- 期刊
依臨床症狀更換靜脈留置針是否增加靜脈炎發生率？
The incidence of phlebitis by Clinically-indicated replacement versus routine replacement of peripheral venous catheters
摘要
形成臨床提問：靜脈注射是給藥、營養、輸血或急救時必要途徑之一，亦會破壞皮膚完整性使微生物侵入血流，約有0.1%的血液感染及36%靜脈炎的機率（Marsh, 2018），反覆的注射反而會增加感染的風險，此外定期更換周邊靜脈留置針除了會增加病人不適，家屬也不忍看到病人被反覆注射，而出現憤怒及無助感，護理人員亦備感壓力，也因此增加臨床護理人力、時間及成本等（郭、王、周，2015）。文獻搜尋的方法與分析：依據實證護理步驟，以P、I、C、O關鍵字，包含自然語言與MeSH term，使用布林邏輯「OR」與「AND」，運用檢索策略6S，設定Filter提升搜尋效率及Create Alert隨時追蹤最新文獻，於UpToDate、DynaMed、PubMed、Cochrane Library、Trip Database、AiritiLibrary華藝線上圖書館等資料庫進行文獻搜尋，納入標準1.限制5年內文獻；2.對象為執行靜脈注射的成年人；3.介入措施為依臨床症狀更換靜脈留置針，最終擷取1篇系統性回顧性文獻、1篇隨機分派臨床試驗，共2篇文獻，最符合臨床問題。文獻的品質評讀：採用最新版CASP之「Systematic Review Checklist」及「Randomised Controlled Trial Checklist」，評讀證據可信性、方法合理性、結果重要性與臨床適用性，證據等級採用2011年牛津實證醫學中心證據等級表，顯示此系統性文獻為Level 1，隨機分派試驗文獻為Level 2，2篇文獻研究結果顯示依臨床症狀更換靜脈留置針不會增加靜脈炎發生率。證據之臨床應用：運用實證知識轉譯七步驟實施計畫，並進行結果分析，於2020年1月1日成立實證小組。地點為南部某醫學中心，收案對象為靜脈留置針放置滿72小時的病人，排除施打周邊靜脈營養溶液（peripheral parenteral nutrition, PPN）、化療、免疫療法、血流感染等病人，常規照護兩組分72小時、96小時更換靜脈留置針，實證應用組為留置滿96小時以上因周邊靜脈注射處有感染症狀、阻塞等需更換周邊靜脈留置針，以2011版靜脈炎評估表（Nurses Society phlebitis scales）為評量工具，研究為前驅性研究，採方便取樣收案。成效評值：本實證臨床應用分3組，共收案88人，常規照護組72小時為34人、96小時為26人，實證應用組28人，在年齡、性別、留置針尺寸等（p>0.05），3組具同質性，結果顯示72小時、96小時與依臨床症狀更換周邊靜脈留置針，其靜脈炎發生率皆無顯著差異（p=1.00）。結論與建議：實證應用結果顯示72小時、96小時與依臨床症狀更換周邊靜脈留置針，顯示靜脈炎發生率皆無顯著差異，但能減少病人注射時的恐懼及疼痛，增加照護滿意度，建議臨床上依臨床症狀再更換周邊靜脈留置針，節省的護理時數更能應用在臨床照護，且可減少注射時面對病人及家屬的壓力。由於此實證只收案三個病房的病人，建議未來可持續實施臨床應用，擴大樣本數，使之更具效力，重要是照護上應確實評估注射部位，治療結束盡早移除留置針，一旦發生靜脈炎症狀需立即重新更換注射部位，以避免靜脈炎發生。
並列摘要
Ask an answerable question (PICO): Intravenous injection is one of the necessary routes for drug administration, nutrition, blood transfusion. It will destroy the integrity of the skin and allow microorganisms to invade the bloodstream. There is a 0.1% chance of blood infection and a 36% chance of phlebitis (Marsh, 2018). Regular Replacing the peripheral intravenous catheters will increase the patient's discomfort, and the family members will not bear to see the patient being repeatedly injected, resulting in anger and a sense of helplessness, and will also increase clinical nursing manpower, time and cost, etc. The Method and Analysis of Literature Review: Based on empirical nursing steps, use P, I,C, O keywords, including natural language and MeSH term, use Boolean logic "OR" and "AND", use search strategy 6S, set Filter to improve search efficiency, and Create Alert to keep track of the latest updates at any time. Documents were searched in the databases of UpToDate, DynaMed, PubMed, Cochrane Library, Trip Database, Airiti Library. The inclusion criteria were 1.Limit the document age to 5 years ; 2.The subject is the patient who needs to perform intravenous injection ; 3. The intervention measures are to replace peripheral venous catheter when clinically indicated , and finally 1 systematic review and 1 randomized controlled trials were selected, which best meets the clinical problem. Critical Appraisal: The literature review tool adopts the "Systematic Review Checklist" and "Randomised Controlled Trial Checklist" of the CASP to assess the validity of the evidence, methodologically sound, the importance of the results and the clinical applicability. The level of evidence adopts the clinical research evidence grading table recommended by the Centre for Evidence Medicine, Oxford University. Systematic review are Level 1. Randomized controlled trials are Level 2.Research results show that replace peripheral venous catheter when clinically indicated does not increase the incidence of phlebitis. Clinical Application of Evidence: Use empirical knowledge to translate the seven-step implementation plan, and analyze the results, and set up an empirical group on January 1, 2020. The location is a medical center in southern Taiwan, and the subjects of the case are patients with intravenous indwelling needles placed for 72 hours, excluding patients who received peripheral parenteral nutrition (PPN), chemotherapy, immunotherapy, and bloodstream infection. The subjects replaced the intravenous indwelling needles at 72 hours and 96 hours in the two components of routine care. In the empirical application group, the peripheral intravenous indwelling needles needed to be replaced due to infection symptoms and blockage at the peripheral intravenous injection site for more than 96 hours, according to "Nurses Society phlebitis scales " of phlebitis assessment form (2011) is an assessment tool. The study was prodromal, and the case was collected by convenience sampling. Evaluation of Effectiveness: This evidence is divided into 3 groups, a total of 88 cases were received, 72 hours: 34 people, 96 hours: 26 people, according to clinical indications: 28 people, there was no significant difference in age, gender, catheter size, etc. (p>0.05), 3 Groups have high homogeneity and comparability. The results showed that, according to clinical symptoms, there was no significant difference in the incidence of phlebitis between 72 h, 96 h and replacement of peripheral venous catheters (p=1.00). Therefore, it is recommended to replace the peripheral venous catheter according to clinical symptoms. Conclusions and Recommendations: Patients said that it can reduce the fear and pain during injection, and increase nursing satisfaction. Colleagues said that the saved nursing hours can be applied to clinical care, and it can reduce the pressure on patients and their families during the injection process. Since this article only accepts patients in three wards, it is recommended to continue to implement clinical applications in the future, expand the number of samples, and collect nationwide empirical data to make it more effective. To remove the catheters as soon as possible, if there are symptoms of phlebitis, the injection site should be replaced immediately to avoid phlebitis.