Discussion

5.1 Introduction:

Venous catheterization is a routine procedure performed for severely infected persons.

This catheter is an assessment and management method in ICU. However, many complications

can result from this procedure, like catheter-related infections, local hematoma, or

pneumothorax. Critical care nurses put essential effort in the treatment of infected people in

ICU. Nurses are accountable for appreciating and preparing patients. Venous catheterization,

either central or peripheral, prevents complications during and after insertion (Awad et al.,

2011). This study aimed to compare peripheral and central venous catheters regarding venous

pressure and complications among critically ill patients at King Saud Medical City in Riyadh.

This chapter described the discussion of the results and related to the old one. Also, the rationale

as the results is demonstrated. It will be discussed according to the four sections:Socio-

demographic and clinical data, venous catheter characteristics, venous pressure readings &

venous catheter complications.

5.2 Demographic and medical data

The recent study performed 60 adult patients of both genders. The results show that the

total age of the researched required sample was 38.8 ± 1.5 years. Most participants were males

and single. Lower than half of patients graduated from high school. The results present that most

patients admitted to SICU were diagnosed with polytrauma and connected to a mechanical

ventilator.

5.3 Venous catheter characteristics

 Venous characteristics include mean insertion time, insertion site, catheter size, catheter

use, length of catheter stay, and removal. The current study results reveal that the most common

purpose of inserting CVCs was hemodynamic monitoring and medication administration. This

result was consistent with Lai et al. (2016); Fang, Yang, Song, Jiang & Liu (2017) Noted that

most insertion of central venous catheters for medication administration, fluid management, and

blood transfusion. The study revealed that most of a CVC introduced site was an insider jugular

vein followed by a subclavian vein. The pattern of observation consistent with Adekola et al.

(2018). CVC in the severe treatment unit is frequently performed through the right internal

jugular approach. Which has been reports of increased success and reduced complication rates

with internal jugular vein catheterization? The jugular venous system's anatomy and the

catheter's design have been reported to facilitate proper insertion.

Dibble et al. (2014) reported that the internal jugular vein is easily imaged with ultrasound.

While subclavian vein maximum incidence of pneumothorax during insertion than the insider

jugular vein. Jahagirdar, Laxmimani, Athiraman& Ravishankar (2013) reported that the right

subclavian vein is considered one of the commonest CVC placements used safely in the care unit

for the administration of vasopressors, inotropes.

Regarding venous catheters (VC's) mean insertion time, the results display that CVC's

mean insertion time was prolonged than PVC. This result could occur because CVC is

considering surgical procedures requiring multiple preparations that take prolonged time like

preparing equipment, wearing personal protective equipment (PPE), and preparing the insertion

site. And using ultrasound during site assessment and chest x-ray after insertion.

Awad et al. (2011) stated that the introduced site was cleaned by povidone-iodine within 30

seconds in peripheral catheter insertion and in central venous catheter insertion within 2 minutes.
 Regarding the use of ultrasound guidance, it was observed that the majority of CVC was

inserted under ultrasound guidance for central venous catheter insertion. In contrast, all PVC

were inserted without ultrasound guidance. This result agrees with Marsh (2017), who stated that

in a big tertiary hospital in Queensland, Australia of a prospective cohort study; Multiple

introduced results of PVC were needed to place (23%) PVCs. No PVCs were inserted with

ultrasound.

While this result contradicted with Beecham & Tackling (2019); Kaur, Rickard, Domer,

&Glover, (2019) and Clinical Excellence Commission (2013), they are showed that in the time

of critical cases, the difficulty of a peripheral venous catheter or multiple placements of the

peripheral line has previously failed, an ultrasound-guided technique may be necessary.

Ultrasound imaging Using CVC insertion contrast to the landmark mechanism criterion

represented to lower difficulties and minimize the amount of introduced trials within the process

of insider jugular vein cannulation (Ravindran et al ., 2017). However, Adekola et al. (2018)

Ravindran et al. (2017) CVC placement is more common through the right internal jugular vein

and anatomical landmark technique.

The present result reveals that 20 cm, 3 lumens,7 Fr CVC was the primary CVC size used.

This result occurs because this was the available size of the selected ICU. On the other hand, the

most used PVC size was 18 gauge. This result consistent with Marsh et al. (2017). They stated

that A third of the PVC (34%) were 18-gauge. However, This result is opposite to O'Horan

(2015) study, who said that 22 gauge is needed to administer intermittent medicines, 20-18 gauge

is required for the administration of radio-opaque contrast medium, In acute cases, 14-16 gauge

are routinely used to help fluids, i.e., bleeding. Regarding VC uses, the results explain that both

PVC and CVC were mostly used for medication administration. This result is like Webster,
Osborne, Rickard, New. (2015), Marsh, Webster, Mihala & Rickard's (2015) studies found that

PVCs were used to administer medications and fluids, blood components, and contrast

intervenors. It is considered a vital element of modern medicine.

