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Anaesthesia, 2002, 57, pages 921–925 .....................................................................................................................................................................................................................

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A dedicated intravenous cannula for postoperative use Effect on incidence and severity of phlebitis A. Panadero,1 G. Iohom,1 J. Taj,1 N. Mackay2 and G. Shorten3 1 Specialist Registrar, 2 Registered Nurse and 3 Professor of Anaesthesia and Intensive Care Medicine, Cork University Hospital, Cork, Ireland Summary

A prospective, randomised, controlled clinical study was performed to compare the incidence and severity of postoperative peripheral venous thrombophlebitis associated with a single intravenous cannula used for both intra-operative and postoperative purposes, and two cannulae, one used intra-operatively and the other postoperatively. Sixty American Society of Anaesthesiologists (ASA) physical status I or II patients aged 18–65 years undergoing elective surgery were studied. The technique of cannula insertion was standardised. After surgery, the cannulation sites were examined daily by a blinded investigator for the presence and severity of thrombophlebitis using the Baxter Scale. The two groups were similar in terms of age, gender, weight, type and duration of surgical procedures, and drugs and fluids administered both intra-operatively and postoperatively. The proportion of patients that developed phlebitis was significantly less in the two cannulae group (26.1%) than in the single cannula group (63.3%) (p < 0.0001). The severity of phlebitis was greater in the single cannula group than in the two cannulae group. These results indicate that the use of a dedicated cannula for postoperative use decreases the incidence and severity of postoperative, peripheral, cannula-related phlebitis. Keywords Catheterisation: peripheral venous, complications, thrombophlebitis. Infusions:

intravenous. Injections: intravenous. . ......................................................................................................

Correspondence to: Dr G. Iohom Accepted: 7 June 2002

Intravenous cannulation is the commonest invasive procedure performed in acute care hospitals and phlebitis is the most frequent complication of intravenous therapy [1, 2]. Phlebitis is defined as inflammation of the vein wall [3]. Infusion-related phlebitis is defined as local inflammation of a vein through which infusions have been administered [4]. When clot formation occurs at the cannula tip or along the inner wall of the vein, the condition is referred to as thrombophlebitis [5]. Several studies have demonstrated that 20–80% of patients receiving peripheral intravenous therapy develop phlebitis that requires removal of the cannula, insertion of a new cannula at a different site or treatment with analgesic drugs [3–7]. Thrombophlebitis can also lead to sepsis, septicaemia, acute bacterial endocarditis and even death [8–10]. Thrombophlebitis can take several weeks to resolve and, during this period, it can impair function in the affected limb [8–10]. The relative importance of 2002 Blackwell Publishing Ltd

recognised aetiological factors for thrombophlebitis has not been defined. Factors that have been reported to increase the risk of thrombophlebitis include material, length and bore of the cannula, operator skills at insertion, site and duration of cannulation, frequency of dressing changes, nature of the intravenous drug therapy, and patient factors such as age, race, gender and the presence of certain underlying diseases [1–10]. In most patients, an intravenous cannula is inserted immediately before surgery. In the postoperative period, these cannulae are retained for the administration of drugs, fluids and blood products [6]. An association has been demonstrated between postoperative cannula-related thrombophlebitis and the intra-operative use of the same cannula [5, 7]. Drugs administered intra-operatively may be an important factor in determining the incidence and severity of thrombophlebitis at peripheral intravenous sites after surgery. 921

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The objective of this study was to examine the effect on the incidence and severity of postoperative phlebitis of the insertion of an additional ÔnewÕ peripheral cannula at the end of the surgical procedure, the new cannula being used exclusively for the postoperative administration of drugs and fluids. Methods

