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Clinically‐indicated replacement versus routine replacement of peripheral venous catheters

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References

References to studies included in this review

Barker 2004 {published and unpublished data}

Barker P, Anderson ADG, Macfie J. Randomised clinical trial of elective re‐siting of intravenous cannulae. Annals of the Royal College of Surgeons of England 2004;86(4):281‐3.

Nishanth 2009 {published data only}

Nishanth S, Sivaram G,  Kalayarasan R, Kate V, Ananthakrishnan N. Does elective re‐siting of intravenous cannulae decrease peripheral thrombophlebitis? A randomized controlled study. The International Medical Journal of India 2009;22(2):60‐2.

Rickard 2010 {published and unpublished data}

Rickard CM, McCann D, Munnings J, McGrail M. Routine resite of peripheral intravenous devices every 3 days did not reduce complications compared with clinically indicated resite: a randomised controlled trial. BMC Medicine 2010;8:53.

Rickard 2012 {published and unpublished data}

Rickard CM. Clinically indicated and routine replacement of peripheral IV catheters did not differ for phlebitis. Annals of Internal Medicine 2013;158:JC8. Ref ID:81.
Rickard CM, Webster J, Wallis MC, Marsh N, McGrail MR, French V, et al. Routine versus clinically indicated replacement of peripheral intravenous catheters: A randomised equivalence trial. Lancet 2012;380(9847):1066‐74.
Tuffaha HW, Rickard CM, Webster J, Marsh N, Gordon L, Wallis M, et al. Cost‐effectiveness analysis of clinically indicated versus routine replacement of peripheral intravenous catheters. Applied Economics and Health Policy 2014;12:51‐8.

Van Donk 2009 {published and unpublished data}

Van Donk P, Rickard CM, McGrail MR, Doolan G. Routine replacement versus clinical monitoring of peripheral intravenous catheters in a regional hospital in the home program: A randomized controlled trial. Infection Control and Hospital Epidemiology 2009;30(9):915‐7.

Webster 2007 {published and unpublished data}

Webster J, Lloyd S, Hopkins T, Osborne S, Yaxley M. Developing a research base for intravenous peripheral cannula re‐sites (DRIP trial). A randomised controlled trial of hospital in‐patients. International Journal of Nursing Studies 2007;44(5):664‐71.

Webster 2008 {published and unpublished data}

Webster J, Clarke S, Paterson D, Hutton A, van Dyke S, Gale C, et al. Routine care of peripheral intravenous catheters versus clinically indicated replacement: randomised controlled trial. BMJ 2008;337:a339.

References to studies excluded from this review

Arnold 1977 {published data only}

Arnold RE, Elliot EK, Holmes BH. The importance of frequent examination of infusion sites in preventing postinfusion phlebitis. Surgery, Gynecology and Obstetrics 1977;145(1):19‐20.

Cobb 1992 {published data only}

Cobb DK, High KP, Sawyer RG, Sable CA, Adams RB, Lindley DA, et al. A controlled trial of scheduled replacement of central venous and pulmonary‐artery catheters. The New England Journal of Medicine 1992;327(15):1062‐8.

Eyer 1990 {published data only}

Eyer S, Brummitt C, Crossley K, Siegel R, Cerra F. Catheter‐related sepsis: prospective, randomized study of three methods of long‐term catheter maintenance. Critical Care Medicine 1990;18(10):1073‐9.

Haddad 2006 {published data only}

Haddad FG, Waked CH, Zein EF. Peripheral venous catheter inflammation. A randomized prospective trial. Le Journal Médical Libanais 2006;54:139‐45.

Kerin 1991 {published data only}

Kerin MJ, Pickford IR, Jaeger H, Couse NF, Mitchell CJ, Macfie J. A prospective and randomised study comparing the incidence of infusion phlebitis during continuous and cyclic peripheral parenteral nutrition. Clinical Nutrition 1991;10(6):315‐9.

May 1996 {published data only}

May J, Murchan P, MacFie J, Sedman P, Donat P, Palmer D, et al. Prospective study of the aetiology of infusion phlebitis and line failure during peripheral parenteral nutrition. British Journal of Surgery 1996;83(8):1091‐4.

Nakae 2010 {published data only}

Nakae H, Igarashi T, Tajimi K. Catheter‐related infections via temporary vascular access catheters: a randomized prospective study. Artificial Organs 2010;34(3):E72‐6.

Panadero 2002 {published data only}

Panadero A, Iohom G, Taj J, Mackay N, Shorten G. A dedicated intravenous cannula for postoperative use. Effect on incidence and severity of phlebitis. Anaesthesia 2002;57(9):921‐5.

Rijnders 2004 {published data only}

Rijnders BJ, Peetermans WE, Verwaest C, Wilmer A, Van Wijngaerden E. Watchful waiting versus immediate catheter removal in ICU patients with suspected catheter‐related infection: a randomized trial. Intensive Care Medicine 2004;30(6):1073‐80.

