PIDSP Journal, 2005 Vol. 9 No. 2
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Ronald Allan N. Geraldez, MD*, Ma. Liza M. Gonzales, MD*
In UP-PGH pediatric wards and emergency Background: Superficial phlebitis is a common
room, a proper and successful IV catheter insertion is complication of venoclysis although its incidence one of the most basic skill that interns and residents should especially in pediatric hospital setting is not often known learn. This can be made difficult by the fact that and evaluated. A standard aseptic technique in IV line peripheral veins of pediatric patients are small and often insertion is observed to decrease its incidence but the difficult to locate visually and by palpation. Formal IV use of topical antibiotic is rarely used.
therapy training for hospital personnel has been shown Study objectives: Our objective was to determine if
to decrease leakage, phlebitis and infiltration topical application of antibiotic mupirocin will affect the complications of IV cannulation.5 In PGH, however, most incidence of superficial phlebitis as compared to using medical interns learn the technique by practice while alcohol alone in the preparation of the IV insertion site.
serving their rotation in the pediatrics department.
Setting: Pediatric department wards and emergency room
A proper and effective way of doing IV of the University of the Philippines-Philippine General catheterization entails an aseptic technique that every health personnel performing the procedure should Methodology: In a randomized control study, 69 pediatric
observe. However, the incidence of phlebitis may still patients for intravenous catheter insertion were evaluated.
occur in the insertion site requiring the removal of the IV Thirty-six patients were assigned in the control group cannula and reinsertion of new cannula in another site.
whose IV insertion site were prepared with alcohol alone Several factors may predispose to the while 33 patients in the case group received topical development of superficial phlebitis in IV cannulation site mupirocin after application of alcohol in the IV insertion foremost of which is the length of time the cannula is in site. The IV insertion site were than evaluated daily by place or the dwell time. The Center for Disease Control the investigator for the development of superficial phlebitis guidelines recommends replacement of IV catheter every until the IV cannula were removed.
48 to 72 hours for adults but no such recommendation Results: Eight out of the 36 patients (22%) in the control
for pediatric patients exists.6 Studies however has shown group while 4 out of the 33 patients (12%) in the case that there is no significant differences between phlebitis group developed phlebitis.
rate of cannula with dwell time of 72 hour and 96 hour.7,1 Conclusion: The use of topical mupirocin in the IV
Thus, considering the difficulty of successful cannulation, insertion site prior to cannulation can decrease the the limited number of skin sites, and the cost of the devise, incidence of superficial phlebitis.
the cannula may be left in place for longer than 48 hours.9Among neonates, catheter life is on the average lasts for only 30 hours. Extravasation, erythema, accidental Phlebitis in insertion site is not an uncommon displacement, and worse, phlebitis may require the complication of peripheral intravenous catheterization with removal and reinsertion into another site of the cannula.
cases reported to range from a low 2.3% to as high as Without these complications however, catheter can be 31%.1.2,3,4 It can manifest as an inflammation in the safely maintained with adequate monitoring for up to 144 insertion site to cellulitis and suppuration in the contiguous areas to a more severe catheter related sepsis.
It is advisable that IV cannula should be used only once per attempt but this is not always the case in *Department of Pediatrics, UP-PGH
PGH where the same cannula can be used several times Key Words: intravenous cannulation, mupirocin, pediatrics, superficial phlebitis, topical antimicrobial
PIDSP Journal, 2005 Vol. 9 No. 2
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in an attempt at successful cannulation. A transparent IV cannulation site administered prior to IV cannulation polyurethane cannula (Insyte) is the most commonly type compared to applying alcohol alone decreases the of used which compared to butterfly steel cannula is incidence of phlebitis.
said to decrease the risk of phlebitis.10, 11, 12 A significant factor in the development of Secondary objectives include: phlebitis is the infusate or the type and frequency of 1. to determine and assess the factors that predisposes medication or fluid infused and pushed. Drug irritation is to the development of superficial phlebitis namely: the most reliable predictor of phlebitis.13 Total parenteral a. the length of time the IV cannula is in place nutrition, blood products, potassium and sodium b. the type of IV medications infused bicarbonate drips are just some of the infusate commonly c. the number of attempts before the cannula has been implicated in phlebitis.
There are commercially available IV cannula d. the type of personnel (i.e. intern, resident) who dressings available in the market such as transparent performed the cannulation dressing and sterile gauze but these are more expensiveand thus has not been popularly used. The use of gauze Type of Study
versus transparent dressing shows no relationship with A randomized controlled trial in which mupirocin IV complications such as bacterial colonization and ointment topically applied prior to IV cannulation is phlebitis although a study has shown less evidence of compared with using alcohol alone.
phlebitis with adhesive bandage compared with gauze.14,3Bacterial colonization or the presence of positive culture in the cannula tip is widely believed to be not correlated Patients in the pediatric wards and emergency with the development of phlebitis.15 There has been no room requiring indwelling peripheral IV cannulation for reported study comparing these commercially available more than 24 hours.
dressing with adhesive tape (Leukoplast) which isgenerally what is being used in PGH.
