Analgesic Pump Tubing Securement to Prevent Dislodgement of Peripheral Vein Indwelling Catheter

AbstractPurpose

This study aims to compare the incidence of complications when using a new approach to secure an indwelling peripheral venous catheter (PVC), involving tying of the tube with a surgical knot at two places and several layers of elastic adhesive bandage, with a standard approach using sterile, transparent, and protective film.

Methods

This study enrolled 311 consecutive adults undergoing thoracoscopic lobectomy under general anesthesia at Taizhou Hospital of Zhejiang Province between October 2017 and May 2018. Patients were randomized to experimental and control groups and were followed for up to 72 hours. The primary endpoint was dislodgement of the PVC. Secondary endpoints were blood in the catheter; analgesia pump obstruction alarm; time taken and cost of PVC replacement; replacement of securing materials and analgesia pump line; and time and cost of replacing them. All adverse events were recorded.

Findings

Final analysis included 248 patients (experimental group: n = 126; control group: n = 122). PVC dislodgement was less frequent in the experimental group than in the control group. In the control group, 78.7% of patients required replacement of securing materials (costing 37 cents each time) and 13.1% required PVC replacement (costing 3.6 dollars each time), necessitating additional nursing time. No patients in the experimental group required replacement of the PVC or securing materials. Blisters were less common in the experimental group than in the control group (0% vs 9.84%, P < .001). No patients had limb edema.

Conclusions

This new method of securing an analgesia pump line can reduce traction on the indwelling PVC, lowering the dislodgement rate.

KeywordsVenous access is often an important component of patient care.Cheung E. Baerlocher M.O. Asch M. Myers A. Venous access: A practical review for 2009. Peripheral venous catheters (PVCs) are frequently used in the hospital setting, and around 50% to 80% of inpatients require a PVC,New K.A. Webster J. Marsh N.M. Hewer B. Intravascular device use, management, documentation and complications: A point prevalence survey.,Fernandez-Ruiz M. Carretero A. Diaz D. et al.Hospital-wide survey of the adequacy in the number of vascular catheters and catheter lumens. with more than a billion devices used worldwide each year.Carr P.J. Higgins N.S. Cooke M.L. Rippey J. Rickard C.M. Tools, clinical prediction rules, and algorithms for the insertion of peripheral intravenous catheters in adult hospitalized patients: A systematic scoping review of literature. However, the use of PVCs is associated with a variety of complications, including dislodgement, hematoma (because of blood leakage), thrombosis, phlebitis/thrombophlebitis (irritation/inflammation of the vein wall), infiltration (fluid leaking into surrounding tissue), occlusion, and local infection.Infusion Nurses Society
Infusion nursing standards of practice.Helm R.E. Klausner J.D. Klemperer J.D. Flint L.M. Huang E. Accepted but unacceptable: Peripheral IV catheter failure.Blanco-Mavillard I. Rodriguez-Calero M.A. de Pedro-Gomez J. Parra-Garcia G. Fernandez-Fernandez I. Castro-Sanchez E. Incidence of peripheral intravenous catheter failure among inpatients: Variability between microbiological data and clinical signs and symptoms. The rate of dislodgement was reported to be 50% to 55%.Miliani K. Taravella R. Thillard D. et al.Peripheral venous catheter-related adverse events: Evaluation from a multicentre epidemiological study in France (the CATHEVAL Project). Up to 50% of PVCs fail prematurely,Helm R.E. Klausner J.D. Klemperer J.D. Flint L.M. Huang E. Accepted but unacceptable: Peripheral IV catheter failure. and a variety of mechanistic factors are thought to contribute to PVC failure.Piper R. Carr P.J. Kelsey L.J. Bulmer A.C. Keogh S. Doyle B.J. The mechanistic causes of peripheral intravenous catheter failure based on a parametric computational study. The failure of a PVC necessitates its replacement, and this places additional burdens on nursing staff while increasing patient discomfort and overall treatment costs.Multimodal analgesia is widely used to reduce pain in patients after surgery.Chou R. Gordon D.B. de Leon-Casasola O.A. et al.Management of postoperative pain: A clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. Because the analgesic method often requires intravenous drug administration for up to 72 hours (and sometimes longer), delivered by an analgesic pump, peripheral venous access is a prerequisite. In clinical practice, the analgesic pump line (ie, the flexible tube connecting the pump to the indwelling PVC device) can exert traction on the indwelling venous catheter, causing deformation or dislodgement of the PVC. Standard fixation of a PVC device with a sterile, transparent, and protective film allows for free access to the catheter while reducing the incidence of infection.Nursing and prevention of common complications of venous indwelling needle. Although various additional devices and dressings have been used to secure PVCs with the aim of reducing complications, studies comparing these approaches have generally not been of sufficiently high quality to allow definitive conclusions to be drawn.Marsh N. Webster J. Mihala G. Rickard C.M. Devices and dressings to secure peripheral venous catheters to prevent complications. In particular, few prospective randomized controlled trials have been carried out to determine the best method of securing an analgesic pump line to reduce its traction on an indwelling PVC, and one that did compare different dressings found a high rate of failure for all dressings studied.Rickard C.M. Marsh N. Webster J. et al.Dressings and securements for the prevention of peripheral intravenous catheter failure in adults (SAVE): a pragmatic, randomised controlled, superiority trial.

