Duration and failure of short intravenous catheters in a paediatric hospital: a 5-year retrospective analysis

Introduction

One of the most commonly performed medical procedures in hospitalised children is obtaining access to peripheral veins [1]. It is estimated that 80% of patients will require at least one short peripheral catheter (SPC) during hospitalisation [1]. SPCs are used for the administration of fluids, medications, blood components, and sometimes parenteral nutrition. Peripheral intravenous access is also obtained electively prior to surgical procedures requiring anaesthesia and in unstable patients for accessibility in case of the need for emergency intravenous drug administration [2]. Although, from a practical point of view, obtaining intravenous access “just in case” is understandable in some situations, up to 50% of SPCs may never be used [3]. Introducing SPCs for strict clinical indications can reduce the number of patients with difficult intravenous access (DIVA) and reduce complications, which affect 50% of SPCs. Failure to introduce SPCs, as well as to maintain them until the end of intravenous therapy, are challenges that are associated with patient discomfort and the economic burden on the health care system of treating complications [4–6].
Complications associated with SPCs are a major clinical problem in paediatric wards, and they include inflammation and thrombosis of superficial veins, vein rupture, catheter-related bloodstream infection (CRBSI), infiltration and extravasation of drug or fluid irritating or non-irritating surrounding tissues, occlusion, displacement, and accidental removal [6–12]. In part, this is due to the immature anatomy and physiology of the skin [13]. Risk factors in children include a significantly reduced thickness of the skin cell layer compared to adults, smaller vein diameter and delicacy, highly elastic and stretchy subcutaneous tissue, reduced adhesion of the dermis to the epidermis, lack of subcutaneous adipose tissue, and constant patient movement [14, 15].
Obtaining intravenous access and maintaining it causes pain, which can have a significant impact on how long it is maintained [15]. The use of appropriate analgesia prior to venipuncture procedures reduces discomfort associated with the procedure and reduces the risk of stress associated with future cannulation [16]. Well-known methods of procedural pain relief include topical anaesthetics [17]. An important aspect of caring for a patient with an acquired intravenous access is proper protection and care of the catheter exit site, proper handling of the infusion line, and strict adherence to minimising infection, i.e. proper hand hygiene and disinfection of the catheter ports and insertion exit site. The use of a standardised aseptic procedure known internationally as Aseptic Non-Touch Technique (ANTT) is recommended by current guidelines [18, 19].
The incidence of complications in the paediatric population varies from unit to unit. In neonatal intensive care units, local complications occur in up to 97% of SPCs [20–22], and the median catheter dwell time is 23-40 hours [20, 23]. Studies conducted in paediatric wards have shown a lower incidence of complications in about a quarter of SPCs [24, 25], with median catheter viability ranging from 29 to 60 hours [26–28].
The aim of this study was to retrospectively analyse data on the duration of SPCs maintenance and complications leading to their premature removal.

Material and methods

Material

The medical records of 58,639 patients of an urban paediatric hospital (Warsaw, Poland) were retrospectively analysed. A total of 77,214 introduced SPCs were analysed. BD Venflon polytetrafluoroethylene cannulas in sizes 17–26 Ga and lengths 19–45 mm were used. Data synthesis was performed on the basis of 6-month reports on nursing observations of SPCs from 2019 to 2023. Documentation was standardised from monthly reports submitted by wards to the hospital infection control team (HICT). Information included in the monthly reports included the following: the number of patients treated in a given month, the number of SPCs inserted and removed in a given month, the number of SPCs removed after 1, 2, 3, or more than 3 days after insertion, and the reason for removal. Descriptive statistics were used to analyse the results.

Methods

Short peripheral catheters were inserted after obtaining parental and/or child consent according to hospital procedure. Catheters were inserted in the treatment rooms of hospital wards according to local procedure. The procedure was documented in the SPC observation chart, which included the insertion site, catheter size, and how it was secured. SPCs were cared for according to the hospital’s procedure.
Short peripheral catheters were observed every 12-hour work shift. The hospital has an HICT that collects and analyses data on patients with obtained intravenous access. The team is also in charge of detecting CRBSI according to the definitions in the Official Journal of the European Union dated 22 June 2018 [29].

Training

Healthcare providers (HPs) are regularly trained in the proper handling of catheters and infusion care. Training is provided by an epidemiology specialist nurse.

