RESEARCH

BMJ: first published as 10.1136/bmj.a339 on 8 July 2008. Downloaded from https://www.bmj.com/ on 5 January 2025 at Dong-A University. Protected by copyright.
Routine care of peripheral intravenous catheters versus
clinically indicated replacement: randomised controlled trial
Joan Webster, nursing director, research; adjunct professor,1,2 Samantha Clarke, clinical nurse,1
Dana Paterson, research nurse,1 Anne Hutton, clinical nurse,1 Stacey van Dyk, research nurse,1
Catherine Gale, intravenous nurse specialist,1 Tracey Hopkins, clinical nurse consultant, intravenous
service1

1
Centre for Clinical Nursing, Royal ABSTRACT infection of the bloodstream, occurs in about 0.1% of
Brisbane and Women’s Hospital, Objective To compare routine replacement of intravenous cases.9
Herston, Qld 4029, Australia
2 peripheral catheters with replacement only when clinically Many interventions have been developed to reduce
Research Centre for Clinical and
Community Practice Innovation indicated. the incidence of phlebitis, including new catheter
Griffith University, Centre for Design Randomised controlled trial. materials,10 11 innovative methods for securing the
Clinical Nursing, Royal Brisbane
and Women’s Hospital
Setting Tertiary hospital in Australia. catheter,12 13 and heparinised catheters.14 The most
Correspondence to: J Webster Participants 755 medical and surgical patients: 379 widely practised intervention, however, is routine
[email protected] allocated to catheter replacement only when clinically replacement of the catheter. The Centers for Disease
indicated and 376 allocated to routine care of catheter Control and Prevention advocate replacing catheters
Cite this as: BMJ 2008;337:a339
doi:10.1136/bmj.a339 (control group). every 72-96 hours to limit the potential for infection,15
Main outcome measure A composite measure of catheter but the recommendation is based on scant evidence.16
failure resulting from phlebitis or infiltration. More recent observational studies indicate that cathe-
Results Catheters were removed because of phlebitis or ters may be safely left in place for longer periods.1 7 11 17
infiltration from 123 of 376 (33%) patients in the control Some evidence also suggests that phlebitis is more
group compared with 143 of 379 (38%) patients in the likely to occur in the two days after catheterisation.1 17 18
intervention group; the difference was not significant Consequently, removing a functional catheter and re-
(relative risk 1.15, 95% confidence interval 0.95 to 1.40). siting it might expose patients to unnecessary risk.
When the analysis was based on failure per 1000 device Despite the ubiquitous use of peripheral intravenous
days (number of failures divided by number of days catheters and the almost universal acceptance of the
catheterised, divided by 1000), no difference could be need for routine replacement, the practice has received
detected between the groups (relative risk 0.98, 0.78 to little rigorous evaluation. We found a total of four
1.24). Infusion related costs were higher in the control randomised controlled trials comparing some form of
group (mean $A41.02; £19.71; €24.80; $38.55) than routine catheter replacement with peripheral venous
intervention group ($A36.40). The rate of phlebitis in both infusion. Two of these trials were small, carried out in a
groups was low (4% in intervention group, 3% in control gastroenterology unit of Scarborough Hospital in the
group). United Kingdom, and enrolled patients only receiving
Conclusion Replacing peripheral intravenous catheters total parenteral nutrition through a peripheral venous
when clinically indicated has no effect on the incidence of catheter.19 20 Because of the uniqueness of this group,
failure, based on a composite measure of phlebitis or results are not relevant to the current discussion. The
infiltration. Larger trials are needed to test this finding third study was carried out in the same unit of the
using phlebitis alone as a more clinically meaningful Scarborough Hospital.21 It was the first trial to compare
outcome. outcomes between groups in a general hospital
Registration number Australian New Zealand Clinical population where the peripheral catheter was either
Trials Registry ACTRN12605000147684. routinely replaced or changed only when clinically
indicated. In the control group (n=26), peripheral
INTRODUCTION venous catheters were replaced every 48 hours and in
Intravenous catheterisation is the most common the intervention group removed “if the site became
invasive procedure among patients admitted to hospi- painful, the cannula dislodged or there were signs of
tal, with about half receiving intravenous therapy peripheral vein thrombosis” (n=21). Phlebitis occurred
during their stay.1 The procedure is not without risks. in 1 (5%) patient in the control group and 11 (42%) in
Between 2.3% and 67% of patients develop throm- the intervention group. The study was criticised for its
bophlebitis; the rate depending on definitions used and small sample size (sample size and power estimates
populations studied.2-8 The more serious complication, were not reported) and the involvement of the chief
BMJ | ONLINE FIRST | bmj.com page 1 of 6
 RESEARCH

investigator in both the randomisation process and the As a follow-up to this study we carried out a

