Clinically indicated and routine replacement of peripheral intravenous catheters did not differ for catheter failure
Ms J Webster, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia;
In hospital inpatients, is clinically indicated replacement of peripheral intravenous (IV) catheters better than routine replacement for catheter failure due to phlebitis or infiltration?
randomised controlled trial (RCT).
up to 5 consecutive catheters for each patient.
general tertiary hospital in Queensland, Australia.
755 medical and surgical inpatients ⩾18 years of age (mean age 59 y, 64% men) who were expected to have a peripheral venous catheter for ⩾4 days. Exclusion criteria were bacteraemia or current immunosuppressive therapy.
379 patients were allocated to catheter replacement only when clinically indicated and 376 to routine catheter replacement every 3 days.
composite of catheter failure because of phlebitis (⩾2 of pain, tenderness, warmth, erythema, swelling, or a palpable cord) or infiltration (swelling of tissue at catheter site because of permeation of IV fluid into the interstitial compartment), and other reasons for catheter failure.
100% (intention-to-treat analysis).
Clinically indicated and routine catheter replacement did not differ for patients who had catheter failure (table) or catheter failure due to phlebitis or infiltration per 1000 device days (60 v 61).
In hospital inpatients, replacing peripheral intravenous catheters only when clinically indicated did not reduce catheter failure more than routine catheter replacement.
*Information provided by author.
Webster J, Clarke S, Paterson D, et al. Routine care of peripheral intravenous catheters versus clinically indicated replacement: randomised controlled trial. BMJ 2008;337:a339.
Clinical impact ratings: General/internal medicine 6/7; Intravenous/infusion 6/7; General surgery 7/7
Source of funding: Queensland Nursing Council and RBWH Research Foundation.
The insertion and maintenance of peripheral IV catheters in hospital inpatients is common, costly, and labour intensive. The study by Webster et al was done in a tertiary general hospital in Australia and included adult patients from Australia as well as neighbouring countries in the south west Pacific. These factors preclude generalisation of the results to paediatrics or critical care and may raise some questions about applicability in district-level hospitals.
This RCT challenged the standard of the US Centers for Disease Control and Prevention of replacing peripheral IV catheters every 72–96 hours.1 Primary outcome measures were limited to phlebitis or infiltration. The results of the trial, which are relevant to nursing and medical practitioners, procurement managers, hospital and community managers, and budget holders, concur with previous studies2 that found no difference between routine and clinically indicated catheter changes, making it a valuable addition to the body of clinical knowledge.
The pragmatic nature of the trial and inclusion of both surgical and medical patients increase the generalisability of the results. However, it was designed as a superiority trial and would have been underpowered to determine equivalence or non-inferiority of treatments. Therefore, stating that replacing catheters as required has no effect on catheter failure is not justified; this assumes an equivalence or non-inferiority design.
Generally, changing to a non-routine approach would rely on the vigilance and knowledge of nursing practitioners to identify the optimal point at which catheters should be changed, particularly in the absence of specialist IV teams. Advantages of changing practice could include reduced risk and pain for patients, less nursing or medical time spent changing catheters unnecessarily, and substantial reductions in costs. However, the study by Webster et al does not provide convincing evidence, and a larger equivalence or non-inferiority trial is needed to confirm the findings.