静脉留置针更换策略及采血有效性的系统评价
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摘要
研究背景
静脉留置针常用于静脉输液治疗,它可较长时间留置在血管内,反复使用,减轻患者由于反复穿刺而造成的痛苦,并能够起到保护血管的作用,保证合理用药时间,很大程度上减轻了护理工作量。
本研究分为两个部分,第一部分是比较目前临床护理实践中的两种更换静脉留置针的策略:一个是定期常规更换策略,一般是3天或4天更换。另一个是按需更换策略,即不是定期更换导管,而是对导管置入位点进行监测,当出现拔管指征才予以更换,按需更换策略留置时间差异较大,不少研究报道留置时间可在7天以上,最长时间可达29天。
在不增加导管相关感染等并发症的前提下,按需更换策略是更好的选择。因为这种更换策略留置时间较长,减少了患者反复穿刺的痛苦和护理工作量。因此本研究拟对这两种策略进行系统评价,比较两者并发症的发生率,以期找出较好的策略。
第二部分是对静脉留置针采集血标本有效性的系统评价:静脉留置针是否可以用来替代传统的穿刺方法采集血标本?由于没有相关的参考标准和循证研究支持,目前临床可见两种不同的做法。一种是做法是:一边持疑问态度,一边使用静脉留置针采血,尤其是一些需要反复多次采血、血管状况很差或婴幼儿患者,而且在一些相关的要求如弃血量、输液暂停时间等操作上存在很大的差异。还有一种做法是:即使在有现成的静脉留置针可用于采血的情况下,因为没有证据支持,仍然采用传统穿刺法采集血标本,以确保准确的实验室检查结果。
如果两种方法采集的血标本的检测结果没有差异的话,使用已有的静脉留置针采血是更好的选择。因为这样可以减少患者痛苦、保护血管、减轻护理工作量,也可以使得采血的时间更为精确。本研究拟对静脉留置针采集血标本的有效性进行系统评价,以为临床实践提供更好的证据。
研究目的
我们希望通过采用国际循证医学Cochrane协作网的系统评价方法,对目前全世界关于静脉留置针更换策略及采血有效性的临床试验进行系统评价,以期获得以下问题的相关证据:
1)定期常规更换静脉留置针与根据置入位点的临床症状按需更换静脉留置针,导管相关感染及其他并发症的发生率是否有差异?
2)静脉留置针采血的结果是否准确?是否会受封管液的影响?是否可以直接采血还是需要先弃去部分血液?合适的弃血量又是多少?静脉留置针主要用于静脉输液,输液成分是否会影响检测结果?
方法
遵循循证医学的原则,运用Cochrane系统评价的方法,采用机检和手工检索相结合的方法,检索PUBMED(1966-2009.1)、EMBASE(1966-2008.12)、OVID、Cochrane图书馆、CINAHL(1982-2008.12)、CBMdisc(中国生物医学数据库,1979-2009.1)、CNKI(1994-2008.11)、VIP(1994-2008.11),同时追踪检索已确定文献的参考文献。收集所有关于静脉留置针留置时间的临床随机对照和半随机对照试验,以及比较静脉留置针与传统穿刺方法采血结果的临床自身同期对照试验、随机对照和半随机对照试验。由两名评价者对文献进行质量评定和数据收集。统计软件用Cochrane协作网提供的RevMan 5.0.18,对提取的定量资料进行异质性检验、Meta分析和敏感性分析。
结果
【第一部分】
1.共纳入了6个RCT研究(共1292例患者),研究质量2个为A级,2个为B级,2个为C级。
2.按需更换静脉留置针组静脉炎发生率高于定期更换静脉留置针组(RR:2.47,95%CI:1.48-4.13)。
3.按需更换静脉留置针组与定期更换静脉留置针组导管相关血行感染发生率没有差异(RR:0.96,95%CI:0.19-4.81)。
【第二部分】
1.共纳入了27个研究,研究质量3个为A级,14个为B级,10个为C级。
2.成人静脉留置针采血的溶血发生率高于传统穿刺采血(RR:7.06,95%CI:2.77-18.01);儿童静脉留置针采血的溶血发生率低于传统穿刺采血(RR:0.18,95%CI:0.07-0.49);
3.儿童静脉留置针负压抽吸采血方法首次采血成功率低于传统穿刺采血方法(RR:0.88,95%CI:0.81-0.96);自流式方法采血方法首次采血成功率高于传统穿刺采血方法(RR:1.26,95%CI:1.14-1.39);
4.静脉留置针采血的血培养标本污染率高于传统穿刺采血方法(RR:2.75,95%CI:2.15—3.53);
5.静脉留置针封管采血时不弃血的标本检测值低于传统穿刺方法采血(SMD:-0.75,95%CI:-1.31—-0.19);静脉留置针封管采血时弃血量1ml、2ml、3ml与传统穿刺方法采血对血样标本检测值的比较的Meta分析结果表明,差异均没有统计学意义;
6.静脉留置针输液时直接采血时,检测输入液体中含有的成分时,检测值高于传统穿刺采血方法(SMD:6.88,95%CI:-3.24—10.52);检测输入液体中不含有的成分时,检测值低于传统穿刺采血方法(SMD:-2.70,95%CI:-2.70,-1.30);
7.合并结果显示,不论是输入液体中含有的成分,还是不含有的成分,静脉留置针输液时暂停1min采血与传统穿刺方法采血对血样标本含有输液成分的检测值的差异都没有统计学意义。但亚组分析表明,在暂停1min后,静脉留置针组的红细胞比容仍低于于传统穿刺方法采血组(SMD:-0.74,95%CI:-1.17—0.32)。另外,输入液体中含有的成分时,在暂停1min后,钠和氯化物已没有差异,但血糖值静脉留置针组仍高于传统穿刺方法采血组(SMD:9.40,95%CI:7.36—11.44);
8.在暂停输液2min后,静脉留置针组的红细胞比容与传统穿刺方法采血组差异不显著(SMD:-0.74,95%CI:-2.07—0.58)。
9.输入葡萄糖溶液时检测血糖值,即使暂停输液3min后,检测血糖值,静脉留置针组仍高于传统穿刺方法采血组(SMD:1.18,95%CI:0.77—1.59)。
10.筛选文献和提取数据过程中发现,不少研究将留置针三种不同状态的采血结果同时分析,因此无法纳入而被排除。不同状态的静脉留置针用于采血时,其影响因素不同,不应混淆:①静脉留置针封管时采血,主要的影响因素是采血弃血量,此时应排除静脉留置针输液时采血的患者,以排除输入液体对结果的影响;②静脉留置针输液时采血,主要的影响因素是需要暂停输液的时间,此时应排除没有弃血以及弃血量小于最低需要量(本研究提示为1ml)的研究,以排除封管液和管腔内残留的液体对结果的影响:③而研究前两种状态时,必须排除初次置管采血的患者。
结论
【第一部分】
1.静脉留置针按需更换策略较之定期更换策略发生静脉炎的风险增大;
2.按需更换策略对导管相关血行感染的发生率没有影响;
3.尚不能肯定按需更换策略是否会影响皮下血肿、液体渗漏、导管堵塞等并发症的发生率;
4.静脉留置针用于输入含脂肪乳剂的TPN时,留置时间不应超过24h,不建议使用按需更换策略,目前国内医院普遍留置超过24h的做法值得重视;
5.尽管近些年来,有不少研究说明静脉留置针按需更换策略不会增加发生静脉炎的风险。但是本研究的Meta分析结果并不支持这种观点。在临床使用按需拔管策略时应持慎重态度;
6.经严格质量评价,认为不能排除存在测量偏倚和发表偏倚的可能性,因此有待于更多地开展设计严谨的相关RCT研究,以提供坚实可靠的证据,在方法学上,一定要注意盲法的使用,尽量避免测量偏倚。