BMJ: first published as 10.1136/bmj.a339 on 8 July 2008. Downloaded from https://www.bmj.com/ on 5 January 2025 at Dong-A University. Protected by copyright.
outcome assessment.22 Moreover, the incidence of randomised trial to compare routine changes of
phlebitis in the intervention group was much higher catheters with clinically indicated changes among a
than contemporary rates. broader group of acute patients admitted to hospital.
We recognised the need to test current standards We used a pragmatic design that excluded few patients
using an appropriately powered randomised con- and that was carried out under routine hospital
procedures. We tested the safety and efficacy of the
trolled trial. In March 2004 we began a study using a
process on a wider population.
small sample to compare the safety and efficacy of
replacing intravenous catheters after three days with
METHODS
only when clinically indicated.23 Challenging the
We recruited inpatients from a general tertiary referral
guidelines from the Centers for Disease Control and
teaching hospital (982 beds) with several specialties,
Prevention made the trial controversial and so we including medicine, surgery, orthopaedics, psychiatry,
limited our sample to patients in whom the catheter had oncology, obstetrics, gynaecology, and trauma ser-
been inserted by the intravenous therapy team; a group vices. The hospital is the largest in Queensland,
of nurses with extensive collective experience and Australia, and provides services to patients throughout
expertise in the area. Also we excluded patients who the state, northern New South Wales, the Northern
were immunocompromised, had a current blood- Territory, and from neighbouring countries in the
stream infection, or were unable to sign consent. We south west Pacific. Patients were eligible for inclusion if
randomised participants into two groups (routine care they were at least 18 years of age, had no current
of the catheter or replacing the catheter only when bacteraemia, were not receiving immunosuppressive
clinically indicated) and used a composite measure of therapy, and were scheduled or expected to have a
any unplanned reason for removal of the catheter as peripheral venous catheter for at least four days. As the
our primary outcome, including phlebitis, blockage, or patient was the unit of measurement for the study we
infiltration. The secondary outcome was cost. Among entered patients requiring multiple or consecutive
the 206 participants studied we found no significant catheters into the study once only. In the earlier trial we
differences between groups on the primary outcome. had to exclude many, otherwise eligible, participants
The duration of peripheral catherisation was similar in because an altered mental state prevented them from
both groups (mean 123.3 hours in the intervention giving informed consent. For the current trial we
group, mean 125.9 hours in the control group) but sought permission from the hospitals’ human research
significantly more re-siting occurred in the control ethics committee for the next of kin to sign for patients
group (166 resites in the intervention group, 216 resites who were unable to consent themselves.
in the control group). Three cases of phlebitis occurred
Intervention, allocation concealment, and masking
(one in the intervention group, two in the control
We randomised patients either to routine care (control
group).
group), with catheters scheduled to be replaced every
three days according to hospital policy, or to a group
where the peripheral intravenous catheter was not
Potentially eligible participants (n=1620) replaced unless there was a clinical indication (clini-
cally indicated group). Irrespective of the assignment, a
Reasons for exclusion (n=865): decision to change a catheter at any time because of
Enrolment

Did not want to participate (n=159)

Altered mental state (n=393) clinical indications such as phlebitis, infiltration, or
Too ill (n=190) unexplained fever could be implemented. We
Language barrier (n=123)
recorded the reason for replacement of catheters and
deviations from the catheter replacement protocol for
Randomised (n=755)
each group.
Block randomisation was by a computer generated
random number list prepared by an investigator with
Allocation

Allocated to intervention group (n=379) Allocated to control group (n=376) no clinical involvement in the trial. We stratified by
Received allocated intervention (n=357) Received allocated intervention (n=376) admission for an oncology related procedure. After the
Routinely changed (n=22)
research nurse had obtained the patient’s consent, she
telephoned a contact who was independent of the
recruitment process for allocation consignment.
Follow-up

