Key messages
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We didn’t find any clear difference in bloodstream infection outcomes, or death, between removing PVCs only when needed or regularly, because despite many studies on the topic, serious problems don’t happen often.
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The evidence suggests little to no difference in thrombophlebitis (painful vein irritation).
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Infiltration (fluid seeping into the tissue around the PVC) and PVC blockage may be slightly reduced when PVCs are changed regularly.
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Cost is reduced when PVCs are removed for clinical reasons only.
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Future research should focus on testing PVC removal beyond 96 hours, patient preferences for routine or clinically indicated PVC removal, more rigorous studies and use of ultrasound to assess PVC complications, and report outcomes using more sensitive measures (e.g. per 1000 days of PVC use).
What are peripheral intravenous catheters, and what are they used for?
A PVC – also known as an intravenous (IV) drip or IV cannula – is a small hollow tube that is inserted into a small vein close to the surface of the skin. Most hospital patients require a PVC to deliver medication, fluids or nutrition directly into the bloodstream.
Historically, there has been variability in PVC management. PVCs were either removed and replaced every two, three or four days, provided they were still needed, and a complication had not already occurred, or removed/replaced only when a treatment was completed or a complication occurred (clinically indicated).
PVCs often stop working before treatment is completed, and this can happen on any day of treatment. Failure is commonly caused by vein inflammation, catheter blockage, fluids leaking into the surrounding tissues instead of staying inside the vein, or the catheter falling out. Very rarely, serious infections develop. If any of these complications happen, the PVC has to be removed and a new PVC inserted, which can be painful and may cause an interruption/delay in medical treatment.
What did we want to find out?
We wanted to find out if leaving a PVC inserted until medical treatment is complete or PVC complications develop resulted in fewer complications than replacing a PVC every three to four days in people requiring a PVC for at least three days.
What did we do?
We searched medical databases up to 21 January 2025 for randomised controlled trials (a type of study where participants are randomly assigned to one of two or more treatment groups) that compared routine PVC removal with clinically indicated removal.
What did we find?
We found 14 studies involving 11,428 participants comparing clinically indicated versus routine PVC removal. Overall, there was insufficient information to confidently determine whether clinically indicated or routine removal of PVCs was better.
We found that for catheter-related bloodstream infection, bloodstream infection from any cause, local infection and death, there were too few events to determine which method of removal was superior. This means the risk of these problems happening is already extremely low, regardless of clinically indicated or routine removal. Removing the PVC only when clinically indicated might not change vein inflammation, but we can't be sure based on the evidence we have. There's a high chance that the effect could be very different. Changing PVCs regularly might help reduce problems like fluid leaking into the skin or the PVC getting blocked. With clinically indicated removal of peripheral venous catheters, slightly more people may experience complications compared with routine removal: about 37 per 1000 may develop infiltration (range 2 to 83) and about 57 per 1000 may develop catheter blockage (range 7 to 123). These numbers reflect the uncertainty in the evidence. These complications can occur for many people even if there was a planned routine removal. The treatment for these complications is almost always to remove the PVC and replace it if therapy is still required. Removing PVCs only when clinically indicated saves money. The research gives a good idea of this effect, but there's a medium chance that the actual effect could be quite different.
What are the limitations of the evidence?
We considered the overall certainty of the evidence to be low for most results, making the findings somewhat uncertain. We are not confident in the evidence for the studies investigating infection because there were not many infections found during the study. Other uncertainty is largely due to outcomes, such as thrombophlebitis, catheter blockage and leakage, being assessed by people who were aware of the participant's assigned group, which may or may not affect their decision about whether a problem is present or absent.
How up-to-date is the evidence?
This is the fourth update of a review first published in 2010. The evidence is current to 21 January 2025.
Read the full abstract
US Centers for Disease Control guidelines recommend replacement of peripheral intravenous catheters (PIVC) no more frequently than every 72 to 96 hours. Routine replacement is thought to reduce the risk of phlebitis and bloodstream infection. Catheter insertion is an unpleasant experience for patients and replacement may be unnecessary if the catheter remains functional and there are no signs of inflammation or infection. Costs associated with routine replacement may be considerable. This is the third update of a review first published in 2010.
Objectives
To assess the effects of clinically indicated removal versus routine removal of PVCs.
Search strategy
We searched the CENTRAL, MEDLINE, Embase and CINAHL databases, and the WHO ICTRP and ClinicalTrials.gov registries to 21 January 2025. We also searched the reference lists of retrieved studies and potentially useful articles.
Selection criteria
We included randomised controlled trials that compared routine removal of PIVC with removal only when clinically indicated, in hospitalised or community-dwelling patients receiving continuous or intermittent infusions.
Data collection and analysis
Three review authors independently reviewed trials for inclusion, extracted data, and assessed risk of bias using Cochrane methods. We used GRADE to assess the overall evidence certainty.
