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Accepted but Unacceptable

Peripheral IV Catheter Failure

2019 Follow-up

Helm, Robert E., MD

doi: 10.1097/NAN.0000000000000324
Features: Classic Article Update

EDITOR'S NOTE Still considered a “hot topic” 4 years later, JIN is pleased to reprint this classic article from May/June 2015, Issue 3. Since publication, “Accepted but Unacceptable: Peripheral IV Catheter Failure” has been downloaded nearly 400 times and cited dozens of times in other related research. Based on these data, we asked the lead author to update readers on the status of catheter failure and what has been improved since 2015.

Portsmouth Regional Hospital, Department of Cardiothoracic and Vascular Surgery, Portsmouth, New Hampshire.

Robert E. Helm, MD, is chief of cardiothoracic and vascular surgery at Portsmouth Regional Hospital in Portsmouth, New Hampshire.

The author has no conflicts of interest to disclose.

Years ago, as a cardiac surgeon involved in daily frontline patient care, I became cognizant of a pervasive problem and its impact on patient care: short peripheral catheter (SPC) failure. I had once again been called to see one of my preoperative patients awaiting valve surgery because of “severe phlebitis” at the catheter insertion site. A series of adverse events then followed, including disruptive cancellation of the scheduled surgery, removal and replacement of the SPC due to a clearly infected site, and local and systemic treatment of this presumed site infection knowing that a foreign body (a prosthetic valve) was to be inserted in the near future. On the basis of this patient experience, I decided to more closely examine the problem of SPC failure and to see if any new technology or set of optimized care practices could help reduce or even eliminate the problem of SPC failure.

I scoured all of the literature that I could find, trying to piece together why SPC failure occurs, and to hopefully find a better way to address this problem. “Accepted but Unacceptable: Peripheral IV Failure” was the result of these efforts. In reviewing the recent literature to write this follow-up, unfortunately 4 years later it is clear that the problem of SPC failure has yet to be solved.1 As my coauthors and I stated, the number of SPC failures would not be tolerated in the food processing or airline industries, so why is it tolerated in the most common inpatient procedure performed worldwide, a procedure that places a foreign body directly into the bloodstream, thereby creating a direct conduit from the outside world to the inside of the ailing human body? This remains unacceptable.

The good news is that 4 years later, this failure is far less accepted. Significant effort has been put forward by expert clinicians in the field, and by an industry that I believe strives to make product improvements. Having re-reviewed the literature that has been put forward since our article was published, my coauthors and I have several comments.

First, the underlying cause of SPC failure has not changed. It is the interaction of 2 basic forces applied over time: trauma and contamination. These 2 forces interact in varying degrees to cause the 5 general modes of SPC failure described in the literature and delineated in our article: infiltration, occlusion/mechanical failure, dislodgement, phlebitis, and infection. Viewing the cause of catheter failure helps to question and understand past long-standing beliefs and assumptions—for instance, that redness and warmth at the insertion site is noninfectious “phlebitis,” that “no touch” technique leads to a noncontaminated insertion site, and that a simple transparent dressing is adequate to fully stabilize and secure an SPC for a prolonged period of time. These assumptions have created clinical confusion regarding the true underlying cause of SPC failure, serving to slow forward progress. Viewing the cause of SPC failure as the end result of the forces of trauma and contamination serves to expose fundamental aspects of care that must be changed and optimized to truly decrease the rate of SPC failure.

If trauma is viewed as any force that shifts the SPC within the vein causing tissue injury or mechanical loss of the catheter, this points to the fact that improved catheter stabilization and securement is necessary to eliminate traumatic movement and its sequelae. But such stabilization must be introduced into the SPC care and management practices in a way that is clinically simple, highly reproducible, and cost-effective. Efforts are under way as new products are being developed.

If contamination is viewed as outside material including bacteria being allowed to enter the catheter lumen, catheter surface structure, skin tract, vessel wall penetration point, or vessel lumen and its contained bloodstream, then current insertion protocols that lead to multiple breakpoints in sterility are insufficient (as can be seen when analyzing the many online videos on the subject). Furthermore, the still most commonly used dressing—the simple transparent adhesive dressing with supportive tape—does not fully and durably protect the catheter insertion site from the external environment, a status quo that should be strongly questioned in the era of multiresistant superbugs—especially knowing that SPCs are used in the very places where these dreaded organisms are selected for and dwell (hospitals and other health care institutions). When transparent dressings are not applied and maintained properly, contamination at the insertion can occur, leading to preventable complications. While SPCs have been used for well over 75 years, is it acceptable knowing that 35% to 50% of them fail in the best of hands at the world's leading tertiary centers?

One fascinating aspect of SPC failure is the use of the word “phlebitis.” As my coauthors and I outlined, we believe that phlebitis is largely a misnomer—one that has significantly helped decrease progress in eliminating the general problem of SPC failure. Redness, warmth, pain, and even drainage at an insertion site are not the signs and symptoms of an inflamed vein well below the skin surface but, rather, a localized catheter skin insertion-site infection. Calling it “phlebitis” serves to artificially reduce the apparent incidence of SPC infection, protecting it from the scrutiny and analysis that would otherwise occur, and that could lead to true advances in technology and technique. When phlebitis is noted, the SPC is simply removed and replaced; an infection related to an SPC has far broader implications.

SPC insertion and care on the patient care units of my hospital unfortunately is much as it was 4 years ago when “Accepted but Unacceptable: Peripheral IV Catheter Failure” was first published. However, catheter failure and its sequelae are far less accepted, and the need for improvement is firmly recognized. By understanding the forces that lead to failure, and then systematically eliminating these forces through advances in technology and technique, catheter failure can be significantly decreased or even eliminated. Something acceptable indeed.

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1. Rickard C, Marsh N, Webster J, et al Dressings and securements for the prevention of peripheral intravenous catheter failure in adults (SAVE): a pragmatic, randomized, controlled superiority trial. Lancet. 2018;392(10145):419–430. doi:10.1016/S0140-6736(18)31380-1.
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