Anesth Analg 2003;96:387-391
© 2003 International Anesthesia Research Society
PEDIATRIC ANESTHESIA
Traditional Versus New Needle Retractable IV Catheters in Children: Are They Really Safer, and Whom Are They Protecting?
Charles J. Coté, MD, DABA, FAAP*,
,
Andrew G. Roth, MD, DABA, FAAP
,
Melissa Wheeler, MD, DABA, FAAP, DABPM,
Carolyn ter Rahe, MD, DABA,
Bronwyn R. Rae, MBBS, FANZCA, DCH (Lond), DABA,
Richard M. Dsida, MD, DABA, FAAP, and
H. J. Przybylo, MD, DABA, FAAP
*Department of Anesthesiology and Pediatrics, Feinberg Medical School, Northwestern University; and
Departments of Pediatric Anesthesiology and
Anesthesiology, Children’s Memorial Hospital, Northwestern University Medical School, Chicago, Illinois
Address correspondence and reprint requests to Charles J. Coté, MD, Department of Pediatric Anesthesiology #19, Children’s Memorial Hospital, 2300 Children’s Plaza, Chicago, IL 60614. Address e-mail to ccote{at}northwestern.edu
 |
Abstract
|
|---|
Retractable needle IV catheters are designed to reduce needle-stick injuries; their use is mandated by federal regulations. We undertook a prospective data collection with the "traditional" IV catheters (JELCO) versus the "new" (AngiocathTM AutoguardTM). Assignment of catheter type was randomized by week. Data collected included assessment of the difficulty of IV access; number of catheters used; and splatters or spills of blood on skin, linen, floor, clothing, and operating room table. There were 473 attempted insertions in 330 patients over 20 days. No needle-stick injuries occurred. Seventy-seven blood spills or splatters occurred in 42 patients. The number of splatters or spills was four times more with the new compared with the traditional catheters. There were significantly more total splatters or spills and patients who experienced splatters or spills with new catheters when they were placed by attendings but not when placed by trainees. Our study suggests that use of this technology by more experienced anesthesiologists may increase the risk of exposure of health care providers to blood-borne pathogens. Practitioners should choose the IV system that allows the most efficient venous access with the least potential for blood contamination. Hospitals should allow the choice to be made by the individuals using the devices.
IMPLICATIONS:Use of retractable needle safety IV catheters may increase rather than decrease exposure to blood. The choice of IV system should be left to the clinician’s best judgment to balance the efficient establishment of venous access with the least potential for blood contamination.
|
Introduction
|
|---|
Government regulations have mandated the availability of retractable needle systems for IV catheters to reduce the incidence of accidental needle-stick injuries (1,2). Although the goal is laudable, the introduction of new technology may increase other risks, because blood-borne pathogens can be spread by other means, such as mucocutaneous exposure (3,4). Our experience after 5 months with such systems was that successful venipuncture was more difficult to recognize and achieve. In part this seemed to be a result of the increased weight and size of the new compared with the traditional IV catheter system. This seemed to result in additional attempts at catheter placement and more time to achieve successful venous access. In addition, factors such as unintended needle retraction, needle withdrawal to determine whether the catheter is in the vein, and the apparent need for additional attempts at venipuncture seemed to result in increased exposure of operating room (OR) personnel to spilled or splattered blood. Because in our experience, needle-stick injuries are rare, our primary outcomes measures were ease of catheter insertion, number of catheters used per patient, spills and splatters of blood, and time for catheter insertion.
|
Methods
|
|---|
We undertook a prospective study of "traditional" versus "new" IV catheter technology. Because use of the new IV catheters is mandated, the IRB indicated that informed consent was not required. We assigned catheter type—traditional (JELCO; Johnson & Johnson Medical) or new (AngiocathTM AutoguardTM, BD Medical Systems, Inc.)—by week in the OR and requested that staff fill out a questionnaire after catheter placement regarding the following: number of catheters used; patient age; patient weight; operative procedure; splattering (forceful propulsion of blood out of the IV catheter, e.g., with unintended or intended needle retraction or flipping of the catheter) or spilling (passive loss of blood from a puncture site or IV catheter) of blood on linen, OR table, floor, the skin or clothing of the person inserting the catheter, or the skin or clothing of other OR personnel; accidental needle stick; and insertion time (defined as the time from initial skin puncture to successful running of IV fluid, timed with a stopwatch by either the attending or the resident, depending on who was inserting the catheter). Participation by attending anesthesiologists was voluntary.
