How Safe Are Peripherally Inserted Intra-Vascular Devices (IV Cannula)?

By
Dr Kadiyali M Srivatsa

Abstract

Winchester and Eastleigh Healthcare NHS Trust (UK) begun prescribing the insertion of
intra-vascular device (cannula) and reduced MRSA infection by 100%. This work proves
beyond doubt the association of intra-vascular device with increased infection rate in
hospitals.

Multiple punctures put patients at risk for local and systemic infectious complications,
including local site infection. IVD can now be classified similar to a classified drug as its use
can result in serious harm to the patients. This may result in the introduction the organism
present on the skin, resulting in severe toxemia & shock, and possible death. As doctors we
must respect our ethics and ask this question “Is this cannula safe?” How do we defend our
action ?

Introduction

Winchester and Eastleigh Healthcare NHS Trust (UK) (BBC News, 8th May 2008) begun
prescribing the insertion of intra-vascular device (cannula). Doctors were able to monitor
the tubes more closely for signs of infection. Since the introduction of this protocol last
November there have been no new cases of MRSA infections. This figure covers all forms
of MRSA, including bacteraemia and wound infections. This compares to 2007/08 when
there was 11 reported bloodstream infections. This work proves beyond doubt the
association of intra-vascular device with increased infection rate in hospitals.

The emergence of new epidemic strains of CA-MRSA in the community, among patients
without established MRSA risk factors, may present new challenges to MRSA control in
healthcare settings(1). Klevens RM et al; reported Invasive MRSA is a major public health
problem primarily related to health care but no longer confined to intensive care units, acute
care hospitals, or any health care institution (2). Chhadia, AM et al; published the result of
their study CA-MRSA Hand Infections in an Urban Setting, claiming 73% of healthy adults
are said to carry this organism on their hands(3)
Doctors, patients and healthcare workers must look carefully at various procedures carried
out in hospitals. We have been taking a close look at the most common procedures per-
formed in modern-day medical practice is insertion of intravenous cannulation – is hated by
all. As house officers claim the success of inserting a cannula is the first attempt is about
60% and rate improved to 90% as seniors doctor (4)

Multiple punctures put patients at risk for local and systemic infectious complications,
including local site infection. Peripheral venous catheters / cannulae are the devices most
frequently used for vascular access. Although the incidence of local or bloodstream
infections (BSIs) associated with peripheral venous catheters was said to be low. Now due
to serious infectious complications produce considerable annual morbidity because of the
frequency with which such catheters are used.

PVCs inserted in the emergency department caused the highest number of episodes and
had a shorter duration to bacteraemia than those inserted in other hospital areas. This is
probably due to the fact that in the emergency department, PVCs are used excessively and
are frequently inserted under poor aseptic conditions (5). Unsuccessful attempts not only
cause distress to the patient and make cannulation more difficult, but each unnecessary
puncture wound provides an access route for MRSA or other drug-resistant organisms into
the bloodstream. The CDC and the UK Department of Health have addressed this issue by
recommending that all PVCs inserted in emergency situations must be removed or changed
on hospital wards within the first 48 h of admission and every 72 h irrespective of the pres-
ence of infection.(6). Ward nurses are, however, highly reluctant to change recently insert-
ed vascular catheters. Furthermore, other studies have been unable to demonstrate an in-
creased risk of complications after three days of peripheral vascular catheterisation and
have questioned the CDC recommendation for the routine replacement of PVCs. (7)

The various guidelines advise healthcare professionals to use the hand to place an intra-
vascular device. Avoid the routine use of the veins of the lower extremities due to the in-
creased risk of embolism, thrombophlebitis of and infection (8). These studies were carried
out in intensive care settings and were based on central venous catheters (CVC). CDC has
published their guidelines on hand hygiene in health care in their website, and this will soon
need updating based on the present information.

In September 2007, Spanish doctors published a paper and concluded the incidence of
bacteria associated staphylococcus infection of blood is more common in patients having
an Intra-venous Device (IVD) administered in ER and said to occur within 48 hours (5).
Crnich, CJ et al assessed the risk of bloodstream
Infection in adults with different intravascular devices and published their result in Mayo
Clinic Proceedings: The results show that all types of IVDs pose a risk of bloodstream
infection (BSI) and can be used for benchmarking rates of infection caused by the various
types of IVDs in use at the present time (9).

Since almost all the national effort and progress to date to reduce the risk of IVD-related
infection has focused on short-term no cuffed IVD as used in hospitals; infection control
programs must now strive to consistently apply essential control measures and preventive
technologies with all types of IVD’s.

There are very convincing reports from respected institutions that will make doctors feel
very uncomfortable in introducing cannulae in healthy adults. IVD can now be classified
similar to a classified drug as its use can result in serious harm to the patients. The cleaning
solution may not be as effective as claimed. This may result in the introduction the
organism present on the skin, resulting in severe toxemia & shock, and possible death of
the patients within 48 hours. As doctors we must respect our ethics and ask this question
“Is this cannula safe?” How do we defend our action when a patient dies from an ICU-
acquired infection related to methicillin-resistant Staphylococcus aureus (10)?

We have identified several potential causes that need updating. Use of non-sterile or sterile
gloves, use of ported cannula, problems with cleaning solutions, introduction techniques,
failure rates and fixation of devices to be the important factors requiring further assessment.
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