Number completing trial (n=379) Number completing trial (n=376) Allocation concealment avoided selection bias but
clinical staff were subsequently aware of the treatment
group. This was necessary to ensure that catheters
scheduled for routine replacement were changed and
Analysis

Number analysed (n=379) Number analysed (n=376) that those in the clinically indicated group were not
removed if the catheter was functional and there was no
sign of local inflammation or infection. Research staff
Flow of participants through trial had no involvement in nominating the reason for
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 RESEARCH

catheter removal or in diagnosing phlebitis. Staff in the permeation of intravenous fluid into the interstitial

BMJ: first published as 10.1136/bmj.a339 on 8 July 2008. Downloaded from https://www.bmj.com/ on 5 January 2025 at Dong-A University. Protected by copyright.
microbiological laboratory were blind to group assign- compartment, causing swelling of the tissue around the
ment of catheters submitted for testing. site of the catheter.
We used several secondary outcomes including
Procedures infusion related cost, which was calculated in two
After consent and randomisation the research nurse ways—costs associated with catheters inserted for the
collected baseline personal, clinical, and catheter intermittent administration of intravenous drugs, and
related data, which included the type of infusate and cost associated with catheters inserted for continuous
any additives, drugs injected into the intravenous set infusion. For patients receiving intermittent drugs
and their pH level, type and size of catheter used, and (estimated to be 52% of the population on the basis of
the site of insertion. Choice of catheter type and gauge data from the earlier trial) we calculated a total cost of
was at the discretion of the nurse or doctor inserting the $A16.4. This included 20 minutes nursing per medical
catheter. Catheter insertion sites were inspected daily time (locating patient, preparation, and insertion), a
by a nurse from the intravenous therapy team and by catheter, a three way tap, a basic dressing pack, gloves,
ward nurses when intravenous solutions were changed a syringe, transparent adhesive dressing, skin disinfec-
or when drugs were added. Because research staff were tion, and local anaesthetic per insertion. For patients
not responsible for recording the reason for catheter receiving a continuous infusion we calculated a total
removal, a specially designed form was developed for cost of $A28.84 per insertion. This included the costs of
completion by the nurse removing the cannula. This the initial cathether set plus the cost of replacing
was to optimise the standardisation of reporting associated lines, solutions, and additives, which are
outcome measures. discarded when a catheter is replaced (intravenous
administration set, 1 litre sodium chloride 0.09%). We
Any deviations from the protocol were recorded (if
also included other reasons for catheter failure as
the catheter was replaced at a time other than indicated
secondary outcomes: occlusion or blockage, local
by the allocated group). We collected data for up to five
infection at the insertion site (defined as erythema
consecutive catheters for each patient.
with cellulitis at the site or pus at the site), or catheter
related bloodstream infection (on the basis of the
Outcome measures
isolation of a phenotypically identical organism from a
For the primary outcome we used a composite measure catheter segment and a blood culture).11 We also
of catheter failure as a result of phlebitis or infiltration. included phlebitis and infiltration as independent
Phlebitis was defined as the presence of two or more of secondary outcomes.
pain, tenderness, warmth, erythema, swelling, or a
palpable cord. 1 -2 5 Infiltration was defined as Statistical analysis
We based our sample size on the combined incidence
Table 1 | Baseline personal, clinical, and catheter related details of patients allocated to routine of phlebitis and infiltration in controls from our earlier
care of intravenous catheter (control group) or to replacement of catheter only when clinically study (33.5%).23 To detect a difference of at least 30%
indicated (intervention group). Values are numbers (percentages) of patients unless stated between groups with a two sided test, α of 0.05, and 90%
otherwise power we determined that we needed about 380
Intervention group patients in each arm.
Variable (n=379) Control group (n=376)† Trial data were entered using SPSS version 15 and
Mean (SD) age (years) 60.1 (17.1) 58.8 (18.8) analysed on an intention to treat basis (all randomised
Male 248 (65) 233 (62) patients were analysed in the assigned groups). A
Type of admission: validity check was undertaken on a random sample of
Medical 238 (63) 214 (57) 5% of the data. We compared baseline clinical and
Surgical 141 (37) 162 (43) personal characteristics to test adequacy of the
>1 comorbidity 280 (74) 270 (72) randomisation process. We calculated the relative
Oncology related condition 55 (15) 56 (15)
risks and 95% confidence intervals for the proportion
Current wound infection (including ulcers) 100 (26) 70 (19)
of patients with a failed catheter and for the individual
History of phlebitis 13 (3) 4 (1)
factors that made up the composite measure. We also
calculated the failure rate for each group per 1000
Indwelling urinary catheter 63 (17) 79 (21)
device days, which is a more meaningful measure for
Wound drain 72 (19) 43 (11)
this outcome, by dividing the total number of catheter
Mean (SD) haemoglobin level on admission 126.4 (23.7) 124.5 (23.5)
failures by the total number of days catheterised,
Skin turger fair or poor 233 (62) 228 (61)
multiplied by 1000. When appropriate, we used a two
High risk of acquiring nosocomial infection 36 (10) 30 (8)
sided Fisher’s exact test to compare discrete data;
Poor veins 127 (34) 143 (38)
results are presented as P values. We used the
Catheter inserted by:
independent sample t test to compare the differences
Intravenous team 502 (74) 563 (74)
in the infusion related costs and total catherisation time
Medical officer 66 (10) 58 (8)
between the groups. The guidelines for the consoli-
Other nurse (not intravenous team) 113 (17) 140 (18) dated standards of reporting trials26 were followed from
Person inserting catheter was unknown in 14 instances. the point of recruitment.
BMJ | ONLINE FIRST | bmj.com page 3 of 6
 RESEARCH

