Spotlight Case

1. Spotlight Case Peripheral IV in Too Long

2. Source and Credits • This presentation is based on the September 2012AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME credit is available • Commentary by: Chi-Tai Fang, MD, PhD; Associate Professor, National Taiwan University Hospital • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Bradley A. Sharpe, MD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • Appreciate the complications associated with peripheral intravenous (IV) catheters • Describe the optimal sterile technique that should be used in placing peripheral IVs • Describe best practices for day-to-day management of peripheral IVs in the hospital • State how frequently peripheral IVs should be changed in adult patients

4. Case: In Too Long (1) A 75-year-old man with a history of coronary artery disease and congestive heart failure (CHF) was admitted to the hospital with a CHF exacerbation. He was given intravenous (IV) diuretics and improved over the first 4 days in the hospital. At this medical center, there was a standard protocol that called for all peripheral IV catheters to be replaced after 4 days to prevent infection.

5. Case: In Too Long (2) Because of edema in his extremities, placing a new peripheral IV was going to be difficult. The bedside nurse asked the covering physician if the peripheral IV could be extended for an additional day or two. The physician was planning on discharging the patient the next day, so the extension was approved.

6. Background: Peripheral IVs • Peripheral IV catheters are incredibly common in modern hospitals • Peripheral IVs allow reliable and convenient delivery of life-saving medications for hospitalized patients • Peripheral IVs can be associated with multiple complications

7. Complications of Peripheral IVs • Phlebitis (inflammation of the vein) complicates IV therapy in 2.3%−60% of cases in different series • Most cases of phlebitis are noninfectious but can progress to serious soft-tissue infections • Peripheral IV catheter–related bacteremia is rare (0.1% of cases) but can be a serious complication See Notes for references.

8. Replacement of Peripheral IVs • To decrease the risk of catheter-related infections, scheduled replacement of peripheral IV catheters every 48–72 hours or every 72–96 hours has been widely used • However, there is no strong evidence to support this practice • The Centers for Disease Control and Prevention (CDC) recommends against replacing peripheral IV catheters more frequently than every 72–96 hours See Notes for references.

9. Monitoring & Management • The IV catheter site should be inspected daily, either at the time of changing dressing or by palpation through an intact dressing • Erythema, tenderness, or other evidence of local inflammation should prompt removal of the IV catheter • If peripheral IV catheter–related infections do occur, infected catheters should be quickly removed See Notes for references.

10. Case: In Too Long (3) The next day, the patient was worse and required ongoing hospitalization. The peripheral IV was kept in place for 2 more days. On hospital day 6, the patient developed erythema around the IV site. With concerns for infection, the IV was removed and a new peripheral IV was placed. Later that day, the patient developed fever and chills.

11. Case: In Too Long (4) Blood cultures drawn at the time grew methicillin-resistant Staphylococcus aureus (MRSA), most likely secondary to the infected peripheral IV catheter. Subsequently, the patient complained of back pain and a magnetic resonance imaging (MRI) of the spine revealed an epidural abscess, which on aspiration grew MRSA. He required 6 weeks of IV antibiotics for the MRSA bacteremia and epidural abscess. The patient ultimately recovered and was discharged to home.

12. Unfortunate Complication • This patient's unexplained clinical deterioration was likely caused by a peripheral IV catheter infection • Cost for diagnostic tests and treatments for MRSA bacteremia and abscess is likely to be in the hundreds of thousands of dollars • This case therefore highlights the serious costs—both clinical and economic—that can be associated with peripheral IV catheter infections

13. Case: In Too Long (5) In response to this event, the medical center involved developed a strict policy under which peripheral IVs must be changed every 3 days. They can be extended for one additional day with a physician's order but no longer. In addition, the medical center changed some of the nursing documentation to include the date of peripheral IV insertion and a description of the site during each shift.

14. Issues with IV Management • Multiple issues with IV management in this case: • Insertion may have been difficult in the presence of edema • Staff with limited experience may have been unable to maintain good aseptic technique • There was inadequate and delayed recognition of the infection • There may have been an overall lack of expertise in the day-to-day management of IVs and IV sites

15. IV Therapy Teams • One of the most effective ways to prevent peripheral IV complications is through the use of IV therapy teams • IV therapy teams include registered nurses specially trained for inserting IV catheters and inspecting catheter sites • IV teams can significantly reduce complications and prevent infections from peripheral IV catheters See Notes for references.

16. Best Practices for Management (1) • In adults, upper extremities are the preferred site for catheter insertion • Inserting catheters in the lower extremities is an independent risk factor for soft tissue infection • For skin disinfection, 2% chlorhexidine is more effective than 10% povidone-iodine • After placement, the catheter site should be covered by sterile gauze or a sterile semipermeable dressing See Notes for references.

17. Best Practices for Management (2) • Use of a continuous infusion to maintain IV catheter patency is an independent risk factor for microbiologically-proven catheter infection • Intermittent flushing is the preferred method • For IV catheters not used for infusion of blood product or lipid emulsions, the IV administration sets in continuous use, including secondary sets and add-on devices, should be changed no more frequently than every 96 hours, but at least every 7 days See Notes for references.

18. Changing Peripheral IVs (1) • Based on the evidence, extending scheduled catheter replacement from 48−72 hours to 72−96 hours does not significantly increase the risk of true catheter infection • In the absence of well-trained IV teams, replacement only when indicated (e.g., not functioning, evidence of inflammation) carries the risk of delayed recognition of true infection See Notes for references.

19. Changing Peripheral IVs (2) • In the end, replacement of peripheral IV catheters at 72−96 hours or when clinically indicated is the current best practice • This practice should be combined with enhancing expertise in catheter insertion and maintenance, ideally with well-trained IV teams See Notes for references.

20. Take-Home Points Best practices to reduce risk of peripheral IV catheter–related infectious complications: • Use IV therapist teams for peripheral IV catheter insertion and day-to-day management • Place the IV catheter in upper extremities • Use 2% alcoholic chlorhexidine for skin disinfection before the insertion of peripheral IV catheter • Use intermittent flushing to maintain the peripheral IV catheter patency • Replace peripheral IV catheters every 72–96 hours, but not more often (unless specific indications exist), in adult patients