Band 1980

Band JD, Maki DG. Steel needles used for intravenous therapy. Morbidity in patients with hematologic malignancy. Archives of Internal Medicine 1980;140(1):31‐4.

Bregenzer 1998

Bregenzer T, Conen D, Sakmann P, Widmer AF. Is routine replacement of peripheral intravenous catheters necessary?. Archives of Internal Medicine 1998;158:51‐6.

Catney 2001

Catney MR, Hillis S, Wakefield B, Simpson L, Domino L, Keller S, et al. Relationship between peripheral intravenous catheter dwell time and the development of phlebitis and infiltration. Journal of Infusion Nursing 2001;24(5):332‐41.

Cornely 2002

Cornely OA, Bethe U, Pauls R, Waldschmidt D. Peripheral Teflon catheters: factors determining incidence of phlebitis and duration of cannulation. Infection Control and Hospital Epidemiology 2002;23:249‐53.

Everitt 1997

Everitt NJ, Krupowicz DW, Evans JA, McMahon MJ. Ultrasonographic investigation of the pathogenesis of infusion thrombophlebitis. British Journal of Surgery 1997;84:642‐5.

Gupta 2007

Gupta A Mehta Y, Juneja R, Trehan N. The effect of cannula material on the incidence of peripheral venous thrombophlebitis. Anaesthesia 2007;62:1139‐42.

Hadaway 2012

Hadaway. Short peripheral intravenous catheters and infections. Journal of Infusion Nursing 2012;35:230‐40.

Higgins 2003

Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistencies in meta‐analysis. BMJ 2003;327(7414):557‐60.

Higgins 2008

Higgins JPT, Deeks JJ. Selecting studies and collecting data. In: Higgins JPT, Green S editor(s). Cochrane Handbook for Systematic Reviews of Interventions. Wiley‐Blackwell, 2008.

Higgins 2011a

Higgins JPT, Altman DG, and Sterne JAC on behalf of the Cochrane Statistical Methods Group and the Cochrane Bias Methods Group. Chapter 8: Assessing risk of bias in included studies. In: Higgins JPT, Green S, editor(s). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane‐handbook.org.

Ho 2011

Ho KHM, Cheung DSK. Guidelines on timing in replacing peripheral intravenous catheters. Journal of Clinical Nursing 2011;21(11‐12):1499‐506.

Homer 1998

Homer LD, Holmes KR. Risks associated with 72‐ and 96‐hour peripheral intravenous catheter dwell times. Journal of Intravenous Nursing 1998;21:301‐5.

Infusion Nurses Society 2011

Infusion Nurses Society. Infusion Nursing Standards of Practice. Journal of Infusion Nursing 2011;34(1S):S57.

Lai 1998

Lai KK. Safety of prolonging peripheral cannula and i.v. tubing use from 72 hours to 96 hours. American Journal of Infection Control 1998;26:66‐70.

Loveday 2014

Loveday HP, Wilson JA, Pratt RJ, Golsorkhi M, Tingle A, Bak A, et al. epic3: National Evidence‐based guidelines for preventing healthcare‐associated infections. Journal of Hospital Infection 2014;86 Suppl 1:S1‐70.

Maddox 1977

Maddox RR, Rush DR, Rapp RP, Foster TS, Mazella V, McKean HE. Double‐blind study to investigate methods to prevent cephalothin‐induced phlebitis. American Journal of Hospital Pharmacy 1977;34:29‐34.

Maki 1973

Maki DG, Goldman DA, Rhame FS. Infection control in intravenous therapy. Annals of Internal Medicine 1973;79(6):867‐87.

Maki 1991

Maki DG, Ringer M. Risk factors for infusion‐related phlebitis with small peripheral venous catheters. A randomized controlled trial. Annals of Internal Medicine 1991;114:845‐54.

Maki 2006

Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clinic Proceedings 2006;81(9):1159‐71.

Maki 2008

Maki DG. Improving the safety of peripheral intravenous catheters. BMJ 2008;337(7662):122‐3.

Malyon 2014

Malyon L, Ullman AJ, Phillips N, Young J, Kleidon T, Murfield J, et al. Peripheral intravenous catheter duration and failure in paediatric acute care: a prospective cohort study. Emergency Medicine Australasia 2014;26:602‐8.

Monreal 1999

Monreal M, Quilez F, Rey‐Joly C, Vega J, Torres T, Valero P, et al. Infusion phlebitis in patients with acute pneumonia: a prospective study. Chest 1999;115:1576‐80.

O'Grady 2011

O'Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, et al. 2011 Guidelines for the prevention of intravascular catheter‐related infections. http://www.cdc.gov/hicpac/bsi/bsi‐guidelines‐2011.html.

Ray‐Barruel 2014

Ray‐Barruel G, Polit DF, Murfield JE, Rickard CM. Infusion phlebitis assessment measures: a systematic review. Journal of Evaluation in Clinical Practice 2014;20:191‐202.