【第二部分】
1.成人静脉留置针采血组的溶血率高于传统穿刺组,而儿童组静脉留置针采血组的溶血率低于传统穿刺组;
2.儿童静脉留置针采血时,自流式方法成功率较高;
3.静脉留置针采血方法的血培养标本污染率高于传统穿刺采血方法,血培养标本最好仍使用传统方法采集;
4.封管液对结果的影响不可忽略,封管时静脉留置针采血前应当弃去一定量的含封管液的血液,以避免封管液对结果的影响;
5.封管时静脉留置针采血最佳的弃血量为1ml;
6.静脉输液时禁止在输液侧手臂直接采血;
7.静脉输液时,检测输入液体中不含有的成分时,可在暂停输液后1min采血;
8.静脉输液时,检测红细胞比容需在暂停输液后2min采血;
9.静脉输液时,检测输入液体中含有的成分时,若此成分含量较低,分子量较小时,(如输入生理盐水时检测钠和氯化物)时,可在暂停输液后1min采血;
10.静脉输液时,检测输入液体中含有的成分时,若此成分含量较高,分子量较大时,(如输入葡萄糖溶液时检测血糖值)时,不建议在输液侧手臂采血,最好仍在对侧手臂采血。
11.进行静脉留置针采血的研究时必须清楚区分留置针的三种状态,此外还要注意对操作实施者进行严格的培训和质量控制,血标本保存和送检环节也要注意质量控制。
Background
Peripheral venous catheter used in intravenous infusion,it can be left in vein for a longer period,re-used,reducing the pain because of repeated venipuncture,and be able to play a role in the protection of blood vessels,to ensure the exact time of medication administration,or to a large extent reduce the workload on the care at the same time.
This study has two parts,the first part is comparison of two peripheral venous catheter replacement strategies:One is routine replacement strategy,generally 3 or 4 days to replace.The other is clinical indicated strategy,that is,not the regular replacement of catheter,but removing catheter when there is only to be replaced indications.So it need insertion site monitoring.Retention time of catheters with clinical indicated replacement are different.Many studies have reported retention time at more than seven days,the longest up to 29 days.
If no additional complications such as catheter-related infection,clinical indicated replacement strategy is the better choice.Since such a replacement strategy for a longer retention time,reducing the suffering of patients with repeated puncture and nursing workload.Therefore this study intend to systematically compare the incidence of complications between the two strategies,with a view to identifying the better one.
The second part is a systematic review for efficacy in blood collection of peripheral venous catheter:Whether or not peripheral venous catheter can be an alternative to traditional venipuncture method of collecting blood samples? Because there is no relevant standards and evidence-based research support,at present we can see two different clinical practices.One way is:Continue to use peripheral venous catheter for blood collection with the doubt attitude,especially for repeated blood sampling,poor blood vessels or infant and child patients.In this case there are significant differences in some key steps such as blood discarded,wait period and so on.The other way is:even if a existing peripheral venous catheter can be used, because there is no evidence to support,is still using the traditional venipuncture method collecting blood sample in order to ensure accurate results of laboratory tests.
If the two methods no difference between the test results,the peripheral venous catheter is a better option.Because it can reduce pain,protect blood vessels,reduce the nursing workload,it also can get more precise sampling time.This study intented to conduct systematic review for efficacy in blood collection of peripheral venous catheter to provide better evidence for clinical practice.
