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Rosalita Almonte
Sanjay Patole
Reinhold Muller*
John Whitehall
From the Neonatal Intensive Care Unit, Kirwan Hospital for Women, Thuringowa,
Queensland, Australia 4817 and * School of Public Health and Tropical Medicine, James Cook University, Townsville, Queensland, Australia 4811
Reprint requests: Dr. Sanjay Patole, Neonatal Intensive Care Unit, Kirwan Hospital for Women, Thuringowa, QLD 4817, Australia. Fax: 07-4773 0320.
Manuscript received: September 9,1998; Initial review completed: November 3, 1998; Revision accepted: December 7,1998.
With increasing survival of critically ill neonates in the surfactant era, the
need for venous access has risen dramatically. To our knowledge, there is no
available data regarding better ways of taping and the longevity of the peripheral jiptravenous. (IV) cannulas in neonates in the surfactant era. Semiocclusive polyurathane dressings (SOPD) like Opsite®
have been shown to enhance dermal repair and inhibit bacterial muitiplication(1-3). We therefore compared the longevity of peripheral IV cannulas after taping in the traditional way using an adhesive tape (Leukoplast®) and after taping with an SOPD like (Tegaderm®).
Subjects and Methods
This prospective study was conducted in a regional Level III neonatal
nursery between November 1996 and January 1997. An in formed consent approved by the institutional
ethics committee was obtained from the parents prior to randomizing the enrolled infants to either of the two taping methods. Infants needing resiting of the cannula were assigned to the next available taping method on the randomization list.
Procedure for IV Cannulation
An aseptic technique for IV cannulation involved thorough handwashing for two
minutes and cleansing of the insertion site with 10% povidone-iodine prior to cannulation
attempt. A contact time of one minute was required before the topical iodine was wiped off with 0.5% chlorhexidine in 70% alcohol. The site was then allowed to dry up before cannulation was attempted. Handwashing for 30 seconds was mandatory after completing the procedure. Cannulation was performed by the registrar-on-call using a Vialon material catheter (Insytegauge 24, Becton-Dickinson, Sandy, Utah). During the study period, four registrars worked for 12-hour shifts on a '4-days on and 4 days off' roster.
Procedure for Taping the IV Cannula
Method A (Using Transparent Sterile Dressing, Tegaderm, 3M, Canada)
A piece of the Tegaderm®
was placed
across the inserted cannula covering distal third of the hub. Afterwards, another piece was placed covering the length of the inserted cannula and the hub but ending well before the T-piece connection. Care was taken to ensure that the dressing adhered completely to the contours of the cannula. Finally a strip of Leukoplast®
adhesive tape was placed across the hub of the cannula extending onto the limb.
Method B
(Using Adhesive Tape,
Leukoplast®,Beiersdorf,
Hamburg, Germany)
Two pieces of Leukoplast@ were applied
underneath the hub of the cannula, each with the adhesive side up and brought above where they were crossed in a V-pattern.
It was ensured that the tapes adhered completely to the undersurface and side of the hub. Finally, a strip of Leukoplast®
was placed across the hub of the cannula extending onto the limb.
Monitoring of the IV Cannulation Site
The insertion site was inspected hourly by the nurse caring for the infant. The cannula was removed if either extravasation/local signs of inflammation developed or the venous access was no longer needed. In the latter case, the babies were excluded from statistical analysis.
Blood culture was done in infants developing clinical signs of sepsis. Cannula-related sepsis (CRS) was defined as: (i) development of clinical signs of sepsis while the cannula was in-situ or during 72 hours after removal of the cannula, and (ii) clinical and microbiologic
data that disclosed no other apparent source for the septicemia. Quantitative
cultures were not used to define catheter- related sepsis in an attempt to
overcome technical difficulties and to minimize phlebotomy losses.
In order to study the risk of infection related to pre-cut adhesive tapes, ten random samples each of newly-cut and pre-cut Leukoplast adhesive tapes were cultured.
Statistical Methods
A total of 52 cannulations occurred in 38
study infants (method A
=
24, method
B
=
28). Only 14 infants received both methods of taping. Unpaired testing using all 52 observations (with a minor loss of statistical power) was preferable to paired testing of the 14 infants who received taping by both methods (which would have
implie a severe decrease in sample in size).
The distributions of some of the continuous variables proved to be quite skewed, hence, nonparametric Wilcoxon-Rank tests were used to compare the medians between the two methods of taping. Kruskal-WallIis tests were used to compare continuous variables
with categorical items with more than two values. Relationships between two
categorical variables were tested by means of common chi-squared tests. When the
expected values for one or more cells were too small to allow standard chi-square tests, Fischer's exact tests were used. The alpha level for statistical significance was set to 5% for all tests.
Results
A total of 52 cannulas (method A=24, method B=28) were used in 38 infants.
Fourteen infants received both methods of taping. No significant difference
could be found between the 2 groups with respect to gestational age, birthweight, sex and the postnatal age at which the IV cannula was inserted.
The duration of cannulas in situ was not
.
significantly different between method A and B (p=O.81). The median dqration for method A was found to be 56.3 hours (mean 62.2; range=10-148). The median duration for method B was 54.3 hours (mean 62.2; range=6-150). Seventy-seven percent of the cannulations occurred within the first 10 days of life. Characteristics related to IV cannulas are listed in Table I. Cannulation sites and contents of the intravenous infusate were not significantly different in the two study groups. In total, upper extremities were used as cannulation sites in 73% of the cases. There was no difference in the longevity of the cannula when each site of cannulation was compared between the two groups (p=0.58).