The elastic adhesive bandage has been widely used in clinical practice to secure indwelling PVCs. In our experience, appropriate use of an elastic adhesive bandage is without adverse effects and can help to prevent inadvertent forces being transmitted to an indwelling catheter. We hypothesized that a novel method of securing an analgesic pump line, involving tying of the tube with a surgical knot at two places and use of several layers of elastic adhesive bandage, would reduce the incidence of complications such as dislodgement. Therefore, the aim of this prospective study was to compare the incidence of complications between our novel method of securing an indwelling PVC and a standard approach.

Materials and Methods Study Design

This was a prospective randomized controlled trial. Patients who had undergone thoracoscopic lobectomy under general anesthesia were selected because (1) the frequency of this procedure in our hospital was sufficiently high to allow the recruitment of a large sample size; (2) postoperative hospital stay and duration of analgesia pump use are generally greater than 3 days, permitting follow-up for 72 hours in most patients; and (3) they were without skin integrity, tortuous veins, large amount of hair on the area, and tape allergy.

 Setting and Sample

Consecutive patients who underwent thoracoscopic lobectomy under general anesthesia at the Department of Cardiothoracic Surgery, Taizhou Hospital of Zhejiang Province between October 2017 and May 2018 were enrolled. The inclusion criteria were (1) age 18 to 80 years old; (2) the presence of a lung mass; (3) thoracoscopic lobectomy carried out under general anesthesia; and (4) an analgesia pump was used postoperatively for 72 hours and/or more. The exclusion criteria were (1) previous chest surgery; (2) history of pleural infection; (3) severe pleural thickening or adhesions; (4) emergency lobectomy or severe disease; (5) change in surgical methods (eg, conversion to thoracotomy); (6) unable to tolerate surgery or single-lung ventilation because of poor cardiopulmonary function; (7) impaired consciousness; (8) analgesia pump discontinuation because of adverse reactions (including dizziness, nausea, and vomiting); (9) analgesia pump not used for at least 72 hours (eg, postoperative hospital stay of less than 72 hours); and (10) inability to fully cooperate with the study investigators (eg, because of impairment of hearing, speech, or intellectual capacity).

The incidences of dislodgement of the indwelling PVC in the experimental and control groups were estimated to be 1% and 20%, respectively. With two-sided significance set at 0.05 and power set at 90%, the sample size required to detect differences was 50. Considering a lost-to-follow-up rate of about 20%, we planned to enroll at least 62 patients for each group.

The patients were then randomly divided into two groups (experimental group and control group).

 Ethical Consideration

This study was approved by the ethics committee of our hospital. All patients enrolled in the study provided informed written consent.

 Randomization

A computer-generated random table was used to allocate the patients to their groups, and allocation concealment was achieved using sequentially generating numbers before the patients were included. Neither the patient nor the study investigators were blinded to the method used for securing the analgesia pump line.