Objective
With international Cochrane Collaboration methods,systematic review the present clinical trials all over the world regarding the replacement strategy and efficacy in blood collection of peripheral venous catheter to obtain evidence of the following questions:
1 ) Whether or not,the incidence of catheter-related infection and other complications is different between routine replacement strategy and clinical indicated replacement strategy of peripheral venous catheter?
2)Is the test results of blood collected by peripheral venous catheters accurate? Will it be affected by the different blood collection methods,lock solution or infusion ingredients? Do we need to discard a certain amount of blood or stop infusion for a period before sampling? How much is the best discarded volume? How long is the best wait period?
Methods
Guided by the principles of evidence-based medicine and the methods of Cochrane systematic reviews,PUBMED(1966-2009.1),EMBASE(1966-2008.12), OVID,Coehrane library,CINAHL(1982-2008.12),CBMdisc(1979-2009.1), CNKI(1994-2008.11),VIP(1994-2008.11) and the reference lists of identified studies were searched.We identified randomized controlled trials or quasi-randomized control trials of replacement strategy and efficacy in blood collection of peripheral venous catheter,as well as self-concurrent control trials of efficacy in blood collection of peripheral venous catheter.The quality of included trials was evaluated by two reviewers.Meta-analysis was conducted including homogeneous studies and sensitivity analysis with RevMan 5.0.18.
Results
【Section one】
1.Six studies(1241 Patients) were included.All included studies were graded in term of randomization,allocation concealment,and blinding.Two studies were graded A, two were graded B and the other two were graded C.
2.Meta-analysis showed that the incidence of phlebitis of clinical indicated replacement of peripheral venous catheter group was higher than routine replacement group(RR:2.47,95%CI:1.48-4.13).
3.The difference of catheter-related blood infection rate between two groups had no statistical significance(RR:0.96,95%CI:0.19-4.81).
【Section two】
1.Twenty seven studies were included.Three studies were graded A,Fourteen were graded B and the other ten were graded C.
2.Hemolysis rate of blood samples of peripheral venous catheter group was higher than venipuncture group in adult patients(RR:7.06,95%CI.2.77-18.01 );and was lower than venipuncture group in children(RR:0.18,95%CI:0.07-0.49);
3.Success rate of blood sampling of venipuncture method group was higher than drawing method group in children(RR:0.88,95%CI:0.81-0.96);and was lower than flowing method group in children(RR:1.26,95%CI.1.14-1.39);
4.Contamination rate of blood culture samples of peripheral venous catheter group was higher than venipuncture group(RR:2.75,95%CI:2.15-3.53);
5.Test value of blood samples of peripheral venous catheter group(no blood discarded )was lower than venipuncture group(SMD:-0.75,95%CI: -1.31-0.19);The difference of test values between various blood discarded group and venipuncture group had no statistical significance;
6.Detecting ingredients included in the infusion solution,test value of blood samples of peripheral venous catheter group(no wait period)was higher than venipuncture group(SMD.6.88,95%CI:-3.24-10.52);and was lower than venipuncture group as detecting ingredients not included in the infusion solution(SMD:-2.70,95%CI: -2.70,-1.30);
7.The total combined result showed that the difference of test values of blood samples between 1min wait period group and venipuncture group had no statistical significance.Yet subgroup analysis indicated,after 1 min wait period,haematocrit of peripheral venous catheter group was still lower than venipuncture group(SMD: -0.74,95%CI:-1.17-0.32);and blood glucose value of peripheral venous catheter group was still higher than venipuncture group as dextrose soltion used(SMD: 9.40,95%CI:7.36-11.44);
8.After 2 min wait period,the difference of haematocrit value of blood samples between peripheral venous catheter group and venipuncture group had no statistical significance(SMD:-0.74,95%CI:-2.07-0.58);
9.Even though after 3 min wait period,blood glucose value of peripheral venous catheter group was still higher than venipuncture group as dextrose soltion used (SMD:1.18,95%CI:0.77-1.59)。
10.As screening of documents we found that many studies analyze the three different states of peripheral venous catheter at the same time,and therefore be excluded. Because different states there are different impact factors,it should not be confused with:①As blood sampling with a saline lock(no infusion,the catheters standby with a saline lock),the impact of blood discarded volume is main problem;②As blood sampling through peripheral venous catheter with a ongoing infusion,the impact of wait period is main problem;③Researching on the first two states,it is important to rule out the blood sampling immediately after catheter insertion.
Conclusions:
【Section one】
1.Compared with routine replacement strategy,clinical indicated replacement strategy of peripheral venous catheter may increase the incidence of phlebitis;
2.Clinical indicated replacement strategy doesn't affect Catheter-related blood infection rate;
3.Still not sure whether clinical indicated replacement strategy will affect the incidences of swelling,infiltration or occlusion;
4.As uesd for TPN including lipid,retention time of peripheral venous catheter should not be more than 24h.Does not recommend clinical indicated replacement strategy.At present,the practice of reserving more than 24h in most Chinese hospitals deserves our attention;
5.Although in recent years,many studies indicated that the clinical indicated replacement strategy of peripheral venous catheter will not increase catheter-related infections and other complications.However,the meta-analysis results of this study do not support this view.In clinical Cautious attitude should be held about the clinical indicated replacement strategy of peripheral venous catheter;
6.After strict quality evaluation,consider the possibility of a higher measurement bias and publication bias.More relevant RCT studies should be carry out to provide solid and reliable evidences.On the methodology,we must pay attention to the use of the blindness,as far as possible to avoid measurement bias.