Table
I
Characteristics Related to the Cannulas
|
|
Method A
(n = 24) |
Method
B
(n = 28) |
|
Infusate contents
|
|
|
|
1. Intravenous antibiotics |
7 (29.2) |
11 (39.3) |
|
2. Intravenous alimentation |
15
(62.5)
|
21 (75)
|
|
3. Total parenteral nutrition |
4
(16.7)
|
4
(14.3)
|
|
Cannula site
|
|
|
|
Hand |
13 (54) |
16 (57.5) |
|
Antecubital fossa |
3 (13) |
3 (11) |
|
Forearm |
2 (8) |
I (4) |
|
Foot |
4 (17) |
6 (22) |
|
Popliteal fossa |
2 (8) |
2 (7) |
|
Complications |
|
|
|
1. Local infiltration |
17 (70.8) |
21 (70.5) |
|
2. Local phlebitis |
0 |
0 |
|
3. Extravasation burns |
1 |
2 |
|
Figures in parantheses indicate percentages. |
Seventy-three per cent of the cannulas had
to be resited due to infiltration. Phlebitis was not noted in any of the infants
studied. Presumed cannula-related sepsis (CRS) occurred in 3 infants and were
the only infants with septicemia during the study. The frequency of CRS did not differ significantly with respect to the taping methods (p=0.59, Fishers exact test). Two of these infants were assigned to method A with both blood cultures growing coagulase negative staphylococci. The third infant was assigned to method B and the blood cultures grew Staphylococcus epidermidis.
With respect to the culture results of the pre-cut and freshly-cut Leukoplast®
strips, 8 out of ten precut strips grew Coagulase negative staphylococci (2 to >20 colonies), 2 had mixed skin flora (>20 colonies). Out of the 10 newly-cut strips, 4 grew coagulase negative staphylococci (1 to 18 colonies), and 6 grew mixed skin flora (3 to >50 colonies). The
exact Fisher test revealed no significant difference between the two types of strips for growing Coagulase negative staphylococci.
Discussion
We have documented that the longevity of the peripheral Vialon IV cannulas was not altered after taping with 'Tegaderm'.
The median duration of cannula in situ in our study is longer than that
reported by other researchers. A review of literature showed an average dwell
time of 0.98 days for steel needles com- pared with an average dwell time of
1.35 days for Teflon catheters(4). Differences in study design, patient
population, and catheter material along with an overall improvement in the standards of neonatal care in the last decade may explain this finding. An increased aware- ness about careful taping of the cannulas may have added to the longevity of the cannulas in our study. However, we did not compare duration of cannulas in situ prior to the study with our current results. Maturational status of the infant's skin may be related to longevity of the cannulas.
Regardless of the gestational age at birth, the skin of preterm infants matures fast within seven to ten days after birth(5). We found no evidence that cannulas inserted after a postnatal age of ten days lasted longer than those inserted earlier. Failure to detect such a difference may be explained by the fact that 77% of the cannulations occurred within the first ten days of life.
In this study, we did not routinely resite the cannulas even in the presence of septicemia or after 48 to 72 hours as suggested by others(6). Infectious complications related to IV cannulas have been reported to increase with duration in situ(7,8). Maki et al. however encountered no catheter-related bacteremias in 2088 peripheral Teflon venous catheters studied prospectively, even though 25% had been in situ over 72 hours(9). Tegaderm®
and
three other dressing regimens were compared in this study. Cutaneous colonization and rate of local catheter-related infection was similar irrespective of the type of the dressing regimen used. The authors likewise noted that only three catheter-related bacteremias occurred among nearly 4000
IV catheters studied in previous trials of transparent dressings.
Definitions used for Catheter/Cannula Related Sepsis (CRS) vary widely. The most objective means of distinguishing CRS from an unrelated sepsis in a neonate with a catheter/cannula is by obtaining semiquantitative or quantitative blood cultures drawn through the catheter/cannula and from a peripheral site(10.11). We did not obtain such cultures due to technical difficulties and also due to our policy to minimize phlebotomy losses. Al- though the number of patients in our study is small the incidence of septicemia and CRS nonetheless was very low. Presumed cannula
related sepsis (CRS) occurred in only 3 infants (method A=2, method B=l). The
numbers being too small, comparisons were not possible. Despite our practice against routine resiting, we have not observed any undue rise in such complications prior to the study. Infiltration occurs frequently following IV cannulation and manifests as swelling or erythema around the cannulation site. Depending on the con- tents of the solution infused, the extravasated
IV solution produces damage to the surrounding tissue. The consequences range from blisters to gangrene necessitating amputation(12- 14). Majority (73%) of the cannulas in our study were resited due to local infiltration. This is similar to the findings of Askas et at. where local infiltration was noted to be 79% among 319 cannulas studies(l5). Sheehan et at. reported an infiltration rate of 78% with Teflon IV catheters in a randomized controlled trial of IV catheter performance in neo- nates(4). In another study, MacCara reported phlebitis in 18.8% to 39% of patients where
plastic catheters were used(l2). However, phlebitis related to IV cannulas was not noted in any of the infants in our study.
We conclude that taping with a semi- occlusive polyurethane dressing (SOPD) like "Tegaderm" is not associated with a de- creased duration in situ or increased local complications related to peripheral intravenous cannulas. SOPDs like Opsite®
have been shown to enhance dermal repair and inhibit bacterial multiplication(1-3). The safety of Tegaderm®
dressing left on till the cannula is in situ has already been demonstrated(9). Given this information we believe that larger prospective, randomized trials are needed to study the cost-benefits of such dressings and their impact on cannula-related sepsis in newborn infants.
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