Main results
This update contains two new trials, taking the total to nine included studies with 7412 participants. Eight trials were conducted in acute hospitals and one in a community setting. We rated the overall certainty of evidence as moderate for most outcomes, due to serious risk of bias for unblinded outcome assessment or imprecision, or both. Because outcome assessment was unblinded in all of the trials, none met our criteria for high methodological quality.
Primary outcomes
Seven trials (7323 participants), assessed catheter-related bloodstream infection (CRBSI). There is no clear difference in the incidence of CRBSI between the clinically indicated (1/3590) and routine change (2/3733) groups (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.08 to 4.68), low-certainty evidence (downgraded twice for serious imprecision).
All trials reported incidence of thrombophlebitis and we combined the results from seven of these in the analysis (7323 participants). We excluded two studies in the meta-analysis because they contributed to high heterogeneity. There is no clear difference in the incidence of thrombophlebitis whether catheters were changed according to clinical indication or routinely (RR 1.07, 95% CI 0.93 to 1.25; clinically indicated 317/3590; 3-day change 307/3733, moderate-certainty evidence, downgraded once for serious risk of bias). The result was unaffected by whether the infusion was continuous or intermittent. Six trials provided thrombophlebitis rates by number of device days (32,709 device days). There is no clear difference between groups (RR 0.90, 95% CI 0.76 to 1.08; clinically indicated 248/17,251; 3-day change 236/15,458; moderate-certainty evidence, downgraded once for serious risk of bias).
One trial (3283 participants), assessed all-cause blood stream infection (BSI). We found no clear difference in the all-cause BSI rate between the two groups (RR 0.47, 95% CI 0.15 to 1.53; clinically indicated: 4/1593 (0.02%); routine change 9/1690 (0.05%); moderate-certainty evidence, downgraded one level for serious imprecision).
Three trials (4244 participants), investigated costs; clinically indicated removal probably reduces device-related costs by approximately AUD 7.00 compared with routine removal (MD −6.96, 95% CI −9.05 to −4.86; moderate-certainty evidence, downgraded once for serious risk of bias).
Secondary outcomes
Six trials assessed infiltration (7123 participants). Routine replacement probably reduces infiltration of fluid into surrounding tissues compared with a clinically indicated change (RR 1.16 (95% CI 1.06 to 1.26; routine replacement 747/3638 (20.5%); clinically indicated 834/3485 (23.9%); moderate-certainty evidence, downgraded once for serious risk of bias).
Meta-analysis of seven trials (7323 participants), found that rates of catheter failure due to blockage were probably lower in the routine-replacement group compared to the clinically indicated group (RR 1.14, 95% CI 1.01 to 1.29; routine-replacement 519/3733 (13.9%); clinically indicated 560/3590 (15.6%); moderate-certainty evidence, downgraded once for serious risk of bias).
Four studies (4606 participants), reported local infection rates. It is uncertain if there are differences between groups (RR 4.96, 95% CI 0.24 to 102.98; clinically indicated 2/2260 (0.09%); routine replacement 0/2346 (0.0%); very low-certainty evidence, downgraded one level for serious risk of bias and two levels for very serious imprecision).
One trial (3283 participants), found no clear difference in the incidence of mortality when clinically indicated removal was compared with routine removal (RR 1.06, 95% CI 0.27 to 4.23; low-certainty evidence, downgraded two levels for very serious imprecision).
One small trial (198 participants) reported no clear difference in device-related pain between clinically indicated and routine removal groups (MD −0.60, 95% CI −1.44 to 0.24; low-certainty evidence, downgraded one level for serious risk of bias and one level for serious imprecision).
The pre-planned outcomes 'number of catheter re-sites per patient', and 'satisfaction' were not reported by any studies included in this review.
Authors' conclusions
Clinically indicated removal of PVCs makes no difference to the risk of catheter-related bloodstream infection, primary bloodstream infection, local infection or mortality, and likely has little to no effect on thrombophlebitis incidence or rate per 1000 catheter-days, compared to routine removal. The evidence suggests that routine removal may result in a small reduction in the incidence of infiltration and catheter occlusion, but little to no effect on their rates per 1000 catheter-days; however, our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect. Clinically indicated removal may reduce costs by a small amount compared with routine removal.
Funding
This update of the Cochrane review had no dedicated funding.
Registration
Protocol (2009): https://doi.org/10.1002/14651858.CD007798
Original review (2010): https://doi.org/10.1002/14651858.CD007798.pub2
Review update (2013): https://doi.org/10.1002/14651858.CD007798.pub3
Review update (2015): https://doi.org/10.1002/14651858.CD007798.pub4
Review update (2019): https://doi.org/10.1002/14651858.CD007798.pub5