Schűnemann 2011

Schűnemann HJ, Oxman AD, Vist GE, Higgins JPT, Deeks JJ, Glasziuo P, et al. Chapter 12: Interpreting results and drawing conclusions. In: Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). Available from www.cochrane‐handbook.org.

Tager 1983

Tager IB, Ginsberg MB, Ellis SE, Walsh NE, Dupont I, Simchen E, et al. The Rhode Island Nosocomial Infection Consortium. An epidemiologic study of the risks associated with peripheral intravenous catheters. American Journal of Epidemiology 1983;118(6):839‐51.

Tuffaha 2014

Tuffaha HW, Rickard CM, Webster J, Marsh N, Gordon L, Wallis M, et al. Cost‐effectiveness analysis of clinically indicated versus routine replacement of peripheral intravenous catheters. Applied Economics and Health Policy 2014;12:51‐8.

Tuffaha 2014a

Tuffaha HW, Rickard CM, Inwood S, Gordon L, Scuffham P. The epic3 recommendation that clinically indicated replacement of peripheral venous catheters is safe and cost‐saving: How much would the NHS save?. Journal of Hospital Infection 2014;87(3):183‐4.

Uslusoy 2008

Uslusoy E, Mete S. Predisposing factors to phlebitis in patients with peripheral intravenous catheters: a descriptive study. Journal of the American Academy of Nurse Practitioners 2008;20:172‐80.

White 2001

White SA. Peripheral intravenous therapy‐related phlebitis rates in an adult population. Journal of Intravenous Nursing 2001;24:19‐24.

References to other published versions of this review

Webster 2009

Webster J, Osborne S, Hall J, Rickard C. Clinically indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database of Systematic Reviews 2009, Issue 2. [DOI: 10.1002/14651858.CD007798]

Webster 2010

Webster J, Osborne S, Rickard C, Hall J. Clinically‐indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database of Systematic Reviews 2010, Issue 3. [DOI: 10.1002/14651858.CD007798.pub2]

Webster 2013

Webster J, Osborne S, Rickard CM, New K. Clinically‐indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database of Systematic Reviews 2013, Issue 4. [DOI: 10.1002/14651858.CD007798.pub3]

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Jump to:

Barker 2004

Methods

Study design: Single‐centre RCT.

Method of randomisation: Computer generated.

Concealment of allocation: Sealed envelopes.

Participants

Country: England.

Number: 47 patients in general medical or surgical wards. Clinically indicated: 43 catheters were inserted in 26 patients. Routine replacement: 41 catheters were inserted in 21 patients.

Age: Clinically indicated 60.5 yrs (15.5); routine replacement 62.7 yrs (18.2).

Sex (M/F): Clinically indicated 15/11; routine replacement 14/7.

Inclusion criteria: Hospital inpatients receiving crystalloids and drugs.

Exclusion criteria: Not stated.

Interventions

Clinically indicated: Catheters were removed if the site became painful, the catheter dislodged or there were signs of PVT.

Routine replacement: Catheters were replaced every 48 hours.

Outcomes

Primary: Incidence of PVT defined as "the development of two or more of the following: pain, erythema, swelling, excessive warmth or a palpable venous cord".

Notes

PVT was defined as "the development of two or more of the following: pain, erythema, swelling, excessive warmth or a palpable venous cord". However, in the discussion, the author stated that "even a small area of erythema was recorded as phlebitis" (i.e., only one sign).

It is unclear what proportion of patients were on continuous infusion.

Catheters were inserted "at the instruction of the principal investigator".

"All patients were reviewed daily by the principal investigator, and examined for signs of PVT at the current and all previous infusion sites".

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Comment: Computer generated (personal communication with author).

Allocation concealment (selection bias)

Low risk

Comment: Sealed envelopes (personal communication with author).

Blinding (performance bias and detection bias)
All outcomes

High risk

Comment: Neither study personnel nor participants were blinded.

Incomplete outcome data (attrition bias)
All outcomes

High risk

Comment: In this small sample, there were five fewer patients in the routine replacement group. No explanation was provided for the unequal sample size. No dropouts or loss to follow up were reported.

Selective reporting (reporting bias)

Low risk

Comment: Phlebitis was the only outcome planned.

Other bias

High risk

Comment: The chief investigator allocated patients and was responsible for outcome evaluation.

No sample size calculation.

Nishanth 2009

Methods

Study design: Single‐centre RCT.

Method of randomisation: Not stated

Concealment of allocation: Sequentially numbered sealed envelopes.

Participants

Country: India.

Number: 42 patients in surgical wards. Clinically indicated: 21. Routine replacement: 21.

Age: Clinically indicated 40.2 yrs (15.0); routine replacement 42.9 yrs (15.0).

Sex (M/F): Clinically indicated 17/4; routine replacement 16/5.

Inclusion criteria: Hospital inpatients admitted for major abdominal surgery

Exclusion criteria: Receiving total parenteral nutrition, duration of therapy expected to be < three days, if a cannula was already in situ, terminally ill patients.