Skin disinfection

To perform skin disinfection before the cannulation procedure, 70% isopropyl alcohol or 2% alcohol-based chlorhexidine (CHG) was used. According to hospital procedure, it was necessary to wait until the preparation was completely dry before starting the procedure. For children under 2 months of age, 70% isopropyl alcohol was used.

Protection of the SPC exit site

Short peripheral catheters were secured with a sterile, flexible, self-adhesive and hypoallergenic Elastopor IV dressing made of hydrophobic nonwoven fabric for breathability. The dressings were changed every 24–48 hours, and in the case of the transparent dressing, every 7 days at most.

Patency and infusion line

Extension sets and negative-pressure needleless connectors (NFCs) were used. Mostly SPCs were secured with a sterile disinfectant cap with 70% alcohol Curos 3M. Alcohol-based 2% CHG was used to disinfect NFCs without disinfectant caps. After each administration of drugs or fluids, the SPC was flushed with 0.9% NaCl.

Assessment of the SPC exit site

The visual infusion phlebitis (VIP) scale was used to evaluate the SPC exit site [30]. If infection of the catheter exit site was suspected, blood was drawn from the peripheral vein and from the SPC. A microbiological swab was also taken from the SPC tip. SPCs were inserted and removed by nurses on the ward. The length of time the SPCs was kept in the veins depended on the onset of clinical signs of complications associated with their presence. During the years analysed, the duration of SPC maintenance changed from removing them after 72 hours to using them for as long as they work and there are no complications.

Results

Summary records managed from 2019 to 2023 were analysed. During the analysed period, 77,214 short intravenous catheters were inserted in 58,639 patients. Table 1 shows the number of SPCs in each period. On average, each patient required more than one catheter during their stay, including 27.18% of patients in whom the SPC was removed after the first day of function (Table 2). 68.76% of SPCs were removed due to the end of intravenous therapy. Complications leading to premature catheter removal occurred in 31.24% of patients. SPC occlusion occurred in 15.49% of patients (Table 3). Suspected local infection with purulent leakage (as many and background scores according to the scale we adopted) was observed in < 1% of cases, but symptoms such as pain, redness, and induration around the SPC exit site were attributed to symptoms of phlebitis or thrombosis, so this result should be approached with caution (Table 3). Suspected phlebitis or thrombosis occurred in 1.81%. Pain occurred in 1.30%, but this complication may be related to the very presence of the catheter without its dysfunction due to its material or an early sign of other recorded complications such as thrombosis, phlebitis, or local infection. The average number of person-days with SPCs was 2.8, while the average number of person-days of stay was 3.3 (Table 4).

Discussion

Indications

Short peripheral catheters are often the primary and most commonly inserted devices used for vascular access during hospitalisation in this hospital. Practically, only the intensive care unit uses either midline catheters (MCs) or central venous catheters (CVCs). Obviously, if a patient is hospitalised for a long time or there is a problem with inserting SPCs, a MC or CVC is inserted. Patients in the wards are hospitalised according to their needs. In surgical wards, such as laryngology or one-day surgery, patients are hospitalised for a short period of time, usually leaving the hospital the next day after the procedure. In the neonatal and infant pathology, paediatric, and intensive care units, stays are longer. The average number of person-days with vascular access was 2.8, while the average number of person-days of stay was 3.3.

Complications

The most common reason for SPC removal was either the end of treatment or patient discharge, accounting for 68.76% (n = 53,095). The incidence of vascular access complications in the present study is lower (31.24%) compared to the overall incidence of complications of 34% in a recently published meta-analysis by Indarwati et al. [30]. This may be due to the length of time the SPC is maintained in the vein. Patients on the wards are hospitalised for a short period of time. The average number of days with vascular access was 2.8, while the average number of person-days of stay was 3.3. Most SPCs were removed after the second and third day after insertion, accounting for 55.26% (n = 58,639). SPCs removed after day 4 after insertion accounted for 17.96% (n = 58,639).
Considering the rates of complications caused by catheter occlusion, this study found rates (15.49%) within the range of values reported in other studies, where occlusion ranged from 1.4 to 39% [31, 32]. According to the study, most SPC patency problems were related to catheter occlusion caused by blood reflux [33]. Other types of occlusion account for only a small percentage and are mainly caused by drugs, lipid deposits, mineral deposits, or mechanical obstructions [33]. According to a study by Dillon et al., catheter occlusion is also influenced by the diameter of the catheter; the smaller the catheter, the faster the occlusion occurs. Catheter diameter was the most significant predictor of increased vascular access dwell time [34].

