有臨床症狀再更換周邊靜脈留置針的成人患者是否比常規更換者更容易得到靜脈炎Is the incidence of phlebitis higher for irregular replacing peripheral intravenous catheter group than regular replacing catheter group?

7045 76 959         DOI:doi.org/10.30131/TWNA_EBHC_Library.DB_2021080016A/Text

2022-01-03 已刊登
綜 整 預防/治療/介入類型

作  者

宋婕 翁芝爾*

文章類別

A 類:實證健康照護綜整

問題類型

治療/預防性問題

健康狀況

其他 (other)  

治療/介入措施

其他(Others) - 靜脈留置針有臨床症狀再更換

專長類別

五官、皮膚及其他護理照護

中文關鍵詞

#成人患者、周邊靜脈留置針、更換時機、靜脈炎、疼痛

英文關鍵詞

#adult patient # peripheral venous catheter # timing of replacement # phlebitis # pain

機構名稱

長庚醫療財團法人基隆長庚紀念醫院

申請單位

長庚醫療財團法人基隆長庚紀念醫院

中文摘要

形成臨床提問:
周邊靜脈留置針是臨床最常見的侵入性處置,成人周邊靜脈留置針在臨床照護現況上,多數為常規每72~96小時重新更換,目的在預防靜脈炎等合併症,然而頻繁更換周邊靜脈留置針,除增加病患疼痛與壓力經驗外,也會增加護理人員工作負荷與醫療資源的耗費。鑑此,擬以實證手法瞭解成人不常規更換周邊靜脈留置針,是否會造成靜脈炎的發生率增加。
文獻搜尋的方法與分析:
本文以臨床情境提問形成PICO,利用主要關鍵字:【P】具周邊靜脈留置針的患者(Peripheral venous catheters)、【I】臨床症狀更換(Clinically indicated replacement)、【C】常規更換(Routine replacement)、【O】靜脈炎發生率(Phlebitis),以布林邏輯(And或Or)串聯,搜尋發表於PubMed、Cochrane Library、EMBASE以及華藝線上圖書館(CEPS)四個資料庫的學術文獻,文獻設定在5年內(2017年至2021年)、不限定語言、研究類型以系統性文獻回顧(Systematic review, SR)及統合分析(Meta analysis, MA)為優先,其次為隨機對照試驗(Randomized controlled trial, RCT)的文獻。排除研究對象為兒童、留置管路非周邊靜脈留置針以及介入措施非比較常規與有症狀時更換文獻。初步共得到34篇,最後選擇1篇2019年的系統性文獻回顧及1篇2021年的隨機對照試驗研究,共計2篇文獻進行評讀。
文獻的品質評讀:
第一篇為系統性文獻回顧(SR),評讀工具採用英國(2006)的CASP進行文獻品質評讀,評讀結果為9分,屬於高品質文獻。第二篇為隨機對照試驗研究(RCT),評讀工具採用考科藍組織(2016)的RoB 2.0進行文獻品質評讀,評讀結果為低誤差風險(Low risk of bias),本文主題為臨床經常性發生之議題,經評讀後確認文獻品質與證據等極佳,可有效應用於臨床參考。
結果、結論與建議:
經實證手法得知,成人患者周邊靜脈留置針的更換時機(有臨床症狀再更換與常規更換相較),在靜脈炎的發生率上無明確定論。第一篇SR的研究結果顯示靜脈炎的發生率在兩組間無顯著差異,第二篇RCT則表示「臨床症狀更換組」在靜脈炎的發生率上,顯著高於「常規更換組」。但在注射成本上「臨床症狀更換組」較具備優勢,SR的研究結果顯示「常規更換組」的注射成本顯著較高,大約高出7~654澳元,約等於增加159~13734元台幣花費。因此,雖然有臨床症狀再更換靜脈留置針會降低成人患者注射的痛苦經驗及減少住院花費,但靜脈炎的發生率也可能較高,基於病人安全考量,筆者建議本院成人周邊靜脈留置針的更換時機仍維持常規更換,同時達到維護病人安全及兼顧照護品質的目的,此外,國內仍缺乏相關主題的研究發表,建議未來可擴大樣本數於國內執行,使研究結果更具參考價值。

英文摘要

Ask an answerable question (PICO):
Peripheral venous catheter (PVC) placement is the most common invasive clinical treatment during hospital care. According to Centres for Disease Control guidelines, recommend scheduled for replacement peripheral venous catheters is at least every 72-96 hours in adults to prevent phlebitis. However, frequent PVC replacement might increase pain and stress in patients, workload of nurses, as well as medical resource consumption. Therefore, empirical methods were used in this study to understand whether irregular replacement of PVCs caused increased incidence of phlebitis in adult patients.
The Method and Analysis of Literature Review:
This study used the PICO (patient–intervention–comparison–outcome) framework to analyze the clinical questions using the following keywords: adult patients with PVCs (P), clinically indicated replacement (I), routine replacement (C), and incidence of phlebitis (O). These keywords were connected using Boolean logic (i.e., “and” or “or”) to search for literature in PubMed, Cochrane Library, EMBASE, and Airiti Library (Chinese Electronic Periodical Services). Studies which published in last 5 years (2017–2021) with adult participants were included. The search was not limited to any language, and studies with a systematic review (SR) or meta-analysis design were preferred, followed by those with a randomized controlled trial (RCT) design. Studies that did not meet the inclusion criteria were excluded, such as children, non-peripheral intravenous catheter; and interventions that were not relatively routine and changed when symptomatic. Initially, 34 studies were acquired, which were then narrowed down to 1 SR study published in 2019 and 1 RCT study published in 2021 for the subsequent appraisal.
Critical Appraisal:
The UK Critical Appraisal Skills Programme checklist (2006) was employed for the appraisal of the SR study. The appraisal yielded a result of 9 points, indicating the study to be of high quality. For the RCT study, RoB 2.0 (2016), a revised Cochrane tool for risk-of-bias assessment in randomized trials was used for the appraisal, which yielded a low risk of bias for the study. These two studies, which investigated problems that commonly occurred in clinical setting, were verified by the appraisal to have satisfactory quality and evidence; thus, their findings could provide valuable references for clinical practice.
Results, Conclusions and Recommendations:
The empirical investigations revealed conclusion unclear on the relationship between the PVC replacement timings (replacement after identification of clinical symptoms vs. routine replacement) and incidence of phlebitis in adult patients. According to the SR study, the incidence of phlebitis was not significantly different between patients receiving PVC replacement at the aforementioned two timings. By contrast, the RCT study revealed a significantly higher incidence of phlebitis in patients receiving PVC replacement after identification of clinical symptoms than those receiving routine PVC replacement. Nevertheless, the SR study showed that the injection cost was higher in routine PVC replacement by approximately AU$7–AU$654 (equivalent to NT$159–NT$13,734) than in clinical-symptom-based replacement. Despite reducing the frequency of pain experienced by adult patients in PVC injection and cost spent in hospital stay, replacing PVCs after identification of clinical symptoms, could increase the incidence of phlebitis. Considering of patients’ safety, current study recommends that PVCs should be replaced regularly for the hospital to ensure patients’ safety and higher quality of care. Given the lack of Taiwanese research on related topics, future research may be conducted with a larger sample size in the context of Taiwan to increase the referential value of research findings to Taiwan hospitals.