Perusing the Literature: Skin Glue for Peripheral IV Securement

This month we continue our Perusing of the Literature. Once again, this section consists of recent articles that residents and attendings have stumbled across that have raised an eyebrow. These posts are meant to spark a discussion and do not represent a change in the standard of care (unless otherwise noted).

The Article: Bugden S, et al. Skin Glue Reduces the Failure Rate of Emergency Department-Inserted Peripheral Intravenous Catheters: A Randomized Controlled Trial. Ann Emerg Med. 2016;1-6.

The One-Liner: Skin glue, in addition to standard care securement, may reduce peripheral intravenous catheter failure rates at 48 hours for admitted patients after insertion in the ED.

 Background: Frequently initiated in the ED setting, peripheral intravenous (IV) catheters may fail with inadequate fixation serving as the underlying etiology in infection, phlebitis, occlusion, or dislodgement. Failure disrupts hydration, antibiotic therapy, and analgesia for the patient, and incurs the added costs of additional supplies and staff time. In comparison to standard polyurethane dressings, medical-grade skin glue (cyanoacrylate) in addition to a dressing has been proven to be more effective in securing central venous, epidural, and peripheral arterial catheters. As peripheral IVs are administered on such a wide scale, a small increase in efficacy has the potential for great improvements in cost and patient satisfaction.

Methods: This was a single-site, 2-arm, nonblinded, randomized, controlled trial over a 5 month period. Patients were screened for inclusion after being identified as requiring hospital admission and having a patent upper limb peripheral IV. Patients were randomized to standard peripheral IV catheter securement (Tegaderm IV; Figure 1) or standard securement plus the addition of skin glue (single-use Histoacryl; Figure 2). The skin glue group received 1 drop of cyanoacrylate glue at the IV skin insertion site and 1 drop under the IV catheter hub (Video 1). The dressing was applied after allowing the glue to dry for <30 seconds. The primary outcome was peripheral IV catheter failure at 48 hours, defined by infection, phlebitis, occlusion, or dislodgement. Outcomes were assessed by RNs in person or by telephone, if no longer hospitalized. Intention to treat analysis was performed. Definitions for failure are described below:

  • Infection – clinical impression of cellulitis or pus at IV site.
  • Phlebitis – 2 or more symptoms of pain, redness, swelling, or palpable venous cord.
  • Occlusion – inability to flush 10 mL of 0.9% saline solution or history of IV catheter removed because ‘it was not working’.
  • Dislodgement – subcutaneous extravasation or history of ‘IV fell out’.

Figure 1

Figure 1: Standard of care – securement with transparent polyurethane dressing

Figure 2

Figure 2: Skin glue group – securement with 1 drop to skin insertion site and 1 drop under IV catheter hub

Video 1: Skin glue application for securement.

Results:

  • 380 peripheral IVs inserted into 360 adult patients
  • Some differences between standard and skin glue groups- insertion sites were different between groups, which could make big difference in dislodgement rates.
  • 1° outcome: Peripheral IV failure – 17% in skin glue group, 27% in standard care group; D = -10%, 95% CI -18% to -2%, p=0.02)
  • 2° outcome: Peripheral IV failure by dislodgement – 7% in skin glue group, 14% in standard care group; D = -7%, 95% CI -13% to 0%)

Limitations:

  • Blinding impossible due to glue color
  • Single site, question of external validity
  • Question of generalizability as different IV insertion practices are possible (for example, almost 74% of IVs in study were inserted by physicians- can we generalize this to our hospital?)
  • It is unclear if randomization really worked given differences between standard and skin glue groups. Additionally, many potential confounders were not included or reported including BMI, co-morbidities such as end-stage renal disease, or recent ED visits/ hospitalizations with IV placement.
  • Is 48 hours an important time point for ED patients? Maybe future study should consider IV failure in ED.
  • Outcome assessment occurred by telephone, and not direct visualization by research RN, for 209 (58%) patients discharged prior to 48 hour reassessment: This is a very significant limitation as assessing IV failure via phone could lead to underreporting of failures. Authors could have considered performing a sensitivity analysis to address this.
  • Many IVs removed prior to 48 hours, therefore observed failure rates may not be accurate for 48 hours dwell time
  • No cost analysis

Author: Cameron Gettel, MD PGY1
Resident Section Editor: Adam Janicki, MD PGY4
Reviewed by Tracy Madsen, MD, ScM, Assistant Professor, Department of Emergency Medicine

Time to Abandon Epinephrine for OHCA?

This is part of a recurring series examining landmark articles in Emergency Medicine, in the style of ALiEM’s 52 Articles.

Discussing: Wenzel, K. et al. A comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation. N Engl J Med 2004;350(2):105-113.

Main Points:

  1. For out-of-hospital cardiac arrest (OHCA), vasopressin was similar to epinephrine in patients with ventricular fibrillation or pulseless electrical activity, with regards to survival to hospital admission and survival to hospital discharge. Vasopressin was noted to be superior, in both outcomes, for patients with asystole.
  1. In patients with refractory cardiac arrest and no ROSC, vasopressin followed by epinephrine may be more effective than epinephrine alone.

