Gauze vs. Plastic for Peripheral Intravenous Dressings:

Testing a New Technology

BENJAMIN LITTENBERG, MD, LYNN THOMPSON, RN

The authors conducted a randomized, prospective, con- trolled trial of three different dress ings /or peripheral intra- venous catheters in 301 acutely ill medical inpatients. Cath- eters were dressed with dry c lean g a u z e or one of two brands of transparent plastic. The gauze dressings re- mained in p l a c e significantly longer (47 hours median) than either Uniflex~ (39 hours) or Tegaderm® (32 hours) trans- parent plast ic dressings [p = 0.026). Catheters were re- moved for complications (inflammation, mechanical fail- ure, or infiltration) in 35% of the gauze group, compared with 58% of the Uniflex group and 48% of the Tegaderm group (p = 0.015). Not only were inflamed ven/puncture sites s e e n less often with gauze, inflammation occurred later (p = 0.002) and with lesser severity. Dry g a u z e dre~ings resulted in longer catheter llfe, lower complication rates, and less expense than transparent plastic dressings for pe- ripheral intravenous catheters. Key words: bandages; oc- clusive dressings: technology assessment, biomedical; phlebitis. J GEN INTERN MED 1987; 2 : 4 1 1 - 4 1 4 .

TABLE 1 Primary Diagnoses of Study Patients

Gauze Uniflex Tegaderm Significance of Diagnosis (%)* (%)* (%)* Difference~r

Stroke or dementia 4 8 5 p 0.49 Cardiac 7 7 8 p 0.93 Pulmonary 34 39 37 p 0.76 Gastrointestinal 9 13 13 p 0.68 Cancer 17 11 13 p 0.48 Renal 5 3 5 p 0.70 Infectious 14 12 12 p 0.84 Other 9 9 6 p 0.67

*The percentage of catheters in each group in patients with the listed primary diagnosis.

tDetermined by three-way X ~.

ALTHOUGH MILLIONS of intravenous (IV) cannulas a re inserted yearly, traditional methods of caring for IV sites a re imperfect. ~' 2 Recently, severa l manufac- turers h a v e introduced t ransparent plastic adhes ive dressings for use in central as well as per ipheral IV sites.

Little is known of the natural history of IV cath- eters on which to ba se decisions concerning choice of dressing. We undertook a prospective, random- ized, controlled study of three IV dressings to deter- mine which is superior in clinical use.

METHODS AND MATERIALS

The study was conducted on an acute ca re medical nursing unit of 31 beds in a 1,000-bed teach- ing hospital during the winter months of 1985- 86. Three hundred and one catheters in 93 patients were examined. The a v e r a g e a g e of the patients was 70.9 years ; 44.1% were male. The major diag- noses of the patients a re listed in Table 1. Patients were not admit ted to this unit for elective diagnostics

Dr. Littenberg is currently with the Robert Wood Johnson Clinical Scholars Program, Stanford University Medical Center, and the Division of General Internal Medicine, Veterans Administration Medical Center (11C), 3801 Miranda Avenue, Palo Alto, California, 94304. Ms. Thompson is with the Department of Nursing, Hartford Hospital, Hartford, Connecticut.

Presented at the Tenth Annual National Meeting of the Society for Research and Education in Primary Care Internal Medicine, April 30, 1987, and the Third Annual Meeting of the International Society of Tech- nology Assessment in Health Care, May 22, 1987. Supported by Hartford Hospital.

Address correspondence and reprint requests to Dr. Littenberg.

such as ca rd iac catheterization, to exclude myocar- dial infarction, or for elective surgery. Virtually eve ry admission was for an acute medical emer- gency or as a transfer from an intensive ca re unit.

The hospital 's IV Therapy Team consists of spe- cially t ra ined nurses who provide 24-hour catheter insertion service. All per ipheral intravenous cath- eters inserted by the IV Therapy Team during the study period were randomized by a sea led-enve- lope method to one of three dressing protocols. The unit of analysis was the dressing rather than the patient. If a patient had multiple IV sites, simulta- neously or sequentially, e a c h site was randomized individually. Catheters were excluded if they were not inserted by the IV Therapy Team or h a d been inserted before the patient was t ransferred to the nursing unit. Catheters were not excluded b e c a u s e of the na ture of the infusate or because of patient characteristics.

All catheters were inserted using sterile tech° nique with 45-second povodine scrub. No topical antibiotics were applied. The same 18- or 20-gauge Teflon catheters were used for all three groups. Catheters were used for a l l intravenous medica- tions, fluids, and blood products.

The gauze dressing protocol required the cath- eter to be secured to the skin with a thin chevron of plastic tape at insert ion and covered with a c lean 2-inch by 2-inch gauze p a d (Lisco Gauze, Kendall Company, Boston, Massachusetts). Wide pape r tape covered the dressing. The site was inspected without removal of the gauze thrice daily. The dress- ing was c h a n g e d daffy for inspection only; the cath-

411

412 Littenberg, Thompson, GAUZE vs, PLASTIC FOR IV DRESSINGS

eter was left in place. This dressing change was required to insure that ear ly site complications would be observed. Catheters were removed when no longer needed or at the first indication of mal- function, infiltration, or inflammation.

