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The Incidence of Peripheral Intravenous Catheter Phlebitis and Risk Factors among Pediatric Patients
Journal of Pediatric Nursing 50 (2020) 89–93
Contents lists available at ScienceDirect
Journal of Pediatric Nursing journal homepage: www.pediatricnursing.org
The incidence of peripheral intravenous catheter phlebitis and risk factors among pediatric patients Mohammad Suliman, RN PhD a,⁎, Wafa Saleh, RN MSN b, Hind Al-shiekh, RN MSN c, Wafa Taan, RN PhD d, Mohammed AlBashtawy, RN PhD e a
Department of Community and Mental Health Nursing, Al-alBayt University, Mafraq, Jordan Department of Maternal and Child Health Nursing, Al-alBayt University, Mafraq, Jordan Maternal and Pediatric Nursing, Al-alBayt University, Mafraq, Jordan d Department of Community and Mental Health Nursing, Jordan University of Science and Technology, Irbid, Jordan e Department of Community and Mental Health Nursing and Dean of nursing, Al-alBayt University, Mafraq, Jordan b c
a r t i c l e
i n f o
Available online xxxx
Keywords: Intravenous catheter Phlebitis Pediatric unit Guideline Incidence
a b s t r a c t Background: Phlebitis is one of the most common complications of peripheral intravenous catheter (PIVC) that can lead to many complications, including higher medical costs and longer hospital stays. Objective: To identify the incidence of phlebitis associated with PIVC and determine its risk factors among hospitalized pediatric patients. Methods: An observational and cross-sectional design was used. Data such as patient's demographics, medical diagnosis, place of admission, and other PIVC characteristics were recorded. In addition, observations of PIVC sites over 12-hour intervals were conducted to measure PIVC complications using the Visual Infusion Phlebitis (VIP) scale. Sample and Setting. Over a period of six months, a sample consisting of 307 children from five governmental hospitals that are located in north and middle Jordan were targeted. The sample consists of patients under 12 years old with PIVCs who were hospitalized in pediatric departments. Results: PIVC catheterization has been associated with several complications such as phlebitis (N = 164; 53.4%), extravasation (N = 107, 34.9%), pain (N = 37; 12.1%), leakage (N = 37; 12.1%), and obstruction (N = 26; 8.5%). The main risk factors for phlebitis were: children admitted to wards, PIVC inserted by novice nurse, catheter inserted in the lower limbs, and catheter with contaminated dressing. Conclusion: This study enriches knowledge of PIVC complications and risk factors of phlebitis to help nurses avoid complications and initiate prompt treatment, leading to decrease financial burden as well as patient pain and discomfort. © 2019 Elsevier Inc. All rights reserved.
Introduction The introduction of peripheral intravenous catheters (PIVCs) in pediatric settings is a frequent procedure for the administration of drugs, fluids, and nutrients intravenously (Reigart et al., 2012). Pediatric patients are more exposed to infiltration and extravasation than adult patients due to their physiological and developmental characteristics (Özalp Gerçeker et al., 2018). Some factors include weaker vessels, a thinner venous network with narrow-bore vessels, and a high percentage of adipose tissue. Besides, a distressed child and stressed parent contribute to the difficult situation (Bitencourt et al., 2018; Özalp ⁎ Corresponding author. E-mail addresses: [email protected] (M. Suliman), [email protected] (W. Taan), [email protected] (M. AlBashtawy).
https://doi.org/10.1016/j.pedn.2019.11.006 0882-5963/© 2019 Elsevier Inc. All rights reserved.
Gerçeker et al., 2018). Furthermore, there is a higher incidence of PIVC complications in children younger than one year than in children over five years old (Tripathi, Kaushik, & Singh, 2008). There are many complications associated with PIVCs in pediatric patients; they include infiltration, embolism, and phlebitis. Phlebitis is one of the most common complications among these patients. It is characterized by redness and warmth around the PIVC insertion site or along the path of the vein. The incidence of phlebitis among pediatric patients ranges from 1.5 to 71% (Bitencourt et al., 2018). However, the incidence of phlebitis increases in the second and third days of the PIVC insertion (Webster, Osborne, Rickard, & New, 2015). Phlebitis could be categorized as having mechanical, chemical, and bacterial causes. Mechanical phlebitis results from the PIVC gauge being larger than the diameter of the vein lumen or sudden displacement of the PIVC. Chemical phlebitis results from irritation of the vein
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lumen, which is produced by medication or intravenous fluid such as antibiotics or potassium chloride. Bacterial phlebitis is produced by bacterial growth resulting from poor hygiene or lack of aseptic technique during PIVC insertion (Nagpal, Khera, & Kumar, 2015). In Jordan, as in many other countries, the registered nurse is the primary healthcare provider who is responsible for the insertion and management of PIVCs. Responsibilities of registered nurses include inserting the PIVC using an aseptic technique, and regular monitoring of the intravenous therapy and medications administered through the PIVC, in addition to checking the date of the PIVC insertion and replacing the PIVC when necessary (Mermel et al., 2009). Thus, understanding the incidence, complications, and risk factors of PIVC phlebitis is essential to reduce the occurrence of phlebitis among pediatric patients. This study aims to determine the incidence of phlebitis and the risk factors associated with PIVCs among hospitalized children in Jordan. The significance of the study is to increase nurses' knowledge about complications that can occur during and after catheter insertion and to identify the risk factors causing phlebitis to help nurse practitioners and nurse educators through their practice. Method
other complications. The patients' privacy and confidentiality were maintained throughout the study. Instrumentation Background data The data collection sheet asked for information about age, sex, patient medical diagnosis, place of admission, patient length of stay, presence of any systematic infection, number of catheters inserted, and presence of central venous catheter or fistula. Catheter characteristics Catheter characteristics were collected such as: first or subsequent catheter, type of dressing used (transparent adhesive dressing or zinc oxide adhesive plaster), cleanness of the PIVC dressing (clean with no drainage vs. contaminated), gauge of catheter, site of insertion (forearm, upper arm, wrist, back of hand, leg, head, or neck), and type of intravenous fluid used, such as sodium chloride, dextrose, electrolytes, etc., and type of antibiotic, as well as previous history of blood transfusion during current hospitalization, and duration of catheter in site.
