Replacing peripheral venous catheters: have you ditched the routine?

In this first evidence blog in our new series Evidence for Everyday Nursing, I’ve looked at a Cochrane review which found no evidence to support routinely replacing peripheral venous catheters. This was then discussed in a #WeNurses tweetchat, summarised in the blog Getting evidence into nursing practice: replacing the routine.

Editors’ note 11 August 2022: these two related blogs from 2015 have been kept as an example of how evidence can lead to changes in practice, but also that practice change and adherence to guidelines  doesn’t happen seamlessly or all at once. The Cochrane Review was updated again in January 2019 with the addition of two studies and no change to conclusions. 

Routine can be a dangerous thing. It might be a very good thing to do something routinely, of course, but practices that are so entrenched that no-one questions them might not be the best thing at all.

What do you do when it comes to managing peripheral venous catheters (PVCs)? Change them routinely or only when there are clinical signs that this is necessary, such as blockage, pain, redness, infiltration, swelling, leaking or phlebitis?

IV insertion
National guidelines used Cochrane evidence in recommending that peripheral venous catheters are replaced when clinically indicated

The UK’s epic3 National Evidence Based Guidelines recommend that short peripheral catheters should be replaced when clinically indicated, unless the patient is receiving parenteral nutrition peripherally. These guidelines cite the previous version of a Cochrane review, which has recently been updated. There were no new studies to add in 2015.*

The Cochrane Review Clinically‐indicated replacement versus routine replacement of peripheral venous catheters (updated January 2019) brings together the best available evidence from randomized controlled trials (RCTs) comparing routine replacement of PVCs with re-siting them only when clinically indicated. The reviewers were interested in four main outcomes: catheter-related bloodstream infection; phlebitis; all-cause bloodstream infection; and cost. In 2015 they were able to include seven RCTs with 4895 patients in both acute and community settings (for the 2019 update, nine studies with 7412 people).  Routine replacement was done at between 72 and 96 hours in five trials and every 48 hours in two.

Here’s what they found:

  • No difference in catheter-related bloodstream infection (which was between 0.0% and 0.3%)
  • No difference in phlebitis rates (and this was the same whether infusions were continuous or intermittent)
  • No difference between groups when analysed by the number of device days
  • No difference in all-cause bloodstream infection (assessed in one trial)
  • Lower cannulation costs in the clinically-indicated replacement group

How reliable is the evidence?

For the outcomes all cause bloodstream infection and phlebitis the evidence was assessed as moderate quality and for catheter-related bloodstream infection low quality (this has been changed to reflect the latest version of the review, in January 2019).

How much money could this save the NHS?

It has been calculated that if the clinically-indicated strategy was fully implemented in all NHS hospitals in England, the cost savings would be around £40 million over five years (Tuffaha et al, 2014;NICE, 2016)

What about catheter blockage?

Catheter failure due to blockage was more frequent in the clinically-indicated group, as would be expected – all of them fail eventually, but many last the length of treatment. The reviewers point out that this outcome isn’t clinically meaningful; it just indicates that they were in place for longer in the clinically-indicated group. As the ‘treatment’ for a blocked catheter is to replace it, taking it out earlier wouldn’t reduce the need for replacement!

What was missing?

The review team planned to compare ‘the number of catheter re-sites per patient’, ‘pain’ and ‘satisfaction’, but these were not reported in the included studies (one small study added in 2019 reported on pain and found there may be no difference between groups). Five of the studies were conducted in Australia, one in the UK and one in India (the studies added in the 2019 update of the review were conducted in Brazil and China). The reviewers, though noting that the patients were ‘representative of those usually managed in healthcare,’ said it would be useful to see similar studies from other healthcare systems.

What does this mean for your practice?

The review found no evidence to support routinely changing PVCs. I guest-hosted a #WeNurses tweetchat on  17 November to discuss the evidence and practice. Find out more on the €WeNurses chat archive here and in my blog about the chat here.

Images may not be reproduced as they have been purchased from stock.com for Evidently Cochrane

References may be found here

 

 

 

 

 

 

 



Replacing peripheral venous catheters: have you ditched the routine? by Sarah Chapman

is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International

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