The Uniflex® protocol used a 6-cm by 8.5-cm transparent plastic adhesive (Uniflex, Howmedica, Inc., Largo, Florida) in place of gauze. The site was inspected through the dressing three times per day. The Tegaderm® protocol employed a similar 6-cm by 7-cm product (Tegaderm Transparent Dressing, Medical Products Division, 3M Company, St. Paul, Minnesota). Both plastic dressings were left in place for the life of the catheter.

The catheters were evaluated by the bedside nurse and the IV therapy nurse. The protocol for evaluation was the same for the three groups. Al- though the study was randomized, prospective and controlled, the evaluators could not be blinded to dressing type. A da ta record was maintained for each catheter, indicating the times of insertion and removal, the reason for removal, the thrice-daily in- spection record, including the g rade of inflamma- tion, and a rating by the removing nurse of the dressing's overall performance. Inflammation was g raded on a 4-point scale: 0 = no inflammation; 1 + = painful site without other signs; 2+ = painful site with erythema, swelling, or both; 3 + = palpable cord, induration, or frank pus. The overall perform- ance was rated on a subjective scale from 1 (poor) to 5 (excellent). Nurses' comments were also recorded. Catheters were removed at the first sign of malfunc- tion, infiltration of inflammation. Routine removal was scheduled for the third d a y for all catheters.

The study was des igned to answer two main questions: Which dressing promotes longer catheter life? Which dressing is associated with complica- tions least often? Accordingly, two main compari- sons were performed. Because the da t a were not normally distributed, nonparametr ic methods were used. Medians for the three groups were compared using the Kruskal-Wallis test.aRates were compared using the chi-square test.

Other da ta and trends are presented but statis- tical evaluation should be tempered by the recogni- tion that the study was not designed to provide these data; power is low and the problem of multiple com- parisons should be kept in mind. 4 Therefore, tradi- tional p values may be misleading.

RESULTS

Catheter Life and Complications

Table 2 shows that gauze dressings performed significantly better than plastic with regard to cath- eter lifespan (p = 0.026) and complication rate (p = 0.015). Fewer gauze-dressed catheters suffered complications a n d more plastic dressed-catheters were associated with inflammation. When gauze- dressed sites did become inflamed, it happened later (p = 0.002) and with less severity.

The dressings performed equally well with re- gard to mechanical problems, infiltration and acci- dental removals. The nurses' ratings showed no sta- tistically significant preference.

The most common nursing comments were that the t ransparent nature of the plastic dressings was preferred for evaluat ing the site for inflammation

TABLE Z

Catheter Performances by Dressing Material

Gauze Unifiex Performance (%) (%)

Number of catheters 99 103 Median catheter life 47 hours 39 hours Complicated 35% 58% Median time to inflammation 48 hours 35 hours Mean overall nurses' ratingt 3,77 3.77

Removed, by reason: Routine 54% 37% Accidental 11% 5% Inflamed 9% 19% Infiltrated 17% 28% Mechanical 9% 11%

Inflamed, by grade$ Grade 1 6% 8% Grade 2 2% 9% Grade 3 0 2%

Tegaderm (%)

99 32 hours 48% 32 hours 3.59

42% 10% 13% 23% 13%

7% 6% 0

Significance of

Difference*

p ---- 0.026 p = 0 . 0 1 5 p = 0.002 p = 0.601

*Determined by the KruskaI-Wallis test. tNurses' ratings ranged from 1 (poor) to 5 (excellent). $1nflammation grades are described in the text.

JOURNAL OF GENERAL iNTERNAL MEDICINE, Volume 2 (Nov/Dec), 1987 4 1 3

and that the mechanical stability of the gauze dress- ing was superior.

The times of removal differed by removal rea- son as well as by dressing type. Less than 5% of all accidental removals (generally by agi tated or con- fused patients) occurred past 48 hours. Removal for complications usually happened later: 23% of me- chanical problems, 22% of infiltrations, and 40% of inflammations occurred after 48 hours (with all dressing types).

Costs

Current procurement costs for Hartford Hospital were ana lyzed to estimate the cost differences among the dressing types. If a hospital were to switch from a plastic dressing (29.5 cents for the dressing plus 2.3 cents for associated materials) to gauze (3.2 cents for gauze plus 3.1 cents for other materials} they would save 25.5 cents per dressing. Our nursing staff were not aware of a n y systematic differences in the amounts of nursing time required to care for the different dressings.

Catheters last longer when dressed with gauze. Although we replaced the gauze on a daily basis to facilitate site inspection and monitoring for compli- cations, this is not necessary for routine clinical use. Savings would be realized because the longer life- span of the gauze-dressed catheters would require fewer catheter changes, fewer materials, and less nursing time. The smaller number of complications with the gauze dressings m a y represent savings in t r ea tment of complications and hospital length of stay.