Design Outcomes This is a cross-sectional and observational study, in which the incidence of most intravenous catheterization complications was assessed periodically at 12-hour intervals up to 96 h after the insertion of an intravenous catheter. Setting and sampling The setting was five governmental hospitals in the northern and middle areas of Jordan. The sample size was estimated based on the suggestion of using 15 to 20 subjects per predictor in the regression analysis (Schmidt, 1971). Considering 15 predictors in the regression equation that was used in the statistical analysis, a sample of at least 300 subjects were required to achieve the required power. A sample of 307 patients was chosen conveniently from various pediatric units and wards in those hospitals including medical, surgical, neonatal, and intensive care units.
According to the VIP scale, the incidence of phlebitis is indicated by observing two or more of the following signs and symptoms: pain, tenderness, warmth, erythema, swelling at the catheter insertion site, palpable venous cord, and purulent discharge. Gallant and Schultz (2006) found that the VIP scale is a valid and reliable measure for determining when a PIVC catheter should be removed. The VIP scale ranges from 0 (no symptoms of phlebitis) to 5 (severe stage of phlebitis). Regarding the occlusion/patency of the PIVC catheter, the systemic infection was assessed through the presence of all the following signs and symptoms: rigidity, fever, tachycardia, hypotension, malaise, and nausea/vomiting. Infiltration/extravasation of the insertion site was assessed by demonstrating cool skin temperature, blanched, taut skin, edema, IV fluid leaking, burning/stinging pain, redness, and change in infusion flow. Statistical analysis
Inclusion and exclusion criteria The researchers used SPSS 19 (Chicago, IL, USA); descriptive statistics were used to describe sample and catheter characteristics. Also, inferential statistics such as logistic regression were used to examine the major risk factors associated with the incidence of phlebitis. Significant results were considered at P-value b 0.05.
The researchers included all patients who were hospitalized with at least one PIVC, aged b12 years, from both genders, and whose primary caregivers agreed to their participation in the study. However, patients were excluded if they were under corticosteroid therapy, or immunecompromised, because they are at higher risk of phlebitis, or if they had previously inserted PIVCs from outside the hospitals.
Results
Data collection procedure
Patients' characteristics
The authors obtained permission from their university's IRB committee and from the Jordanian ministry of health to conduct the study. After that, data collection was started by two data collectors who hold a master's degree in nursing and who have clinical experience in pediatric settings. The data collectors have received a training course on how to fill out the data collection sheet and the Visual Infusion Phlebitis scale (VIP) scale. In every setting, the data collectors informed the head nurses about the study, and the time and the method of data collection. Written consent forms were obtained from the primary caregivers before the data collection started. Over a period of six months (from September 2018 to February 2019), the data collectors visited the units and wards and completed two sheets, one asked for the patient's background data and PIVC characteristics, and the other sheet comprised a VIP scale to measure the incidence of phlebitis and
A total sample of 307 pediatric patients was observed during the study period. The sample was divided between males (54.4%) and females (45.6%). The mean age of the participants was 2.8 years (SD = 1.15). The majority of our sample was newborns (19.5%), infants (38.1), and toddlers (24.8%). Patients were admitted to different medical diagnoses. The mean length of hospital stay was 3.44 days (SD = 3.3). All of the patients had one PIVC, except one case that had two PIVCs (see Table 1). Catheter characteristics As shown in Table 2, catheters were inserted into different sites; the main insertion site was the wrist, 135 (44%). The majority of the PIVCs were subsequent PIVCs (n = 203, 66.1%). The main PIVC sizes were
M. Suliman et al. / Journal of Pediatric Nursing 50 (2020) 89–93
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Table 1 Patients' characteristics. Items Gender Male Female Age categories Newborn Infant Toddler Pre-school School age Adolescent Place of admission Ward Pediatric ICU Neonatal ICUaw Case Respiratory Gastrointestinal Neurology Hematology Cardiac Endocrine Genetic
Frequency (%) 167 (54.4) 140 (45.6) 60 (19.5) 117 (38.1) 76 (24.8) 30 (9.8) 23 (7.5) 1 (0.3) 222 (72.3) 56 (18.2) 29 (9.4) 171 (55.7) 44 (14.3) 51 (16.6) 10 (3.2) 20 (6.5) 5 (1.6) 2 (0.6)
22-gauge (n = 178, 58.0%). The main method of dressing was zinc oxide adhesive plaster (n = 292, 95.1%). Most of the dressings were clean (n = 198, 64.5%). The mean duration of PIVCs was 18.45 h (SD = 22). Many PIVCs were used for medication only (n = 116, 37.8%), and the most common type of IVF (intravenous fluid) was 0.2 glucose saline (n = 146, 47.6%).
Incidence of PIVC complication The results show that PIVC catheterization has been associated with several complications such as phlebitis (n = 164; 53.4%), extravasation (n = 107, 34.9%), pain (n = 37; 12.1%), leakage (n = 37; 12.1%), and obstruction (n = 26; 8.5%) (see Fig. 1). The incidence of PIVC phlebitis was 164 (53.4%) patients out of 307 observed patients. The majority of patients (n = 93, 56.7%) suffered from grade one phlebitis on the VIP scale (see Table 3). Table 2 PIVC characteristics. Items Size 18 20 22 24 Site of insertion Wrist Forearm Arm Foot Leg Head Number First time Subsequent Type of dressings Zinc oxide Adhesive plaster Transparent adhesive dressing Dressing Clean Contaminated Presence of IVC Phlebitis No Yes
Frequency (%) 2 (0.7) 8 (2.6) 178 (58) 119 (38.8) 135 (44) 59 (19.2) 36 (11.7) 55 (17.9) 9 (2.9) 13 (4.2) 104 (33.9) 203 (66.1) 292 (95.1) 15 (4.9) 198 (64.5) 109 (35.5) 143 (46.6) 164 (53.4)
Fig. 1. PIVC complications.