The most practical way of preventing phlebitis is Patients whom IV cannula was removed within the employment of aseptic technique in the performance 24 hours from insertion.
of the peripheral IV cannulation procedure. The usualpractice in this institution is to topically clean the area in the skin with alcohol and the secure the site with The presence of signs of phlebitis in the area leukoplast. Application of a topical antibiotic where IV cannulation has been placed as assessed by prophylactically in the insertion site such as mupirocin the investigator.
ointment is not usually done except although occasionally,povidone iodine, a topical antiseptic is used. Some studies, however has shown that the use of antimicrobial ointment All patients in the emergency room and wards has resulted in higher proportion of phlebitis.16 for intravenous catheter insertion that was referred for Mupirocin, a topical antibiotic available in inclusion in the study was randomly assigned to case ointment form has been used in the treatment of group or control group. For every patient enrolled in the secondarily infected wounds. It is likewise often used in study a card was drawn from a set of cards randomly the care of indwelling central lines to prophylactically marked with "B" and unmarked cards. Those assigned prevent phlebitis or even treat secondarily infected central with unmarked cards was put in the control group while line site. It is effective against gram positive and gram those with marked "B" was placed in the case group negative organisms including methicillin resistant The choice of IV site for each patient was at Staphylococcus aureus. As to date, there is no local the discretion of the physician and or intern as is the choice study investigating the efficacy of the application of of the IV catheter to be used. The insertion technique mupirocin in the prevention of the development of was done percutaneously without prior skin incision. The superficial phlebitis in peripheral cannulation site.
skin was prepared with alcohol. All patients in the casegroup will have topical mupirocin applied to the area covering at least 0.25 cm prior to IV insertion. The The primary objective is to assess whether single insertion site would then covered with an adhesive tape.
topical application of mupirocin ointment in the peripheral PIDSP Journal, 2005 Vol. 9 No. 2
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The catheters were subsequently handled ac- A. Dwell time
cording to the normal practice of the attending medical The average dwell time for subjects in the control and nursing staff. Each patient was seen daily by the group is 62.9 hours (SD 30.3 hours) as compared to the investigator and the patient was questioned about pain in case group with average dwell time of 62.8 hours (SD the insertion site, or/and the IV site was inspected and 30.4). If subjects whom IV cannula were electively palpated. The presence of phlebitis was defined as the removed or those whom cannulation where removed presence of a palpable cord or the presence of at least 2 because they were no longer need for were excluded, of the following physical changes along the course of the the average dwell time became 62.7 hours (SD 29.9) for vein: warmth, erythema, tenderness and induration.
the control and 65 hours (SD 27.6) for the case group.
Of the total of 12 patients who had phlebitis, 5 had their cannula in place for 24-48 hours, 3 of them for 49-72 Of the 92 patients enrolled in the study, only 36 hours, 2 for 73-96 hours while 2 had their cannula in place in the control group and 33 in the case group were for 145-168 hours.
included in the evaluation. Twelve patients in the controlgroup out of 48 (25%) and 11 out of the 44 (25%) patients in the case group were excluded because their IV cannula were removed in less than 24 hours or the patients were discharged before the investigator was able to assess the IV site. Subject characteristics for both groups were similar with respect to sex although there in terms of age, there were more subjects in the 1 to 12 months age group among the control. For both control and case group, the locations of the IV insertions had almost similar distribution and most were done in the hand.
Final result had shown that 8 out of the 36 (22%) subjectsin the control group developed phlebitis as compared to B. Type of Infusate
the case group in whom 4 out of the 33 (12%) subjects Of the 12 patients in the control group who had phlebitis.
developed phlebitis, 8 were given IV fluids while 4 hadheparin lock. Eight were given IV antibiotics while 3 were given blood products.
Table 2. Subjects in the control group who developed phlebitis
and the type of infusate given
II. Age Group
II. Age Group
Type of infusate
III. IV Cannulation Site
III. IV Cannulation Site
PIDSP Journal, 2005 Vol. 9 No. 2
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Table 2. Subjects in theMupirocin group who developed
phlebitis and the type of infusate given
Phlebitis is the most common complication of IV therapy and several factors has been implicated in itspathogenesis. Chemical factors such as irritant drugs Type of infusate
and physical factors such as duration of cannulation are just few of the identified risk factors for the developmentof phlebitis.