We analyzed the data in three ways: 1) comparing the traditional catheter versus the new catheter for all patients, 2) comparing patients 
3 yr versus patients >3 yr, and 3) comparing catheter insertions by trainees with insertions by attending anesthesiologists. Statistical analyses were performed with SPSS Version 11 (SPSS, Inc., Chicago, IL). Incidence data were analyzed with 
2 or Fisher’s exact tests; Mann-Whitney U-tests were used to determine the relationships between age and the number of catheters used and between individuals and the number of catheters used; the Pearson correlation was used to determine the relationship between the assessed degree of difficulty in IV access versus time for insertion and the number of catheters used. The Mann-Whitney U-test was used to assess time for successful insertion and catheter type.
|
Results
|
|---|
Four-hundred-seventy-three attempted catheter insertions in 330 patients were evaluated during 20 operative days. Three-hundred-twenty-eight catheter placement attempts were made by anesthesia trainees (CA-1 to CA-4), and 145 attempts were made by anesthesia attendings. Two-hundred-nineteen patients’ catheters were successfully inserted by trainees, and 95 were successfully inserted by attending anesthesiologists. Attempts at catheter insertion were initially made in 16 patients by a trainee; this was followed by successful insertion by an attending. Fourteen attending anesthesiologists and a number of residents and fellows participated in the study. All trainees had prior experience with similar new IV catheter systems at their parent institution. The distribution of cases among surgical populations was equivalent between the new versus the traditional catheter groups. There were no accidental needle sticks.
Data on the traditional catheters were collected for 9 days (1 wk had a holiday); data on the new catheter were collected for 11 days. The mean patient age was 6.5 ± 5.1 yr (range, 25 days to 23 yr); 90 patients were 3 yr old, and 240 were >3 yr old. When comparing trainees and attendings, there were no significant differences in the number of patients who required more than one catheter attempt (both catheter types analyzed together; P = 0.086 by 2 analysis). When stratified by age, a larger proportion of children 3 yr required more than 1 catheter to establish venous access (54 had 1 attempt, and 36 had >1 attempt) compared with children >3 yr (190 had 1 attempt, and 50 had >1 attempt; P = 0.001; 2) (Table 1). This finding was true when attending and trainee attempts were combined or when these were compared with each other (Table 2). More patients >3 yr required more than one new catheter for successful IV placement than did those who received the traditional IV catheter (P = 0.017; 2). This was not true for children 3 yr (P = 0.537; 2) (Table 2).
View this table:
[in this window]
[in a new window]
|
Table 2. Patients Who Required One or More Than One Catheter, Number of Splatters or Spills, and Insertion Time, Stratified by Age and Catheter Type
|
|
Seventy-seven spills or splatters of blood occurred during attempted IV placement in 42 patients; 2 patients experienced this with both the attending and trainee (Table 3). There was a larger absolute number of blood spills or splatters with the new compared with the old catheters (61 versus 16), and this occurred more frequently for attendings than trainees (P = 0.049; Fisher’s exact test). When analyzed by patients who experienced a blood spill or splatter, there were more patients with either spills or splatters with the new catheter versus the traditional catheter when catheters were placed by attending physicians compared with trainees (P = 0.026; 2) (Table 4).
Poor flashback was described as a problem in 18 new catheter insertions and in no traditional catheter insertions (P = 0.003; 2). When poor flashback was described compared with good flashback, there were 2.5 times more catheters used (P = 0.001; 2). There was no difference in the distribution of catheter size used between trainees and attendings. There was a positive correlation between time for catheter insertion and assessed degree of difficulty, as well as between the number of catheters used and the assessed degree of difficulty, by both attendings and residents for all sizes of catheters and for either type of catheter (P = 0.01; Pearson correlation). There was no significant difference in time for insertion of one catheter versus the other (Table 1) (P = 0.559; Mann-Whitney U-test). Two new catheters accidentally retracted, and two sheared, whereas none of the old catheters sheared. In one patient, the attending elected to change from the new to the old catheter system.