Predictors of phlebitis A logistic regression model was used to test all possible factors that may contribute to the risk of phlebitis while controlling other confounding variables. The logistic model contained 15 independent variables. As shown in Table 4, the full model that contained all predictors was statistically significant (χ2 (14, N = 307) = 391.2, p = 0.01). Four out of 15 variables (place of admission, nurses' experiences, insertion site, and condition of the PIVC) were statistically significant predictors for the presence of PIVC phlebitis. For instance, a child who was admitted to a general pediatric ward was found to have an 8.5 times larger chance of having PIVC phlebitis than a child who was admitted to a pediatric intensive care unit such as a neonatal intensive care unit (NICU) or pediatric intensive care unit (PICU) (odds ratio = 8.5). Catheter inserted by a novice nurse raised the possibility of having phlebitis to seven times higher than being inserted by an experienced nurse (odds ratio = 7). Having PIVC in a lower limb raised the risk of phlebitis to 3.18 times higher than having PIVC in an upper limb (odds ratio = 3.18). Finally, a contaminated dressing PIVC raised the risk for phlebitis by 7.68 times compared to having a clean dressing PIVC (odds ratio = 7.68).
Discussion The results show that PIVC is a highly used procedure to administer medication and intravenous fluid in pediatric departments. However, the incidence of phlebitis (53.4%) is relatively high. Most patients had grade one phlebitis on the VIP scale (56.7%). Similarly, Nagpal et al. (2015) found that the incidence of phlebitis in pediatric patients was 71.25%. Also, they found that grade 2 phlebitis was most common (46.25%). The incidence of phlebitis started increasing, from 3.7% to 21.2%, after 24 h. and reached 27.5% after 48 h. However, Foster, Wallis, Paterson, and James (2002) found that the incidence of phlebitis among pediatric patients was 6.6%. Racadio, Doellman, Johnson, Bean, and Jacobs (2001) found that the incidence among pediatric patients was 28.8%. With pediatric patients, it is often more difficult to insert PIVCs because of their tiny and fragile veins, which makes the incidence of catheter phlebitis more common in pediatric settings (Andriyani, Satari, & Amalia, 2013). The non-infectious complications of PIVC were also quite high in our study. The main complications in our study were pain (12.1%), leakage (12.1%), extravasation (34.9%), and occlusion (8.5%). Özalp Gerçeker et al. (2018) found that infiltration and extravasation occurred in 2.9% and 2.3% of the pediatric patients, respectively. The non-infectious complications could be a result of a patient's movement. Younger patients are more physically active and less aware of PIVC complications, which may lead to dislocation or occlusion of PIVC as well as pain and leakage. Besides, high activity and low awareness may explain the high rate of using subsequent PIVCs (66.1%) compared with the percentage of first PIVCs (33.9%). Our results show that the patient's presence at different departments of the hospital has a relationship with the incidence of PIVC
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Table 3 Visual infusion phlebitis score (VIP score). Grade
Clinical criteria
Frequency
%
IV site appears healthy
143
46.6
93
30.3
42
13.7
19
6.2
6
2.0
4
1.3
0 One of the following is evident: • Slight pain near IV site or • Slight redness near IV site Two of the following are evident: Pain at IV site • Erythema • Swelling All of the following signs are evident: • Pain along path of PIVC • Erythema • Induration All of the following signs are evident and extensive: • Pain along path of PIVC • Erythema • Induration • Palpable venous cord All of the following signs are evident and extensive: • Pain along path of PIVC • Erythema • Induration • Palpable venous cord • Pyrexia
1
2
3
4
5
phlebitis. For example, a child who was admitted to a general pediatric ward was found to have an 8.5 times larger chance of having PIVC phlebitis than a child who was admitted to a pediatric intensive care unit. This could be because there is more intensive care provided in neonatal and pediatric intensive care units compared to other wards. Our study's results show that catheters inserted by novice nurses increase the risk of having phlebitis to seven times compared with catheters inserted by expert nurses. Similar results were found by Birhane et al. (2017), who found that PIVCs inserted by experienced nurses stayed in place longer compared to PIVCs inserted by less experienced nurses. This may be because experienced nurses are more skillful in inserting and caring for PIVCs. Our results indicate the need for more training courses for nurses about PIVC insertion and care.
Table 4 Predictors of PIVC phlebitis.
Patients' age Patients' gender Patients' length of stay Unit size Place of admission (ward vs. unit) Nurses/patients ratio Nursing care delivery model (primary vs. functional) Experiences of nurse who inserted the PIVC (novice vs. senior) PIVC size Type of PIVC dressing (adhesive plaster vs. transparency dressing) Insertion site (upper limb vs. lower limb) Condition of the PIVC (clean vs. contaminated) Duration of the PIVC (b72 h vs. N72 h Using of Intravenous fluid (yes vs. no) Using of antibiotic (yes vs. no) ⁎ Significant at alpha ≤0.05.
B
S.E.
Wald
df Sig.