The reason for choosing the catheter insertion site may be difficult cannulation consequent

to some sort such as the age of patients and diseases, health professional's experience, cannula

size, and the site area (Piredda et al., 2016). The present study demonstrates that CVC's most

common location was the insider jugular vein, while the many common site for PVC was the

dorsum region. In a survey by Pasalioglu (2014 ), the much usual catheter of site installation was

described in the forearm (59.9%) and wrist (25.1%). While Marsh et al. (2017) (64%) of PVC

were in the hand or cubital fossa. The instroduction of the PVCs was basically the back of the the

forearm (35.4%) and hand (39.7%) (Braga et al .,2018 ). Ravindran et al. (2017) gauge18 of the

peripheral venous catheter was placed in situ for dorsal hand or distal forearm veins on the left

hand. The upper limb's right side was not selected for PVC placement to avoid obstruction to

venous flow.

In the present investigation, the mean duration of patients on PVC was 4.1± 0.1 days. This

result is supported by Dao (2017), who report that the average PVC days for the routine

replacement group was (4.29 days SD 2.47).Moreover, Randomized control trial demonstrated

by Johann, Danski, Vayego, Barbosa & Lind (2016), PVC was introduced without complications

for a common of 3.73 (±2.25) and a more than 10 days in the empirical collection however the

catheter of the monitoring team was recorded for 3.28 (± 1.66) and extreme of week.

Additionally, Katiuska and colleagues 'feedback displays that a period>4 days was related

to diminishing the danger of PVC failed Miliani et al., 2017), which concurs with our feedback.

A research by Abolfotouh et al. (2014) explained that from the first 24 to 30 hours in all problems were
involved (P = 0.0001).

The present research demonstrates that the average timing of patients on CVC was 9.5 ±

0.8. This result has contradicted Hignell (2016) and the Infusion Nurses Society (2016). They

found that the catheter site is expected in each subclavian or the internal jugular site and needed

for greater than two weeks. Furthermore, the present finding illustrates that the CVC removal's

most common reason was no massive fluid resuscitation requirement or no indication for the

catheter.

This result is similar to Korula and Paul's (2015) result. They reported that CVC was

removed once there was no demand for a massive volume of fluids and damaging intravenous

devices (62%). Two middle lines were eliminated because of consistent hematoma and

thrombosis in the vein. While Infusion Nurses Society (2016) stated, the direct elimination of

working of CVC is not recommended by gaining temperature. (Gorski, 2017).

5.4 Venous pressure monitoring

The present study compared the mean PVP and CVP for three consecutive days. The

results found a significant comparison within CVP and PVP on the first day but an insignificant

difference on the second and third days. It also shows that the mean CVP value was higher than

the mean PVP among three days on all readings. Dan& Varghese,(2015) In this process the CVP

and PVP recorded complicatedly by combination of CVP manometer to the middle venous

catheter as well as outer venous catheter of infected persons through the reading of pressure at

exact time, three times in four hours of interval. The present investigation observed that the

grand mean of PVP for three days is higher than CVP (11.28±2.19 vs. 10.38 ± 2.10,

respectively). Furthermore, the present finding illustrates that the CVC removal's most common

reason was no massive fluid resuscitation requirement or no indication for the catheter.
 In comparison, a last research reported by Ravindran et al. (2017) stated that the PVP and

CVP were registered to the closest 1mm Hg at 5 minutes interval. These similarly conducted a

study by Radhakrishna et al. (2019). They are stated that different patients' positions may lead to

the elbow's flexion and result in an erroneous value in PVP. Also, Ravindran et al. (2017)

reported the external compression via the factor or blood pressure cuff and stretching too much

in the arm of the catheterized site can obtain the peripheral vein and elevated PVP.

Moreover, Rajan (2014) reported a possibility of PVP value changes with different hand

positions such as adduction or abduction. They flow through the vein might impede, reflecting as

a false increase in PVP. This result is consistent with our finding Ravindran et al. (2017) set

PVP elevated consistently than the CVP with a mean difference of around 4mm Hg in most

patients. Suni et al. (2016), In an observational study on 40 adult patients undergoing surgical

procedures, it was shown that PVP always had a significantly high value compared with CVP

throughout the study period (P<0.001), showing a positive trend.

Studies by Sheriff et al. (2015); Sunil et al. (2016); Kumar et al. (2015) Showed similar

results. The mean difference between the measurements at different periods concluded that the

PVP has a maximum amount than the CVP. Because of this, the CVP observed through the

measure of PVP. Therefore, Dan & Varghese (2015); Prakash et al. (2018) study evidence a

powerful connection within CVP and PVP, and PVP might be safe monitoring rather than CVP

measurement. Furthermore, this result contradicted Rajeev & Verghese (2017), who reported the

time dependent correlation between CVP and PVP. The final statement found a significant

difference between CVP and PVP on the first day but an insignificant difference on the second

and third days. It also shows that the mean CVP value was higher than the mean PVP among

three days on all readings.

5.5 Venous catheter complications

The resulting complications arise from the venous catheter, including early complications

(Nerve damage, Air embolism, dislodgement (Partial or Complete), Hematoma, Hemothorax,

and Pneumothorax), and late complications. Regarding early complications, the recent study

demonstrated the absence of complications from CVC and PVC.

Morano et al. (2014) demonstrated that CVC's early complications occur because of

variations in numerous factors such as medical expertise, sort of device, and type of method or

vessel use. Shah et al. (2017) showed that Nurses work in essential way to inhibit the CVC

difficulties or catheter-related bloodstream infection; by using standard guidelines like

arrangement of an aseptic environment in CVC introduction.