【Section two】
1.Hemolysis rate of blood samples of peripheral venous catheter group was higher than venipuncture group in adult patients;and was lower than venipuncture group in children;
2.Compared with drawing method,flowing method approaches a higher success rate in children blood collection;
3.Contamination rate of blood culture samples of peripheral venous catheter group was higher than venipuncture group.Blood culture specimens using the traditional venipuncture method are better;
4.Impact on the results of the lock solution can not be ignored.A certain amount of blood including lock solution should be discarded before blood sampling through a peripheral venous catheter;
5.1ml is the best blood discarded volume as collecting blood samples through a peripheral venous catheter;
6.Intravenous infusion side arm can't be used for direct blood collection;
7.During intravenous infusion,detecting ingredients not included in the infusion solution,blood samples can be collect through peripheral venous catheter after 1min stop period;
8.During intravenous infusion,detecting HCT,blood samples can be collect through peripheral venous catheter after 2min stop period;
9.During intravenous infusion,detecting ingredients included in the infusion solution,if it's low concentration in infusion solution and small molecular weight(such as the detection of sodium and chloride When input normal saline), blood samples can be collect through peripheral venous catheter after 1min stop period;
10.During intravenous infusion,detecting ingredients included in the infusion solution,if it's higher concentration in infusion solution and bigger molecular weight(such as the detection of glucose when input dextrose solution),blood sampling is not recommended in the infusion side arm.Contralateral arm blood is better for precise test results.
11.It is important to make a clear distinction between three states of peripheral venous catheter during studies.In addition we must pay attention to the strict training and quality control of operator.Quality controls of preservation and submission of blood specimens are also very important.
静脉留置针常用于静脉输液治疗,它可较长时间留置在血管内,反复使用,减轻患者由于反复穿刺而造成的痛苦,并能够起到保护血管的作用,保证合理用药时间,很大程度上减轻了护理工作量。
本研究分为两个部分,第一部分是比较目前临床护理实践中的两种更换静脉留置针的策略:一个是定期常规更换策略,一般是3天或4天更换。另一个是按需更换策略,即不是定期更换导管,而是对导管置入位点进行监测,当出现拔管指征才予以更换,按需更换策略留置时间差异较大,不少研究报道留置时间可在7天以上,最长时间可达29天。
在不增加导管相关感染等并发症的前提下,按需更换策略是更好的选择。因为这种更换策略留置时间较长,减少了患者反复穿刺的痛苦和护理工作量。因此本研究拟对这两种策略进行系统评价,比较两者并发症的发生率,以期找出较好的策略。
第二部分是对静脉留置针采集血标本有效性的系统评价:静脉留置针是否可以用来替代传统的穿刺方法采集血标本?由于没有相关的参考标准和循证研究支持,目前临床可见两种不同的做法。一种是做法是:一边持疑问态度,一边使用静脉留置针采血,尤其是一些需要反复多次采血、血管状况很差或婴幼儿患者,而且在一些相关的要求如弃血量、输液暂停时间等操作上存在很大的差异。还有一种做法是:即使在有现成的静脉留置针可用于采血的情况下,因为没有证据支持,仍然采用传统穿刺法采集血标本,以确保准确的实验室检查结果。
如果两种方法采集的血标本的检测结果没有差异的话,使用已有的静脉留置针采血是更好的选择。因为这样可以减少患者痛苦、保护血管、减轻护理工作量,也可以使得采血的时间更为精确。本研究拟对静脉留置针采集血标本的有效性进行系统评价,以为临床实践提供更好的证据。
研究目的
我们希望通过采用国际循证医学Cochrane协作网的系统评价方法,对目前全世界关于静脉留置针更换策略及采血有效性的临床试验进行系统评价,以期获得以下问题的相关证据:
1)定期常规更换静脉留置针与根据置入位点的临床症状按需更换静脉留置针,导管相关感染及其他并发症的发生率是否有差异?
2)静脉留置针采血的结果是否准确?是否会受封管液的影响?是否可以直接采血还是需要先弃去部分血液?合适的弃血量又是多少?静脉留置针主要用于静脉输液,输液成分是否会影响检测结果?
方法
遵循循证医学的原则,运用Cochrane系统评价的方法,采用机检和手工检索相结合的方法,检索PUBMED(1966-2009.1)、EMBASE(1966-2008.12)、OVID、Cochrane图书馆、CINAHL(1982-2008.12)、CBMdisc(中国生物医学数据库,1979-2009.1)、CNKI(1994-2008.11)、VIP(1994-2008.11),同时追踪检索已确定文献的参考文献。收集所有关于静脉留置针留置时间的临床随机对照和半随机对照试验,以及比较静脉留置针与传统穿刺方法采血结果的临床自身同期对照试验、随机对照和半随机对照试验。由两名评价者对文献进行质量评定和数据收集。统计软件用Cochrane协作网提供的RevMan 5.0.18,对提取的定量资料进行异质性检验、Meta分析和敏感性分析。