history of phlebitis and presence of a wound infection

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Table 2 | Mean (SD) length of time each catheter remained in place in patients allocated to routine
care of intravenous catheter (control group) or to replacement of catheter only when clinically or infected ulcer, with higher rates in the intervention
indicated (intervention group) group.
Group No Mean (SD) Mean difference (95% CI) P value*
Each catheter was in place for a greater mean length
of time in the intervention group than in the control
Control 372 66.5 (28.1)
−24.12 (−130.53 to −17.71) <0.000 group (table 2). As a result more catheters were placed
Intervention 379 90.6 (56.5)
in the control group (n=749) than in the intervention
Control 190 59.7 (30.6)
−14.98 (−23.94 to −6.01) 0.001 group (n=679), despite the average number of intra-
Intervention 161 74.7 (53.3)
venous therapy days being less in the control group (t=
Control 102 55.7 (28.1)
−17.49 (−30.24 to −4.74) 0.007 −2.77, P=0.007; two sided t test): 6.3 (SD 5.1) days in the
Intervention 82 57.3 (73.2)
intervention group and 5.4 (SD 3.8) days in the control
Control 52 60.4 (34.7)
−26.74 (−50.22 to −3.26) 0.026 group. The total number of days catheterised were
Intervention 34 87.1 (73.7)
2020 in the control group and 2393 in the intervention
Control 33 57.6 (33.8) group.
−3.67 (−25.81 to 18.47) 0.741
Intervention 23 61.2 (49.0)
*Two sided t test. Effect of intervention
Table 3 shows rates for the primary and secondary
RESULTS outcomes. Overall, 123 (33%) participants in the
Between February 2006 and June 2007, 755 of 1620 control group and 143 (38%) in the intervention
potentially eligible participants (46.6%) were included group had catheters removed as a result of phlebitis
in the trial. Almost one quarter of potentially eligible or infiltration; the difference was not significant
patients were excluded because of an altered mental (relative risk 1.15, 95% confidence interval 0.95 to
state. These were generally patients who were confused 1.40). When the analysis was based on catheter failure
or had some form of dementia or delirium. Reasons for per 1000 device hours, no difference could be detected
exclusion are shown in the figure. between the groups. Infusion related costs were higher
in the control group per episode of care than in the
Of those recruited, 376 were randomised to routine
intervention group (mean $A41.02 v mean $A36.40).
care of catheters (control group) and 379 to replace-
Both groups had a low rate of phlebitis (4% in
ment of catheters only when clinically indicated
intervention group, 3% in control group). Infiltration
(intervention group). Twenty two participants (6%) in was the most common reason for failure (36% in
the intervention group had their catheter changed intervention group, 32% in control group). A total of
routinely rather than in response to a clinical indica- 196 (26%) catheters in control participants were
tion. One hundred and twenty five participants (33%) replaced after three days, according to hospital policy,
in the control group had a catheter in place for more despite functioning well.
than 72 hours, reflecting the variation in routine care.
Follow-up from medical records was possible for all DISCUSSION
participants. The routine replacement of peripheral intravenous
Baseline personal, clinical, and catheter related catheters has no effect on the incidence of catheter
characteristics were similar between the groups for failure, on the basis of a composite measure of phlebitis
most risk factors (table 1). The exceptions were a or infiltration. The result replicates findings from our
earlier study, which used narrower inclusion criteria
but a broader definition of failure.23 These two studies
Table 3 | Outcomes for patients allocated to routine care of intravenous catheter (control group) or
toreplacementofcatheteronlywhenclinicallyindicated(interventiongroup).Valuesarenumbers have increased our confidence in changing intravenous
(percentages) of patients unless stated otherwise lines according to clinical signs and symptoms, rather
than using predetermined time frames.15 Changing our
Intervention group
Outcomes (n=379) Control group (n=376) Relative risk (95% CI)
policy would bring the practice in adults in line with
recommendations from the Centers for Disease Con-
Primary:
trol and Prevention for changing peripheral intra-
Catheter failure per 143 (38) 123 (33) 1.15 (0.95 to 1.40)
person venous lines in children—that is, to replace catheters
Catheter failure per 1000 59.8 60.9 only when clinically indicated. Paradoxically, in our
device days hospital peripheral intravenous lines are not routinely
Secondary: changed in premature infants or certain other patients
Mean (SD) intravenous 41.05 (26.6) 46.22 (28.7) −5.16* (−9.12 to −1.21) in whom achieving and maintaining venous access is
cost per catheter difficult. Such populations are arguably at higher risk of
Phlebitis 16 (4) 12 (3) 1.32 (0.63 to 2.76) developing catheter related complications than general
Infiltration 135 (36) 120 (32) 1.12 (0.91 to 1.36) medical and surgical patients in whom routine changes
Blockage 30 (8) 20 (5) 1.49 (0.86 to 2.57) are mandated.
Local infection 2 (1) 0 4.96 (0.24 to 102.98) Our overall combined rate for phlebitis and infiltra-
Suspected bloodstream 1 (0.3) 1 (0.3) 0.99 (0.06 to 15.80) tion was 35%, similar to other reports.27 28 The phlebitis
infection rate in both groups was on the low side of ranges
*Mean difference. reported in recent studies,29 30 despite our population
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A large, multicentre trial is needed to confirm our