Exp (B)
0.211 −0.2630.000 0.027 1.639 0.031 −0.453-
0.126 0.244 0.039 0.019 0.560 0.113 0.438
2.798 1.163 0.000 1.995 8.564 0.076 1.071
1 1 1 1 1 1 1
1.235 0.769 1.000 1.027 5.151 1.032 0.636
0.094 0.281 0.999 0.158 0.003⁎ 0.782 0.301
0.053
0.020 7.064 1
0.008⁎ 1.054
0.981 0.216
0.905 1.175 1 0.620 0.121 1
0.278 0.728
0.521
0.292 3.182 1
0.054⁎ 1.683
0.755
0.272 7.676 1
0.006⁎ 2.127
−0.170- 0.346 0.243 1
2.666 1.241
0.622
0.843
0.268 0.201 1
0.654
1.128
−0.291- 0.425 0.471 1
0.493
0.747
0.120
Most of the previous studies assessed PIVC sites at upper limbs. However, in our study, we included other PIVC sites, such as lower limbs, head, and neck. Özalp Gerçeker et al. (2018) found that infiltration and extravasation in children occurred more commonly in the upper extremities. Contradictory, we found that implanting the PIVC in the lower limb increases the risk of phlebitis to 3.18 times more than in the upper limbs. Having the PIVC in a lower limb could increase the chance of sudden movement and accident, which may increase the risk of mechanical phlebitis and extravasation. Regarding patients' characteristics, we found that patients' gender and age were not statistically significant factors for increased risk of PIVC phlebitis. Foster et al. (2002) found that patients' age came with the greatest risk of phlebitis. They found that neonate patients were 5½ times more likely to have phlebitis than non‑neonate patients. Jacinto, Avelar, Wilson, and Pedreira (2014) found that female children are at greater risk of phlebitis compared with male children. Also, we found the patient's length of stay to be a non-significant risk factor for having PIVC phlebitis. In contrast, Atchison et al. (2014) found that a mean length of stay of N4 days was a significant risk factor for phlebitis. However, it may be because the mean length of stay for patients in our sample was 3.44 days, as the majority of our sample was admitted to hospital to be treated for respiratory infections (55.7%) versus other diseases (40.6%), requiring shorter hospitalizations than other diseases. As a result, pediatric patients undergo intravenous intervention for shorter periods. Most of our sample had a zinc oxide adhesive plaster (95.1%), and our study found that having a zinc oxide adhesive plaster was not a statistically significant factor in increasing the risk of PIVC phlebitis. However, other studies have emphasized that using this type of dressing would lead to PIVC phlebitis (Foster et al., 2002). The explanation for our result is that two-thirds of the dressings used in the sample were clean (64.5%) whilst only one-third (35.5%) were contaminated. However, the result found that a contaminated dressing PIVC is a statistically significant risk for phlebitis. The contaminated dressing is the main source of bacterial growth and infections. Our results show that using IV therapy and/or antibiotics was not associated with the risk of PIVC phlebitis. This finding could be because the high rate of changing PIVCs among our sample may reduce the incidence of chemical phlebitis. The duration of PIVC insertion was not statistically significantly associated with phlebitis. This result confirms the
M. Suliman et al. / Journal of Pediatric Nursing 50 (2020) 89–93
findings of two other studies (Maki & Ringer, 1991; Nassaji-Zavareh & Ghorbani, 2007). Andriyani et al. (2013) suggested that it is not necessary to remove a PIVC after 72 h in pediatric patients as long as no signs of phlebitis appear at the PIVC site.
Declaration of competing interest
Limitations
References
One limitation of this study was using a convenience sample, which may reduce the generalizability of our findings. However, using a relatively large sample size from different hospitals may improve the generalizability of our findings. Another limitation of our study was that we were unable to identify which medication or intravenous fluid could lead to cannula phlebitis since all medications and intravenous fluid are usually given on the same route and time. Finally, since the previous studies used different definitions of phlebitis and different tools to measure the incidence of phlebitis, this makes the comparison between these studies more difficult. Clinical implications This study emphasizes the use of smaller-gauge PIVC, 22–24, with a clean transparent dressing, as well as taking extra care of children in general wards by assigning an expert nurse to monitor the PIVC. The study recommends avoiding PIVC insertion in lower limbs if possible. Also, the study recommends developing in-service education programs about the risk factors of phlebitis and PIVC management. PIVCs insertion and management policies should be reinforced by nursing administrations. Furthermore, more research is required into the complications of PIVC (infectious and non-infectious) among pediatric patients to obtain a full view of the causes and to generate interventions. Conclusion This study measured the incidence and complications of phlebitis using the VIP scale as well as other variables. The incidence of PIVC phlebitis (53.4%) was relatively high. Factors such as place of admission, nurses' experience, insertion site, and condition of the PIVC were found to be statistically significant predictors for the presence of PIVC phlebitis. Prevention of PIVC phlebitis will decrease medical costs, and nurses' workload, as well as decrease patients' stress, pain, and suffering. Authors individual contriputions 1. Mohammad Suliman: primary investigator who write the paper, analyze results, and review the paper 2. Wafa Saleh: data collection, and participating in writing the paper 3. Hind Al-shiekh: data collection, and participating in writing the paper 4. Wafa Taan: revising paper 5. Mohammed AlBashtawy: revising paper
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The authors declare that there is no conflict of interest regarding the publication of this article.
