In-line filtration reduces peripheral
phlebitis in postoperative surgical
patients
Gianluca Villa M.D.
Department of Health Sciences
• 100% of hospitalised patients undergoes to IV pharmacologic administration • Short peripheral venous catheters are the most commonly used IV devices
Tagalakis et al. Am J of Medicine 2002; 113(2):146-151 Peripheral vein infusion
thrombophlebitis is the most frequent complication of peripheral venous infusion
Ray-Barruel et al. J Eval Clin Pract. 2014; 20(2):191-202
30% at day 2 45% at day 3 from catheterization
Maki et al. Ann Intern Med. 1991;114:845-854
Endothelial inflammation &
Thrombosis
Thrombophlebitis: risk factors and pathophysiology
Tagalakis et al. Am J of Medicine 2002; 113(2):146-151
Peripheral venous cannulation
Thrombophlebitis: risk factors and pathophysiology
Tagalakis et al. Am J of Medicine 2002; 113(2):146-151
Peripheral venous cannulation
IV Cannula IV Infusion Patient Size Material Duration Fixing method Insertion procedure pH/Osmolality Drugs combination Contamination Air bubbles Particles Sex/ASA Comorbidities Chemotherapy … Good practice and Clinical guidelines
Co-infusion of two drugs is uncertain in up to 45% of cases
in which the compatibility of drug combination is unknown
90% of
Thrombophlebitis: risk factors and pathophysiology
Tagalakis et al. Am J of Medicine 2002; 113(2):146-151
Peripheral venous cannulation
IV Cannula IV Infusion Patient Size Material Duration Fixing method Insertion procedure pH/Osmolality Drugs combination Contamination Air bubbles Particles Sex/ASA Comorbidities Chemotherapy … Good practice and Clinical guidelines
Rates of colonization highly relates to the frequency of manipulation of the infusion line, particularly during acute interventions in emergency
situations
Thrombophlebitis: risk factors and pathophysiology
Tagalakis et al. Am J of Medicine 2002; 113(2):146-151
Peripheral venous cannulation
Thrombophlebitis: risk factors and pathophysiology
Tagalakis et al. Am J of Medicine 2002; 113(2):146-151
Peripheral venous cannulation
IV Cannula IV Infusion Patient Size Material Duration Fixing method Insertion procedure pH/Osmolality Drugs combination Contamination Air bubbles Particles Sex/ASA Comorbidities Chemotherapy …
Can in-line filtration reduce peripheral vein infusion
Randomised, controlled, clinical trial to assess the efficacy of in-line filtration in reducing the incidence of postoperative phlebitis in a cohort of patients undergoing peripheral short-term (1 to 5 days) vascular cannulation for anaesthesia and surgery.
268 patients 1:1 randomised to -standard care
-standard care + in-line filtration
IV management standardization
- Vascular access proactive planning - Venous/cannula diameters ratio - Site of venipuncture - Procedure of venipuncture - Fixing method - IV drugs compatibility - Intraoperative management - Postoperative management
The postoperative thrombophlebitis evaluation was blindly performed
In-line filtration standardization: Intraoperative
Blended anaesthesia Balanced anaesthesia
In-line filtration standardization: Postoperative
Total intravenous anaesthesia
ClinicalTrials.gov: NCT03193827
Grade Clinical characteristics 0 IV site appears healthy 1 One of the following is evident: • Slight pain near IV site or • Slight redness near IV site 2 Two of the following are evident: • Pain at IV site • Erythema • Swelling 3 All of the following signs are evident: • Pain along path of cannula • Erythema • Induration 4 All of the following signs are evident and extensive: • Pain along path of cannula • Erythema • Induration • Palpable venous cord 5 All of the following signs are evident and extensive: • Pain along path of cannula • Erythema • Induration • Palpable venous cord • Pyrexia
VIP scale/Jackson scale
Ray-Barruel et al. J Eval Clin Pract. 2014; 20(2):191-202 The incidence and severity of phlebitis was
evaluated using the Visual Infusion Phlebitis (VIP) Score every 12 hrs from the end of
surgery until 96 hrs postoperatively.
Assessment of thrombophlebitis
Phlebitis has been defined
Microscopic effect of in-line filters
Sham filter Filter used in the study
Multidisciplinary approach that, besides other best practices, may
contribute to prevent Peripheral Vein Infusion Thrombophlebitis
HR 95%CI p
Phlebitis 0.08 0.024–0.25 <0.0001
A control group patient: 9.92€ (95% CI 4.44€-15.41€)
Cost/n° of disposables
N° of disposables
Study group
Control group
Dressing 11 € 19.6 € Large dressing
16 €/50
19
35
Small dressing
8 €/50
7
11
Sterilstrip
7 €/50
25
41
Sterile gloves
10 €/50
1
3
Sterile gauzes
11 €/200
2
6
Sterile kit for venipuncture
50 €/1
1
3
Infusion Set
266.7 €
766.7 €
Deflussor
55 €/350
54
778
Three-locks tap
32.2 €/200
47
55
Hub
46 €/100
195
220
Peripheral venous cannula
13 €/50
37
71
Midline
415 €/5
1
4
Pre-filled syringe
27.5 €/30
20
37
In-line filters
957 €
0 €
0.2µm/11cm2
3 €/1
134
0
0.2µm/1.65cm2
3 €/1
118
0
1.2µm/4.5cm2
3 €/1
67
0
Work load
189.7 €
542.5 €
Nurse
21.6 €/1hr
402 min
907 min
Anaesthesiologist
52 €/1hr
52 min
250 min
Patient qualitative interview on ‘’in-line filtration experience’’:
• «..This has been the first time that my vascular access has worked for the
entire hospital stay and I have had only one vascular access during hospitalization»
• «..I know that the study is covering only the first 4 postoperative days, but
please do not remove this filter..»
Analysis of quality perceived
0 20 40 60 80 100 120
Not Indifferent Yes
Would you like the "filter" for a future experience? 0 10 20 30 40 50 60 70 80 90
Strongly agree Agree Neutral Disagree Strongly
disagree
According to your previous experience, the "filter" has improved the management of your
vascular access
• Peripheral Vein Infusion Thrombophlebitis is a common complication among hospitalized patients.
• It usually requires the replacement of the vascular access, increasing health care providers workload and patients discomfort.
• Injected particles have a role in the incidence of Peripheral Vein Infusion Thrombophlebitis.
• In-line filtration may reduce the incidence of Peripheral Vein Infusion
Thrombophlebitis without significant increase in health care-associated costs.
• Beside other best-practices on insertion and management of vascular access, in-line filtration may be considered in a mulltidisciplinary effort aimed at reduce
Peripheral Vein Infusion Thrombophlebitis.