With local research ethics committee approval and written informed consent, 60 ASA physical status I or II patients aged 18–65 years undergoing elective, nonambulatory, nononcological surgery, who were expected to need only one peripheral venous cannula, were studied. Patients with a history of thrombophlebitis, those who were immunocompromised and those receiving chemotherapy were not studied. An experienced anaesthetist inserted an 18G Vialon cannula (Insyte, Becton Dickinson, UT, USA) in a vein on the dorsum of each patient’s hand immediately before surgery. An intravenous line extension set was attached to the cannula to decrease cannula movement from hub manipulation. This cannula was used intra-operatively for the induction of anaesthesia and for fluid and drug administration. The insertion technique was standardised as follows: the skin was cleaned with an alcohol swab (Steret, Seton Healthcare, Oldham, UK). The cannula was inserted percutaneously without prior skin incision, after subcutaneous infiltration with lidocaine 1%. The insertion site was covered with a transparent adhesive dressing (Tegaderm i.v., 3M HealthCare Ltd, MN, USA). This dressing was chosen to ensure fixation of the cannula to the skin and to allow easy visualisation of the insertion site. Once applied, the dressing was not disturbed until removal of the cannula. Cannulae were removed by the nursing staff when they were no longer clinically required. The investigator took no part in determining the nature or mode of administration of intravenous drugs or fluids either intra-operatively or postoperatively. The patients were randomly assigned to one of two groups. The single cannula group had a single intravenous cannula that was used before, during and after surgery. A nontransparent adhesive dressing was applied to the corresponding site on the patient’s contralateral hand. The two cannulae group had one cannula inserted for use before and during surgery, and a second cannula inserted in a similar manner to the first in the contralateral hand at the end of surgery. This second cannula was used for all postoperative drug and fluid administration. The first cannula was removed and its insertion site was covered with a nontransparent adhesive dressing. During the postoperative period, the intravenous cannulation sites on both hands were examined daily 922

until the cannula in use was removed by a single investigator blinded to group allocation. The severity of thrombophlebitis was scored according to the Baxter Scale [11] (Table 1). All drugs and fluids administered through the cannula and the duration of cannula usage were recorded. The sample size was based on the use of the unpaired, one-tailed Student’s t-test, with a ¼ 0.05 and b ¼ 0.2. Peripheral cannula-related phlebitis occurs in 55% of patients during the first few days after pre-operative insertion [1, 5, 6], and in 20% of patients during the first few days after insertion of an intravenous cannula for general use [3, 12–17]. This value was used as an estimate of the proportion of patients with a dedicated postoperative cannula who would develop phlebitis. The estimated minimum sample size was 23 patients in each group. The data were analysed using unpaired, one-tailed Student’s t-test with p < 0.05 taken to indicate statistical significance. Non-parametric data were analysed using the Chi-squared test or Fisher’s exact test as appropriate. Results

The two groups were similar in terms of age, gender, weight, type and duration of surgical procedures (Table 2), and drugs and fluids administered intra-operatively and postoperatively (Table 3). Of 60 patients recruited, data from seven were excluded due to breaches of study protocol. All excluded patients were in the two cannulae group. The duration of the study, i.e. the time from surgery to the removal of the intravenous cannula used after surgery, was similar in the two groups (Table 4). On each occasion, the cannula was removed because it was no longer required and not because of thrombophlebitis. Table 1 The Baxter Scale for grading the severity of phlebitis

[11]. Grade

Description

0

No pain at intravenous site, no erythema, no induration, no palpable venous cord Painful intravenous site or erythema, no swelling, no induration, no palpable venous cord Painful intravenous site with erythema or some degree of swelling or both, no induration, no palpable venous cord Painful intravenous site with erythema, swelling and induration or a palpable venous cord < 3 inches above the intravenous site Painful intravenous site with erythema, swelling, induration and a palpable venous cord > 3 inches above the intravenous site Frank vein thrombosis and all the signs of grade 4 above. Intravenous infusion may have stopped running owing to thrombosis

1 2 3

4

5

2002 Blackwell Publishing Ltd

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Table 2 Patient characteristics, duration of surgery and surgical

Table 4 Duration of the study. Values are number of patients

procedures. Values are mean (SD) or median [range].

(%).

Age; years Gender; M:F Weight; kg Duration of surgery; min Surgical procedures Abdominal Pelvic Lower limb

Single cannula group n ¼ 30

Two cannulae group n ¼ 30

44.5 [21–65] 11:19 67.5 [46–93] 126.2 (65)

41.0 [23–65] 12:18 72 [47–96] 121.5 (59)

18 3 9

13 8 9

Postoperative day on which the study was discontinued



Day Day Day Day

13 11 3 3

7 13 1 2

1 2 3 4

(43) (37) (10) (10)

(30) (57) (4) (9)

Table 5 Postoperative day on which thrombophlebitis was first

noted. Values are number of patients (%). Table 3 Intravenous drug and fluid therapy given. Values are

number of patients. Single cannula Two cannulae group group n ¼ 30 n ¼ 30 Intra-operative Antibiotics 14 Fluids Ringer lactate 23 Ringer lactate + Gelofusine 7 Packed red blood cells 1 Induction agents Propofol 25 Thiopental 3 Neuromuscular blocking drugs Vecuronium 14 Atracurium 5 Non-steroidal anti-inflammatory drugs 8 Opioids 30 Postoperative Antibiotics Fluids Ringer lactate Ringer lactate + dextrose saline



Day Day Day Day

12 6 0 1

4 2 0 0

1 2 3 4

(40.0) (20.0) (0.0) (3.3)

(17.4) (8.7) (0.0) (0.0)

16 21 2 0

Table 6 Severity of phlebitis. Values are number of patients (%).