Infiltration and extravasation

Infiltration was the second most common complication, with an incidence of 11.92% (n = 9207) in our study. Infiltration is defined as the unintentional leakage of fluids and/or drugs into the surrounding tissue [31]. These injuries can cause pain, inflammation, tendon or nerve damage, and predispose to local and invasive infections, ulceration, and tissue necrosis [32]. The incidence of infiltration found in publications ranges from 6% to 87%, and the incidence of extravasation ranges from 2% to 77% [35]. Solutions such as antibiotics or irritating fluids with higher osmolality have been implicated in SPC failure. High concentrations of irritating fluids and drugs can increase plasma osmotic pressure and cause fluid to shift from the vascular endothelial cells to the extracellular space causing extravasation and vascular stiffness [30].
Another reason for infiltration in patients is insufficient stabilisation or securing. This leads to poor fixation of SPCs to the skin, allowing the catheter to move in and out of the vein or around and within it, resulting in partial or complete displacement. Poorly stabilised SPCs in the vein can kink or damage the vessel wall, initiating the release of thromboplastic substances and platelets that cause blood clotting [36]. This process can cause stenosis or obstruction of the catheterised vein, which then forces intravenous fluid backflow and potential fluid leakage from the site of SPC insertion or its infiltration/extravasation into surrounding tissues, limiting future venous access in the limb [37]. In the literature, the incidence of displacement of SPCs ranges from 6% to 20% [38]. In addition, additional fixation elements and bandages securing the device make it more difficult to identify the early stages of complications and thus to prematurely discontinue therapy and treatment to minimise complications [35, 39]. Fasteners and bandages are needed for securing so that young children do not damage or remove the vascular access. In older and calmer children, transparent veneers and fixation patches can be used. If a child is uncooperative and a SPC is needed, HPs must further protect the child from accidental removal of the cannula. Accidental cannula removal was 1.63% (n = 1255). Incorporating training on the signs and assessment of infiltration or extravasation and steps to treat it should be an important part of every department’s educational plan. To assess infiltration or extravasation, one can use the Paediatric PIV Infiltration Scale, which aims to organise and categorise individual issues so that the impact of subjective HP evaluation is less [40]. Inflammation of the vein wall can cause discomfort and tissue damage. In our study, the incidence was 1.81%, which is consistent with other reports [41]. According to Arias-Fernández et al. [42], evaluation of phlebitis is difficult because the consensus on diagnosis is unclear. In addition, the lack of consensus on measuring phlebitis has probably contributed to the discrepancy in the reported prevalence of phlebitis [43]. A scale can be used to help assess phlebitis, as well as daily observation and noting the assessment in SPC care charts.
Pain was reported in 1.30% (n = 1002) of cases. Accurate assessment of pain in infants is difficult because the child is not yet able to communicate, and assessment relys on observation. Therefore, careful observation by both HPs and parents is important. Scales for assessing pain should be selected according to the age of the child.
CBRSI accounted for 0.007% or 0.02 per 1000 days of SPC maintenance, which was a lower rate of infection compared to the 0.1% or 0.5 per 1000 days of vascular access maintenance reported in the literature [44]. Another 7-year study from 2017 indicates 0.106 per 1000 days of vascular access maintenance in the adult population [45]. Early detection of signs and symptoms is key to reducing the risk of complications and the use of vascular accesses.

Conclusions

In order to increase the quality of care and prevent the occurrence of phlebitis and extravasation, HPs should analyse patient characteristics, prescribed intravenous medications, expected duration of intravenous treatment, and risk factors for these complications before selecting an intravenous catheter. When observing intravenous access, use assessment tools to detect complications in a timely manner. HPs should have a list of drugs classified as irritants so they can more closely monitor patients receiving fluid infusions containing these drugs.

Limitations

This study was based on a retrospective review of epidemiological reports that are provided to the HICT once a month. Reports were only in aggregate form, which made it impossible to identify patients. Complications were recorded inconsistently depending on the HPs who differentiated the complications. The analysis had limitations because it did not take into account the experience of HPs with IV insertion techniques, and it did not report which patients received solutions characterised as potentially irritating. The year 2020 differs from the other years because the hospital treated children mainly for COVID-19 when scheduled surgeries, procedures, and diagnostics were not performed.

Disclosure

1. Institutional review board statement: Not applicable.
2. Assistance with the article: None.
3. Financial support and sponsorship: None.
4. Conflicts of interest: None.

References