14

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA

SYNOPSIS FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. NAME OF THE CANDIDATE : MR. NUTAN KUMAR.H.C

AND ADDRESS I YEAR M.Sc NURSING

B G S COLLEGE OF NURSING

APOLLO B G S HOSPITAL

MYSORE

2. NAME OF THE INSTITUTION : B G S COLLEGE OF NURSING

MYSORE

3. COURSE OF STUDY AND SUBJECT : I YEAR M.SC NURSING

MEDICAL-SURGICAL NURSING

4. DATE OF ADMISSION OF COURSE : 20-6-2009

5. TITLE OF THE TOPIC : “EFFECTIVENESS OF

THROMBOPHOBE

OINTMENT WITH AND

WITHOUT HOT

FOMENTATION IN

PREVENTING LOCAL

COMPLICATIONS OF IV

CANNULIZATION.”

14

6. BRIEF RESUME OF THE INTENDED WORK.

INTRODUCTION:

“Prevention is better than cure”

The use of intravenous devices is an integral part of patient care in hospitals. These devices are used for the administration of fluid, nutrients, medications, blood products and to monitor the haemodynamic status of a patient. However, intravenous devices also provide a potential route for micro-organisms to enter the blood stream resulting in a variety of local or systemic infections. This cannula related infections are often associated with prolonged hospitalisation, increased morbidity and mortality.1

Intravenous catheterization is one of the most widespread procedures in health care environments. Close to 90% of all hospitalized patients receive intravenous catheters (IVs). The number of patients in hospitals receiving I.V therapy, is 80% plus. Intravenous catheters (or IVs) are a very important part of medical treatment for acute illnesses, cancer, surgery, anaesthesia, and trauma, allowing medications to reach as quickly and effectively as possible, via the bloodstream, the parts of the body where they work. Catheter related infections, particularly catheter related blood stream infections, are associated with increased morbidity, mortality and prolonged hospitalisation.2

The most commonly used IV device is the short peripheral venous cannula which is mainly used in the forearm and hands. The pathogenesis of cannula-related infections is complex but most appear to result from skin organisms at the cannula insertion site migrating into the cannula track, eventually colonising the cannula tip. Contamination of the cannula hub may also be an important contributor to the colonisation of cannula lumens.3

The establishment of intensive infection surveillance and control programmes was strongly associated with reduction in nosocomial infection rates. Essential components of an effective programme include conducting organised surveillance and control activities, trained infection control physicians and nurses, and a system of reporting infection rates.4

A number of factors increase the risk of infection from intravascular devices. For example, infection rates are higher among patients in large hospitals who may be especially ill, those with burns or surgical wounds or those who are malnourished or immune compromised. In addition, the rates are higher for certain devices, the type of fluid being infused and the length of time the catheter is left in place.5

Serious complications related to peripheral IVs are uncommon, but problems do occur, especially with prolonged use. That is why there are guidelines in different hospitals about the recommended duration that a peripheral IV should be in place. As with any side effect or complication of health care procedures, early detection, and good communication between the patient and healthcare provider are important.6

A hot fomentation is described as a local application of moist heat by means of cloth wrung from warm water or from steam tank. Effects of hot fomentation are Increases blood flow to the area. Relaxes muscles. Sedative effect Relaxes pain. Relaxes spasm or cramps Relieves congestions. Produces sweating.7

Thrombophob ointment Composed of heparin sodium equivalent to heparin 50 i.u. Per 20g. in addition to this it composed of Benzyl nicotinate 2mg and preservative sorbic acid 1.97 mg. Pharmacological action of Thrombophob ointment is a novel form of heparin therapy for topical application it inhibits the thrombin formation, promotes fibrinolysis and helps absorption of more superficial micro thrombi. Benzyl nicotinate by vasodilatation and enhances local heparin absorption.8

The ointment is distinguished in particular, by its ability to penetrate pathologically altered tissue immediately upon application without leaving residues or degreasing the skin.8

The properties and mode of action of natural heparin offer all the prerequisites necessary for effective therapy of thrombophlebitis occurring close to the skin and of other superficial inflammations. Heparin assists in strengthening and supporting the connective tissues. Scar tissue becomes soft and regains elasticity and strength. 8

Heparin also has an antiphlogistic and anti-exudative effect, thus alleviating pain and promoting tissue metabolism and the process of healing. It is indicated for Circulatory disorders, Superficial phlebitis and thrombophlebitis, Varicose veins.9

