Clinically indicated removal versus routine removal of peripheral venous catheters

RATIONALE: Catheter-related bloodstream infection is a potentially life-threatening complication of peripheral venous catheters (PVCs). Routine PVC removal at set time intervals may prevent bloodstream infection and thrombophlebitis; however, it requires additional replacement PVC insertions and costs. An alternative is clinically indicated removal when the PVC is no longer needed, functional, comfortable or complication-free. OBJECTIVES: To assess the effects of clinically indicated removal versus routine removal of PVCs. SEARCH METHODS: 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. ELIGIBILITY CRITERIA: We included randomised controlled trials (RCTs) comparing clinically indicated with routine PVC removal for patients requiring a PVC. We excluded randomised cross-over trials. OUTCOMES: Critical outcomes were catheter-related bloodstream infection, primary bloodstream infection, local infection and mortality. Important, but not critical, outcomes were thrombophlebitis, infiltration and catheter occlusion. Outcomes considered of limited importance included cost, pain during infusion, satisfaction and the number of catheters per participant. RISK OF BIAS: For this update (4th; initial publication 2010), we used the Cochrane risk of bias tool (RoB 1) to assess risk of bias in the studies. SYNTHESIS METHODS: Six review authors independently selected studies, extracted data and assessed the risk of bias. Where appropriate, we pooled data using fixed-effect models in the first instance. Effect measures included risk ratios (RR) for categorical outcomes, mean difference (MD) for continuous outcomes and rate ratio (RaR) for incidence rates, each with 95% confidence intervals (CI). We assessed the certainty of evidence using GRADE. INCLUDED STUDIES: All studies in the previous version of the review were included (n = 9), and we identified five new studies. The update included 14 RCTs with 11,428 participants. Studies were conducted in Australia, Brazil, China, India, Iran, Taiwan and the United Kingdom. Thirteen studies were conducted in acute hospitals and one in a community setting. Eleven studies assessed adult populations, and three studies included paediatric or neonatal populations. All studies had a high risk of bias in one or more risk of bias domains. The certainty of the evidence was low to moderate, limited by potential detection bias for subjective outcomes, inconsistency across studies and imprecision due to small sample sizes. SYNTHESIS OF RESULTS: Clinically indicated removal likely results in little to no difference in the incidence of catheter-related bloodstream infection (RR 0.61, 95% CI 0.08 to 4.68; 10 studies, 10,208 participants; low-certainty evidence) or primary bloodstream infection (RR 0.55, 95% CI 0.22 to 1.38; 3 studies, 6370 participants; low-certainty evidence) compared to routine removal. When compared to routine removal, clinically indicated removal results in little to no difference in local infection risk (RR 2.91, 95% CI 0.46 to 18.39; 9 studies, 8993 participants; low-certainty evidence). There was no clear difference in the incidence of mortality when clinically indicated removal was compared with routine removal (RR 1.01, 95% CI 0.36 to 2.89; 2 studies, 6170 participants; low-certainty evidence). The incidence of all critical outcomes was extremely low for both clinically indicated PVC removal and routine removal. We are uncertain about the effect of clinically indicated removal of PVCs on thrombophlebitis (RR 1.31, 95% CI 0.94 to 1.82; 14 studies, 10,780 participants; very low-certainty evidence) with little to no difference in thrombophlebitis rates per 1000 catheter-days (RaR 0.98, 95% CI 0.78 to 1.22; 9 studies, 9658 participants; low-certainty evidence). Low-certainty evidence indicated that routine removal has a small effect on reducing infiltration and occlusion per participant, compared with a clinically indicated removal (RR 1.24, 95% CI 1.01 to 1.53; 11 studies, 10,491 participants; RR 1.46, 95% CI 1.06 to 1.99; 12 studies, 10,691 participants respectively). Clinically indicated removal compared with routine removal may result in little to no difference in infiltration rate per 1000 catheter-days (RaR 1.11, 95% CI 0.79 to 1.57; 8 studies, 9458 participants; low-certainty evidence). Compared with routine removal, low-certainty evidence indicated that clinically indicated removal may result in little to no difference in catheter occlusion per 1000 catheter-days (RaR 1.18, 95% CI 0.85 to 1.63; 9 studies, 9658 participants). Clinically indicated removal of PVCs was associated with a small reduction in device-related costs compared with routine removal (MD -10.88 AUD (Australian dollars) (2024), 95% CI -13.78 to -7.98; 4 studies, 4606 participants). A single study (1319 participants) reported device-related pain and satisfaction results. Clinically indicated removal of PVCs was also associated with a small reduction in the number of catheters required per participant compared with routine removal (MD -0.14, 95% CI -0.25 to -0.03; 8 studies, 8944 participants). 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.