|
Discussion
|
|---|
Recent modifications to federal legislation (1) mandate the availability of new technology with retractable or sheathed needles designed to reduce the potential for needle-stick injury. Some institutions have interpreted this to mean that only needleless systems, safety needles, and retractable IV catheter needle systems should be used. Although the goal of reducing needle-stick injury is important because this type of injury is most often associated with accidental human immunodeficiency virus (HIV) transmission (5,6), changing IV catheter systems may not always be in the best interest of the patient or the health care providers because blood-borne pathogens may be transmitted by non-needle-stick injuries such as cutaneous and mucocutaneous exposure (3,4). Our institution planned to replace all IVs with the new technology. However, because the federal legislation states that the final decision as to which catheter or needle system is best lies with the health care provider, on the basis of a review of the patient circumstances and local experience, we decided to conduct our study.
Our initial experience was that these catheters were more difficult to use in children, particularly those with difficult IV access. We also felt that there was actually an increased incidence of contamination of linen, floors, and health care providers because of more attempts at catheter insertion and unintended needle retraction. We focused in part on the younger patients because we believed that these presented the most technical difficulty in establishing venous access. Our study found that a larger proportion of children 3 yr required more than one catheter to successfully gain IV access. This is no surprise given the technical difficulty of establishing IV access in small and often chubby infants and toddlers (7). We also found that overall there was a positive correlation between number of catheters used, time for insertion, and degree of assessed difficulty in establishing venous access for both trainees and attendings; this was true regardless of the catheter inserted. Our study was underpowered to separate other differences between attendings and trainees in the younger age group.
The most clinically relevant observation was that use of this brand of retractable IV catheter compared with traditional catheters was associated with a statistically significant increase (nearly fourfold) in the splattering and spilling of blood. This was true when examined as patient exposures (multiple sources of contamination but only considered as one for statistical analysis) and as the total number of places where blood was spilled or splattered. This difference in contamination rates between new and traditional catheters was primarily related to attending physicians and not trainees, despite five months of prior experience by the attendings with these devices. Although the risk for accidental needle stick may be theoretically reduced, there is an increase rather than a decrease in exposure of OR personnel to spilled and splattered blood products. Wearing gloves and goggles will reduce some of this exposure; however, not all individuals in the room are so protected. Thus, there may be increased danger of disease transmission to more than the individual inserting the catheter. Our study was underpowered to assess differences in needle-stick injury.
Our results should be viewed as having some limitations because of the inability to accurately quantitate the prior experience with the new catheters of the individuals involved. The difference in contamination rates may reflect a longer experience with these devices by trainees compared with attendings. There is also the potential for reporting bias because the starting hypotheses were that the new catheters were not as user friendly as the traditional catheters and that the results reflect the consensus of the group before the study began. However, because there were nearly twice as many catheters inserted by trainees than by attendings, this bias is less likely. A further possibility is that younger physicians seem more willing to adapt to and to adopt the use of newer technology and protective safety devices, whereas older physicians are experienced with the traditional technology and may find it difficult to change to something that is perceived to be less easy to use (8,9).
Another factor that is more difficult to quantitate is the tendency for attendings to allow trainees the opportunity to start the IV when there is an obvious vein, but not when relatively easy venous access is less assured. Because the total number of IVs used and the time of insertion were correlated with the assessed degree of difficulty, it is hard to completely attribute increased contamination by attendings to their selecting the more difficult IV insertions and allowing the trainees to start the easier IVs. Conversely, it is difficult to determine whether a resident’s assessment of difficult IV access is the same as an attending’s.
Poor flashback of visible blood in the needle was described as a problem in 18 new but no traditional catheter insertions; significantly more catheters were used when poor flashback was described. This is of particular relevance if flashback of blood is used by the practitioner as an indicator of the catheter’s being within a vein. This problem with flashback may indicate in part why attending physicians had more spills and splatters of blood, because all have used this indicator of intravascular catheter location for many years. Of some importance is the observation that 16 of the 17 splatters were attributable to the new catheters, but this difference did not achieve statistical significance. On average, it took slightly longer to successfully establish IV access with the new catheter technology, but this difference also was not statistically significant.