There is no specific contra-indications are known. It should be applied in a thin layer to the skin of the affected part and its surrounds, two to three times a day. It is need not be rubbed or massaged into the skin. It is completely absorbed by the skin in a short time.9

Need For The Study:

A third of patients have unnecessary tubes (cannula) inserted when they are in hospital, needlessly exposing them to serious complications such as infection and blood clots, research launched at the British Pharmaceutical Conference (BPC) in Manchester has shown.10

Complications associated with intravenous (IV) cannula use include problems with veins (phlebitis), leakage of drugs into tissues around the site of the tube (extravasations), serious infection and blood clots.11

Sourced from the National Library of Medicine reveals that the risk of complications in peripheral intravenous therapy is higher on the second day of therapy and may continue to increase with time, making routine restarts after 3 days a common practice. A restarted catheter has a significantly higher risk of complication in its first 24 hours than does an initial catheter. From these results, the authors conclude that restarting catheters at 72 hours does not reduce the risk of complication in the next 24 hours when compared with simply continuing the therapy with the original catheter.12

In the process of review of literature the investigator found that incidence of local complications due to IV cannulisation is very high and it leads to some of the serious systemic complications and the investigator could not find study related to preventive aspect of the local complications. Because of all the above reason researcher would like to conduct study on effectiveness of thrombophobe ointment with & without hot fomentation in preventing complications of IV cannulisation.13

6.2 Review Of Litreature:

6.2.1 Studies related to complications of I V cannulisations.

6.2.2 Studies related to topical anticoagulant therapy.

6.2.3 Studies related to hot fomentation.

6.2.1 Studies Related To Complications Of I V Cannulisation.

A study was conducted to compare the rates of phlebitis of peripheral intravenous lines left in place for 72 hours versus rates of those left in place 96 hours. Design was a prospective, nonrandomized study. Setting was a university teaching hospital with 375 beds. Patients were consecutive adult patients who received peripheral intravenous lines and were admitted to the wards. Results were a total of 2503 peripheral lines were evaluable. The overall phlebitis rate was 6.8%. It was estimated that in 1 month approximately 300 intravenous lines potentially could be prolonged beyond 72 hours; 215 lines were changed at 72 hours despite no signs of inflammation, 61 lines were kept till 96 hours, and 19 lines were kept beyond 96 hours. Conclusion of the study was Phlebitis rate for our peripheral intravenous catheters at 96 hours was not significantly different from that at 72 hours.14

A Randomized Controlled Trial on factors Affecting Complications and Patency of peripheral IVs. This prospective interventional study was conducted over a period of 6 months in a general ward of Lady Hardinge Medical College and Associated Kalawati Saran Hospital. This sample was composed of 88 patients, from neonates to 12-year-olds, on whom a total of 377 catheters were started. Intravenous cannulations were randomized for heparin flushes (1:100 dilutions) and splints. Prospective data was collected regarding duration of patency and complications. Both univariate and multivariate analysis were done. There was a statistically significant increase in the duration of patency with the use of heparin flushes and splints. Shorter patency duration and increased complications were associated with younger age, wrist and scalp insertions, and 24-gauge catheters.15

A study was conducted at Institute of Anesthesiology, Utrecht University Hospital, Heidelberglaan, ontwo groups of patients received one of two intravenous catheters, a 20-gauge Criticon (C group;n=96) or a 20-gauge Vitaflon Plus (V group;n=100). Each catheter was inserted under identical cannulation conditions. All catheters remained in place for a minimum of 4 days. The incidence of early complications (erythema, swelling, tissue hardness, pain) was comparable in both groups. The survival distribution curves for all complications and swelling >2 cm were significantly longer in the V group. The incidence of complications following cannulation was high in both groups. The period from catheter insertion to the clinical onset of phlebitis was prolonged in both groups if antiphlebitogenous fluids were used. The incidence of late complications (phlebitis, displacement of the cannulae, etc.) and damage to the catheters was more frequent in the C group. 16

A study was conducted on Relevance and complications of intravenous infusion at the emergency unit at nice university hospital. Objective of the study was Insertion of peripheral venous catheters (PVCs) is current practice within the hospital environment and particularly in the emergency department (ED). during the study 2515 patients over 16 years of age attended the unit. Overall, 390 PVCs were followed until the time of their removal. Mean duration of IV infusion was 28 h. Among these 390 patients, 62 (15.9%) developed complications, of which 54 (13.6%) had thrombophlebitis and 9 (2.3%) developed local infection. Conclusion of the study was Insertion of PVC is common practice especially in EDs. The excessive use of this procedure leads to extra cost and iatrogenic complications. A renewed definition of its indication and raised awareness among hospital staff concerning the risks involved with this standard procedure should result in less use of PVC and fewer complications. 17