 Data Collection Baseline Demographic and Clinical CharacteristicsThe following baseline data were collected: age, gender, height, weight, body mass index, serum albumin level, postoperative degree of sweating, site of the indwelling PVC, cost of the materials used to secure the analgesia pump line, and time required to secure the analgesia pump line. The degree of postoperative sweating was assessed because the presence of sweat can affect the adhesivity of the materials used to secure the PVC and analgesia pump line. The degree of sweating was classified as mild (increased sweating, but the underwear was dry), moderate (the underwear was sometimes soaked with sweat, but this was tolerated by the patient), or severe (the underwear was soaked by copious amounts of sweat, seriously affecting quality of life).Lai Y.T. Yang L.H. Chio C.C. Chen H.H. Complications in patients with palmar hyperhidrosis treated with transthoracic endoscopic sympathectomy. Follow-Up and Outcome Measures

All patients were followed up every 4 hours for 72 hours. The primary outcome measure was dislodgement (partial or complete) of the indwelling PVC. The secondary outcome measures were the presence of visible blood in the indwelling catheter; sounding of the analgesia pump alarm because of obstruction (with subsequent confirmation of catheter deformation and blockage); cost of replacement of the indwelling PVC; time required to replace the indwelling PVC; replacement of the materials securing the PVC and analgesia pump line; cost of replacing the materials securing the PVC and analgesia pump line; and time required to replace the materials securing the PVC and analgesia pump line. In addition, any occurrence of the following adverse events was noted: the presence of blisters (visible to the naked eye) or edema at the distal end of the fixation.

The placement of the first indwelling PVC was at the patient's expense; the costs of PVC replacement were borne by the hospital.

Procedures Methods Used to Secure the Analgesia Pump Line Experimental GroupTwo nurses, each with more than 15 years of professional experience, performed all the techniques used to secure the analgesia pump line in accordance with standard operating procedures every 4 hours (time point of 8, 12, 16, 20, and 24). The PVC was inserted and secured using Tegaderm film (3M Deutschland GmbH, Neuss, Germany). The analgesia pump line (Gemstar Pump Set tubing, 279 cm/5 mL; Hospira, Lake Forest, IL) was connected to the indwelling PVC (BD Intima II Closed IV Catheter System; Becton Dickinson Medical Devices Co Ltd, Jiangsu, China) so that it lay over the limb of the patient in a U-shaped configuration (Figure 1A). A 3M elastic adhesive bandage (3M Deutschland GmbH) was wrapped around the patient's limb to secure the U-shaped bend in the analgesia pump line to the limb (Figure 1B). Two pieces of adhesive tape (3M 2733-25; 3M Japan Ltd, Tokyo, Japan), each with an attached cord, were stuck onto the elastic adhesive bandage (Figure 1C). The analgesia pump line was looped over the two pieces of adhesive tape so that it was in a circular configuration, and surgical knots were used to secure the line with the two cords attached to the two pieces of adhesive tape (Figure 1D). Finally, several layers of elastic adhesive bandage were applied over the analgesia pump line (which was in a circular configuration) and around the patient's limb to secure the line in place (Figure 1E). The rationale behind this method of securing the analgesia pump line was that traction on the line would be resisted at three levels (with reference to Figure 1D and E: the knot on the left-hand side, the overlying elastic adhesive bandage, and the knot on the right-hand side), thereby reducing the risk of traction on the indwelling PVC and hence its dislodgement.Figure thumbnail gr1Figure 1Photographs to illustrate the methods used for securing the analgesia pump tube and indwelling PVC. (A) In the new method, the analgesia pump line was first connected to the indwelling PVC so that it lay over the limb of the patient in a U-shaped configuration. (B) An elastic adhesive bandage was wrapped around the limb to secure the U-shaped bend in the analgesia pump line to the limb. (C) Two pieces of adhesive tape, each with an attached cord, were stuck onto the elastic adhesive bandage. (D) The analgesia pump line was looped over the two pieces of adhesive tape so that it was in a circular configuration, and surgical knots were used to secure the line with the two cords attached to the two pieces of adhesive tape. (E) Several layers of elastic adhesive bandage were applied over the analgesia pump line (which was in a circular configuration) and around the patient's limb to secure the line in place. (F to K) Durapore tape was used to fix the line to the limb so that it lay in a U-shaped configuration. PVC, peripheral venous catheter. This figure is available in color online at www.jopan.org. Control GroupThe PVC and analgesia pump set tubing used were the same as for the experimental group. Insertion of the PVC was as for the experimental group. The path of the analgesia pump line was planned according to the position of the indwelling PVC. In accordance with standard methods used in our department, Durapore 1538-2 tape (3M) was used to fix the line to the limb so that it lay in a U-shaped configuration (Figure 1F). The control procedure can be seen in Figure 1G to K. Administration of Analgesia

