ORIGINAL ARTICLE

Factors Influencing the Peripheral Venous Catheter Survivalin Critically Ill Children in a Pediatric Intensive Care Unit

Sangeetha Shenoy & B. P. Karunakar

Received: 9 July 2013 /Accepted: 19 March 2014# Dr. K C Chaudhuri Foundation 2014

AbstractObjectives To study the duration of the peripheral venouscatheter access and the effect of variables such as intravenousfluid, medications and blood products on the life span of thecatheter in authors’ pediatric intensive care unit.Methods All peripheral intravenous lines established in sickchildren aged 1 mo to 15 y admitted to authors’ intensive carewere included and details of cannula gauge, insertion site,sampling, drugs administered and the mode of administrationwere noted. The cannulas were monitored regularly for signsof infiltration till removal. The time of insertion and removalalong with the reason for termination was noted and the lifespan was calculated. Mann Whitney test was used to test fordifferences in median survival time with respect to drugsadministered and Kaplan Meir survival analysis was used tocompare the survival of the cannula at different time periodsfor each drug.Results One hundred seventy four catheters were placed on102 children aged 1 mo to 15 y over a period of 2 mo; ofwhich 63 got infiltrated. The mean life span of the catheterwas 39+24.4 h. Administration of phenytoin (13.2 vs. 40 h,p=0.000) and mannitol (14.5 vs. 80 h, p=0.034) significantlydecreased the survival and infusion of blood (66.5 vs. 31.5 h,p=0.002) prolonged the survival of the catheters.Conclusions The catheters in the index study lasted on anaverage for 39 h. Phenytoin, mannitol, blood and blood prod-ucts were found to significantly influence the survival of thecatheters.

Keywords Pediatric intensive care unit . Peripheral venouscatheter . Infiltration

Introduction

An intravenous access is an important requirement to providecare to critically ill children. Establishment of intravenousaccess is one of the most important and frequently performedprocedures in an intensive care unit. Apart from administra-tion of intravenous fluids, drugs, blood products and paren-teral nutrition, it is also inserted prophylactically before pro-cedures and in unstable patients for emergency use [1]. Secur-ing a peripheral venous catheter (PVC) in pediatric age groupis often very difficult and can at times be very time consumingand frustrating. PVC placement in pediatrics has been report-ed as the leading cause of procedure related pain [2] on parwith postsurgical pain. Moderate to severe discomfort hasbeen reported in a significant number of children and adoles-cents on blood sampling [3, 4].

The life span of PVC is an important issue in the pediatricintensive care units (PICU) and its survival depends on manyvariables including the size, frequency of usage, methods ofadministration of medications and fluids, splinting and others.It is noticed that when certain drugs are administered, the PVCgets infiltrated faster. Factors affecting the life span of PVChave been studied in newborns and infants [5–8]. Heparin [9]and limb splinting [10] have been used in an attempt toprolong duration of the PVC. The present study attempts tostudy the effect of certain variables on the life span of PVCs inthe PICU.

Material and Methods

All consecutively admitted children between 1 mo to 15 y,fulfilling the criteria for admission to authors’ PICUwhich is atertiary care hospital, were included in the study after writteninformed consent. PVCs established outside were excluded aswere children on heparin infusion. The study was carried out

S. Shenoy (*) :B. P. KarunakarDepartment of Pediatrics, M.S. Ramaiah Medical College, M.S.R.Nagar, MSRIT post, Bangalore 560054, Karnataka, Indiae-mail: sangeethashenoy@yahoo.co.in

Indian J PediatrDOI 10.1007/s12098-014-1430-7

over a period of 2 mo and was approved by the institutionalethics committee.

The PVCs were inserted by experienced nurses or juniorresidents using aseptic precautions after identifying the mostsuitable vein. Twenty, 22, 24 or 26 gauge Teflon over theneedle PVC of a single brand was used, depending on thenurse’s discretion. Details regarding the needle gauge, site ofinsertion, number of attempts at securing the PVC, cannulawastage and whether the line was used for sampling, werenoted in a predesigned proforma every time PVCwas secured.Details of all the medications administered and the mode ofadministration (infusion or bolus), fluids, and blood productswere recorded. Limb splinting is not practiced as a routine inauthors’ PICU and hence, its effect could not be studied.

The PVC site was monitored regularly for signs of inflam-mation, extravasation and blockage and removed, when anycomplications developed or selectively when not required.The date and time of removal along with the reason fortermination was noted. The life span of the PVC was calcu-lated from the time of insertion to the time of removal. Thechildren discharged or transferred out of the PICU with thePVC in situ were also noted but they were not followed up inthe wards. These PVCs were labeled as the non-infiltratedcases.