Andriyani, R., Satari, H. I., & Amalia, P. (2013). Duration of peripheral intravenous catheter use and development of phlebitis. Paediatrica Indonesiana, 53(2), 117–120. Atchison, C. M., Arlikar, S., Amankwah, E., Ayala, I., Barrett, L., Branchford, B. R., ... Goldenberg, N. A. (2014). Development of a new risk score for hospital-associated venous thromboembolism in noncritically ill children: Findings from a large singleinstitutional case-control study. The Journal of Pediatrics, 165(4), 793–798. Birhane, E., Kidanu, K., Kassa, M., Gerezgiher, D., Tsegay, L., Weldu, B., ... Gerensea, H. (2017). Lifespan and associated factors of peripheral intravenous cannula among infants admitted in public hospitals of Mekelle City, Tigray, Ethiopia, 2016. BMC nursing, 16(1), 33. Bitencourt, E. S., Leal, C. N., Boostel, R., Mazza, V., Felix, J. V. C., & Pedrolo, E. (2018). Prevalence of phlebitis related to the use of peripheral intravenous devices in children. Cogitare Enferm, 23(1), e49361. Foster, L., Wallis, M., Paterson, B., & James, H. (2002). A descriptive study of peripheral intravenous catheters in patients admitted to a pediatric unit in one Australian hospital. Journal of Infusion Nursing, 25(3), 159–167. Gallant, P., & Schultz, A. A. (2006). Evaluation of a visual infusion phlebitis scale for determining appropriate discontinuation of peripheral intravenous catheters. Journal of Infusion Nursing, 29(6), 338–345. Jacinto, A. K., Avelar, A. F. M., Wilson, A. M. M. M., & Pedreira, M. G. (2014). Phlebitis associated with peripheral intravenous catheters in children: A study of predisposing factors. Escola Anna Nery, 18(2), 220–226. Maki, D. G., & Ringer, M. (1991). Risk factors for infusion-related phlebitis with small peripheral venous catheters: A randomized controlled trial. Annals of Internal Medicine, 114(10), 845–854. Mermel, L. A., Allon, M., Bouza, E., Craven, D. E., Flynn, P., O’Grady, N. P., ... Warren, D. K. (2009). Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases Society of America. Clinical Infectious Diseases, 49(1), 1–45. Nagpal, P., Khera, G. K., & Kumar, Y. (2015). A study assesses the clinical pattern of phlebitis among children admitted in a selected hospital of Ambala, Haryana. Nursing and Midwifery Research Journal, 11(2), 68–77. Nassaji-Zavareh, M., & Ghorbani, R. (2007). Peripheral intravenous catheter-related phlebitis and related risk factors. Singapore Medical Journal, 733–736. Özalp Gerçeker, G., Kahraman, A., Yardimci, F., Bilsin, E., Binay, Ş., Çevik Özdemir, H. N., ... Gümüş, M. (2018). Infiltration and extravasation in pediatric patients: A prevalence study in a children’s hospital. The Journal of Vascular Access, 19(3), 266–271. Racadio, J. M., Doellman, D. A., Johnson, N. D., Bean, J. A., & Jacobs, B. R. (2001). Pediatric peripherally inserted central catheters: Complication rates related to catheter tip location. Pediatrics, 107(2), e28. Reigart, J. R., Chamberlain, K. H., Eldridge, D., O’Brien, E. S., Freeland, K. D., Larsen, P., ... Hartzog, T. H. (2012). Peripheral intravenous access in pediatric inpatients. Clinical Pediatrics, 51(5), 468–472. Schmidt, F. L. (1971). The relative efficiency of regression and simple unit predictor weightsin applied differential psychology. Educational and Psychological Measurement, 31, 699–714. Tripathi, S., Kaushik, V., & Singh, V. (2008). Peripheral IVs: Factors affecting complications and patency—A randomized controlled trial. Journal of Infusion Nursing, 31(3), 182–188. Webster, J., Osborne, S., Rickard, C. M., & New, K. (2015). Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database of Systematic Reviews, 8.
Contents lists available at ScienceDirect
Journal of Pediatric Nursing journal homepage: www.pediatricnursing.org
The incidence of peripheral intravenous catheter phlebitis and risk factors among pediatric patients Mohammad Suliman, RN PhD a,⁎, Wafa Saleh, RN MSN b, Hind Al-shiekh, RN MSN c, Wafa Taan, RN PhD d, Mohammed AlBashtawy, RN PhD e a
Department of Community and Mental Health Nursing, Al-alBayt University, Mafraq, Jordan Department of Maternal and Child Health Nursing, Al-alBayt University, Mafraq, Jordan Maternal and Pediatric Nursing, Al-alBayt University, Mafraq, Jordan d Department of Community and Mental Health Nursing, Jordan University of Science and Technology, Irbid, Jordan e Department of Community and Mental Health Nursing and Dean of nursing, Al-alBayt University, Mafraq, Jordan b c
a r t i c l e
i n f o
Available online xxxx
Keywords: Intravenous catheter Phlebitis Pediatric unit Guideline Incidence
a b s t r a c t Background: Phlebitis is one of the most common complications of peripheral intravenous catheter (PIVC) that can lead to many complications, including higher medical costs and longer hospital stays. Objective: To identify the incidence of phlebitis associated with PIVC and determine its risk factors among hospitalized pediatric patients. Methods: An observational and cross-sectional design was used. Data such as patient's demographics, medical diagnosis, place of admission, and other PIVC characteristics were recorded. In addition, observations of PIVC sites over 12-hour intervals were conducted to measure PIVC complications using the Visual Infusion Phlebitis (VIP) scale. Sample and Setting. Over a period of six months, a sample consisting of 307 children from five governmental hospitals that are located in north and middle Jordan were targeted. The sample consists of patients under 12 years old with PIVCs who were hospitalized in pediatric departments. Results: PIVC catheterization has been associated with several complications such as phlebitis (N = 164; 53.4%), extravasation (N = 107, 34.9%), pain (N = 37; 12.1%), leakage (N = 37; 12.1%), and obstruction (N = 26; 8.5%). The main risk factors for phlebitis were: children admitted to wards, PIVC inserted by novice nurse, catheter inserted in the lower limbs, and catheter with contaminated dressing. Conclusion: This study enriches knowledge of PIVC complications and risk factors of phlebitis to help nurses avoid complications and initiate prompt treatment, leading to decrease financial burden as well as patient pain and discomfort. © 2019 Elsevier Inc. All rights reserved.
Introduction The introduction of peripheral intravenous catheters (PIVCs) in pediatric settings is a frequent procedure for the administration of drugs, fluids, and nutrients intravenously (Reigart et al., 2012). Pediatric patients are more exposed to infiltration and extravasation than adult patients due to their physiological and developmental characteristics (Özalp Gerçeker et al., 2018). Some factors include weaker vessels, a thinner venous network with narrow-bore vessels, and a high percentage of adipose tissue. Besides, a distressed child and stressed parent contribute to the difficult situation (Bitencourt et al., 2018; Özalp ⁎ Corresponding author. E-mail addresses: [email protected] (M. Suliman), [email protected] (W. Taan), [email protected] (M. AlBashtawy).
https://doi.org/10.1016/j.pedn.2019.11.006 0882-5963/© 2019 Elsevier Inc. All rights reserved.