The same analgesic drugs were used for patients in both the experimental and control groups. The formulation (300 mL total volume) contained 0.83 μg/mL of sufentanil and 1 mg/mL of flurbiprofen axetil. The analgesic drugs were intravenously infused by a Gemstar pump (Hospira) at a basal rate of 4 mL/h. The drug dosage could be temporarily increased (4 mL bolus, 20-minute lockout time) by the patient in response to the sensation of pain (patient-controlled analgesia). On an occasion, this led to the completion of analgesia administration several hours before the 72-hour follow-up period; in such cases, the patients were routinely observed for 4 to 8 hours, and the analgesia pump was only removed after it was confirmed that the patient was able to tolerate any remaining pain.

 Data AnalysisEpidata 3.1 software (www.EpiData.dk) was used to establish the database, and SPSS 21.0 (IBM Corp, Armonk, NY) was used for the statistical analysis. Normally distributed data are presented as the mean ± SD and were compared between groups using Student t test. Non-normally distributed data are presented as median (range) and were compared between groups using the Mann-Whitney U test. Count data are presented as n (%) and compared between groups using the χ2 test or Fisher exact test. PVC survival was analyzed using the Kaplan-Meier method and log-rank test. P Results Enrollment of the Study ParticipantsAmong 315 patients screened for inclusion, four were excluded before randomization. Thus, 311 patients were enrolled in the study, with 158 patients allocated to the experimental group (80 males) and 153 patients allocated to the control group (78 males). After randomization, 32 patients were excluded from the experimental group and 31 were excluded from the control group. Therefore, the final analysis included 126 patients in the experimental group and 122 patients in the control group. Patient enrollment is summarized in Figure 2.Figure thumbnail gr2

Figure 2Patient enrollment flowchart.

 Baseline Characteristics of the Study ParticipantsThe baseline demographic and clinical characteristics of the patients in the two groups are shown in Table 1. There were no significant differences between the experimental group (n = 126; 62 males) and control group (n = 122; 62 males) in patient age, gender, height, weight, body mass index, serum albumin level, degree of postoperative sweating, or position of the indwelling PVC (Table 1). However, the cost of the materials used to secure the analgesia line/PVC was higher, and the time required to carry out the procedure was significantly longer in the experimental group than in the control group (both P Table 1).

Table 1Baseline Characteristics of the Study Participants

BMI, body mass index; PVC, peripheral venous catheter.

 Primary and Secondary EndpointsThe main outcome measures were compared between groups and are shown in Table 2. The primary endpoint, partial or complete dislodgement of the indwelling PVC, was significantly less common in the experimental group than in the control group (0 vs 13.3%, P 

Table 2Primary and Secondary Outcome Measures

PVC, peripheral venous catheter.

 Adverse ReactionsBlisters were significantly less frequent in the experimental group than in the control group (0% vs 9.84%, P Table S1). PVC SurvivalKaplan-Meier analysis (Figure 3) revealed that indwelling PVC survival (ie, time to failure and replacement) was significantly longer in the experimental group than in the control group (P Figure thumbnail gr3Figure 3Kaplan-Meier analysis of indwelling catheter survival. Catheter survival was significantly longer in the experimental group than in the control group (P < .001, log-rank test). This figure is available in color online at www.jopan.org.Discussion

The main finding of the present study was that dislodgement of an indwelling PVC during a 72-hour postoperative period did not occur in any patients when analgesia pump line was secured using a new method we have developed. However, using of a standard approach resulted in 13.3% of patients who needed replacement of the PVC and 78.7% of patients who needed replacement of the securing material. This led to additional nursing time. Furthermore, blisters did not occur in patients in the experimental group, but occurred as an adverse effect in 9.84% of patients in the control group. Therefore, our new method can reduce traction on an indwelling PVC and lower the rate of dislodgement. We think our new approach may have potential in clinics to reduce the rate of PVC failure because of dislodgement.