22 1

Grade of severity (Baxter Scale)



11 6 5 23

0 1 2 3 4 5 Total 1–5

11 9 9 1 0 0 19

17 2 2 1 1 0 6

3

4

26 4

22 1

The overall incidence of thrombophlebitis, i.e. veins with any degree of thrombophlebitis, was 47.1%. No patient in the two cannulae group developed phlebitis at the site of the removed cannula. In the single cannula group, a greater proportion of patients developed thrombophlebitis on postoperative days 1 (40%) and 2 (20%) than on days 3 (0%) or 4 (3.3%) (p < 0.0001). In the two cannulae group, 17.4 and 8.7% of patients developed thrombophlebitis on postoperative days 1 and 2, respectively. No new thrombophlebitis was noted on days 3 or 4 in the two cannulae group (Table 5). Table 6 displays the severity of phlebitis in each group. More patients developed Grades 1 or 2 phlebitis in the single cannula group (60%) than in the two cannulae group (17.4%) (p < 0.0001). More patients in the two cannulae group had no signs of thrombophlebitis than in 2002 Blackwell Publishing Ltd

Postoperative day on which the study was discontinued

(36.7) (30) (30) (3.3) (0) (0) (63.3)

(73.9)* (8.7)* (8.7)* (4.3) (4.4) (0) (26.1)*

*p ¼ 0.0001 between groups (Fisher’s exact test).

the single cannula group (73.9 and 36.7%, respectively, p ¼ 0.0001). The proportion of patients who developed phlebitis (of any grade) was less in the two cannulae group (26.1%) than in the single cannula group (63.3%) (p < 0.0001). Discussion

The most important finding of our study is that the incidence of phlebitis was lower in patients in whom an additional cannula was inserted at the end of surgery specifically for postoperative use (26.1%) compared with patients in whom the same cannula was used both intraoperatively and postoperatively (63.3%). Our results are consistent with those of other authors. Gaukroger et al. [5] found an overall incidence of thrombophlebitis of 51.9% in cannulae used for 923

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anaesthetic, i.e. intra-operative, and postoperative purposes. Maki & Ringer [6] reported a 41.8% incidence of phlebitis in a group of 441 patients with peripheral cannulae, of which approximately one-third were inserted in the operating theatre before surgery. The results in the two cannulae group are similar to results reported by other authors studying cannulae used only for ÔmedicalÕ purposes. Campbell [17] found an incidence of phlebitis of 26% in 90 ÔmedicalÕ patients. Bregenzer et al. [16] reported an incidence of phlebitis of 19.7% in a total of 609 patients with peripheral intravenous catheters. Rypins et al. [15] found an 18% (84 ⁄ 456 patients) incidence of phlebitis in ÔnonsurgicalÕ patients with no peripheral intravenous hyperalimentation. The cannulae in our study were in situ for 24–96 h. Our results indicate that phlebitis is more likely to occur within 48 h of cannula insertion. This is in accordance with other authors’ findings [5, 17], but contrary to those of Maki & Ringer [6], who found that prolonged (> 48 h) catheterisation carried a higher relative risk for phlebitis (1.79). The difference may be explained by the definition of phlebitis used. Maki & Ringer defined phlebitis as the presence of Ôtwo or more of: pain, tenderness, erythema, swelling, purulence and palpable venous cordÕ. However, these criteria are less rigorous than ours. Several factors determine the likelihood of a vein developing infusion-related thrombophlebitis. Mechanical trauma certainly plays an important role [4, 8]. Vascular endothelium mediates the balance between intravascular thrombosis and thrombolysis, and thrombogenesis is activated by endothelial damage [8]. Vascular endothelial damage is associated with cell necrosis and decreased endothelial anticoagulant activity. Endothelial abrasion is associated with rapid platelet aggregation, which reduces blood flow [8]. Some authors highlight the potential risks associated with the insertion of cannulae in Ôa rough mannerÕ, by an Ôunskilled personÕ or Ôin a hurryÕ, as might occur in an emergency situation [5]. The experience of the person establishing venous access clearly influences the risk of the development of phlebitis [6]. Poor anchorage of cannulae with tape or dressings appears to increase the risk of development of phlebitis [3, 4]. Certain cannula materials appear to increase the risk of phlebitis [4, 5]. For instance, Vialon cannulae are substantially less phlebitogenic than are Teflon cannulae [5]. Cannulae inserted into areas of joint flexion or rotation may slide back and forth, or may roll inside the vein, thereby injuring the vein wall [12]. In our study, the insertion and anchorage of the cannulae were strictly standardised and were performed by a single investigator. Chemical phlebitis occurs due to injury to the vein wall by chemical irritants such as infusion fluids. Both a low pH 924