However, Shah et al. (2017) represented the data in which nurses described the information

for the treatment of CVC. The standard deviation is 10.671 and the mean is 73.65. The use of

ultrasonographic guidance for CVC inroduction has seriously minimizes the bombardment of

prior sudden difficulties range evaluated as 11.8 to 4 to 7% (Kornbau, 2015).

Furthermore, according to Shah et al. (2017) presented that Kalender (2015), the dressing

gauze must be altered daily but the condition is without any flow or elimination and the dressing

would be replaced after every week. According to Kalender, the Disease for Control and

Prevention Centers, they recommended chlorhexidine as the first skin antiseptic preference.

Simultaneously, povidone-iodine and 70% of alcohol must be utilized whenever chlorhexidine is

not present.

Care of the peripheral catheter: the present finding illustrates that the CVC removal's most

common reason was no massive fluid resuscitation requirement or no indication for the catheter.
The CVC site also replaced the dressing regularly after 2 days and once the dressing's

replacement is not done. The insertion site will be inspected daily by visually and palpated the

site clean transparent dressing for tenderness and assessed for signs and symptoms of

complications (Awad et al .,2011).

Dibble et al. (2014) and Adekola et al. (2018) showed that Careful preparation, use of

ultrasound, post-CVC chest radiograph, utilizing standard infection control, and safety

precautions reversal of existing coagulopathies could prevent complication. Article reviews by

Barb, Nickel (2019) demonstrated that failures of peripheral venous catheters with the severe

circumstances of without any coverage, unblockage as well as allergy and phlebitis (Helm,

Klausner, Klemperer, Flint & Huang,2015). The route of the peripheral venous catheter, the

solution, and medication administration has received a few awareness of the patient's safety and

effect patient (Rickard & Marsh,2017).

Peripheral venous catheter-related research's paucity is ironic, considering that three

million CVCs have been given to united states after every 12 months. In contrast, three-hander

fifty million peripheral catheters are inserted per year (Rickard & Marsh,2017). A predestined

60% to 90% ill persons are in hospitals and get an approachable tool with the highest numbers of

short peripheral venous catheters (Helm, Klausner, Klemperer, Flint & Huang, 2015).

But 40% to 70% fail of these peripheral venous catheters pre-therapy completion and the % may

be as rising as 90%.18. Rickard and Marsh identified three contributing reasons for this high

failure rate (Helm, Klausner, Klemperer, Flint & Huang,2015). (1)A Peripheral catheter is visible

like need for the infected people admitted in hospital, half of the considerable PVCs are

examined not on least to be approached for the clinical authorization as well as extended for the

site when the treatment is done (Rickard & Marsh, 2017). (2) The working and proficiency
needed to put a PVC underappreciated successfully. Although vascular approachable group have

been related to increase the prosperity from starting point and minimizing the reverse

happenings, the PVC has transformed from extremely infusion nurses learn how to treat and

behave well with primary nurses. This is not beneficial for every PVC placement to increase the

chances of reverse happening (Helm, Klausner, Klemperer, Flint & Huang,2015). (3) the

sensibility of the high average of failure and low costs associated with PVCs. Almost the

infected people need two alternatives for PVC within a 5-day to do the treatment to inhibit the

reverse changes which can result in the depletion of cure. (Helm, Klausner, Klemperer, Flint &

Huang,2015).

O'Grady et al. stated that the Local infection of PVC is done through the less introduction

or evolution of skin bacteria entering the PVC site that may be on the catheter site as pus;

normally it needs 2-3 days for the result of getting alternative. A predestined 60% to 90% ill

persons are in hospitals and get an approachable tool with the highest numbers of short

peripheral venous catheters (Kaur, Rickard, Domer, &Glover, 2019).

Venous spasm

A current study detected that few patients have PVC developed venous spasm and absence

of venous spasm from CVC. Duan et al., Braswell and Krishnamurthy, Keller stated that venous

spasm could happen during the cool intravenous fluid steeping, issues relevant to drugs or

serious injury of vein at the introduction site (Kaur, Rickard, Domer, &Glover, 2019).

This result consistent with Piper et al. (2018) and Kaur et al. (2019) in their study; it

focuses on PVC failure caused by mechanistic. Moreover, catheter failure was divided into two

predominant failure; the inserting clinician influences insertion failure. The second factor is;

failure after time in situ, which is associated with three definitions: Infiltration, occlusion,
phlebitis or thrombophlebitis, dislodgement, and venous spasm.

Extravasation and infiltration

The findings identified that both complications occur for one-third of patients with PVC

while not observed at the CVC site regarding Extravasation and Infiltration. Makafi et al. (2017)

stated that Extravasation's incidence, Infiltration of PVC, was 3.5% and 7%, respectively. The

PVC complication rate accretion with various things that act as danger like infected person’s age

and gender as well as the imbalance veins related to infection maximize the chances of it.

The device's securement reduces movable of the tool’s and forth in the vein, resulted the

impact of piston and complications decrease like without coverage and Extravasation (Dougherty

and Lister 2015). Kaur, Rickard, Domer, &Glover (2019) announced that Extravasation and

Infiltration caused by inappropriate placement of PVC, dislodgement, distal puncture, or erosion

linked to relative motion of the infected persons and the catheter.