Multimodal analgesia is often administered intravenously for 72 hours or longer. Some guidelines recommend that an indwelling PVC does not need replacing more frequently than every 72 to 96 hours,Webster J. Osborne S. Rickard C.M. Marsh N. Clinically-indicated replacement versus routine replacement of peripheral venous catheters. and they should be replaced only when clinical signs suggest the need. Thus, the life span of a PVC should ideally be at least 72 hours, and minimizing the rate of PVC failure during this period would reduce costs and ease the burden on nursing staff. Several factors can affect the longevity of fixation methods used to secure analgesia pump lines and PVCs. When conventional fixation methods are used, the adhesivity of the tape decreases with time and with the presence of sweat on the patient's skin.Improvement of intravenous indwelling needle fixation.,A new method for the fixation of indwelling needle on sweating skin. During body movements, such as turning over, traction on the analgesic pump line can cause accidental pulling on or deformation of the indwelling PVC, potentially causing partial or complete dislodgement of the catheter from the vein. Our new method of securing an analgesia pump line was developed using a large number of in vitro simulation tests and designed to provide three buffering actions against the effects of accidental traction (one buffering action provided by the elastic bandage and two provided by the surgical knots that tethered the tube to the adhesive tapes). Partial or complete dislodgement of the PVC occurred in none of the patients in the experimental group, showing that this fixation technique is effective at preventing accidental traction on the analgesia pump line being transmitted to the indwelling catheter. Improving the stability and life span of an indwelling PVC has several potential advantages. First, permitting uninterrupted analgesia to be delivered and avoiding the need for the insertion of replacement catheters improve patient comfort in the immediate postoperative period. Second, reduced costs were associated with replacement of the PVC and/or the materials used to secure it. Third, reducing the burden on nursing time. Fourth, because deformation and partial dislodgement can increase the risk of local infection,Investigation and analysis of how to reduce the incidence of nosocomial infection induced by central venous indwelling needle.,Velissaris D. Karamouzos V. Lagadinou M. Pierrakos C. Marangos M. Peripheral inserted central catheter use and related infections in clinical practice: A literature update. our new technique might also reduce the incidence of infection at the catheter site (although this was not assessed in the present study).It was notable that no patients in the experimental group experienced dislodgement of the catheter or obstruction. By contrast, dislodgement of the PVC occurred in 13.1% of patients in the control group, which was consistent with previous studies' incidences of 7.8% to 10.2%.Rickard C.M. McCann D. Munnings J. McGrail M.R. Routine resite of peripheral intravenous devices every 3 days did not reduce complications compared with clinically indicated resite: A randomised controlled trial.,Mestre G. Berbel C. Tortajada P. et al.Successful multifaceted intervention aimed to reduce short peripheral venous catheter-related adverse events: A quasiexperimental cohort study. The rate of obstruction in the control group (58.2%) was substantially higher than several other studies (10% to 12.4%).Miliani K. Taravella R. Thillard D. et al.Peripheral venous catheter-related adverse events: Evaluation from a multicentre epidemiological study in France (the CATHEVAL Project).,Ascoli G.B. Deguzman P.B. Rowlands A. Peripheral intravenous catheter complication rates between those indwelling >96 hours to those indwelling 72-96 hours: A retrospective correlational study.,Salgueiro-Oliveira A. Veiga P. Parreira P. Incidence of phlebitis in patients with peripheral intravenous catheters: The influence of some risk factors. The reason for this apparent discrepancy may reflect differences in the definition of obstruction. In our study, obstruction was defined as sounding of the infusion pump alarm and in most cases did not necessitate replacement of the PVC. Whereas in other investigations, obstruction may have been defined more strictly as mechanical dysfunction resulting in permanent catheter failure. The rate of blood return in the catheter was similar between the two groups in our study (8.7% to 10.7%) and comparable to the value of 13.1% determined by previous research.Miliani K. Taravella R. Thillard D. et al.Peripheral venous catheter-related adverse events: Evaluation from a multicentre epidemiological study in France (the CATHEVAL Project).