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WHAT IS ALREADY KNOWN ON THIS TOPIC
results, using phlebitis or bloodstream infection as the
Peripheral intravenous catheterisation is the most common invasive procedure among primary outcome. Several serious adverse events were
inpatients reported during the trial. None of these were related to
Changing catheters every three days to prevent infection is standard procedure but the practice trial procedures.
has not been rigorously tested
Strengths and limitations
WHAT THIS STUDY ADDS
The major strengths of the study were the processes
Catheters may be safely left in place for longer than 72 hours if no contraindications are present used to eliminate selection bias, to ensure allocation
When catheters are replaced only when clinically indicated 25% of infusion related costs are concealment, and to ensure that the study was
saved adequately powered to detect differences in our
primary outcome. We also included a broad range of
participants and did not impose any caveats on how or
being elderly and unwell, with almost 75% having at by whom catheters should be inserted. This was to
least one comorbidity. Reported rates depend on match normal clinical practice and to ensure that
definitions used, and although we applied a standard results could be extrapolated to other populations of
definition, interpretation of signs and symptoms could complex inpatients. We were able to enrol 47% of
still be affected by subjectivity or omission of reporting. potentially eligible patients compared with about 25%
For example, it has been argued that infiltration (easy to in the earlier trial. Most of those we were unable to
diagnose) may result from unrecognised phlebitic recruit were either too frail or their mental state
changes to the vein wall (hard to diagnose) leading to prevented them from providing informed consent.
under-reporting of phlebitis.27 It is perhaps more useful From the point of randomisation, no losses to follow-up
to use the composite measure of infiltration or phlebitis occurred.
as it avoids any potential for misdiagnosis. The study would have been strengthened if monitor-
Despite allocation to the control or intervention ing of outcomes had been more stringent. As it was, we
group, participants showed little difference in dwell extracted most of the outcome data from medical
times. Two factors contribute to this. Firstly, it is not records. A more standardised approach would have
possible to modify all routinely scheduled changes been preferable, using staff trained in the process and
precisely 72 hours after insertion—for example, some data collected in real time. Another potential limitation
catheters may be left to the next morning rather than was that outcome assessment was done by people who
waking a patient during the night. Secondly, for various were not blinded to group allocation. Although
reasons many of the catheters in the intervention group catheters were removed by ward staff or intravenous
failed before 72 hours—although catheters in the service staff, part of their normal practice is to record
intervention group remained in place longer than reasons for removal in the patient’s medical record. To
those in the control group, the average dwell time was falsify such an observation because of group allocation
within the 72-96 hours recommended by the Centers would be unlikely, so we believe our results have not
for Disease Control and Prevention. This confirms that been compromised. Finally, the study was not powered
all catheters fail eventually but that many remain to study differences in the secondary outcomes.
functional for prolonged periods. We found that about
