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A Critical Appraisal of Three Research Studies Related To Peripheral Venous Cannulae and the Incidence of Phlebitis.

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A CRITICAL APPRAISAL OF THREE RESEARCH STUDIES RELATED TO PERIPHERAL VENOUS CANNULAE AND THE INCIDENCE OF PHLEBITIS. INTRODUCTION It is widely acknowledged that intravenous therapy is an integral part of total patient care of many hospital patients. (Goodinson 1990, Stonehouse 1996, Parker 1999). A variety of devices are used to deliver intravenous fluids, medication, total patient nutrition and blood products. The most common delivery method being by the percutaneous insertion of a peripheral venous cannula. According to Campbell (1998) twenty five million NHS patients per year are estimated to receive some form of intravenous therapy via a peripheral route. Peripheral venous cannulation has been associated with sepsis that causes substantial morbidity in patients, prolonged hospitalisation and increased hospital costs. (Maki 1991 cited in Campbell 1998 p1308, Pearson 1996 cited in Scales 1997 pS4, Curran et al 1998). Three main theories appear to provide a basis for predicting the occurrence of phlebitis. Physical theories support the premise that veins are traumatised by physical contact with organic or inorganic materials, The principle of the septic theory suggests that phlebitis develops as a direct result of sepsis or infection. Whilst Chemical theories propose that phlebitis is caused by the irritation of the vein wall by infusion fluids. (Campbell 1998). However, the literature appears to suggest that most cannula-related infections result from the migration of skin organisms at the insertion site, eventually colonizing the cannula tip and entering the blood stream. (Kelsey and Gosling 1984, Fletcher and Bodenham 1999). The complications of the use of peripheral cannulation can therefore, as Horton and Parker (1997 cited in Parker 1999 p1492) indicate, range along a spectrum of symptoms including, most commonly, phlebitis but also extravasation and other localised and systemic infections. According to Pearson (1996 cited in Scales 1997 pS4), the length of time the cannula is in situ is an important factor in the development of sepsis, with the risk increasing the longer the cannula is in place. ...read more.


(Dinley 1976, Maddox and Rush 1977, Baxter Healthcare Ltd. 1988 cited in Campbell 1998 p 1311) However, there are limitations and weaknesses with the tools used in the studies under review. None of the researchers have discussed how validity and reliability was assessed. Although both Lai (1998) and Homer (1998) have used tools that do not appear to have been used in previous situations, there is no report on a pilot study being carried out prior to the main study. Lai's (1998) measurement tool has a number of limitations. Within the study Lai (1998) reports that the intravenous site was "monitored according to a well-defined inflammation scale" and has published the indicators and rating for the inflammation scale in the study. However, the tool that Lai used to obtain the data on phlebitis in his study was not the reported inflammation scale. Lai (1998) appears to have used elements of the inflammation scale and designed a scale that has some differences from the inflammation scale that he reported was used. The inflammation scale uses pain and swelling as clinical indicators but in the scale that was used in the study swelling has been excluded and pain has reduced to tenderness. Another point of concern is the implication that the severity of phlebitis could be measured on a scale designed to measure the presence and severity of inflammation. This may lead to confusion between rating phlebitis and inflammation. In other words, it is not certain that the tool actually used measured what it was supposed to measure. Homer (1998) referred to other studies before adopting a different set of clinical indicators in his scale that he reports as being more rigorous than Maki and Ringer's (1991 cited in Homer 1998 p5) scale but less so than Tager's (1983 cited in Homer 1998 p5). However, there does not appear to be any reference to testing validity of the scale. A point of accuracy concerns the use of the scale for measuring infiltration as well as phlebitis. ...read more.


Similarly, the lack of account of confounding variables in two of the studies (Lai 1998, Homer 1998) also suggests limitations with internal validity. Serious threats to internal validity may have an effect on the quality of the data collected and it's compatibility with other relevant evidence. There are also some limitations with the sampling that may affect external validity. Lack of clarity in Curran et al's (2000) study regarding the setting and the sample numbers raised concerns over generalisability. Most importantly, this review highlighted that the lack of consensus over clinical indicators and rating of phlebitis is a potentially serious knowledge gap that has implications for risk management and safe practice. Another gap appears to be in relating the causes of phlebitis to theoretical or conceptual frameworks. Also, although it was not the prime rationale for the studies being undertaken, it has also shown that resource awareness and financial implications cannot be divorced from clinical practice. In summary, all of the studies reviewed reached similar conclusions and recommendations concerning the length of time a peripheral venous cannula could safely remain in situ, The studies reviewed in this assignment were three of fifteen retrieved from the literature search. The conclusions drawn from these three studies cannot to be used to inform best practice without further exploration of the relevant literature. However, undertaking the review has highlighted the importance of critical appraisal of research studies before findings are applied to practice. From a nursing perspective, the review has caused me to reflect on the current practice, assessment and documentation of what is considered to be a routine daily task, within my Trust. In addition, conducting a critical appraisal of the studies for this review has highlighted areas for my own development. In particular, weaknesses with understanding some of the tests for inferential statistics. On the otherhand it has also raised my confidence in appraising research studies, a skill which I can continue to develop and share with colleagues. 013444 1 1 ...read more.

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