结果
【第一部分】
1.共纳入了6个RCT研究(共1292例患者),研究质量2个为A级,2个为B级,2个为C级。
2.按需更换静脉留置针组静脉炎发生率高于定期更换静脉留置针组(RR:2.47,95%CI:1.48-4.13)。
3.按需更换静脉留置针组与定期更换静脉留置针组导管相关血行感染发生率没有差异(RR:0.96,95%CI:0.19-4.81)。
【第二部分】
1.共纳入了27个研究,研究质量3个为A级,14个为B级,10个为C级。
2.成人静脉留置针采血的溶血发生率高于传统穿刺采血(RR:7.06,95%CI:2.77-18.01);儿童静脉留置针采血的溶血发生率低于传统穿刺采血(RR:0.18,95%CI:0.07-0.49);
3.儿童静脉留置针负压抽吸采血方法首次采血成功率低于传统穿刺采血方法(RR:0.88,95%CI:0.81-0.96);自流式方法采血方法首次采血成功率高于传统穿刺采血方法(RR:1.26,95%CI:1.14-1.39);
4.静脉留置针采血的血培养标本污染率高于传统穿刺采血方法(RR:2.75,95%CI:2.15—3.53);
5.静脉留置针封管采血时不弃血的标本检测值低于传统穿刺方法采血(SMD:-0.75,95%CI:-1.31—-0.19);静脉留置针封管采血时弃血量1ml、2ml、3ml与传统穿刺方法采血对血样标本检测值的比较的Meta分析结果表明,差异均没有统计学意义;
6.静脉留置针输液时直接采血时,检测输入液体中含有的成分时,检测值高于传统穿刺采血方法(SMD:6.88,95%CI:-3.24—10.52);检测输入液体中不含有的成分时,检测值低于传统穿刺采血方法(SMD:-2.70,95%CI:-2.70,-1.30);
7.合并结果显示,不论是输入液体中含有的成分,还是不含有的成分,静脉留置针输液时暂停1min采血与传统穿刺方法采血对血样标本含有输液成分的检测值的差异都没有统计学意义。但亚组分析表明,在暂停1min后,静脉留置针组的红细胞比容仍低于于传统穿刺方法采血组(SMD:-0.74,95%CI:-1.17—0.32)。另外,输入液体中含有的成分时,在暂停1min后,钠和氯化物已没有差异,但血糖值静脉留置针组仍高于传统穿刺方法采血组(SMD:9.40,95%CI:7.36—11.44);
8.在暂停输液2min后,静脉留置针组的红细胞比容与传统穿刺方法采血组差异不显著(SMD:-0.74,95%CI:-2.07—0.58)。
9.输入葡萄糖溶液时检测血糖值,即使暂停输液3min后,检测血糖值,静脉留置针组仍高于传统穿刺方法采血组(SMD:1.18,95%CI:0.77—1.59)。
10.筛选文献和提取数据过程中发现,不少研究将留置针三种不同状态的采血结果同时分析,因此无法纳入而被排除。不同状态的静脉留置针用于采血时,其影响因素不同,不应混淆:①静脉留置针封管时采血,主要的影响因素是采血弃血量,此时应排除静脉留置针输液时采血的患者,以排除输入液体对结果的影响;②静脉留置针输液时采血,主要的影响因素是需要暂停输液的时间,此时应排除没有弃血以及弃血量小于最低需要量(本研究提示为1ml)的研究,以排除封管液和管腔内残留的液体对结果的影响:③而研究前两种状态时,必须排除初次置管采血的患者。
结论
【第一部分】
1.静脉留置针按需更换策略较之定期更换策略发生静脉炎的风险增大;
2.按需更换策略对导管相关血行感染的发生率没有影响;
3.尚不能肯定按需更换策略是否会影响皮下血肿、液体渗漏、导管堵塞等并发症的发生率;
4.静脉留置针用于输入含脂肪乳剂的TPN时,留置时间不应超过24h,不建议使用按需更换策略,目前国内医院普遍留置超过24h的做法值得重视;
5.尽管近些年来,有不少研究说明静脉留置针按需更换策略不会增加发生静脉炎的风险。但是本研究的Meta分析结果并不支持这种观点。在临床使用按需拔管策略时应持慎重态度;
6.经严格质量评价,认为不能排除存在测量偏倚和发表偏倚的可能性,因此有待于更多地开展设计严谨的相关RCT研究,以提供坚实可靠的证据,在方法学上,一定要注意盲法的使用,尽量避免测量偏倚。
【第二部分】
1.成人静脉留置针采血组的溶血率高于传统穿刺组,而儿童组静脉留置针采血组的溶血率低于传统穿刺组;
2.儿童静脉留置针采血时,自流式方法成功率较高;
3.静脉留置针采血方法的血培养标本污染率高于传统穿刺采血方法,血培养标本最好仍使用传统方法采集;
4.封管液对结果的影响不可忽略,封管时静脉留置针采血前应当弃去一定量的含封管液的血液,以避免封管液对结果的影响;
5.封管时静脉留置针采血最佳的弃血量为1ml;
6.静脉输液时禁止在输液侧手臂直接采血;
7.静脉输液时,检测输入液体中不含有的成分时,可在暂停输液后1min采血;
8.静脉输液时,检测红细胞比容需在暂停输液后2min采血;
9.静脉输液时,检测输入液体中含有的成分时,若此成分含量较低,分子量较小时,(如输入生理盐水时检测钠和氯化物)时,可在暂停输液后1min采血;
10.静脉输液时,检测输入液体中含有的成分时,若此成分含量较高,分子量较大时,(如输入葡萄糖溶液时检测血糖值)时,不建议在输液侧手臂采血,最好仍在对侧手臂采血。
11.进行静脉留置针采血的研究时必须清楚区分留置针的三种状态,此外还要注意对操作实施者进行严格的培训和质量控制,血标本保存和送检环节也要注意质量控制。
Background
Peripheral venous catheter used in intravenous infusion,it can be left in vein for a longer period,re-used,reducing the pain because of repeated venipuncture,and be able to play a role in the protection of blood vessels,to ensure the exact time of medication administration,or to a large extent reduce the workload on the care at the same time.
This study has two parts,the first part is comparison of two peripheral venous catheter replacement strategies:One is routine replacement strategy,generally 3 or 4 days to replace.The other is clinical indicated strategy,that is,not the regular replacement of catheter,but removing catheter when there is only to be replaced indications.So it need insertion site monitoring.Retention time of catheters with clinical indicated replacement are different.Many studies have reported retention time at more than seven days,the longest up to 29 days.