All the quantitative parameters such as weight and agewere summarized as mean ± standard deviation. Median lifespan of the PVC along with interquartile range was calculatedaccording to the medication used, since the data did not followthe normal distribution. Non parametric test of significance(Mann Whitney) was employed to test for difference in themedian survival time with each of the drugs used among theinfiltrated group. Kruskal Wallis test was employed to test forthe differences in the median survival time with respect to thedifferent gauges of the PVC. Qualitative variables wereexpressed as percentages. A p value of <0.05 was taken assignificant. The Kaplan Meir survival curve was used toestimate the probability of survival at different time periods.The non-infiltrated PVC (the lines which were patent onshifting to the wards; the lines selectively removed and thelines which were accidentally pulled out by the patient) are thecensored cases. The data from the censored cases was includ-ed for the overall survival curve. The censored cases formed64 % (n=111) of the total number of cases. Therefore, whileanalyzing the effect of variables on the life span of PVC byKaplan Meir procedure the censored cases were excluded.The median survival time is the time when half the PVCsgot infiltrated. Analysis was performed using SPSS soft-ware18.0 version.

Based on a study conducted by Gupta et al. [5], it wasfound that the mean duration of insertion of PVCwas 40.8 h±27.6 (mean ± SD). With an absolute precision of 4.5 anddesired confidence level of 95 %, the sample size for thepresent study was worked out to be 145.

Results

A total of 174 PVCs were placed on 102 children rangingfrom 1 mo to 15 y (mean age: 4 y) with weight ranging from2.7–55 kg (median 13 kg). Majority (63.5 %) of the childrenwere within 5 y of age. The total life span of these 174 PVCsamounted to 6,650 h. The mean duration of life span amongthe non-functional PVCs was 39±24.4 h (range: 3.5–111.5 h).

Of the 174 PVCs, 63 (36 %) became non functional andwere removed. The rest were either removed selectively orshifted to the wards with the PVC in situ. The reason forremoval was extravasation in 78 % (n=49), obstruction in10 % (n=6) and inflammation in 12 % (n=8). Four (2.3 %)out of the 174 PVCs were pulled out by the patient.

The most frequently used site for placement of the PVCwas the dorsum of the hand in 80 % (n=139), followed by thesaphenous vein in 8.6 % (n=15). The other sites used weredorsum of the feet, wrist, forearm and elbow in 4, 2.9, 2.3 and2.3 % cases respectively.

Central venous line was placed in two instances, the indi-cations being administration of higher glucose concentrationin a child with persistent hypoglycemia and monitoring ofcentral venous pressure in a child with viral hemorrhagic feverwith shock.

The placement of PVCwas successful in the first attempt in84 % (0=146), second attempt in 12 % (n=21) and thirdattempt in 2.3 % (n=4). Three PVC placements requiredfourth, fifth and sixth attempts respectively.

The life span of the PVC was significantly reduced by theadministration of phenytoin (p=0.000), mannitol (p=0.035),and intravenous fluids (p=0.019) whereas the administrationof ranitidine (p=0.01), vitamin K (p=0.006) and vancomycin(p=0.041) significantly increased the life span (Table 1). Theinfusion of blood products (p=0.002) also significantlylengthened the duration of the PVC. The PVC infiltratedsignificantly faster in boys (median 27.5 h, interquartile range15.4–43.2 h) compared to girls (median 45 h, interquartilerange, 29.5–65 h) (p=0.004). The other drugs which did notalter the duration of the PVC were ceftriaxone, cefotaxim,cefuroxime, augmentin, amikacin, ampicillin, metronidazole,phenobarbitone, calcium gluconate, and dopamine. The dura-tion of the PVC was also not affected by the age of the child,whether the line was used for sampling, the site of placementand the cannula gauge. The median survival time as expressedby Kaplan Meir analysis was 51 h (95th CI 36.7–65.3). Thecontinuation of the PVC at 24, 48, 72, and 96 h was 77.9, 53.1,34.7 and 14.6 % respectively (Table 2).

The PVC survival time decreased significantly with admin-istration of mannitol (median 14 h, 95 % confidence interval10.9–17 h) as compared to survival time of PVC in those notreceiving it (median 38 h, 95 % confidence interval 31.7–44.3 h) (p=0.009); as also with phenytoin (median 12.5 h,95% confidence interval 6.5–18.4 h) (p=0.00) as compared to

Indian J Pediatr

those not receiving it (median 40 h, 95 % confidence interval33–46.9). On the other hand, infusion of blood productssignificantly increased the survival time (median 66.5 h,95 % confidence interval 29.9–103 h) as compared to thosein which blood was not transfused (median 30.5 h, 95 %confidence interval 23.3–37.7 h) (p=0.005). To identify inde-pendent predictors for the survival of the PVCs, all the factorswhich revealed significance in the univariate Kaplan Meiranalysis namely, phenytoin, mannitol and blood productswere included. Cox regression module was attempted. Theanalysis revealed phenytoin (RR=6.95, 95th CI=3.79–16.52)and blood products (RR=0.4, 95th CI=0.19–0.88) as theindependent predictors. As revealed in the univariate analysis,phenytoin decreased the survival time and blood was a pro-tective factor.

