in 2016.

Why was this study needed?

Peripheral venous catheters – also known as intravenous drips or intravenous cannulae – are commonly used in hospital treatment to administer fluids or medication. In light of risks from ongoing placement, such as introducing infection to the bloodstream or irritating the vein, previous guideline recommendations were cautious, in favour of scheduled catheter replacement.

A Cochrane review in 2013 found no evidence that this was safer than changing according to clinical need, but practitioners have been reluctant to abandon the cautious, scheduled approach of former recommendations and these authors looked for any new research on the topic.

Repeatedly placing a tube into a vein is a painful process and changing the catheter according to a time schedule is potentially costly, due to the large number of patients and qualified health professionals involved. Confirming the evidence may provide the reassurance required to change practice.

What did this study do?

This Cochrane review updated the 2013 version by checking for relevant new trials published by March 2015. It included seven randomised controlled trials, covering 4,895 participants. Relevant trials compared routine removal of peripheral venous catheters with replacement when needed, for people receiving continuous or intermittent infusions for at least three days.

The main outcomes were catheter-related bloodstream infection, and inflammation of veins around the catheter. Secondary outcomes included catheter-related problems such as blockages, and costs of the procedures.

Cochrane reviews are carried out to a high standard. The overall quality of the evidence was rated as being high for most of the outcomes, except for catheter related blood stream infection, for which the evidence was moderate. 

What did it find?

  • No new trials were added to the review since the previous Cochrane review in 2013.
  • From five trials, there was no significant difference in frequency of catheter-related bloodstream infection between the groups where replacement was by clinical need 1/2,365 and the routine replacement after 72-96 hours group, 2/2,441 (risk ratio [RR] 0.61, 95% confidence interval [CI] 0.08 to 4.68). The confidence interval was very wide reflecting the small number of adverse events.
  • There was no difference in rates of vein inflammation between the two approaches (replacement by clinical need 186/2,365; changing after 72 hours, 166/2,441; RR 1.14, 95% CI 0.93 to 1.39).
  • From three trials in Australia, overall procedural costs were lower by approximately $AUS 7 (equivalent to £3.40 at January 2016 exchange rates) for catheter replacement by clinical need, compared with changing after 72-96 hours (mean difference -6.96, 95% CI -9.05 to -4.86).
  • There was no significant difference in frequency of catheter related problems (such as blockages) between the two approaches.

What does current guidance say on this issue?

UK guidance from 2014 recommends that peripheral vascular catheters should be re-sited when clinically indicated and not routinely, unless device specific recommendations from the manufacturer state otherwise. Peripheral vascular catheter insertion sites should be inspected at least each shift, as a minimum.

Updated guidance from the Royal College of Nursing on Intravenous therapy is expected in 2016.

What are the implications?

UK guidance published in 2014 is supported by evidence in the previous (2013) and current (2015) versions of this Cochrane review. However, practitioners report that cultural barriers still exist against changing to this practice.

Health care professional organisations may wish to promote the message that it is safe to adopt catheter change based on clinical need, for example using blogs such as Evidently Cochrane or professional TweetChats.

Further UK research on cost saving implications of the change in practice in the UK may also help practitioners change to clinical-need based catheter replacement.

Citation

Webster J, Osborne S, Rickard CM, et al. Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database Syst Rev. 2015;(8):CD007798.

Bibliography

Chapman, S. Getting evidence into nursing practice: replacing the routine. In: Evidently Cochrane [blog]. Cochrane Library; 21 November 2015.

Loveday H, Wilson J, Pratt R, et al. epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. Journal of Hospital Infection. 2014;86:S1-S70.

NICE. Intravenous fluid therapy in adults in hospital. CG174. London: National Institute for Health and Care Excellence; 2013.

RCN. Infusion therapy. London: Royal College of Nursing; 2008. Update due for publication in 2016.

Clinically-indicated replacement versus routine replacement of peripheral venous catheters

Published on 15 August 2015

Webster, J.,Osborne, S.,Rickard, C. M.,New, K.

Cochrane Database Syst Rev Volume 8 , 2015

BACKGROUND: US Centers for Disease Control guidelines recommend replacement of peripheral intravenous (IV) catheters no more frequently than every 72 to 96 hours. Routine replacement is thought to reduce the risk of phlebitis and bloodstream infection. Catheter insertion is an unpleasant experience for patients and replacement may be unnecessary if the catheter remains functional and there are no signs of inflammation. Costs associated with routine replacement may be considerable. This is an update of a review first published in 2010. OBJECTIVES: To assess the effects of removing peripheral IV catheters when clinically indicated compared with removing and re-siting the catheter routinely. SEARCH METHODS: For this update the Cochrane Vascular Trials Search Co-ordinator searched the Cochrane Vascular Specialised Register (March 2015) and CENTRAL (2015, Issue 3). We also searched clinical trials registries (April 2015). SELECTION CRITERIA: Randomised controlled trials that compared routine removal of peripheral IV catheters with removal only when clinically indicated in hospitalised or community dwelling patients receiving continuous or intermittent infusions. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted data. MAIN RESULTS: Seven trials with a total of 4895 patients were included in the review. The quality of the evidence was high for most outcomes but was downgraded to moderate for the outcome catheter-related bloodstream infection (CRBSI). The downgrade was due to wide confidence intervals, which created a high level of uncertainty around the effect estimate. CRBSI was assessed in five trials (4806 patients). There was no significant between group difference in the CRBSI rate (clinically-indicated 1/2365; routine change 2/2441). The risk ratio (RR) was 0.61 (95% CI 0.08 to 4.68; P = 0.64). No difference in phlebitis rates was found whether catheters were changed according to clinical indications or routinely (clinically-indicated 186/2365; 3-day change 166/2441; RR 1.14, 95% CI 0.93 to 1.39). This result was unaffected by whether infusion through the catheter was continuous or intermittent. We also analysed the data by number of device days and again no differences between groups were observed (RR 1.03, 95% CI 0.84 to 1.27; P = 0.75). One trial assessed all-cause bloodstream infection. There was no difference in this outcome between the two groups (clinically-indicated 4/1593 (0.02%); routine change 9/1690 (0.05%); P = 0.21). Cannulation costs were lower by approximately AUD 7.00 in the clinically-indicated group (mean difference (MD) -6.96, 95% CI -9.05 to -4.86; P </= 0.00001). AUTHORS' CONCLUSIONS: The review found no evidence to support changing catheters every 72 to 96 hours. Consequently, healthcare organisations may consider changing to a policy whereby catheters are changed only if clinically indicated. This would provide significant cost savings and would spare patients the unnecessary pain of routine re-sites in the absence of clinical indications. To minimise peripheral catheter-related complications, the insertion site should be inspected at each shift change and the catheter removed if signs of inflammation, infiltration, or blockage are present.

Expert commentary

The findings of this review helpfully support the national evidence-based guidelines for preventing healthcare-associated infections in NHS Hospitals in England which were published in 2014. If peripheral venous cannulae are only to be replaced when clinically indicated it is important that when the insertion site is inspected, a Visual Infusion Phlebitis score is recorded in the patients notes to enable monitoring of this approach. In addition, a peripheral venous catheter should be removed as soon as it has been assessed that it is no longer required.

Carole Fry, Nurse Specialist, Infection Prevention and Control, Public Health England