One review regarding needle-stick injury prevention states that the presence of a "safe" device does not guarantee that it is "safer" and that satisfaction of the user is paramount to the success of safer needle devices (10). The results of our study pose an interesting dilemma: does reducing the potential of needle-stick injury with this retractable needle system offset the potential for transmission of blood-borne diseases through increased cutaneous blood exposure? The estimate for HIV seroconversion after a needle puncture is related to the size of the inoculum, the depth of the puncture, and the viral load of the patient. No such study has been performed for cutaneous blood exposure. Because HIV, hepatitis B, and other hepatitis seroconversions have been reported with both routes of transmission (3,4,11) and because it is more likely with a puncture than with cutaneous exposure, our study is greatly underpowered to resolve this question (5,6).
The results of our study support our decision regarding this IV catheter system. We will continue to have both the traditional and the new systems available in the OR so that the clinician and trainee can use their best judgment in selecting the catheter system that allows the most efficient venous access with the least potential for blood contamination and the greatest clinician satisfaction. For some individuals, it will be the new system, and for others, the traditional. It is refreshing that the federal regulations state: "No one medical device is appropriate in all circumstances of use." "An employer. . ..shall solicit input from non-managerial employees responsible for direct patient care. . .in the identification, evaluation, and selection of effective engineering and work practice controls. . ." (1). This language allows the ultimate decision of device selection to rest in the hands of the practitioner.
|
Footnotes
|
|---|
Presented as a poster exhibit at the annual meeting of the Society for Pediatric Anesthesia and the American Academy of Pediatrics’ Section on Anesthesiology and Pain Management, Miami, FL, March, 2002; and the annual meeting of the American Society of Anesthesiologists, Orlando, FL, October, 2002.
|
References
|
|---|
- Occupational exposure to bloodborne pathogens: needlestick and other sharps injuries—final rule. Federal Register 2002;66:5317–5325. 29 CFR Part 1910, Docket H370A.
- More work needed on injuries in anesthesia. OR Manager 1997; 13: 23–4.
- Sattar SA, Tetro J, Springthorpe VS, Giulivi A. Preventing the spread of hepatitis B and C viruses: where are germicides relevant? Am J Infect Control 2001; 29: 187–97.[Medline]
- Beltrami EM, Williams IT, Shapiro CN, Chamberland ME. Risk and management of blood-borne infections in health care workers. Clin Microbiol Rev 2000; 13: 385–407.[Abstract/Free Full Text]
- Cardo DM, Culver DH, Ciesielski CA, et al. A case-control study of HIV seroconversion in health care workers after percutaneous exposure: Centers for Disease Control and Prevention Needlestick Surveillance Group. N Engl J Med 1997; 337: 1485–90.[Abstract/Free Full Text]
- Ippolito G, Puro V, Heptonstall J, et al. Occupational human immunodeficiency virus infection in health care workers: worldwide cases through September 1997. Clin Infect Dis 1999; 28: 365–83.[Web of Science][Medline]
- Patel N, Tignor GH. Device-specific sharps injury and usage rates: an analysis by hospital department. Am J Infect Control 1997; 25: 77–84.[Web of Science][Medline]
- Michalsen A, Delclos GL, Felknor SA, et al. Compliance with universal precautions among physicians. J Occup Environ Med 1997; 39: 130–7.[Web of Science][Medline]
- Akduman D, Kim LE, Parks RL, et al. Use of personal protective equipment and operating room behaviors in four surgical subspecialties: personal protective equipment and behaviors in surgery. Infect Control Hosp Epidemiol 1999; 20: 110–4.[Medline]
- Porta C, Handelman E, McGovern P. Needlestick injuries among health care workers: a literature review. AAOHN J 1999; 47: 237–44.[Medline]
- Ricketts M, Deschamps L. Reported seroconversions to human immunodeficiency virus among workers worldwide: a review. Can J Infect Control 1992; 7: 85–90.[Medline]
Accepted for publication October 18, 2002.
This article has been cited by other articles:
|
|
|
|
 
B. Prunet, E. Meaudre, A. Montcriol, Y. Asencio, J. Bordes, G. Lacroix, and E. Kaiser
A Prospective Randomized Trial of Two Safety Peripheral Intravenous Catheters
Anesth. Analg.,
July 1, 2008;
107(1):
155 - 158.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
Retractable IV Catheters: Safer by What Definition?
Journal Watch Emergency Medicine,
February 12, 2003;
2003(212):
9 - 9.
[Full Text]
|
|
|
Top
Abstract
Introduction