6.2.2 Studies Related To Topical Anticoagulant Therapy:

A study was conducted on Anti-coagulant ointment in the prevention of post-infusion thrombophlebitis. 169 cases were included (84 experimental, 85 control) to study the effect of topical anticoagulant ointment. The finding was the Topical anticoagulant ointment was effective in decreasing the incidence of thrombophlebitis if the duration of infusion was up to 12 hours or less, the use of anticoagulant ointment reduced the average number of days of recovery especially in moderate to severe grades of thrombophlebitis. 18

A study was conducted on Topical heparin for the treatment of acute superficial phlebitis secondary to indwelling intravenous catheter A double-blind, randomized, placebo-controlled trial. Objective of the study was to assess the clinical efficacy of a topical gel containing 1000 IU.g−1 of heparin, applied three times daily for a maximal period of 7 days to patients with acute superficial phlebitis secondary to indwelling intravenous catheter. Result of the study was, after treatment for 7 days superficial phlebitis healed in 27 of the 61 patients (44.3%) who received topical heparin, and in 17 of the 65 patients (26.1%) receiving placebo, giving a relative risk of 1.69 (1.03–2.78). Conclusion of the study was the topical heparin is safe and effective for the treatment of superficial phlebitis secondary to indwelling intravenous catheter.19

A study was conducted on Topically Applied Heparins for the Treatment of peripheral Vascular Disorders. A total of 1055 patients participated in a total of 20 studies that compared topical heparin formulations with placebo, no treatment, subcutaneous heparin or with each other in the treatment of superficial thrombophlebitis. In head-to-head studies comparing different topical heparin formulations, all preparations appeared effective. Conclusion of the study was topical heparin preparations may be useful for relieving the signs and symptoms of vascular disorders while improving microcirculation.20

6.2.3 Studies Related To Hot Fomentation.

A study was conducted on Effect of warm and cold applications on the resolution of IV infiltrations. Differences in pain intensity, surface area measurements of indurations and erythema, and interstitial fluid volume when warm versus cold applications were randomly made to an intentional intravenous infiltrate of 5 mL of a designated solution were examined. Three solutions were used: 0.5 saline (154 mOsm), normal saline (308 mOsm), and 3% saline (1027 mOsm). The sample was 18 healthy adults between 20 and 45 years. Pain intensity did not differ by treatment but a significant difference was found by solution, with 3% saline producing the greatest difference. Erythema was absent with all solutions. Study reveals that there is no significant difference between the cold and warm application in resolution of IV infiltrations. 21

A study was conducted on local warming and insertion of peripheral venous cannulas it is a single blinded prospective randomised controlled trial and single blinded randomised crossover trial. Objective of the study was to determine whether local warming of the lower arm and hand facilitates peripheral venous cannulation. Setting was Neurosurgical unit and haematology ward of university hospital participants were 100 neurosurgical patients and 40 patients with leukaemia who required chemotherapy. Intervention was given was Neurosurgical patients' hands and forearms were covered for 15 minutes with a carbon fibre heating mitt. Results were In neurosurgical patients, it took 36 seconds (95% confidence interval 31 to 40 seconds) to insert a cannula in the active warming group and 62 (50 to 74) seconds in the passive insulation group (P=0.002). The crossover study in patients with leukaemia showed that insertion time was reduced by 20 seconds (8 to 32, P=0.013) with active warming and that failure rates at first attempt were 6% with warming and 30% with passive insulation (P<0.001). Conclusion of the study was Local warming facilitates the insertion of peripheral venous cannulas, reducing both time and number of attempts required. This may decrease the time staff spend inserting cannulas, reduce supply costs, and improve patient satisfaction.22

6.3 Statement Of The Problem:

“A FACTORIAL STUDY ON EFFECTIVENESS OF THROMBOPHOB OINTMENT WITH & WITHOUT HOT FOMENTATION IN PREVENTING LOCAL COMPLICATIONS OF IV CANNULIZATION AMONG PATIENTS IN SELECTED HOSPITALS AT MYSORE.”

6.4 Objectives Of The Study: