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Time to Retire Routine Replacement of Peripheral IVs
Study question: Do peripheral I.V.s need to be changed every 72-96 hours per the CDCs recommendations or can they be changed as clinically indicated?
How many times as a resident did you receive a call at 4 a.m., often at the very moment you were about to close your eyes, requesting a new peripheral intravenous catheter (PIV). When you inquired, “why does the patient need a new IV?” the response was often that the current IV “has expired”. I always wondered where this policy came from and figured it was likely the result of a catastrophic infection due to a PIV. As it turns out, many hospitals have this policy and current CDC recommendations are in agreement. The CDC recommends, albeit with category IB evidence, that all peripheral IVs be changed every 72-96 hours, regardless of how the PIV is working and whether or not there is induration around the IV site. Notably, evidence from the last 20 years of research on central venous catheters suggests that there is no benefit to routinely changing central venous lines and, in fact, suggest that a strategy of routine removal and replacement of central venous lines every 3 days may be harmful. In the pediatric world, PIVs are not routinely changed every 72-96 hours. Small trials have suggested that leaving PIVs in for >96 hours may be safe and effective for adults, but larger trials were needed.
What They Did
In the September issue of the Lancet, Whitby et al test the commonly held belief that PIVs must changed every 72-96 hours. The authors conducted a large (3283 patients) multi-center randomized equivalence trial of the standard practice of changing PIVs every 72-96 hours vs. changing PIVs as clinically indicated. Clinical indications for changing PIVs included phlebitis, suspected infection, infiltration or occlusion. Notably, patients, research nurses and clinical staff could not be blinded to this intervention. The primary outcome of the study was phlebitis at the IV site during use or 48 h following removal. Other outcome measures included infusion failure, infiltration, occlusion, catheter related blood stream infection, cost and mortality. The equivalence margin was set at 3% for the study.
What They Found
The major finding of this study is that these two approaches to managing PIVs -- changing PIVs every 72-96 hours vs. changing them as clinically indicated -- are equivalent. There was no difference detected in the follow key endpoints:
- Phlebitis during use or 48 hours after removal
- Infusion Failure
- Catheter related blood stream infection
- All blood stream infections
In addition, adopting an approach of changing PIVs based on clinical indications may save materials and money. The conventional treatment group required an average of 1.9 IVs while the clinically indicated group required 1.7 IVs. This is a small but statistically significant difference that resulted in an average savings of $7 per patient (in the Australian healthcare system).
What It Means
Based on the results of this large well conducted multi-center trial, you can now respond to the nurses question with an evidence-based response. There is no need to change PIVs every 72-96 hours. Instead, symptom triggered removal and replacement, based on phlebitis, pain or malfunction are better triggers for changing PIVs. These results are in line with the major change in central venous catheters insertion and removal that resulted from a major study in the NEJM 20 years ago as well as several smaller studies in children. In addition to saving potential pain and suffering associated with repeated attempts at PIV insertion, this study suggests that adopting an as needed approach to changing PIVs may save healthcare dollars as well as nursing and physician time. The results of this trial should prompt the CDC to revise their current recommendations regarding PIVs. In addition, hospitals should consider revising their guidelines regarding the duration PIVs can stay in place.
Rickard CM et al. Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial. Lancet 2012 Sep 22;380(9847):1066-74.