Interventions

Clinically indicated: Catheters were removed if the site became painful, the catheter dislodged or there were signs of PVT.

Routine replacement: Catheters were replaced every 48 hours.

Outcomes

Primary: Incidence of PVT defined as "the development of two or more of the following: pain, erythema, swelling, excessive warmth or a palpable venous cord".

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Not stated.

Allocation concealment (selection bias)

Low risk

Quote "group name was placed (on) an opaque serially numbered sealed envelope (SNOSE)."

Comment: Presumably the authors meant 'in' an opaque serially numbered sealed envelope ‐ based on subsequent information.

Blinding (performance bias and detection bias)
All outcomes

High risk

Evidence for participants: Quote "unblinded study".

 

Evidence for personnel: As above.

 

Evidence for outcomes: As above.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Comment: Data for all patients were available.

Selective reporting (reporting bias)

Low risk

Comment: Stated outcomes were reported but original protocol not sighted.

Other bias

Unclear risk

Extreme results: In this small trial, 100% of participants in the clinically indicated group developed phlebitis compared with 9% in the 2‐day change group, which suggests that chance or other unknown bias affected results.

Rickard 2010

Methods

Study design: Single‐centre RCT.

Method of randomisation: Computer generated.

Concealment of allocation: Telephone service.

Participants

Country: Australia.

Number: 362 patients requiring IV therapy in general medical or surgical wards. Clinically indicated: 280 catheters were inserted in 185 patients. Routine replacement: 323 catheters were inserted in 177 patients.

Age: Clinically indicated 62.7 yrs (15.5); routine replacement 65.1 yrs (17.3).

Sex (M/F): Clinically indicated 82/103; routine replacement 81/91.

Inclusion criteria: Patients in over 18 years, expected to have a peripheral intravenous device (IVD), requiring IV therapy for at least 4 days.

Exclusion criteria: Patients who were immunosuppressed, had an existing bloodstream infection or those in whom an IVD had been in place for > 48 hours.

Interventions

Clinically indicated: Catheters were removed if there were signs of phlebitis, local infection, bacteraemia, infiltration or blockage.

Routine replacement: Catheters were replaced every 72 ‐ 96 hours.

Outcomes

Primary: Phlebitis per person and per 1000 IVD days (defined as two or more of the following: pain, erythema, purulence, infiltration, palpable venous cord). IVD‐related bacteraemia.

Secondary: Hours of catheterisation; number of IV devices; device‐related bloodstream infection; infiltration; local infection.

Notes

Approximately 75% of patients were receiving a continuous infusion.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Comment: Computer generated.

Allocation concealment (selection bias)

Low risk

Quote "assignment was concealed until randomisation by use of a telephone service".

Blinding (performance bias and detection bias)
All outcomes

High risk

Comment: Neither study personnel nor participants were blinded.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Comment: Results from all enrolled patients were reported.

Selective reporting (reporting bias)

Low risk

Comment: The protocol was available. All nominated outcomes were reported.

Other bias

Unclear risk

Comment: Significantly more patients in the routine change group received IV antibiotics (73.1% versus 62.9%).

Rickard 2012

Methods

Study design: Multi‐centre RCT.

Method of randomisation: Computer generated, stratified by site.

Concealment of allocation: Allocation concealed until eligibility criteria was entered into a hand‐held computer.

Participants

Country: Australia.

Number: 3283 patients requiring IV therapy in general medical or surgical wards. Clinically indicated: 1593 patients. Routine replacement: 1690 patients.

Age: Clinically indicated 55.1 yrs (18.6); routine replacement 55.0 yrs (18.4).

Sex (M/F): Clinically indicated 1022/571; routine replacement 1034/656.

Inclusion criteria: Patients, or their representative able to provide written consent; over 18 years, expected to have a peripheral intravenous device (IVD) in situ, requiring IV therapy for at least 4 days.

Exclusion criteria: Patients who were immunosuppressed, had an existing blood stream infection or those in whom an IVD had been in place for > 48 hours or it was planned for the catheter to be removed < 24 hours.

Interventions

Clinically indicated: Catheters were removed if there were signs of phlebitis, local infection, bacteraemia, infiltration or blockage.

Routine replacement: Catheters were replaced every 72 ‐ 96 hours.

Outcomes

Primary: Phlebitis during catheterisation or within 48 hrs of removal (defined as two or more of the following: pain, erythema, swelling, purulent discharge, palpable venous cord).

Secondary: Catheter‐related bloodstream infection, all‐cause bloodstream infection, local venous infection, colonisation of the catheter tip, infusion failure, number of catheters per patient, overall duration of intravenous therapy, cost, mortality.

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "Random allocations were computer‐generated".

Allocation concealment (selection bias)

Low risk

Quote: "Random allocations were computer‐generated on a hand‐held device, at the point of each patient's entry, and thus were concealed to patients, clinical staff and research staff until this time".