Gerçeker et al., 2018). Furthermore, there is a higher incidence of PIVC complications in children younger than one year than in children over five years old (Tripathi, Kaushik, & Singh, 2008). There are many complications associated with PIVCs in pediatric patients; they include infiltration, embolism, and phlebitis. Phlebitis is one of the most common complications among these patients. It is characterized by redness and warmth around the PIVC insertion site or along the path of the vein. The incidence of phlebitis among pediatric patients ranges from 1.5 to 71% (Bitencourt et al., 2018). However, the incidence of phlebitis increases in the second and third days of the PIVC insertion (Webster, Osborne, Rickard, & New, 2015). Phlebitis could be categorized as having mechanical, chemical, and bacterial causes. Mechanical phlebitis results from the PIVC gauge being larger than the diameter of the vein lumen or sudden displacement of the PIVC. Chemical phlebitis results from irritation of the vein
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lumen, which is produced by medication or intravenous fluid such as antibiotics or potassium chloride. Bacterial phlebitis is produced by bacterial growth resulting from poor hygiene or lack of aseptic technique during PIVC insertion (Nagpal, Khera, & Kumar, 2015). In Jordan, as in many other countries, the registered nurse is the primary healthcare provider who is responsible for the insertion and management of PIVCs. Responsibilities of registered nurses include inserting the PIVC using an aseptic technique, and regular monitoring of the intravenous therapy and medications administered through the PIVC, in addition to checking the date of the PIVC insertion and replacing the PIVC when necessary (Mermel et al., 2009). Thus, understanding the incidence, complications, and risk factors of PIVC phlebitis is essential to reduce the occurrence of phlebitis among pediatric patients. This study aims to determine the incidence of phlebitis and the risk factors associated with PIVCs among hospitalized children in Jordan. The significance of the study is to increase nurses' knowledge about complications that can occur during and after catheter insertion and to identify the risk factors causing phlebitis to help nurse practitioners and nurse educators through their practice. Method
other complications. The patients' privacy and confidentiality were maintained throughout the study. Instrumentation Background data The data collection sheet asked for information about age, sex, patient medical diagnosis, place of admission, patient length of stay, presence of any systematic infection, number of catheters inserted, and presence of central venous catheter or fistula. Catheter characteristics Catheter characteristics were collected such as: first or subsequent catheter, type of dressing used (transparent adhesive dressing or zinc oxide adhesive plaster), cleanness of the PIVC dressing (clean with no drainage vs. contaminated), gauge of catheter, site of insertion (forearm, upper arm, wrist, back of hand, leg, head, or neck), and type of intravenous fluid used, such as sodium chloride, dextrose, electrolytes, etc., and type of antibiotic, as well as previous history of blood transfusion during current hospitalization, and duration of catheter in site.
Design Outcomes This is a cross-sectional and observational study, in which the incidence of most intravenous catheterization complications was assessed periodically at 12-hour intervals up to 96 h after the insertion of an intravenous catheter. Setting and sampling The setting was five governmental hospitals in the northern and middle areas of Jordan. The sample size was estimated based on the suggestion of using 15 to 20 subjects per predictor in the regression analysis (Schmidt, 1971). Considering 15 predictors in the regression equation that was used in the statistical analysis, a sample of at least 300 subjects were required to achieve the required power. A sample of 307 patients was chosen conveniently from various pediatric units and wards in those hospitals including medical, surgical, neonatal, and intensive care units.
According to the VIP scale, the incidence of phlebitis is indicated by observing two or more of the following signs and symptoms: pain, tenderness, warmth, erythema, swelling at the catheter insertion site, palpable venous cord, and purulent discharge. Gallant and Schultz (2006) found that the VIP scale is a valid and reliable measure for determining when a PIVC catheter should be removed. The VIP scale ranges from 0 (no symptoms of phlebitis) to 5 (severe stage of phlebitis). Regarding the occlusion/patency of the PIVC catheter, the systemic infection was assessed through the presence of all the following signs and symptoms: rigidity, fever, tachycardia, hypotension, malaise, and nausea/vomiting. Infiltration/extravasation of the insertion site was assessed by demonstrating cool skin temperature, blanched, taut skin, edema, IV fluid leaking, burning/stinging pain, redness, and change in infusion flow. Statistical analysis
Inclusion and exclusion criteria The researchers used SPSS 19 (Chicago, IL, USA); descriptive statistics were used to describe sample and catheter characteristics. Also, inferential statistics such as logistic regression were used to examine the major risk factors associated with the incidence of phlebitis. Significant results were considered at P-value b 0.05.
The researchers included all patients who were hospitalized with at least one PIVC, aged b12 years, from both genders, and whose primary caregivers agreed to their participation in the study. However, patients were excluded if they were under corticosteroid therapy, or immunecompromised, because they are at higher risk of phlebitis, or if they had previously inserted PIVCs from outside the hospitals.
Results
Data collection procedure
Patients' characteristics
The authors obtained permission from their university's IRB committee and from the Jordanian ministry of health to conduct the study. After that, data collection was started by two data collectors who hold a master's degree in nursing and who have clinical experience in pediatric settings. The data collectors have received a training course on how to fill out the data collection sheet and the Visual Infusion Phlebitis scale (VIP) scale. In every setting, the data collectors informed the head nurses about the study, and the time and the method of data collection. Written consent forms were obtained from the primary caregivers before the data collection started. Over a period of six months (from September 2018 to February 2019), the data collectors visited the units and wards and completed two sheets, one asked for the patient's background data and PIVC characteristics, and the other sheet comprised a VIP scale to measure the incidence of phlebitis and
A total sample of 307 pediatric patients was observed during the study period. The sample was divided between males (54.4%) and females (45.6%). The mean age of the participants was 2.8 years (SD = 1.15). The majority of our sample was newborns (19.5%), infants (38.1), and toddlers (24.8%). Patients were admitted to different medical diagnoses. The mean length of hospital stay was 3.44 days (SD = 3.3). All of the patients had one PIVC, except one case that had two PIVCs (see Table 1). Catheter characteristics As shown in Table 2, catheters were inserted into different sites; the main insertion site was the wrist, 135 (44%). The majority of the PIVCs were subsequent PIVCs (n = 203, 66.1%). The main PIVC sizes were
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Table 1 Patients' characteristics. Items Gender Male Female Age categories Newborn Infant Toddler Pre-school School age Adolescent Place of admission Ward Pediatric ICU Neonatal ICUaw Case Respiratory Gastrointestinal Neurology Hematology Cardiac Endocrine Genetic
Frequency (%) 167 (54.4) 140 (45.6) 60 (19.5) 117 (38.1) 76 (24.8) 30 (9.8) 23 (7.5) 1 (0.3) 222 (72.3) 56 (18.2) 29 (9.4) 171 (55.7) 44 (14.3) 51 (16.6) 10 (3.2) 20 (6.5) 5 (1.6) 2 (0.6)
22-gauge (n = 178, 58.0%). The main method of dressing was zinc oxide adhesive plaster (n = 292, 95.1%). Most of the dressings were clean (n = 198, 64.5%). The mean duration of PIVCs was 18.45 h (SD = 22). Many PIVCs were used for medication only (n = 116, 37.8%), and the most common type of IVF (intravenous fluid) was 0.2 glucose saline (n = 146, 47.6%).