Catheter occlusion

In the present result, the main reason for PVC removal was catheter occlusion. Kaur,

Rickard, Domer, &Glover, (2019) stated Rickard & Ray-Barruel demonstrated that occlusion. It

can come from mechanical blockage of the PVC's or fibrin deposition on the catheter's top. It

may also form phlebitis veins swollen at the site where it colloid the catheter and inhibit the

motion.

This coordinated outcome with Wallis et al. (2014) set various complications as

obstruction, phlebitis, leakage, seepage, and accidental removal result from the use of peripheral

venous catheters. Moreover, they reported that in adult patients, the large size of peripheral
catheters is 18 gauge or more with the increase of thrombosis range, and lower amount

peripheral catheters of 22 gauge or less for the maximum range of dislodgment and blockage.

Also, Wallis et al. (2014) found that the longer length of stay for clinically indicated replacement

patients may have resulted in a higher frequency of cannula re-siting resulting similarly in a

higher rate of occlusion; a previous study has shown that the rate of occlusion increases after

removal of the initial catheter.

Accidental removal

A recent study found accidental removal happened to a few patients with PVC while it did

not occur to CVC. The results from the same point of view as Dougherty and Lister(2015). They

reported that some peripheral cannulas have wings that help secure the skin device to prevent a

piston-like movement of the vein and accidental removal.

Moureau (2018)Accidental dislodgement or removal of CVC and PVC can be given for

numerous causes: motion of the catheter under a comfortable dressing, tape, or securement

device; compulsory elimination of sudden or intentional. Also, the cause can be either ill patient

(80%), the patient physically eliminates catheter (74%), and intravenous catheter securement

lose (65%).

Lorente et al. (2004) The significance of accidental removal of the peripheral venous

catheter lies in the complications because of removal itself and catheter reinsertion. The longer

length of stay for clinically indicated replacement patients may have resulted in a higher

frequency of cannula re-siting resulting similarly in a higher rate of occlusion; a previous study

has shown that the rate of occlusion increases after removal of the initial catheter. They reported

that some peripheral cannulas have wings that help secure the skin device to prevent a piston-like

movement of the vein and accidental removal.

 Bacteriological examination

Catheter-relevent blood issues are a remarkable way of infection preventable in hospitals

(Mermel, 2017). The present result found that the (3.3 %) catheter positive tip culture for CVC

rarely occurred to studied patients. This may result from the strict disinfectant technique in CVC

care protocol followed in the King Saud Medical City. This result is matched with Korula and

Paul (2015), who indicated that only one incidence of catheter tip infection was detected in their

study. However, in a previous study demonstrated by Bell & O'Grady (2017), a widespread

problem for patients who have a middle site within the 48 hours of catheter insertion was central

line-associated bloodstream infection (CLABSI).

Also, Mermel, 2017; Ray-Barruel et al., 2018; Zhang 2016 Studies reported that develop

bloodstream infections because of catheter use recurrently causes morbidity, prolonged hospital

placement, and an maximizing in health system costs. Longer length of stay for clinically

indicated replacement patients may have resulted in a higher frequency of cannula re-siting

resulting similarly in a higher rate of occlusion; a previous study has shown that the rate of

occlusion increases after removal of the initial catheter.

The 65% of CVC had positive tip culture than 43.3% of CVC, and 56% of PVC had

negative tip culture (no growth) than 35% of CVC (Awad et al., 2011).

In our study, one patient had a beneficial culture on the top of the central line. Factors that

affect culture such as parenteral nutrition, blood transfusion, maximizing extended stay of middle

line on-site, and central line-associated bloodstream infections increase at femoral access. But

logistic regression of multivariate for the central line's total duration, TPN, patient comorbidities,

and our study site central line insertion did not display any significant infection incidence.

(Korula& Paul,2015).
 Many factors affect CVC; the researcher views the patient's age, the prolonged duration in

hospital, the selection of CVC types, and these factors may affect CVC. Besides the adnatages of

CVCs which also contained the powerful portals for localized bloodstream issues (Bell &

O'Grady,2017).

5.6 Correlation within central venous pressure and peripheral venous pressure (N:60)

Once upon a time, PVP insert as easy and minimal invasive applied for monitor

hemodynamic and utilized as CVP (Ravindran et al., 2017). In the overall view of the present

study finding, the correlation between the total mean of PVP and CVP indicates a strong positive

correlation. The PVP value increase is positively correlated ( r=0.896, P<0.05) to the rise in CVP

value, showing a clinically acceptable result(Sunil et al., 2016). As in other investigations was

agree with our outcome-related PVP, a strong correlation with CVP in neurosurgical cases

(Ravindran et al., 2017).

The weak relative correlation between CVP and PVP reported by Yanagisawa1 et al .,2017,

give the end product with the higher range of variability in the infected peoples’ history as well

as hemodynamic parameters. Yanagisawa1 et al. (2017) supported that many studies have

demonstrated that CVP and PVP's difference varies with CVP's value. This research revealed a

high correlation of 0.896 (p<0.05). The PVP value increase is positively correlated ( r=0.896,

P<0.05) to the rise in CVP value, showing a clinically acceptable result (Awad et al.,2011) But

logistic regression of multivariate for the central line's total duration, TPN, patient comorbidities,

and our study site central line insertion did not display any significant infection incidence.

To describe the correlation the regression equation is CVP= .706 + 0.858* PVP and PVP=

1.559 + 0.936* CVP . Dan& Varghese,2015; Ravindran et al., 2017.