Blinding (performance bias and detection bias)
All outcomes

High risk

Evidence for participants: Quote "Patients and clinical staff could not be blinded".

 

Evidence for personnel: Quote "Research nurses were similarly not masked".

 

Evidence for outcomes: Quote "... laboratory staff were masked for rating of all microbiological end‐points, and a masked, independent medical rater diagnosed catheter‐related infections and all bloodstream infections".

Incomplete outcome data (attrition bias)
All outcomes

Low risk

ITT analysis reported.

Selective reporting (reporting bias)

Low risk

The protocol was available and all pre‐defined outcomes were reported.

Other bias

Low risk

No other known risks of bias.

Van Donk 2009

Methods

Study design: RCT.

Method of randomisation: Computer generated.

Concealment of allocation: Sealed envelopes.

Participants

Country: Australia.

Number: 200. Clinically indicated: 105 patients. Routine replacement: 95 patients.

Age: Clinically indicated 62.8 yrs (18.2); routine replacement 54.5 yrs (19.0).

Sex (M/F): Not stated.

Inclusion criteria: Adult patients who could be treated at home for an acute illness and had a 20, 22, or 24 gauge catheter inserted in an upper extremity.

Exclusion criteria: Not stated.

Interventions

Clinically indicated: Catheters were removed if there were signs of phlebitis, local infection, bacteraemia, infiltration or blockage.

Routine replacement: Catheters were replaced every 72 ‐ 96 hours.

Outcomes

Primary: Phlebitis per patient and per 1000 device days (phlebitis was defined as a total score of 2 or more points from the following factors: pain (on a 10‐point scale, 1 = 1 point, and 2 or more = 2 points; redness (less than 1cm = 1 point, and 1 or more cm = 2 points); swelling (as for redness); and discharge (haemoserous ooze under dressing = 1 point, and haemoserous ooze requiring dressing change or purulence = 2 points).

Also reported on: Suspected IVD‐related bacteraemia and occlusion/blockage.

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Comment: Computer generated allocation (personal communication with author).

Allocation concealment (selection bias)

Low risk

Quote: "Randomization was concealed until treatment via sealed envelopes".

Blinding (performance bias and detection bias)
All outcomes

High risk

Comment: Neither study personnel nor participants were blinded.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Comment: Participant flow chart provided. Results from all enrolled patients were reported.

Selective reporting (reporting bias)

Low risk

Comment: All planned outcomes were reported.

Other bias

Low risk

No other known risks of bias.

Webster 2007

Methods

Study design: Single‐centre RCT.

Method of randomisation: Computer generated.

Concealment of allocation: Allocation concealed until telephone contact made with an independent person.

Participants

Country: Australia.

Number: 206. Clinically indicated: 103 patients. Routine replacement: 103 patients.

Age: Clinically indicated 60.2 yrs (16.2); routine replacement 63.1 yrs (17.3).

Sex (M/F): Clinically indicated 53/50; routine replacement 54/49.

Inclusion criteria: At least 18 yrs of age, expected to have a peripheral intravenous device (IVD) in situ, requiring IV therapy for at least 4 days, catheter inserted by a member of the IV team.

Exclusion criteria: Immunosuppressed patients and those with an existing bloodstream infection.

Interventions

Clinically indicated: Catheters removed if there were signs of phlebitis, local infection, bacteraemia, infiltration or blockage.

Routine replacement: Catheters replaced every 3 days.

Outcomes

Primary: Composite measure of any reason for an unplanned catheter removal.

Secondary: Cost (For intermittent infusion: 20 minutes nursing/medical time,  a cannula, a 3 way tap, a basic dressing pack, gloves, a syringe, transparent adhesive dressing, skin disinfection and local anaesthetic per insertion. For patients receiving a continuous infusion: all the above costs plus the additional cost of replacing all associated lines, solutions and additives which are discarded when an IV catheter is changed (based on an intravenous administration set, 1 litre sodium chloride 0.09%).

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "randomization was by computer generated random number list, stratified by oncology status".

Allocation concealment (selection bias)

Low risk

Quote: "Allocation was made by phoning a person who was independent of the recruitment process".

Blinding (performance bias and detection bias)
All outcomes

High risk

Evidence for participants: Comment: Participants could not be blinded.

 

Evidence for personnel: Quote "clinical staff were subsequently aware of the treatment group".

 

Evidence for outcomes: Quote: "research staff had no involvement in nominating the reason for catheter removal or in diagnosing phlebitis".

"Staff in the microbiological laboratory were blind to group assignment of catheters submitted for testing".

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Comment: All recruited patients were accounted for in the results.

Selective reporting (reporting bias)

Low risk

Comment: Protocol was available. All planned outcomes were reported.

Other bias

Low risk

No other known risks of bias.

Webster 2008

Methods

Study design: Single‐centre RCT.

Method of randomisation: Computer generated.

Concealment of allocation: Telephone randomisation.

Participants

Country: Australia.