Incidence of PIVC complication The results show that PIVC catheterization has been associated with several complications such as phlebitis (n = 164; 53.4%), extravasation (n = 107, 34.9%), pain (n = 37; 12.1%), leakage (n = 37; 12.1%), and obstruction (n = 26; 8.5%) (see Fig. 1). The incidence of PIVC phlebitis was 164 (53.4%) patients out of 307 observed patients. The majority of patients (n = 93, 56.7%) suffered from grade one phlebitis on the VIP scale (see Table 3). Table 2 PIVC characteristics. Items Size 18 20 22 24 Site of insertion Wrist Forearm Arm Foot Leg Head Number First time Subsequent Type of dressings Zinc oxide Adhesive plaster Transparent adhesive dressing Dressing Clean Contaminated Presence of IVC Phlebitis No Yes
Frequency (%) 2 (0.7) 8 (2.6) 178 (58) 119 (38.8) 135 (44) 59 (19.2) 36 (11.7) 55 (17.9) 9 (2.9) 13 (4.2) 104 (33.9) 203 (66.1) 292 (95.1) 15 (4.9) 198 (64.5) 109 (35.5) 143 (46.6) 164 (53.4)
Fig. 1. PIVC complications.
Predictors of phlebitis A logistic regression model was used to test all possible factors that may contribute to the risk of phlebitis while controlling other confounding variables. The logistic model contained 15 independent variables. As shown in Table 4, the full model that contained all predictors was statistically significant (χ2 (14, N = 307) = 391.2, p = 0.01). Four out of 15 variables (place of admission, nurses' experiences, insertion site, and condition of the PIVC) were statistically significant predictors for the presence of PIVC phlebitis. For instance, a child who was admitted to a general pediatric ward was found to have an 8.5 times larger chance of having PIVC phlebitis than a child who was admitted to a pediatric intensive care unit such as a neonatal intensive care unit (NICU) or pediatric intensive care unit (PICU) (odds ratio = 8.5). Catheter inserted by a novice nurse raised the possibility of having phlebitis to seven times higher than being inserted by an experienced nurse (odds ratio = 7). Having PIVC in a lower limb raised the risk of phlebitis to 3.18 times higher than having PIVC in an upper limb (odds ratio = 3.18). Finally, a contaminated dressing PIVC raised the risk for phlebitis by 7.68 times compared to having a clean dressing PIVC (odds ratio = 7.68).
Discussion The results show that PIVC is a highly used procedure to administer medication and intravenous fluid in pediatric departments. However, the incidence of phlebitis (53.4%) is relatively high. Most patients had grade one phlebitis on the VIP scale (56.7%). Similarly, Nagpal et al. (2015) found that the incidence of phlebitis in pediatric patients was 71.25%. Also, they found that grade 2 phlebitis was most common (46.25%). The incidence of phlebitis started increasing, from 3.7% to 21.2%, after 24 h. and reached 27.5% after 48 h. However, Foster, Wallis, Paterson, and James (2002) found that the incidence of phlebitis among pediatric patients was 6.6%. Racadio, Doellman, Johnson, Bean, and Jacobs (2001) found that the incidence among pediatric patients was 28.8%. With pediatric patients, it is often more difficult to insert PIVCs because of their tiny and fragile veins, which makes the incidence of catheter phlebitis more common in pediatric settings (Andriyani, Satari, & Amalia, 2013). The non-infectious complications of PIVC were also quite high in our study. The main complications in our study were pain (12.1%), leakage (12.1%), extravasation (34.9%), and occlusion (8.5%). Özalp Gerçeker et al. (2018) found that infiltration and extravasation occurred in 2.9% and 2.3% of the pediatric patients, respectively. The non-infectious complications could be a result of a patient's movement. Younger patients are more physically active and less aware of PIVC complications, which may lead to dislocation or occlusion of PIVC as well as pain and leakage. Besides, high activity and low awareness may explain the high rate of using subsequent PIVCs (66.1%) compared with the percentage of first PIVCs (33.9%). Our results show that the patient's presence at different departments of the hospital has a relationship with the incidence of PIVC
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Table 3 Visual infusion phlebitis score (VIP score). Grade
Clinical criteria
Frequency
%
IV site appears healthy
143
46.6
93
30.3
42
13.7
19
6.2
6
2.0
4
1.3
0 One of the following is evident: • Slight pain near IV site or • Slight redness near IV site Two of the following are evident: Pain at IV site • Erythema • Swelling All of the following signs are evident: • Pain along path of PIVC • Erythema • Induration All of the following signs are evident and extensive: • Pain along path of PIVC • Erythema • Induration • Palpable venous cord All of the following signs are evident and extensive: • Pain along path of PIVC • Erythema • Induration • Palpable venous cord • Pyrexia
1
2
3
4
5
phlebitis. For example, a child who was admitted to a general pediatric ward was found to have an 8.5 times larger chance of having PIVC phlebitis than a child who was admitted to a pediatric intensive care unit. This could be because there is more intensive care provided in neonatal and pediatric intensive care units compared to other wards. Our study's results show that catheters inserted by novice nurses increase the risk of having phlebitis to seven times compared with catheters inserted by expert nurses. Similar results were found by Birhane et al. (2017), who found that PIVCs inserted by experienced nurses stayed in place longer compared to PIVCs inserted by less experienced nurses. This may be because experienced nurses are more skillful in inserting and caring for PIVCs. Our results indicate the need for more training courses for nurses about PIVC insertion and care.