One disadvantage of our new method was higher initial cost, equivalent to 60 dollars per 100 patients. However, the additional cost of replacing the indwelling PVC in the control group (needed for 13 in every 100 patients at a cost of 3.6 dollars per patient) or fixation materials (needed in 78 in every 100 patients at 37 cents per patient) amounted to 75.7 dollars. The use of our method saved around 15.7 dollars per 100 patients. Similarly, although the novel procedure required more time to implement (a difference in median time of 112 seconds per patient), this was outweighed by the additional time required to replace dysfunctional PVCs or fixation materials when the conventional method was used (equivalent to around 200 seconds per patient when the rates of failure are taken into account). Thus, the overall cost and nursing time were lower when failure rates (and hence the need for replacements) were taken into consideration.

With regard to adverse reactions, neither group had any patients experiencing edema near the site of the PVC. Although patients in the experimental group had several layers of elastic bandage placed around the limb to secure the analgesia pump line, this was not associated with any increased risk of edema formation. It may be that the good elasticity of the bandage, which has been widely used in clinical practice for many years, means that it does not compromise the circulation in the distal limb if it is applied at an appropriate tightness. None of the patients in the experimental group developed blisters, whereas around 10% of the patients in the control group experienced blisters as an adverse reaction. This may have resulted from accidental traction on the analgesic pump line causing the fixed adhesive tape to exert excessive force on the skin; irritation from or allergy to the adhesive tape may also have contributed.Application of medical tape and 3L transparent dressing in body position arrangement in renal surgery.,Cause analysis of tension vesicle induced by transradial percutaneous coronary intervention and relevant nursing strategies. Although adhesive tape was more viscous and more firmly adhered to the skin, it is more likely to cause tension damage to the skin and cause blisters in the presence of an analgesic pump tubing.The related factors and nursing strategies for skin infection caused by venous indwelling needles in preterm infants.An additional factor worth noting was that, in our clinical experience, traction on the indwelling PVC occurs mainly during the night because of involuntary movements of the patient's body during sleep. This is the time at which the number of nursing staff on the wards is at a minimum, potentially delaying timely intervention for a dislodged PVC. Ineffective fixation of an indwelling PVC can increase the risk of infection.Mc Auliffe D. Karac A. Murphy N. The measurement of damage initiation, particle adhesion and cohesive strength from traction displacement curves of a nano-toughened epoxy. Thus, the new fixation method might potentially reduce the risk of infection.Limitations

This study has some limitations. First, this was a single-center study, so the generalizability of the findings is not known. Second, neither the patients nor the investigators were blinded to the intervention used, which may potentially lead to some bias. Third, only patients receiving continuous drug infusion for 72 hours were included, so the potential merits of the new technique in patients not receiving continuous intravenous infusion were not assessed. Fourth, the incidences of certain complications, such as local infection, phlebitis/thrombophlebitis, and infiltration, were not investigated. Further research is needed to confirm and extend our findings. Fifth, because of the influence of climate, the effect of sweat in summer on adhesive tape is relatively larger. Sixth, during the test, to avoid indwelling needle replacement caused by the indwelling needle quality itself, needle is only used to take the analgesic pump medicine, which can avoid the need of replacement because of the needle itself. All these limitations may be avoided by future large-scale, long-term, and multicenter studies.

Conclusions

In conclusion, this novel technique for fixing an analgesia pump line connected to an indwelling PVC can reduce traction on the catheter and lower the rate of dislodgement. We propose that our new method be adopted more widely in patients receiving intravenous drug infusion to reduce the rate of PVC failure because of dislodgement, which may be a potential treatment for clinical surgery.

Supplementary Data

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Table S1Adverse Reactions

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