DISCUSSION

Intravenous therapy complications may be re- lated to the physical material used for the catheter, s the length of the catheter, e the staff inserting the catheter, 2 the time in place, 2, ~ the skin preparation, 8 the patient's other medical problems, 9 and the na- ture of the infusate, l' m

Recently, the type of dressing material used for peripheral IV sites has also come under scrutiny as manufacturers bring new products to market. Al- though there are few da ta demonstrat ing that trans- parent plastic dressings are advan tageous in this setting, m a n y hospitals have expanded their use from wound care and central alimentation catheter dressing to peripheral IV sites. In fact, there are some da ta to show that plastic dressings are signifi- cantly l e ss advantageous .

Epidemiologists in Michigan linked an outbreak of IV site infections by S t a p h y l o c o c c u s a u r e u s to the hospital 's use of plastic dressings. ~ When the dress- ings were replaced by gauze, the rate of new infec- tions declined dramatically.

Gantz et al., 7 in a non-randomized study, dem- onstrated an increased risk of catheter malfunction necessitating removal in sites dressed with plastic rather than gauze. They also noted a significant cost savings associated with gauze dressings and im- proved performance among gauze dressings that were changed less frequently.

Kelsey and Gosling ~2 also used a non-random- ized design a n d found variations in performances associated with time in place, catheter type, a n d dressing type. Compared with patients whose cath- eters were dressed with gauze, the plastic-dressing group h a d more phlebitis and more positive catheter tip cultures.

Plastic dressings m a y have certain advantages.13-~s Perhaps fewer scheduled dressing changes are needed. The site m a y be quickly in- spected without removing the dressing. The trans- parent nature of the dressing m a y be a disadvan- tage for those patients disturbed by the sight of the catheter entering their skin.~S These theoretical ben- efits are outweighed by the significantly poorer per- formance of the plastic dressings in this and other reports.

The present study is the only prospective, ran- domized comparison of gauze and plastic dressing materials for peripheral intravenous catheters to date. However, several cautions concerning this study should be noted. We studied peripheral IV sites only a n d have no da t a to offer concerning the use of plastic dressings for central lines, wound care, and other applications. Likewise, the study was per- formed on a general nursing unit with cannulas in- serted by skilled nurse-specialists. Other settings (intensive care units, emergency wards, operating rooms, dialysis units) with different patient popula- tions and different personnel may have different requirements.

For the purposes of the trial, and to facilitate observation of the catheter sites, the gauze dress- ings were removed daily. Because of their transpar- ent nature, this was not necessary for the plastic dressings. This m a y have introduced two biases into our results. First, this additional manipulation m a y have increased the rate of complications in the gauze group. Second, the nurses' threshold to record a complication and change the catheter m a y have been lower when the dressing was a l ready re- moved. Both of these factors would tend to increase the reported complication rate in the gauze group. Recognition of these potential biases strengthens our conclusion in favor of gauze. It is also possible that frequent removal of the gauze had a beneficial effect on catheter longevity. Although we believe this is unlikely, it m a y have biased our results in favor of gauze.

The observers (the rating nurses} were not

4 1 4 Littenberg, Thompson, GAUZE VS. PLASTIC FOR IV DRESSINGS

blinded to dressing type for practical reasons. The similarity in nurses' overall ratings (Table 2) among the three groups argues that there was no significant observer bias in favor of gauze. It also indicates that none of the dressing types is perferred by nursing staff for reasons not explicitly evalua ted in the study.

We did not perform microbiologic investigations to determine the rate of catheter-associated sepsis among our patients. No catheters were removed for unexplained fevers, and no bacteremias in the study group were attributable to peripheral IV catheters. Previous work indicates that peripheral IV sites with t ransparent plastic dressings are twice as likely to become contaminated or colonized as sites dressed with dry gauze. Is

Of the known predictors of catheter perform- ance (catheter material, length, inserter skill, skin preparation, etc.), we controlled for all but co-mor- bidity a n d infusate characteristics. Post-randomiza- tion analysis revealed no differences in the frequen- cies of major diagnoses among the three groups (Table 1). The type of infusate was not recorded; it is possible that randomization did not allocate the more damag ing infusates evenly among the three groups. In view of the success of randomization for the other variables examined, we believe this is highly unlikely.

There is no clear explanation for the poorer per- formance of the plastic dressings. Higher coloniza- tion rates m a y lead to infiltration or phlebitis without apparen t infection. Perhaps superior mechanical stability explains the lower rate of venous inflamma- tion and early removal found in the gauze-dressed group.

In summary, we found gauze dressings to be superior to t ransparent plastic dressings for periph- eral IV sites by several criteria. Substantial in- creases in morbid complications and patient dis- comfort were found when catheters were dressed with plastic rather than gauze dressings.

The authors gratefully acknowledge their debts to Joseph Klimek, MD, Laurie An- drews, RN, Pat Karwoski, RN, the nurses of the Hartford Hospital IV Therapy Team, and especially the nurses and staff of C8L for the important roles they played in performing this study.

Tegaderm is a registered trademark of 3M Company, St. Paul, Minnesota. Uniflexis a registered trademark of Howmedica, Inc., Largo, Florida.

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