Table 4 Predictors of PIVC phlebitis.
Patients' age Patients' gender Patients' length of stay Unit size Place of admission (ward vs. unit) Nurses/patients ratio Nursing care delivery model (primary vs. functional) Experiences of nurse who inserted the PIVC (novice vs. senior) PIVC size Type of PIVC dressing (adhesive plaster vs. transparency dressing) Insertion site (upper limb vs. lower limb) Condition of the PIVC (clean vs. contaminated) Duration of the PIVC (b72 h vs. N72 h Using of Intravenous fluid (yes vs. no) Using of antibiotic (yes vs. no) ⁎ Significant at alpha ≤0.05.
B
S.E.
Wald
df Sig.
Exp (B)
0.211 −0.2630.000 0.027 1.639 0.031 −0.453-
0.126 0.244 0.039 0.019 0.560 0.113 0.438
2.798 1.163 0.000 1.995 8.564 0.076 1.071
1 1 1 1 1 1 1
1.235 0.769 1.000 1.027 5.151 1.032 0.636
0.094 0.281 0.999 0.158 0.003⁎ 0.782 0.301
0.053
0.020 7.064 1
0.008⁎ 1.054
0.981 0.216
0.905 1.175 1 0.620 0.121 1
0.278 0.728
0.521
0.292 3.182 1
0.054⁎ 1.683
0.755
0.272 7.676 1
0.006⁎ 2.127
−0.170- 0.346 0.243 1
2.666 1.241
0.622
0.843
0.268 0.201 1
0.654
1.128
−0.291- 0.425 0.471 1
0.493
0.747
0.120
Most of the previous studies assessed PIVC sites at upper limbs. However, in our study, we included other PIVC sites, such as lower limbs, head, and neck. Özalp Gerçeker et al. (2018) found that infiltration and extravasation in children occurred more commonly in the upper extremities. Contradictory, we found that implanting the PIVC in the lower limb increases the risk of phlebitis to 3.18 times more than in the upper limbs. Having the PIVC in a lower limb could increase the chance of sudden movement and accident, which may increase the risk of mechanical phlebitis and extravasation. Regarding patients' characteristics, we found that patients' gender and age were not statistically significant factors for increased risk of PIVC phlebitis. Foster et al. (2002) found that patients' age came with the greatest risk of phlebitis. They found that neonate patients were 5½ times more likely to have phlebitis than non‑neonate patients. Jacinto, Avelar, Wilson, and Pedreira (2014) found that female children are at greater risk of phlebitis compared with male children. Also, we found the patient's length of stay to be a non-significant risk factor for having PIVC phlebitis. In contrast, Atchison et al. (2014) found that a mean length of stay of N4 days was a significant risk factor for phlebitis. However, it may be because the mean length of stay for patients in our sample was 3.44 days, as the majority of our sample was admitted to hospital to be treated for respiratory infections (55.7%) versus other diseases (40.6%), requiring shorter hospitalizations than other diseases. As a result, pediatric patients undergo intravenous intervention for shorter periods. Most of our sample had a zinc oxide adhesive plaster (95.1%), and our study found that having a zinc oxide adhesive plaster was not a statistically significant factor in increasing the risk of PIVC phlebitis. However, other studies have emphasized that using this type of dressing would lead to PIVC phlebitis (Foster et al., 2002). The explanation for our result is that two-thirds of the dressings used in the sample were clean (64.5%) whilst only one-third (35.5%) were contaminated. However, the result found that a contaminated dressing PIVC is a statistically significant risk for phlebitis. The contaminated dressing is the main source of bacterial growth and infections. Our results show that using IV therapy and/or antibiotics was not associated with the risk of PIVC phlebitis. This finding could be because the high rate of changing PIVCs among our sample may reduce the incidence of chemical phlebitis. The duration of PIVC insertion was not statistically significantly associated with phlebitis. This result confirms the
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findings of two other studies (Maki & Ringer, 1991; Nassaji-Zavareh & Ghorbani, 2007). Andriyani et al. (2013) suggested that it is not necessary to remove a PIVC after 72 h in pediatric patients as long as no signs of phlebitis appear at the PIVC site.
Declaration of competing interest
Limitations
References
One limitation of this study was using a convenience sample, which may reduce the generalizability of our findings. However, using a relatively large sample size from different hospitals may improve the generalizability of our findings. Another limitation of our study was that we were unable to identify which medication or intravenous fluid could lead to cannula phlebitis since all medications and intravenous fluid are usually given on the same route and time. Finally, since the previous studies used different definitions of phlebitis and different tools to measure the incidence of phlebitis, this makes the comparison between these studies more difficult. Clinical implications This study emphasizes the use of smaller-gauge PIVC, 22–24, with a clean transparent dressing, as well as taking extra care of children in general wards by assigning an expert nurse to monitor the PIVC. The study recommends avoiding PIVC insertion in lower limbs if possible. Also, the study recommends developing in-service education programs about the risk factors of phlebitis and PIVC management. PIVCs insertion and management policies should be reinforced by nursing administrations. Furthermore, more research is required into the complications of PIVC (infectious and non-infectious) among pediatric patients to obtain a full view of the causes and to generate interventions. Conclusion This study measured the incidence and complications of phlebitis using the VIP scale as well as other variables. The incidence of PIVC phlebitis (53.4%) was relatively high. Factors such as place of admission, nurses' experience, insertion site, and condition of the PIVC were found to be statistically significant predictors for the presence of PIVC phlebitis. Prevention of PIVC phlebitis will decrease medical costs, and nurses' workload, as well as decrease patients' stress, pain, and suffering. Authors individual contriputions 1. Mohammad Suliman: primary investigator who write the paper, analyze results, and review the paper 2. Wafa Saleh: data collection, and participating in writing the paper 3. Hind Al-shiekh: data collection, and participating in writing the paper 4. Wafa Taan: revising paper 5. Mohammed AlBashtawy: revising paper
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The authors declare that there is no conflict of interest regarding the publication of this article.
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