Number: 755. Clinically indicated: 379 patients. Routine replacement: 376 patients.

Age: Clinically indicated 60.1 yrs (17.1); routine replacement 58.8 yrs (18.8).

Sex (M/F): Clinically indicated 248/131; routine replacement 233/143.

Inclusion criteria: At least 18 yrs of age, expected to have a IVD in situ, requiring IV therapy for at least 4 days.

Exclusion criteria: Immunosuppressed patients and those with an existing bloodstream infection.

Interventions

Clinically indicated: Catheter removed if there were signs of phlebitis, local infection, bacteraemia, infiltration or blockage.

Routine replacement: Catheter replaced every 3 days.

Outcomes

Primary: A composite measure of phlebitis (defined as two or more of the following: pain, erythema, purulence, infiltration, palpable venous cord) and infiltration.

Secondary: Infusion‐related costs. Cost (For intermittent infusion: 20‐minutes nursing/medical time, a cannula, a 3‐way tap, a basic dressing pack, gloves, a syringe, transparent adhesive dressing, skin disinfection and local anaesthetic per insertion. For patients receiving a continuous infusion: all the above costs plus the additional cost of replacing all associated lines, solutions and additives which are discarded when an IV catheter is changed (based on an intravenous administration set, 1 litre sodium chloride 0.09%).

Individual reasons for catheter failure (occlusion/blockage, local infection).

Also reported: Bacteraemia rate.

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "Block randomisation was by a computer generated random number list".

Allocation concealment (selection bias)

Low risk

Quote: ".... telephoned a contact who was independent of the recruitment process for allocation consignment".

Blinding (performance bias and detection bias)
All outcomes

High risk

Neither study personnel nor participants were blinded.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All recruited patients were accounted for in the results.

Selective reporting (reporting bias)

Low risk

Protocol was available. All planned outcomes were reported.

Other bias

Low risk

No other known risks of bias.

IV: intravenous
IVD: peripheral intravenous device
PVT: peripheral vein infusion thrombophlebitis
RCT: randomised controlled trial

Characteristics of excluded studies [ordered by study ID]

Jump to:

Study

Reason for exclusion

Arnold 1977

Not a randomised controlled trial

Cobb 1992

Involved central, not peripheral lines

Eyer 1990

Involved pulmonary artery or arterial catheters, not peripheral catheters

Haddad 2006

End point was lymphangitis

Kerin 1991

Patients were receiving parenteral nutrition

May 1996

Patients were receiving parenteral nutrition

Nakae 2010

Involved central, not peripheral lines

Panadero 2002

Compared the use of a single intraoperative and postoperative catheters with two catheters, one used intraoperatively and a separate catheter for postoperative use

Rijnders 2004

Involved central, not peripheral lines

Data and analyses

Open in table viewer
Comparison 1. Clinically‐indicated versus routine change

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Catheter‐related blood stream infection Show forest plot

5

4806

Risk Ratio (M‐H, Fixed, 95% CI)

0.61 [0.08, 4.68]

Analysis 1.1

Comparison 1 Clinically‐indicated versus routine change, Outcome 1 Catheter‐related blood stream infection.

Comparison 1 Clinically‐indicated versus routine change, Outcome 1 Catheter‐related blood stream infection.

2 Phlebitis Show forest plot

5

4806

Risk Ratio (M‐H, Fixed, 95% CI)

1.14 [0.93, 1.39]

Analysis 1.2

Comparison 1 Clinically‐indicated versus routine change, Outcome 2 Phlebitis.

Comparison 1 Clinically‐indicated versus routine change, Outcome 2 Phlebitis.

2.1 Continuous infusion

4

4606

Risk Ratio (M‐H, Fixed, 95% CI)

1.11 [0.89, 1.39]

2.2 Intermittent infusion

1

200

Risk Ratio (M‐H, Fixed, 95% CI)

1.29 [0.85, 1.96]

3 Phlebitis per device days Show forest plot

5

26191

Risk Ratio (M‐H, Fixed, 95% CI)

1.03 [0.84, 1.27]

Analysis 1.3

Comparison 1 Clinically‐indicated versus routine change, Outcome 3 Phlebitis per device days.

Comparison 1 Clinically‐indicated versus routine change, Outcome 3 Phlebitis per device days.

4 All‐cause blood stream infection Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Analysis 1.4

Comparison 1 Clinically‐indicated versus routine change, Outcome 4 All‐cause blood stream infection.

Comparison 1 Clinically‐indicated versus routine change, Outcome 4 All‐cause blood stream infection.

5 Cost Show forest plot

3

4244

Mean Difference (IV, Fixed, 95% CI)

‐6.96 [‐9.05, ‐4.86]

Analysis 1.5

Comparison 1 Clinically‐indicated versus routine change, Outcome 5 Cost.

Comparison 1 Clinically‐indicated versus routine change, Outcome 5 Cost.