5.7 Relation between demographic characteristics and venous catheters complications

(N:60)

5.7.1 Peripheral venous catheter

Peripheral venouscatheterization is associated with several complications caused by

mechanical and non-mechanical factors (Kaur et al., 2019). In the present study, patients were

assessed for common late complications of PVC., venous spasm, Extravasation, Infiltration,

catheter occlusion, and accidental removal. They were chosen due to their frequent occurrence

and clinical relevance.

Venous spasm

Venous spasm is another complication due to procedural lapse. Several factors have been

attributed to venous spasm, including vein trauma due to improper insertion, infusion of cold

intravenous fluid, and irritation due to certain drugs (Braswell 2011). Venous spasm also occurs

during line removal (Bourgeois et al. 2011). Complications like venous spasm were detected in

two female patients in the age group of 30-49 years. We found a significant association of

venous spasm with gender (χ2 =6.79, p<0.05), and according to the correlation test, the

correlation coefficient (r= -0.337) indicates a strong negative correlation. The result revealed

that female patients were more prone to venous spasm than males (ẞ = 0.143, and CI [0.038-

0.248], p = 0.009).

Catheter occlusion

Regarding catheter occlusion as late complications for PVC, the complication was higher

among the patients aged between 20-39, and a higher rate of occlusions was found in males.

Contrary to one of the earlier findings, the female gender was a predictor of occlusion (Marsh et
al. 2018). This result, opposite Marsh et al. (2017)&A Abolfotouh (2014), reported that there is a

highly significant catheter occlusion on female patients than males. That was due to the of

females' lower vein caliber, infect the effect resulted after peripheral venous catheter size gauge

adjustment.

Extravasation and infiltration 4 grade (leakage)

Published reports suggest that extravasations were more common through peripheral

intravenous catheters (Loubani and Green, 2015). In this study, Extravasation and Infiltration

(grade 4 leakage) were predominantly recorded in patients belonging to 20-29 years and 50-59

years with a higher amount of skin index. Erdogan& Denat supports the result of the study that

uncoverage is usually seen in the infected people within the ages of 50-59 (11.8%). Infiltration

was found to the highest incidence in the age group of 12-21 years old, which was 2.6% (Makafi

and Marfega,2017). Boyd et al. 's study support the survey's result that extravasation introduction

done usually at the age 62-71 years old (Makafi and Marfega,2017).

In a previous study, that gender did not affect Infiltration (Erdogan& Denat,2016). While

our presented outcome shows that 22% of cases with the complication were males, 16.9%

married, and 11.9% were graduated from high school. However, in 2014 the females were

showed significantly higher Extravasation than males reported by Abolfotouh.

On the other hand, Makafi and Marfega state that approximately the resulting contrast with

the present study by (17.5%) of Extravasation was more likely to males than females. Makafi et

al., 2017 state that Osei-Tutu et al. and Kaur et al. upholds showed that females are mostly

produce the issues as compared to men when we talk about unblockage which is 58%. In this

research, without coverage examination is more approachable as compare to the other

diadvatages which discussed the 36% elimination of cathedral. The variation is in the drugs,

kinds and the quantity of the staffs’ abilities (Fayazi et al. ,2016). Last research indicated a

connection within the young and aged blockage through which the danger of increasing the

diseases is maximum. Few researches have indicated that there is no connection within various

teams of different ages and their issues like leakage, Extravasation, occlusion is relatively high.

Remarkably, this supported our result (Fayazi et al. ,2016).

Bacteriological examination of peripheral venous catheter

In our study, there is no result of PVC infection. It is similar to a study done in March

2017. He stated that no infection happened from the peripheral venous catheter.

5.7.2 Central venous catheter

Although CVCs do effective effort in the cure of infected people in the ICU, they may

cause severe complications if proper precautions are not taken (Ravindran et al., 2017& Padilla,

2017). In the present study, the CVC complication was infection found positive to gram-positive

bacilli.

Bacteriological examination of Central venous catheter

Though indispensable for critically ill patients, CVC often leads to severe complications

like central-line related to bloodstream issues (Patel et al., 2020). In the present study, two CVC

patients in 50-59 years were found positive to gram-positive bacilli. These infections might be

due to inadequate aseptic measures or lack of sufficient training or expertise of the attending

health professionals (Cotogni and Pittiruti, 2014). Patel et al. (2020) reported a 0.24% central

line-related bloodstream issues in severely infected people. The risk of infections also depends

on indwelling duration; infection risk increases with indwelling time (Polderman and Girbes,
2002).

5.8 Correlation between participants clinical data and venous catheters complications

(N:60)

5.8.1 Peripheral venous catheter

In the present study, the patients with a septic shock were found to have minimal

complications of Extravasation and Infiltration, dislodgement, catheter occlusion, or venous

spasm, compared to patients with surgical, respiratory, or trauma issues.

Catheter occlusion complication was higher among patients with polytrauma, surgical, and

respiratory disorders. Moreover, The most exposed patient to occlusion complications was in

infected people with large mean body mass index (27.4± 6.2). Several factors have been

attributed to catheter occlusions, including mechanical blockage of the cannula, blockage due to

infusates, fibrin disposition, improper insertion, and placement (Rickard and Ray-Barruel, 2017).

