38 / 68
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23(4)
:192–198
Sepsis is a systemic inflammatory response syndrome sec-
ondary to an infection.
16
The term phlebitis is used if one of the
following criteria was fulfilled: swelling and erythema >4mm, ten-
derness, palpable venous cord, pain or fever with local symptoms.
Isolated swelling is not defined as phlebitis.
Insertion
When?
PVC will be inserted when the duration of a given endovenous
therapy is expected to be shorter than 6 days and the PVC will
not be used for major procedures as hemodialysis, plasmapheresis,
chemotherapy, parenteral nutrition, monitoring or administration
of fluid large volumes. When any of these circumstances is to be
expected, it is preferable to insert a single-, double- or triple-lumen
central venous line (peripherally inserted or not) as the risk of
chemical phlebitis, the need for high-speed volume infusion or fre-
quent manipulations do not support a short catheter (
I-A
).
17,18
An
isolated transfusion does not need a central venous line insertion.
Before placing any venous line, even peripheral, it is mandatory the
evaluation of the actual need. Venous lines are often placed as rou-
tine; this meant to be an act reflecting the provision of care. It is also
frequently shown that to treat the patient a “prophylactic” line was
not mandatory. A study showed that up to 35% of peripheral venous
lines place in the emergency department are unnecessary.
19
Where?
A PVC can be inserted in every accessible vein. However, upper
extremity veins are preferable for patient comfort and lesser risk
of contamination. Some studies reported a higher risk of phlebitis
after lines were placed at the cubital crease, thus becoming prefer-
able avoiding this site in benefit of arm, forearm or dorsal aspect of
the hand/wrist
20,21
(
II-A
).
Furthermore, other patient-related factors like accessibility to
the venous system or comfort after insertion have to be taken into
account. It does not make much sense to insert a PVC onto a central
vein (
III-A
).
How?
The insertion of PVC must be performed under maximal aseptic
techniques. It is not necessary to prep a surgical field as it is the
when inserting a central venous line. The skin must be disinfected
with 2% alcoholic chlorhexidine solution or, if not available, with a
70% iodine or alcohol solution
9,22,23
(
I-A
).
The insertion site should not be touched after disinfection. The
catheter must be handled from its proximal end when inserted.
The caregiver inserting the PVC must previously perform hand
hygiene with water and soap and/or wash hands with alcohol
solution. Single-use clean gloves must be used. An enhanced asep-
sis is not required if the endovenous segment of the PVC is not
manipulated
9
(
III-B
). As it is the case when inserting central venous
lines, the use of additional protectionmeasures like facemask is not
recommended. However, this is a topic for consideration and analy-
sis if in a given institution higher than expected rates of PVC-related
bacteremia are observed.
Sterile gauze dressing or semi permeable transparent sterile
dressing to cover the insertion site will be used
23,24
(
II-A
). Ster-
ile gauze dressing will be inspected and replaced every other day
and transparent dressing should not stay in place over 7 days.
9
If
there is humidity, sweating or blood it is more appropriate to use
non-occlusive gauze dressing
24,25
(
III-B
). Revision or replacement
of dressing must be performed with single-use clean gloves.
9
Table 2
Checklist for an appropriate manipulation of peripheral catheters. If these are not
fulfilled, the prompt removal of the catheter is advised
(Evidence A)
.
-Insertion
- Correct hand hygiene
- Field disinfection
- Use single-use clean gloves
- Do not touch the insertion site
- Do not touch the endovenous segment of the catheter
- Sterile dressing (gauze or transparent)
-Manipulation
- Daily assessment of the need for the PVC
- Daily inspection of the insertion site
- Daily assessment of the function of the catheter
- Adequate replacement of infusion sets
-Catheter and events registry
- Fluid extravasation
- Presence of blood
- Inflammatory signs
- Dressing status
PVCs placed on urgent basis or without considering minimal
hygiene rules must be removed and replaced before 48 h to avoid
the risk of infection
17,26,27
(
II-A
).
The use of techniques facilitating identification of veins as laser
or ultrasound
28,29
in patients with poor venous flow are also rec-
ommended for insertion. However, these techniques do not reduce
the risk of infection. A meta-analysis on this topic showed that its
routine use is not justified
30
(
I-A
).
Checklist
The adhesion to recommendations in the form of checklist is
associated to better results in prevention of post-insertion compli-
cations after insertion of central venous lines and PVCs
10,31
(
I-A
).
This is reflected in Table 2.
Maintenance
The catheter and the need for usage have to be assessed daily.
It is advisable to remove the PVC if it is not necessary as the risk of
infection or phlebitis gradually increases as PVC days go by
18,32,33
(
II-A
). It is advisable to insert new PVC, if required, than keeping in
place an inactive line that might be useful at later stage.
The status of the insertion site must also be assessed daily,
seeking for eventual discomfort/symptoms at the endovascular
segment suggesting early stages of phlebitis and checking its func-
tional status. Phlebitis should be suspected if any of the following
signs develop: warmth, tenderness, erythema or palpable cord. In
an abnormality at the insertion site is detected, dressing must be
removed and the site inspected
34,35
(
III-A
). The catheter must then
be removed and its tip sent for Microbiology according to the cri-
terion of the attending physician
17
(
III-A
).
No antiseptic cream shall be used at the insertion point
36
(
III-C
).
Every manipulation of the catheter must be performed with
single-use clean gloves. There is no consensus on the type of con-
nectors to be used. It is preferable a three-way stopcock than caps
requiring connection-disconnection after every use. Closed connec-
tors for catheter access can be used as long as they are disinfected
with alcohol-impregnated wipes at every attempt to access the
catheter
37
(
II-A
).
Ameta-analysis revealed that there are no advantages of replac-
ing the infusion system earlier than 96 h
38,39
(
I-A
) other when they
are used for blood transfusion or infusion of lipid emulsions (should
this be the case, they have to be replaced every time). There is no
evidence that neither antibiotic prophylaxis at insertion nor the
antibiotic-lock are cost-efficient to keep PVC free from infection.