and a high osmolarity of intravenous fluids and medications are reported to be associated with chemical phlebitis [13]. Additives such as potassium chloride, antibiotics and cytotoxic drugs can produce severe venous inflammation [17, 18]. The presence of particulates in infusion fluids has been cited as a major cause of chemical phlebitis [17]. In the intra-operative period, cannulae are used for the rapid administration of a large number of drugs and fluids. Therefore, they are considered to be more at risk of inducing infusion thrombophlebitis. Our results suggest that the use of a dedicated cannula for postoperative use may decrease both the incidence and severity of postoperative peripheral cannula-related thrombophlebitis. Patients at risk of developing infusion thrombophlebitis may benefit from this simple manoeuvre. References 1 Knitsch W, Schultz A, Schultz B, Heiringhoff KH, Pichlmayr I. Complications of intravenous therapy with peripheral indwelling catheter. Geburtshilfe Frauenheilkunde 1990; 50: 40–2. 2 Stonehouse J, Butcher J. Phlebitis associated with peripheral cannulae. Professional Nurse 1996; 12: 51–4. 3 Sherertz RJ, Stephens JL, Marosok RD et al. The risk of peripheral vein phlebitis associated with chorhexidinecoated catheters: a randomised, double-blind trial. Infection Control and Hospital Epidemiology 1997; 18: 230–6. 4 May J, Murchan P, MacFie J et al. Prospective study of the aetiology of infusion phlebitis and line failure during peripheral parental nutrition. British Journal of Surgery 1996; 83: 1091–4. 5 Gaukroger PB, Roberts JG, Manners TA. Infusion thrombophlebitis. A prospective comparison of 645 Vialon and Teflon cannulae in anaesthetic and postoperative uses. Anaesthesia and Intensive Care 1988; 16: 265–71. 6 Maki DG, Ringer M. Risk factors for infusion-related phlebitis with small peripheral venous catheters. A randomised controlled trial. Annals of Internal Medicine 1991; 114: 845–54. 7 Russell WJ, Micik S, Gourd S, Mackay H, Wright S. A prospective clinical comparison of two intravenous polyurethane cannulae. Anaesthesia and Intensive Care 1997; 25: 42–7. 8 Everitt NJ, Krupowicz DW, Evans JA, McMahon MJ. Ultrasonographic investigation of the pathogenesis of infusion thrombophlebitis. British Journal of Surgery 1997; 84: 642–5. 9 Maki DG, Goldman DA, Rhame FS. Infection control in intravenous therapy. Annals of Internal Medicine 1973; 79: 876–87. 10 Lewis GB, Hecker JF. Infusion thrombophlebitis. British Journal of Anaesthesia 1985; 57: 22–33. 11 Baxter Healthcare Ltd. Principles and Practice of I V Therapy. Compton, UK: Baxter Healthcare Ltd, 1988.


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12 Hessov I. Prevention of infusion thrombophlebitis. Acta Anaesthesiologica Scandinavica 1985; 82: 33–7. 13 Turco SJ. Phlebitis associated with intravenous drug administration. Bulletin of Parenteral Drug Association 1975; 29: 89–97. 14 Feldstein A. Detect phlebitis and infiltration before they harm your patient. Nursing 1986; 16: 44–7. 15 Rypins EB, Johnson BH, Reder B, Sarfeh IJ, Shimoda K. Three-phase study of phlebitis in patients receiving peripheral intravenous hyperalimentation. American Journal of Surgery 1990; 159: 222–5.


16 Bregenzer T, Conen D, Sakmann P, Widmer AF. Is routine replacement of peripheral catheters necessary? Archives of Internal Medicine 1998; 158: 151–6. 17 Campbell L. IV-Related phlebitis, complications and length of hospital stay: 2. British Journal of Nursing 1998; 7: 1364– 73. 18 Garland JS, Nelson DB, Cheah TE, Hennes HH, Johnson TM. Infectious complications during peripheral intravenous therapy with Teflon catheters: a prospective study. Pediatric Infectious Diseases Journal 1987; 6: 918–21.

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