The occlusion of the line can be minimized by flushing with saline and heparin solution after

blood sampling and infusions (Bourgeois et al. 2011). It has been suggested that appropriate

planning for vascular access and insertion competency can minimize occlusion complications to

a large extent (Kaur et al. 2019). besides, the patients' height was significantly correlated with

venous spasm and accidental removal complications from PVC (p<0.05), with correlation

coefficients of(r=-0.251,r=-.263 respectively) indicates a strong negative correlation.

5.8.1 Central venous catheter

CVC's clinical characteristics with patients who had the positive result of gram-positive

bacilli were represented with a high mean body mass index 31.1 ± 12.2. Simultaneously, the

complication of CVC was insignificantly correlated with patients' BMI, height, and weight, with
correlation coefficients ranging between r=-0.115 to 0.128, p >0.05. In the present research,

infected people with septic shock and surgical disorders were found to have complications of

gram-positive bacilli infection was reported in 2 cases. In comparison, there is no infection on

PVC as the results show a statistically significant association between CVC complication and

diagnosis with significant differences (X2=30.443, P<.05).

5.9 Relation between central venous catheter site, size of catheter, duration, and catheter

site infection.

The subclavian vein is the most favorable site for catheterization, owing to its least

infection probability (Sadaf and Bashir, 2020). In the present study, infected cases were found

when the insider jugular vein was inserted for the venous catheter (7-Fr 20cm,3 lumens). It has

been described elsewhere that the chances of infection are relatively high for the femoral vein,

intermediate for the jugular vein, and minimum for the subclavian veins (Polderman and Girbes,

2002). The duration of catheter insertion in minutes is 30 minutes. There were no differences (60

cases have 30 minutes); that’s why I didn't analyze this variable; it's invalid statistically.

5.10 Connection within the complication of peripheral venous catheter and catheter

characteristics

In the present study, Venous spasm complication was significantly correlated with the

catheter duration in days with an effective, strong connection coefficient (r=0.296, p<0.05).

While accidental removal complication was associated considerably with catheter insertion

duration in days and minutes with positive correlations coefficient (r=.280, r=261, respectively,

P<.05). While Table 4.6.11 demonstrates that there are no statically significant correlations
between other variables.

5.11Relation between catheters size, catheters site, duration of the catheter, and total mean

pressure

The findings showed that the most highest mean PVP was among PVC that was inserted in

the forearm (11.86±1.55), with a catheter size of 18 gauge(11.35±2.18), and 3 minutes of

duration PVC (12.28±1.02), and five days of catheter presence(12.03±1.51). Also, the table

shows insignificant correlations between PVP and catheter characteristics.

Although there were insignificant correlations between either PVP or CVP with catheter

characteristics, not much variation between mean PVP and CVP was observed. The result is

consistent with the earlier findings on the connection within peripheral and central venous

pressures within various sites of infected people, catheter amount and introduction place (Tugrul

et al. 2004).

The most elevated CVP mean was among CVC inserted in the subclavian (11.17±2.13),

with a catheter size of 7-Fr 15 cm, 2 lumens (10.97±1.64), and with 10 to 19 days of duration of

the catheter presence. In contrast, the table shows that the Pearson correlation test findings

indicate insignificant correlations between CVP and the catheter characteristics. The all input

values in the duration of CVC insertion in minutes are 30 minutes; there were no differences (60

cases have 30 minutes); that's why it didn't analyze this variable; it's invalid statistically.

The findings show that PVP showed some correlation with CVP, indicating PVP as a

viable alternative to CVP.this finds the end in a sequence with the last research on the basis of

two enforcement calculations (Sunil et al., 2016).

5.12 Summary
 The researcher discussed the current study results supported by other studies as evidence

to answer the research questions.

Chapter 6
Conclusion and Recommendations
6.1 Introduction:

In this chapter, the researcher presented a result, power and disadvantages in the research

from various studies. Moreover, the researcher gave complete advices in the modern research

that depend on future with the research result.

6.2 Conclusion:

The current study constructs that differences statistically significant between the mean CVP and PVP on

the first day. Still, there were no significant differences found on the second and third days. The mean

PVP during the three days was higher than CVP was observed.

There were no early complications found from both CVC and PVC. Regarding late complications, the

findings demonstrate that catheter occlusion was the most common late complication for PVC, followed

by Extravasation and infiltration grade 4. Also, the most common late complication from CVC was a

catheter-related infection.

The bacteriological of the Laboratory tests were detected. The CVC had three a positive result, with

two gram-positive bacilli, and one had gram-negative bacilli. At the same time, the bacteriological
examination for PVC was negative. At the same time, the bacteriological examination for PVC was

negative.

6.3 Recommendations:

Based on this study's results, the researcher suggests the following recommendations about

administration, clinical practice, research studies, and educational programs for healthcare

professionals, especially nurses and students.

6.3.1 Recommendations for administration:

The finding from the current work recommended hospital manager may undertake several

types of research include the following:

 Hospitals and nurse managers must give whole advice resources require to increase

peripheral and central venous catheter care to prevent complications.

 Nursing authorization must believe nurses' awareness for peripheral and central venous

catheters care guidelines and rules and thorough observation for applicability.

6.3.2 Recommendations of Practice :

The concluded of the recent research based on the given below in clinical practice are

advised as:

1. The selected and assessed catheter insertion site should be before the catheter

introduction to lower the issues.