6 Infiltration Show forest plot

4

4606

Risk Ratio (M‐H, Fixed, 95% CI)

1.17 [1.05, 1.31]

Analysis 1.6

Comparison 1 Clinically‐indicated versus routine change, Outcome 6 Infiltration.

Comparison 1 Clinically‐indicated versus routine change, Outcome 6 Infiltration.

7 Catheter blockage Show forest plot

5

4806

Risk Ratio (M‐H, Random, 95% CI)

1.25 [0.91, 1.71]

Analysis 1.7

Comparison 1 Clinically‐indicated versus routine change, Outcome 7 Catheter blockage.

Comparison 1 Clinically‐indicated versus routine change, Outcome 7 Catheter blockage.

8 Local infection Show forest plot

4

4606

Risk Ratio (M‐H, Fixed, 95% CI)

4.96 [0.24, 102.98]

Analysis 1.8

Comparison 1 Clinically‐indicated versus routine change, Outcome 8 Local infection.

Comparison 1 Clinically‐indicated versus routine change, Outcome 8 Local infection.

9 Mortality Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Analysis 1.9

Comparison 1 Clinically‐indicated versus routine change, Outcome 9 Mortality.

Comparison 1 Clinically‐indicated versus routine change, Outcome 9 Mortality.

Study flow diagram.
Figures and Tables -
Figure 1

Study flow diagram.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figures and Tables -
Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figures and Tables -
Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Forest plot of comparison: 1 Clinically‐indicated versus routine change, outcome: 1.1 Catheter‐related bloodstream infection.
Figures and Tables -
Figure 4

Forest plot of comparison: 1 Clinically‐indicated versus routine change, outcome: 1.1 Catheter‐related bloodstream infection.

Forest plot of comparison: 1 Clinically‐indicated versus routine change, outcome: 1.2 Phlebitis.
Figures and Tables -
Figure 5

Forest plot of comparison: 1 Clinically‐indicated versus routine change, outcome: 1.2 Phlebitis.

Forest plot of comparison: 1 Clinically‐indicated versus routine change, outcome: 1.3 Phlebitis per device days.
Figures and Tables -
Figure 6

Forest plot of comparison: 1 Clinically‐indicated versus routine change, outcome: 1.3 Phlebitis per device days.

Forest plot of comparison: 1 Clinically‐indicated versus routine change, outcome: 1.4 All‐cause bloodstream infection.
Figures and Tables -
Figure 7

Forest plot of comparison: 1 Clinically‐indicated versus routine change, outcome: 1.4 All‐cause bloodstream infection.

Forest plot of comparison: 1 Clinically‐indicated versus routine change, outcome: 1.5 Cost.
Figures and Tables -
Figure 8

Forest plot of comparison: 1 Clinically‐indicated versus routine change, outcome: 1.5 Cost.

Forest plot of comparison: 1 Clinically‐indicated versus routine change, outcome: 1.6 Infiltration.
Figures and Tables -
Figure 9

Forest plot of comparison: 1 Clinically‐indicated versus routine change, outcome: 1.6 Infiltration.

Forest plot of comparison: 1 Clinically‐indicated versus routine change, outcome: 1.7 Catheter blockage.
Figures and Tables -
Figure 10

Forest plot of comparison: 1 Clinically‐indicated versus routine change, outcome: 1.7 Catheter blockage.

Forest plot of comparison: 1 Clinically‐indicated versus routine change, outcome: 1.8 Local infection.
Figures and Tables -
Figure 11

Forest plot of comparison: 1 Clinically‐indicated versus routine change, outcome: 1.8 Local infection.

Forest plot of comparison: 1 Clinically‐indicated versus routine change, outcome: 1.9 Mortality.
Figures and Tables -
Figure 12

Forest plot of comparison: 1 Clinically‐indicated versus routine change, outcome: 1.9 Mortality.

Comparison 1 Clinically‐indicated versus routine change, Outcome 1 Catheter‐related blood stream infection.
Figures and Tables -
Analysis 1.1

Comparison 1 Clinically‐indicated versus routine change, Outcome 1 Catheter‐related blood stream infection.

Comparison 1 Clinically‐indicated versus routine change, Outcome 2 Phlebitis.
Figures and Tables -
Analysis 1.2

Comparison 1 Clinically‐indicated versus routine change, Outcome 2 Phlebitis.

Comparison 1 Clinically‐indicated versus routine change, Outcome 3 Phlebitis per device days.
Figures and Tables -
Analysis 1.3

Comparison 1 Clinically‐indicated versus routine change, Outcome 3 Phlebitis per device days.

Comparison 1 Clinically‐indicated versus routine change, Outcome 4 All‐cause blood stream infection.
Figures and Tables -
Analysis 1.4

Comparison 1 Clinically‐indicated versus routine change, Outcome 4 All‐cause blood stream infection.

Comparison 1 Clinically‐indicated versus routine change, Outcome 5 Cost.
Figures and Tables -
Analysis 1.5

Comparison 1 Clinically‐indicated versus routine change, Outcome 5 Cost.