If no additional complications such as catheter-related infection,clinical indicated replacement strategy is the better choice.Since such a replacement strategy for a longer retention time,reducing the suffering of patients with repeated puncture and nursing workload.Therefore this study intend to systematically compare the incidence of complications between the two strategies,with a view to identifying the better one.
The second part is a systematic review for efficacy in blood collection of peripheral venous catheter:Whether or not peripheral venous catheter can be an alternative to traditional venipuncture method of collecting blood samples? Because there is no relevant standards and evidence-based research support,at present we can see two different clinical practices.One way is:Continue to use peripheral venous catheter for blood collection with the doubt attitude,especially for repeated blood sampling,poor blood vessels or infant and child patients.In this case there are significant differences in some key steps such as blood discarded,wait period and so on.The other way is:even if a existing peripheral venous catheter can be used, because there is no evidence to support,is still using the traditional venipuncture method collecting blood sample in order to ensure accurate results of laboratory tests.
If the two methods no difference between the test results,the peripheral venous catheter is a better option.Because it can reduce pain,protect blood vessels,reduce the nursing workload,it also can get more precise sampling time.This study intented to conduct systematic review for efficacy in blood collection of peripheral venous catheter to provide better evidence for clinical practice.
Objective
With international Cochrane Collaboration methods,systematic review the present clinical trials all over the world regarding the replacement strategy and efficacy in blood collection of peripheral venous catheter to obtain evidence of the following questions:
1 ) Whether or not,the incidence of catheter-related infection and other complications is different between routine replacement strategy and clinical indicated replacement strategy of peripheral venous catheter?
2)Is the test results of blood collected by peripheral venous catheters accurate? Will it be affected by the different blood collection methods,lock solution or infusion ingredients? Do we need to discard a certain amount of blood or stop infusion for a period before sampling? How much is the best discarded volume? How long is the best wait period?
Methods
Guided by the principles of evidence-based medicine and the methods of Cochrane systematic reviews,PUBMED(1966-2009.1),EMBASE(1966-2008.12), OVID,Coehrane library,CINAHL(1982-2008.12),CBMdisc(1979-2009.1), CNKI(1994-2008.11),VIP(1994-2008.11) and the reference lists of identified studies were searched.We identified randomized controlled trials or quasi-randomized control trials of replacement strategy and efficacy in blood collection of peripheral venous catheter,as well as self-concurrent control trials of efficacy in blood collection of peripheral venous catheter.The quality of included trials was evaluated by two reviewers.Meta-analysis was conducted including homogeneous studies and sensitivity analysis with RevMan 5.0.18.
Results
【Section one】
1.Six studies(1241 Patients) were included.All included studies were graded in term of randomization,allocation concealment,and blinding.Two studies were graded A, two were graded B and the other two were graded C.
2.Meta-analysis showed that the incidence of phlebitis of clinical indicated replacement of peripheral venous catheter group was higher than routine replacement group(RR:2.47,95%CI:1.48-4.13).
3.The difference of catheter-related blood infection rate between two groups had no statistical significance(RR:0.96,95%CI:0.19-4.81).
【Section two】
1.Twenty seven studies were included.Three studies were graded A,Fourteen were graded B and the other ten were graded C.
2.Hemolysis rate of blood samples of peripheral venous catheter group was higher than venipuncture group in adult patients(RR:7.06,95%CI.2.77-18.01 );and was lower than venipuncture group in children(RR:0.18,95%CI:0.07-0.49);
3.Success rate of blood sampling of venipuncture method group was higher than drawing method group in children(RR:0.88,95%CI:0.81-0.96);and was lower than flowing method group in children(RR:1.26,95%CI.1.14-1.39);
4.Contamination rate of blood culture samples of peripheral venous catheter group was higher than venipuncture group(RR:2.75,95%CI:2.15-3.53);
5.Test value of blood samples of peripheral venous catheter group(no blood discarded )was lower than venipuncture group(SMD:-0.75,95%CI: -1.31-0.19);The difference of test values between various blood discarded group and venipuncture group had no statistical significance;
6.Detecting ingredients included in the infusion solution,test value of blood samples of peripheral venous catheter group(no wait period)was higher than venipuncture group(SMD.6.88,95%CI:-3.24-10.52);and was lower than venipuncture group as detecting ingredients not included in the infusion solution(SMD:-2.70,95%CI: -2.70,-1.30);
7.The total combined result showed that the difference of test values of blood samples between 1min wait period group and venipuncture group had no statistical significance.Yet subgroup analysis indicated,after 1 min wait period,haematocrit of peripheral venous catheter group was still lower than venipuncture group(SMD: -0.74,95%CI:-1.17-0.32);and blood glucose value of peripheral venous catheter group was still higher than venipuncture group as dextrose soltion used(SMD: 9.40,95%CI:7.36-11.44);
8.After 2 min wait period,the difference of haematocrit value of blood samples between peripheral venous catheter group and venipuncture group had no statistical significance(SMD:-0.74,95%CI:-2.07-0.58);
9.Even though after 3 min wait period,blood glucose value of peripheral venous catheter group was still higher than venipuncture group as dextrose soltion used (SMD:1.18,95%CI:0.77-1.59)。
10.As screening of documents we found that many studies analyze the three different states of peripheral venous catheter at the same time,and therefore be excluded. Because different states there are different impact factors,it should not be confused with:①As blood sampling with a saline lock(no infusion,the catheters standby with a saline lock),the impact of blood discarded volume is main problem;②As blood sampling through peripheral venous catheter with a ongoing infusion,the impact of wait period is main problem;③Researching on the first two states,it is important to rule out the blood sampling immediately after catheter insertion.