2. The maintenance and care of the vascular approach devices must prevent complications

most started from the interval of catheter introduction until the catheter elimination.

3. The middle venous catheter placement duration must not increased from ten days,

however the peripheral venous catheter period must not increased 72-96 hours or as an
indication.

4. Peripheral venous catheters can estimate body volume status to minimize complications

instead of central venous catheters used.

6.3.3 Recommendations for education:

 The nursing education faculty must give the learning service and practices about peripheral

and central venous catheter care based on recent evidence to all new staff as part of their

orientation program and refresh course to senior and juniors nursing staff.

 Nursing education must permit nurses to join conferences and workshops, national,

regarding peripheral and central venous catheter care.

 Learn more about measured venous enforcement from peripheral venous pressure like

central venous pressure equipment and measuring it.

 Nursing education should motivate nursing staff and students to keep reading about

evidence-based practice regarding peripheral and central venous catheters care.

 The nursing education department should activate or implement a checklist for the daily

assessment of peripheral venous catheters to follow any signs and symptoms of ICU

complications.

6.3.4Recommendations for study:

The finding of this study provides the following insights for future research include the

following:

• Further researches are needed to investigate the impact of learning interventions and

observation at peripheral and central venous catheter regarding venous pressure and

complications among critically ill patients.

 • Other related area for the modern research to study the impacts of peripheral and central

venous catheter regarding venous pressure and complications among critically ill patients.

6.4 Power of the study:

Many strengths in this research need to be acknowledged:

1. This study is the first study to compare peripheral and central venous catheter regarding

venous pressure and complications among critically ill patients at KSMC in Riyadh, KSA.

2. The study provides evidence to health care providers about the peripheral or central venous

catheters uses, which can be lead to more complications in the peripheral or central venous

catheter. Furthermore, we can use peripheral venous pressure instated of Central venous

pressure.

Summary

A venous catheter can be inserted either central or peripheral. The peripheral venous

catheters and central venous catheters are some of the equipment used for measuring peripheral

venous pressure and central venous pressure for seriously infected people. Although these

instruments are similar to uses, they have their differences.

The most common central venous catheter using is the hemodynamic monitoring method

that shows important part in managing critically ill people. Both PVC and CVCs are very

important among severely infected persons. Moreover, they are used in severe treatment camps

to monitor fluids and therapy. CVC is also used in measuring CVP, but complications are the

undesirable outcome of both PVC and CVCs.

Central venous pressure is the hydrostatic enforcement calculated in the thoracic vena cava

close to the right atrium. In severely infected people, central venous pressure judgement is
helpful to monitor the fluid authorization and know the right ventricular filling pressure. Central

venous catheter procedures have many associated complications that increase morbidity&

mortality rate, length of hospital stays, and healthcare costs.

Central venous catheter procedures have many associated complications that increase

morbidity& mortality rate, length of hospital stays, and healthcare costs. Problems related to

central venous catheters occur in nearly 15% of infected people, mainly are mechanical

complications, infectious complications, and thrombotic complications.

One-third of the deaths have done through central line-associated bloodstream infection

through 12%-25%. Moreover, various trials have been done for the completion of research and to

utilize more comfortable, and less intrusive process to approach critically ill patients' fluid

quantity status like peripheral venous catheters to measure central venous pressure from

peripheral venous pressure.

Moreover, Peripheral venous catheter is one of the widely utilized medical tools in the

world. Peripheral venous catheters is a catheter that is placed in peripheral veins and has several

therapeutic uses. Still, they result in complications such as pain, hematoma, phlebitis, and

infiltration, leakage, Extravasation, occlusion, blockage, and accidental removal. Bloodstream

disease related to peripheral venous catheters is not normal. It produces nearly 0.1% of the

intravenous or 0.5 per 1,000 catheter days.

Peripheral venous catheters associated to the introduction of methods used in this research

to the catheter. Measuring peripheral venous pressure from peripheral venous catheters is a more

uncomplicated, safer technique, cost-effective, and portion for the middle venous pressure

analyzing and therapeutic replacement, monitoring, and low morbidity issues. The bacteriological

of the Laboratory tests were detected. The CVC had three a positive result, with two gram-positive bacilli,
and one had gram-negative bacilli.

There are many patients requiring hospitals health care to receive intravenous therapy as

fluids, blood transfusions, nutrition, and other drugs like contrast media through PVC. PVC is

the more utilized catheter due to giving the approach to the vascular system in rapid way,

minimum intrusive as well as less complicated process. Establishment of peripheral line or

peripheral IV cannulation, involves introduction of a thin cylinder made of plastic into a

peripheral vein of critically ill patients. The devices are also known as venous

lines, peripheral IV, cannulas, or catheters.

Sixty patients a purposive sample who meet inclusion criteria were selected from ICUs at King

Saud Medical City using one comparative design for the study; calculate the sample size based

on the power analysis Bland -Altman formula (The Mean difference between CVP & PVP

(mmHg) = -2.4 ± 9.51).

In this research, the patient was chosen depend upon the following range: Male or female

patients between the ages of 20 and 60—patients in the ICU with a central venous catheter

(subclavian). Although infected people were omitted based on exclusion criteria, including

patients with cardiac disorders and elderly, burn patients, patients with a femoral central line,

contraindicated patients to place the peripheral intravenous catheter, skin infection at the

intended insertion site, pregnant women and children.