Comparison 1 Clinically‐indicated versus routine change, Outcome 6 Infiltration.
Figures and Tables -
Analysis 1.6

Comparison 1 Clinically‐indicated versus routine change, Outcome 6 Infiltration.

Comparison 1 Clinically‐indicated versus routine change, Outcome 7 Catheter blockage.
Figures and Tables -
Analysis 1.7

Comparison 1 Clinically‐indicated versus routine change, Outcome 7 Catheter blockage.

Comparison 1 Clinically‐indicated versus routine change, Outcome 8 Local infection.
Figures and Tables -
Analysis 1.8

Comparison 1 Clinically‐indicated versus routine change, Outcome 8 Local infection.

Comparison 1 Clinically‐indicated versus routine change, Outcome 9 Mortality.
Figures and Tables -
Analysis 1.9

Comparison 1 Clinically‐indicated versus routine change, Outcome 9 Mortality.

Summary of findings for the main comparison. Clinically‐indicated versus routine changes for peripheral venous catheter‐related complications

Clinically‐indicated versus routine changes for peripheral venous catheter‐related complications

Patient or population: patients with peripheral venous catheter‐related complications
Settings: Hospitals and community settings
Intervention: clinically‐indicated versus routine changes

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Clinically indicated versus routine changes

Catheter‐related bloodstream infection
Positive blood culture from a peripheral vein; clinical signs of infection; no other apparent source for the bloodstream infection except the intravenous catheter; and colonised intravenous catheter tip culture with the same organism as identified in the blood

Study population

RR 0.61
(0.08 to 4.68)

4806
(5 studies)

⊕⊕⊕⊖
moderate1,2,3,4

1 per 1000

1 per 1000
(0 to 5)

Moderate

0 per 1000

0 per 1000
(0 to 0)

Phlebitis
Any definition used by the author

Study population

RR 1.14
(0.93 to 1.39)

4806
(5 studies)

⊕⊕⊕⊕
high1,3

68 per 1000

78 per 1000
(63 to 95)

Moderate

68 per 1000

78 per 1000
(63 to 95)

All‐cause bloodstream infection

Study population

RR 0.47
(0.15 to 1.53)

3283
(1 study)

⊕⊕⊕⊕
high1,3

5 per 1000

3 per 1000
(1 to 8)

Moderate

5 per 1000

2 per 1000
(1 to 8)

Cost
Estmated. Based on materials and staff costs5,6

The mean cost in the intervention groups was
AUD $6.96 lower
(9.05 to 4.86 lower)

4244
(3 studies)

⊕⊕⊕⊕
high

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Although patients and those recording outcomes were aware of group allocation, it seems unlikely that this knowledge would have affected results. None of those recording outcomes were investigators and the diagnosis was based on verifiable data in patients medical records.
2 In three of the five trials, no CRBSI occurred in either arm of the study. In the other two trials there was considerable overlap in the confidence intervals, consequently there was no statistical heterogeneity.
3 Participants, interventions and outcomes were similar across studies.
4 Confidence intervals were wide for this outcome, indicating a level of uncertainty around the effect size.
5 The overall cost for cannula replacement varies by cost of materials, time, solutions, additives to the solution.
6 Mean cost is reported in Australian dollars.

Figures and Tables -
Summary of findings for the main comparison. Clinically‐indicated versus routine changes for peripheral venous catheter‐related complications
Comparison 1. Clinically‐indicated versus routine change

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Catheter‐related blood stream infection Show forest plot

5

4806

Risk Ratio (M‐H, Fixed, 95% CI)

0.61 [0.08, 4.68]

2 Phlebitis Show forest plot

5

4806

Risk Ratio (M‐H, Fixed, 95% CI)

1.14 [0.93, 1.39]

2.1 Continuous infusion

4

4606

Risk Ratio (M‐H, Fixed, 95% CI)

1.11 [0.89, 1.39]

2.2 Intermittent infusion

1

200

Risk Ratio (M‐H, Fixed, 95% CI)

1.29 [0.85, 1.96]

3 Phlebitis per device days Show forest plot

5

26191

Risk Ratio (M‐H, Fixed, 95% CI)

1.03 [0.84, 1.27]

4 All‐cause blood stream infection Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

5 Cost Show forest plot

3

4244

Mean Difference (IV, Fixed, 95% CI)

‐6.96 [‐9.05, ‐4.86]

6 Infiltration Show forest plot

4

4606

Risk Ratio (M‐H, Fixed, 95% CI)

1.17 [1.05, 1.31]

7 Catheter blockage Show forest plot

5

4806

Risk Ratio (M‐H, Random, 95% CI)

1.25 [0.91, 1.71]

8 Local infection Show forest plot

4

4606

Risk Ratio (M‐H, Fixed, 95% CI)

4.96 [0.24, 102.98]

9 Mortality Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Figures and Tables -
Comparison 1. Clinically‐indicated versus routine change