Among the 69 subjects both in the control and mupirocin group evaluated in this study, 12 developed phlebitis thereby giving an incidence rate of 17%. This is within range of the incidence of phlebitis reported in other studies which is from a low of 2.3% to a high 31%.1,2,3,4 For those in the control group, 22% (8/36)developed phlebitis, a rate that is higher than in the case C. Number of times the IV cannula were used
group with 12% (4/33). With using topical topical There could be several attempts in IV insertion mupirocin the absolute risk reduction is 10% and the in a subject and a cannula could be used several times by relative risk reduction of 46%. The results therefore the intern or the residents before a successful cannulation.
suggests that applying topical mupirocin (Bactroban) in Majority of IV insertion fortunately was successful on the IV insertion site may the decrease the risk of phlebitis.
first attempt. Seven out of 51 of those who developed However, using the statistical analysis Fisher's exact test phlebitis had the IV cannula used only once in an attempt.
this finding is not statistically significant with a 2-tail p There were 2 subjects whose cannula was used 4 times but did not developed phlebitis.
The rationale for the use of topical antimicrobial Table 4. No of times the cannulla has been used and the inci-
in the preparation of the skin for IV insertion can decrease dence of phlebitis
the bacterial load of the skin thus decreasing thecolonization in the point of entry. Topical antimicrobial is Times the
often employed in the care of central venous catheter IV Cathwas
but its use in percutaneous IV cannulation is not by Subjects + Phlebitis
standards observed. Some studies even discourage theuse of antimicrobial ointment because it can result in higher incidence of phlebitis.
The length of time that the IV cannula is in place is traditionally believed to be directly correlated with the incidence of phlebitis. Two subjects however whosedwell time exceeds 144 hours did not developed phlebitis D. Type of Personnel Performing the cannulation.
although 2 subjects with dwell time of 121-144 hours did.
In PGH pediatric wards and emergency room, Five subjects in the control group with dwell time less the interns were the first in line who should perform the than 48 hours had phlebitis. The per day risk of phlebitis IV insertion, thus 70% (36/53) of the IV insertion were is not evident in this study and this supports the no longer performed by the interns while the rest were done by the acceptable practice of replacing IV cannula every three residents. Seven out of the 36 insertions done by the interns developed phlebitis while 4 out of the 18 insertions In this study, the IV insertion performed by done by the residents had phlebitis.
interns showed 16% (7/44) rate of phlebitis as compared Table 5. The type of personnel performing the IV cannulation
with residents who had 19% (5/26). In PGH, it is usually and the incidence of phlebitis
the interns who were first in line to do the IV insertionand the procedure would be referred to the residents in cases of difficult insertion. The higher rate of phlebitis among those done by residents can be probably explainedby their more difficult tasks of IV insertion especially among chronic patients.
PIDSP Journal, 2005 Vol. 9 No. 2
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Since IV cannula is sometimes used several times drugs that has been infused and recognized to be often in an insertion, the number of times the cannula has been implicated in the development of phlebitis has been IV used before a successful cannulation has been recorded fluids with KCl and Ca gluconate incorporation and blood and analyzed as a risk factor of phlebitis. Although products packe RBC and platelet concentrate. There is majority of the insertion has been successful on 1st however particular classification of infusate as to their attempt, 14% (7/51) has developed phlebitis while 23%, abiltity and degree to irritate the veins and cause phlebitis.
(3/13), 50% (1/2) and 50%(1/2) has developed phlebitis The application of topical mupirocin may not decrease when the cannula has been reinserted twice, thrice and the incidence of chemical phlebitis or those caused by four times respectively. It is therefore recommended irritant infusate in contrast to those with infectious etiology that the IV cannula be used only once and be discarded although both factors may co-exist in the development if attempt is unsuccessful. The cost of IV cannula will of phlebitis.
however make this suggestion impractical.
The potential of topical mupirocin in decreasing These results lead to the question of whether the incidence of phlebitis therefore needs further there is a direct relationship between difficulty of insertion confirmation. The amount of ointment used per as evaluated subjectively by those performing the IV cannulation is so small that it will not greatly increase the cannulation and by the number of attempts before a cost of IV therapy. The only problem however is the successful cannulation has been made. A similar study more tedious way of inserting the cannula since the skin with such an objective is therefore recommended.
site can have more glare from the shiny ointment once The type of infusate such as irritant IV medication applied as reported by the residents and interns who is a significant factor in the development of phlebitis.
participated in the study. However, if proven by further Among subjects who developed phlebitis, some of the studies and by evidenced based medicine, the decreasedcost of reinsertion and decreased pain for the patient canbe beneficial.
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Benefit Sharing in ABS:Options and Elaborations This report was written byMS Suneetha, Biodiplomacy Programme, United Nations University Institute of Advanced Studies, and Balakrishna Pisupati, Division for Environmental Law and Conventions, United Nations Environment Programme AcknowledgementsThe authors would like to thank David Leary, Claudio Chiarol a, Geoff Burton, Sam Johnston and Hiroji Isozaki

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