Phlebitis alone would have been a more clinically
3% remained trouble free for over seven days and some
important end point but we were limited by restrictions
for as long as two weeks. Because of this we believe that
on funding. For the same reason we did not culture
routinely changing catheters may be an unnecessary
catheter tips. This may have provided additional
and painful intervention for patients, and costly for the
information to inform practice and future studies.
organisation.
Potential cost savings of about 25% for infusion Conclusion
related costs could be made if our policy was to be
Replacing peripheral intravenous catheters only when
changed in line with recent evidence. Cost estimates
clinically indicated does not reduce the incidence of
used in our study were conservative, based on a simple
catheter failure, on the basis of a composite measure of
intravenous event. Others have suggested that about
phlebitis or infiltration. Larger trials are needed to test
2.5% of total drug costs are wasted when preparations
this finding using phlebitis alone as a more clinically
are destroyed.31 On the basis of recent data from
meaningful outcome.
England this could translate to a cost saving of about
£61m per annum.32 Contributors: JW conceived the idea, based on earlier work, secured
funding, wrote the protocol, supervised the preparation and conduct of the
The study was not sufficiently powered to show trial, analysed the data, and wrote the paper. SE developed databases and
differences in our secondary clinical outcomes. Despite assisted in the development of study materials and in data management.
this, non-significant results favoured the control group DP collected data for primary outcomes and developed a system for
for lower rates of phlebitis, blockage, and local categorising the pH of drugs. AH was responsible for assessing suitability
and supervising recruitment of acute admissions. SvD collected data for
infection. Numbers were small for these outcomes primary outcomes, helped in the development of study materials, and
and confidence intervals wide but with a larger collated data. CD liaised with the intravenous service, hospital staff, and
enrolment this risk could reach statistical significance. participants, and assisted in data management. CG contributed to the

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 RESEARCH

protocol and assisted with expert advice throughout the trial. All authors 15 O’Grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO,

BMJ: first published as 10.1136/bmj.a339 on 8 July 2008. Downloaded from https://www.bmj.com/ on 5 January 2025 at Dong-A University. Protected by copyright.
contributed to and approved the final draft. JW is guarantor. Maki DG, et al. Guidelines for the prevention of intravascular catheter-
Funding: Queensland Nursing Council research grant (RAN:0513) and the related infections. Infect Control Hosp Epidemiol 2002;23:759-69.
RBWH Research Foundation. 16 Lai KK. Safety of prolonging peripheral cannula and iv tubing use from
72 hours to 96 hours. Am J Infect Control 1998;26:66-70.
Competing interests: None declared. 17 Homer LD, Holmes KR. Risks associated with 72- and 96-hour
Ethical approval: Royal Brisbane and Women’s Hospital human research peripheral intravenous catheter dwell times. J Intraven Nurs
ethics committee (No 2005/93). 1998;21:301-5.
Provenance and peer review: Not commissioned; externally peer 18 Catney MR, Hillis S, Wakefield B, Simpson L, Domino L, Keller S, et al.
reviewed. Relationship between peripheral intravenous catheter dwell time and
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