Conclusions:
【Section one】
1.Compared with routine replacement strategy,clinical indicated replacement strategy of peripheral venous catheter may increase the incidence of phlebitis;
2.Clinical indicated replacement strategy doesn't affect Catheter-related blood infection rate;
3.Still not sure whether clinical indicated replacement strategy will affect the incidences of swelling,infiltration or occlusion;
4.As uesd for TPN including lipid,retention time of peripheral venous catheter should not be more than 24h.Does not recommend clinical indicated replacement strategy.At present,the practice of reserving more than 24h in most Chinese hospitals deserves our attention;
5.Although in recent years,many studies indicated that the clinical indicated replacement strategy of peripheral venous catheter will not increase catheter-related infections and other complications.However,the meta-analysis results of this study do not support this view.In clinical Cautious attitude should be held about the clinical indicated replacement strategy of peripheral venous catheter;
6.After strict quality evaluation,consider the possibility of a higher measurement bias and publication bias.More relevant RCT studies should be carry out to provide solid and reliable evidences.On the methodology,we must pay attention to the use of the blindness,as far as possible to avoid measurement bias.
【Section two】
1.Hemolysis rate of blood samples of peripheral venous catheter group was higher than venipuncture group in adult patients;and was lower than venipuncture group in children;
2.Compared with drawing method,flowing method approaches a higher success rate in children blood collection;
3.Contamination rate of blood culture samples of peripheral venous catheter group was higher than venipuncture group.Blood culture specimens using the traditional venipuncture method are better;
4.Impact on the results of the lock solution can not be ignored.A certain amount of blood including lock solution should be discarded before blood sampling through a peripheral venous catheter;
5.1ml is the best blood discarded volume as collecting blood samples through a peripheral venous catheter;
6.Intravenous infusion side arm can't be used for direct blood collection;
7.During intravenous infusion,detecting ingredients not included in the infusion solution,blood samples can be collect through peripheral venous catheter after 1min stop period;
8.During intravenous infusion,detecting HCT,blood samples can be collect through peripheral venous catheter after 2min stop period;
9.During intravenous infusion,detecting ingredients included in the infusion solution,if it's low concentration in infusion solution and small molecular weight(such as the detection of sodium and chloride When input normal saline), blood samples can be collect through peripheral venous catheter after 1min stop period;
10.During intravenous infusion,detecting ingredients included in the infusion solution,if it's higher concentration in infusion solution and bigger molecular weight(such as the detection of glucose when input dextrose solution),blood sampling is not recommended in the infusion side arm.Contralateral arm blood is better for precise test results.
11.It is important to make a clear distinction between three states of peripheral venous catheter during studies.In addition we must pay attention to the strict training and quality control of operator.Quality controls of preservation and submission of blood specimens are also very important.
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32.Norberg AMD.Contamination Rates of Blood Cultures Obtained by Dedicated Phlebotomy vs Intravenous Catheter[R].JAMA,2003,289(6):726-729.
33.Ramsook C.Comparison of blood-culture contamination rates in a pediatric emergency room:Newly inserted intravenous catheters versus venipuneture[J].Infection Control and Hospital Epidemiology,2000,21(10):649-651.
34.孙会会,马笑平,李红梅等.留置针在葡萄糖-胰岛素释放试验采血中的应用[J].第四军医大学学报,2000,21(11):1320
35.张亚莉,李飞娥,李涛.静脉留置套管针采血对葡萄糖耐量试验的影响[J].解放军护理杂志,2001,18(3):19-20
36.杨丽芳,刘小珍,谭丽明等.静脉留置套管针采血应用于标准馒头餐试验的分析[J].现代护理,2003,9(5):336-7
37.武素军.留置静脉套管针采血对葡萄糖耐量试验的影响[J].山东医药,2002,42(27):3-4
38.辛莉莉,王力,仲蓓等.静脉留置针采血对葡萄糖耐量试验结果的影响[J].中华护理杂志,2005,40(10):784-5
39.石丹琴,冯润芬,黄正茂等.静脉留置针采血标本对检验结果的影响[J].医学理论与实践,2002,15(6):695-6
40.李飞娥,朱京慈,唐维佳等.套管针采血对胰岛素和C肽测定结果的影响[J].第三军医大学学报,2002,24(3):334-5
41.黄凤毛,张小红,周湘青,黄静艳,.静脉留置针采血对糖尿病患者血糖测定结果的影响[J].当代护士,2006,(8):38-9
42.Prue-Owens K.Use of peripheral venous access devices for obtaining blood samples for measurement of activated partial thromboplastin times[J].Critical Care Nurse,2006,26(1):30.
43.Zengin NM,Enc NP.Comparison of two blood sampling methods in anticoagulation therapy:venipuncture and peripheral venous catheter[J].Journal of Clinical Nursing,2008,17(3):386-393.
44.杨丽,缪国斌,康静等.外周静脉留置针采血对老年患者血标本结果影响的研究[J].中国实用护理杂志,2006,26(3):39-41
45.Zlotowski SJ,Kupas DF,Wood GC.Comparison of laboratory values obtained by means of routine venipuncture versus peripheral intravenous catheter after a normal saline solution bolus[J].Ann Emerg Med,2001,38(5):497-504.
46.Himberger JR,Himberger LC.Accuracy of drawing blood through infusing intravenous lines[J].Heart Lung,2001,30(1):66-73.
47.Herr RD,Bossart PJ,Blaylock RC,et al.Intravenous catheter aspiration for obtaining basic analytes during intravenous infusion[J].Ann Emerg Med,1990,19:789-792.
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49.Watson KR,O' Kell RT,Joyce JT.Data regarding blood drawing sites in patients receiving intravenous fluids[J].Am J Clin Pathol,1983,79:119-121.
