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Eighty percent of hospitalized patients receive an intravenous cannula, which is a routine clinical procedure performed in hospitals that is essential to deliver medications and fluids for therapeutic purposes.
As an under-evaluated area in the realm of health care-associated infections, the call for more effective prophylaxis strategies is urgent. The purpose of this Commentary is to provide insights and revisit current strategies in the prevention of phlebitis.
Firstly, we present a simple and innovative solution of splinting. Splinting of the joints with intravenous cannulation is a firmly established practice in pediatric patients and decreases the risk of phlebitis.
To illustrate the role of splinting in the prevention of phlebitis in adults, we conducted a preliminary study. With wrist flexion and extension, a volunteer study noted a 6.7-mm excursion despite fixation by a transparent dressing. The trauma caused to the veins is evidenced by the horizontal pistoning of the intravenous catheter at the wrist joint, which is illustrated in Figure 1. Given that patients with a cannula at the wrist are subjected to repeated wrist flexion and extension, it is considered that this continual excursion must predispose to infection. Figure 2 shows an example of a wrist splint.
While splinting demonstrates great potential in the prophylaxis of phlebitis, it has yet to be established in current clinical practice guidelines on phlebitis prevention in adults by the Centers for Disease Control and Prevention.
Implementing new changes will require hospitals to amend their protocols, as well as education and collaborative efforts by physicians, nurses, and administrators.
Secondly, we challenge the standard practice of changing intravenous cannula routinely as a preventive strategy for phlebitis. According to the Centers for Disease Control and Prevention, it is recommended to change the catheter site every 72 to 96 hours.
However, whether catheters should be replaced based on clinical indications remains unresolved. This is despite increasing convincing evidence that clinically indicated catheter replacement may not increase the risk of phlebitis compared with routine replacement of catheters.
In a multicentered, nonblinded randomized equivalence trial, the incidence of phlebitis was 7% in both the routine group, whereby catheters were replaced every 72 to 96 hours, and also the clinically indicated group, whereby catheters were replaced in the event of phlebitis, infiltration, occlusion, accidental removal, or suspected infection related to the catheter.
It can increase patient satisfaction and decrease equipment requirements and staff time by 40%. It is projected to result in $203,380.80 in annual savings. This is similarly demonstrated in a cost-effectiveness analysis performed alongside a randomized controlled trial.
Given that there are no significant differences between clinically indicated, as compared with routine, replacement of catheters, it would be recommended to modify current guidelines for catheters to be changed when clinically indicated.
The implementation of this change is predicated on the basis that the clinical manifestations of phlebitis can be recognized in a standardized manner. However, change may be difficult in view of the fact that current assessment tools for phlebitis are highly observer dependent according to a systematic review.
In summary, the provision of effective prevention strategies is a barrier to minimizing the occurrence of this nosocomial infection. The stepping stone to the implementation of the prevention strategies would be changing the hospital protocols, and effectiveness can be achieved only with collaborative effort involving all rungs of the health care system. Priorities for future research may include the elucidation of the role of splinting or the optimal duration for catheter change to provide for more compelling evidence upon which effective prophylaxis and management should be based.
For prevention and treatment of infusion phlebitis.