Discussion

Intravenous lines provide much needed vascular access formanaging critically ill children and despite their necessity,they are associated with a substantial risk of local and system-ic complications like local site infection, catheter related blood

stream infection, septic thrombophlebitis and other metastaticinfections [11, 12]. Among the intravascular catheters, PVCand peripherally inserted central lines have lesser incidence ofcomplications compared to central venous catheters [13, 14].

The median life span of PVC’s in current study is similar tothat reported by other studies [6, 7]. Phelps and Helms [7]estimated the median life span as 40 h (range 10 to 187 h),Johnson and Don [8] estimated as 33 h. A similar study [5]done in the neonatal intensive care unit estimated the medianlife span to be 40.8 h (range 1–136 h).

Extravasation was the commonest reason for discontinua-tion of the PVC in the index study. Infiltration of drugs andfluids can occur due to mechanical, obstructive and inflam-matory causes [15] like injury to the vein during cannulaplacement, and cannula dislodgement. Phlebitis which is acuteinflammation of the intima of the vein can be mechanical,physical or chemical and occurs in 20–80 % with majority ofthem occurring within 8–16 h [16–18].

The upper limb, preferably the dorsum of hand (88 %) wasused for cannulation in the index study. The risk of phlebitis islower in the hand veins as compared to the veins on wrist orupper arm [19]. Cannula site was observed to be an importantfactor for the development of phlebitis [20, 21]. Cannulationwas successful at the first attempt in 84 % in the index studywhich was better than other studies which reported a successrate of 69.9 % [5] and 46–76 % [17].

Medications with high osmolality (greater than 600mOsm/L)and acid/basic drugs with a pH <5 or >9 can predispose thepatient to phlebitis by irritating the vein [22]. Administration ofphenytoin and mannitol as infusion in the index studysignificantly decreased the survival of PVC. It could beattributed to the alkaline nature of phenytoin (pH of 12) andthe hyperosmolality of mannitol (274–1,098 Osm/L). Antiep-ileptic drugs have been observed to be one of theimportant determinants of extravasation, the others being

Table 1 Comparison of PVC lifespan with respect to drugsadministered

Drug Number n=63 Median (h) Interquartile range (h) p value

Phenytoin Yes 12 13.2 8.6–16.9 0.000No 51 40 26–64

Mannitol Yes 6 14.5 12–31.6 0.035No 57 38 21–62.3

Intravenous fluids Yes 59 33 18–50 0.016No 4 64.5 56.5–68.8

Vancomycin Yes 8 53 33.4–64.8 0.041No 55 33 17.5–52

Rantac Yes 24 42.5 29.1–66.5 0.01No 39 29.5 15–44

Vitamin K Yes 7 80 38–87 0.005No 56 32.8 17.6–48.8

Blood products Yes 9 66.5 43–83.5 0.002No 54 31.5 17.3–45

Table 2 Survival of PVC at different time periods

Time (h) Cumulative percentagesurvival (%)

Number of babies exposedto the risk

24 77.9 106

48 53.1 52

72 34.7 24

96 14.6 8

120 5 2

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age less than 1 y and catheter time in situ [23]. Intrave-nous site reactions are known to occur with phenytoin espe-cially with loading doses [24]. Certain drugs like cefotaximeand pancuronium have been observed to affect the duration ofthe PVC [5, 8].

However, the authors also observed that infusion ofblood products significantly increased the PVC survivalwhich was also noted in other studies [6, 24]. It washypothesized that the acidic solutions being infused in thePVC may be buffered by the pH of the blood [25].Cannula site and gauge did not have any effect on thecannula survival similar to other studies [5, 6].

Conclusions

The index study showed that catheters in PICU last for anaverage 39 h. Mannitol, phenytoin, blood and blood productswere found to significantly influence the survival of PVCs.Further studies are however required to study the effect ofvariables on the survival of these catheters to increase theireffectiveness.

Acknowledgments The authors would like to thank Prof NS Murthyfor his tremendous help in statistical analysis and the PICU nursing stafffor their cooperation.

Conflict of Interest None.

Source of Funding None.

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