50.Van Vonderen MG,Voerman BJ,Hensgens BE.Effect of intravenous infusions on laboratory results in blood specimens drawn proximal to the insertion site of an intravenous canula[J].Neth J Med,1998,53(5):224-7.
51.Cox,SR.Blood samples drawn from Ⅳ catheters have less hemolysis when 5-mL(vs 10-mL)collection tubes are used[J].J Emerg Nurs,2004,30(6):529-33.
52.葛君华,李振华.两类留置针在OGTT采血过程中的比较[J].护士进修杂志,2000,15(1):11-12
53.McQuillen K.Intravenous catheter blood cultures:utility and contamination[J].Pediatrics,1999,103(4):52.
54.Powers JM.Obtaining blood samples for coagulation studies from a normal saline lock[J]. Am J Crit Care,1999,8(4):250-3.
55.Mohler M.The reliability of blood sampling from peripheral intravenous infusion lines.Complete blood cell counts,electrolyte panels,and survey panels[J].J Intraven Nurs,1998,21(4):209-14.
56.Fincher RK,Strong JS,Jackson JL.Accuracy of measurements of hemoglobin and potassium in blood samples from peripheral catheters[J].Am J Crit Care,1998,7(6):439-43.
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32.Norberg AMD.Contamination Rates of Blood Cultures Obtained by Dedicated Phlebotomy vs Intravenous Catheter[R].JAMA,2003,289(6):726-729.
33.Ramsook C.Comparison of blood-culture contamination rates in a pediatric emergency room:Newly inserted intravenous catheters versus venipuneture[J].Infection Control and Hospital Epidemiology,2000,21(10):649-651.
34.孙会会,马笑平,李红梅等.留置针在葡萄糖-胰岛素释放试验采血中的应用[J].第四军医大学学报,2000,21(11):1320
35.张亚莉,李飞娥,李涛.静脉留置套管针采血对葡萄糖耐量试验的影响[J].解放军护理杂志,2001,18(3):19-20
36.杨丽芳,刘小珍,谭丽明等.静脉留置套管针采血应用于标准馒头餐试验的分析[J].现代护理,2003,9(5):336-7
37.武素军.留置静脉套管针采血对葡萄糖耐量试验的影响[J].山东医药,2002,42(27):3-4
38.辛莉莉,王力,仲蓓等.静脉留置针采血对葡萄糖耐量试验结果的影响[J].中华护理杂志,2005,40(10):784-5
39.石丹琴,冯润芬,黄正茂等.静脉留置针采血标本对检验结果的影响[J].医学理论与实践,2002,15(6):695-6
40.李飞娥,朱京慈,唐维佳等.套管针采血对胰岛素和C肽测定结果的影响[J].第三军医大学学报,2002,24(3):334-5
41.黄凤毛,张小红,周湘青,黄静艳,.静脉留置针采血对糖尿病患者血糖测定结果的影响[J].当代护士,2006,(8):38-9
42.Prue-Owens K.Use of peripheral venous access devices for obtaining blood samples for measurement of activated partial thromboplastin times[J].Critical Care Nurse,2006,26(1):30.
43.Zengin NM,Enc NP.Comparison of two blood sampling methods in anticoagulation therapy:venipuncture and peripheral venous catheter[J].Journal of Clinical Nursing,2008,17(3):386-393.
44.杨丽,缪国斌,康静等.外周静脉留置针采血对老年患者血标本结果影响的研究[J].中国实用护理杂志,2006,26(3):39-41
45.Zlotowski SJ,Kupas DF,Wood GC.Comparison of laboratory values obtained by means of routine venipuncture versus peripheral intravenous catheter after a normal saline solution bolus[J].Ann Emerg Med,2001,38(5):497-504.
46.Himberger JR,Himberger LC.Accuracy of drawing blood through infusing intravenous lines[J].Heart Lung,2001,30(1):66-73.
47.Herr RD,Bossart PJ,Blaylock RC,et al.Intravenous catheter aspiration for obtaining basic analytes during intravenous infusion[J].Ann Emerg Med,1990,19:789-792.
48.Read D,Viera H,Arkin C.Effect of drawing blood specimen proximal to an in-place but discontinued intravenous solution.Can blood be drawn above the site of a shut-off Ⅳ?[J]Am Clin Pathol,1988,6:702-6.
49.Watson KR,O' Kell RT,Joyce JT.Data regarding blood drawing sites in patients receiving intravenous fluids[J].Am J Clin Pathol,1983,79:119-121.
50.Van Vonderen MG,Voerman BJ,Hensgens BE.Effect of intravenous infusions on laboratory results in blood specimens drawn proximal to the insertion site of an intravenous canula[J].Neth J Med,1998,53(5):224-7.
51.Cox,SR.Blood samples drawn from Ⅳ catheters have less hemolysis when 5-mL(vs 10-mL)collection tubes are used[J].J Emerg Nurs,2004,30(6):529-33.
52.葛君华,李振华.两类留置针在OGTT采血过程中的比较[J].护士进修杂志,2000,15(1):11-12
53.McQuillen K.Intravenous catheter blood cultures:utility and contamination[J].Pediatrics,1999,103(4):52.
54.Powers JM.Obtaining blood samples for coagulation studies from a normal saline lock[J]. Am J Crit Care,1999,8(4):250-3.
55.Mohler M.The reliability of blood sampling from peripheral intravenous infusion lines.Complete blood cell counts,electrolyte panels,and survey panels[J].J Intraven Nurs,1998,21(4):209-14.
56.Fincher RK,Strong JS,Jackson JL.Accuracy of measurements of hemoglobin and potassium in blood samples from peripheral catheters[J].Am J Crit Care,1998,7(6):439-43.