Background:

With more than 600,000 sudden death in North America and Europe annually, optimization of CPR is crucial to improve a patient’s chance of survival. Epinephrine use has become controversial as it induces increased myocardial consumption and ventricular arrhythmias post-resuscitation. Endogenous vasopressin levels have been known to be elevated in successfully resuscitated patients. In small prior studies, vasopressin has been associated with higher rate of short term survival and improved blood flow to vital organs when compared to epinephrine. Current guidelines recommend the use of epinephrine during cardiac resuscitation, with vasopressin as a secondary alternative.

Details:

This study was a double-blind, prospective randomized clinical trial, conducted in 44 Emergency Medical Service units in three European countries, including those with OHCA unresponsive to defibrillation. 1186/1219 patients with OHCA were included in the trial with randomization to two injections of either 40 IU of vasopressin or 1 mg epinephrine, followed by additional treatment with epinephrine at the discretion of the emergency physician managing the resuscitation. Average age 66 years, 70% men, 61% attributed to cardiac causes, 78% arrests witnessed. 33 patients were excluded due to a missing study drug code. The rates of hospital admission were similar between the two treatment groups for patients with ventricular fibrillation (46.2 vs 43%, p=0.48) and pulseless electrical activity (33.7 vs 30.5%, p=0.65). Patients with asystole treated with vasopressin were more likely to survive to hospital admission (29.0 vs 20.3%, p=0.02) and hospital discharge (4.7 vs 1.5%, p=0.04). Among 732 patients without ROSC, additional treatment with epinephrine resulted in improvement in rates of survival to hospital admission (25.7 vs 16.4%, p=0.002) and discharge (6.2 vs 1.7%, p=0.002) in the vasopressin group, but not the epinephrine group. Continue reading

Perusing the Literature (PTL): Steroids for Anaphylaxis?

This month we continue our Perusing of the Literature. Once again, this section consists of recent articles that residents and attendings have stumbled across that have raised an eyebrow. These posts are meant to spark a discussion and do not represent a change in the standard of care (unless otherwise noted).

January 2016:

The Article: Grunau BE, et al. Emergency Department Corticosteroid Use for Allergy or Anaphylaxis Is Not Associated With Decreased Relapses. Ann Emerg Med. 2015;66:381-389.

The One-Liner: Corticosteroid use does not appear to be associated with a decrease in allergy-related ED revisits in patients presenting with allergic reactions or anaphylaxis.

Background: Allergy-related ED visits account for approximately 1.0% of all visits. Aside from antihistamines, corticosteroids use in allergic reactions has increased from 22% to 50% from 1993-2004. The anti-inflammatory effect of steroid therapy intends to reduce risk of biphasic reactions, decrease the severity of reactions, and decrease ED return visits.

Methods: This was a retrospective cohort study in 2 urban EDs during a 5-year period, assessing patient encounters classified as ‘anaphylaxis’ or ‘allergic reaction’. The primary aim of this study was to determine if steroid administration in ED allergy patients decreased relapses to additional care within 7-days. Authors also aimed to identify potential benefits of steroids in decreasing death, clinically important biphasic reactions, or all-cause repeated ED visits. There were no defined protocols for allergic reactions and physicians managed the patients in an individualized manner. The patient’s health number was used to identify all patients who returned to any regional ED or died within the province during a 7-day follow-up period.
Anaphylaxis was defined as meeting 1 of the following 3 criteria:
• Skin or mucosal involvement AND respiratory compromise or SBP • Two of the following after exposure to ‘likely allergen’: 1) Skin or mucosal involvement, 2) respiratory compromise, 3) SBP • SBP An allergic reaction was defined as a clinical presentation in which criteria for anaphylaxis were not met, but provider deemed the cause of signs/symptoms to be result of allergic process.

Results:
• Total of 2701 ED patient encounters
• Corticosteroids administered to 1181 (44%) patients; 469 (17%) received parenteral, 786 (29%) received oral formulation; prescription for oral steroid at ED discharge in 819 (30%) encounters
• During the 7-day follow-up period, there were 170 (6.3%) allergy-related revisits – 75 (5.8%) patients in the steroid group and 95 (6.7%) in the nonsteroid group (95% CI 0.63 to 1.17).
• Anaphylaxis patients (n=473); there were 15/348 (4.3%) allergy-related re-visit in the steroid group, and 7/125 (5.6%) in the non-steroid group (95% CI 0.41 to 3.27)
• Allergic reaction patients (n=2228); there were 60/940 (6.4%) allergy-related revisits in the steroid group, and 88/1288 (6.8%) in the non-steroid group (95% CI 0.63 to 1.31)
• NNT with steroids to prevent 1 additional ED revisit was 176
• No deaths during any of index visits or within follow-up period for any patient (2698/2715; 99.4% patients able to be have provincial data linkage established)
• 5 clinically important biphasic reactions. 4 in steroid group, 1 in non-steroid group.

Limitations:
• Clinical impression was the basis for the diagnosis of allergic reaction
• Cannot confirm filling of prescriptions or tolerance of steroid course
• Physicians on index visit may have instructed patients to return for reassessment
• Patients with biphasic reactions may have represented out of the region

Author: Cameron Gettel, MD PGY1
Resident Section Editor: Adam Janicki, MD PGY4
Reviewed by Gita Pensa, MD, Clinical Assistant Professor, Department of Emergency Medicine