In this current study, The device is utilized for again observation of their recent literature

study. It has one tool I Venous catheter assessment sheet utilized for data collection and divided

into four parts:

Part I demographic and clinical data, the patient's demographic characteristics, and clinical
data. It has age, gender, marital status, diagnosis, height, level of education, weight, and body

mass index. Part II venous catheter characteristics central and peripheral venous catheter clinical

features include the date of insertion, site of insertion, size of a line, time-consuming to

placement, uses of fluoroscopy with insertion. Part III: venous pressure monitoring follows up

sheet, which includes peripheral and central venous pressure. Venous pressure affected factors

section: mechanical ventilation mode; Fio2, tidal volume, PEEP, respiratory rate and pressure

support, medication vasopressor, patient position, and vital signs (blood pressure, temperature,

mean arterial pressure, respiration rate, rate for heart beat, oxygen saturation).

Part IV: venous catheter-related complications observation checklist used to observe

central venous catheter and peripheral venous catheter complications. Central venous catheter

and peripheral venous catheter complications consist of early and late complications. This study's

approval was come from the nursing department’s ethical committee at King Abdul-Aziz

University in Jeddah and the ethical Committee at King Abdul-Aziz University hospital (KAUH)

and Research center of King Saud Medical City (KSMC) in Riyadh. Additional approval to

facilitate conducting a data collection for the study from the Research center from KSMC to

ICU. Also, authority to take out the task has been collected from the optional placement of

administration after explaining the study's reason.

The study tool's validity, the data collection tool will be tested by five experts in the

clinical-surgical field of the faculty of nursing at King Abdul Aziz University to check the

accuracy, completeness and validity of objcts. All five evaluators had an agreement on

constructing the measurement tool with "Kappa" value = 0.714 (P=0.035), and the minor

corrections suggested by a jury were adopted. The developed tool reliability was tested by

"Cronbach's alpha" (α=0.90) test. "Intra-class correlation" (ICC) of these responses was observed
to be "r =+0.90" (P=0.000), which was statistically significant with Internal consistency.

The information was resulted from the help of flow chart at the morning. Selected 60

patients for the study admitted to the severe care faculty at King Saud Medical City in Riyadh.

Additional approval to facilitate conducting a data collection for the study from the Research

center from KSMC to ICU.

Inferential statistics ANOVA and Chi-Square observation was done. An effective P<0.05

for interpretation of end product of observation of advantages. Central venous catheter and

peripheral venous catheter complications consist of early and late complications

The study results were presented in four parts: (a) Demographic and clinical data of the

study sample. (b) venous catheter characteristics. (c) venous pressure. (d) venous catheter

complications.

The study results showed that peripheral venous pressure was greater than central venous

pressure, as well as are effective by connecting. This relation is maximizes by the time within

central venous pressure and peripheral venous pressure. It was observed that the mean peripheral

venous pressure during the three days was higher than central venous pressure (11.5±2.5,

11.3±2.2, 10.8±4 vs. 10.5 ± 2.1, 10.6± 2.04, 9.9± 3.70, respectively). The results also show no

early complications from the central venous catheter and peripheral venous catheter. Regarding

late complications, the findings demonstrate that catheter occlusion was the latest complications

for peripheral venous catheter (33%), followed by Extravasation and Infiltration grade 4

(28.4%).

In comparison, the most common late complications from central venous catheters were

catheter-related infection (5%). The results detected that three central venous catheters had
positive results regarding the bacteriological examination, with two of them were gram-positive

bacilli, and one had gram-negative bacilli. At the same time, the bacteriological examination for

peripheral venous catheter was negative.

Finally, the study's finding illustrates that using a peripheral venous catheter for measuring

peripheral venous pressure as an exchange by using central venous pressure in ICU. It was

observed that the mean peripheral venous pressure during the three days was higher than central

venous pressure. Moreover, A higher mortality rate observes on central venous catheters than

peripheral venous catheters.

The majority of complication was an infection in Central venous catheters While peripheral

venous catheter had no infection. Peripheral venous catheters have higher complications, a rate

like occlusion of the catheter while zero in central venous catheters. Therefore, the researchers

recommend using cure tools for the maintenance of introduction of catheter and until catheter

elimination to inhibit complications. The assessment of the introduction site must be daily for

any points and symptoms of issues.

Summary

A venous catheter can be inserted either central or peripheral. The peripheral venous

catheters and central venous catheters are some of the equipment used for measuring peripheral

venous pressure and central venous pressure for critically ill patients. Although these instruments

are similar to uses, they have their differences.

The most common central venous catheter using is the hemodynamic monitoring method
that plays an essential role in managing critically ill patients. The information was resulted from

the help of flow chart at the morning. Selected 60 patients for the study admitted to the severe

care faculty at King Saud Medical City in Riyadh. Additional approval to facilitate conducting a

data collection for the study from the Research center from KSMC to ICU.

Central venous pressure is the hydrostatic pressure calculated in the thoracic vena cava

close to the right atrium. In severely infected people, central venous pressure observing is helpful

to monitor fluid authorization and know the right ventricular filling pressure.

A peripheral venous catheter (PVC) is a catheter placed in the vascular during therapy. It

introduced using a needle, such as that used to draw blood. It is the most used type of catheter in

medicine, and in most cases, it is inserted PVC in the hand or arm vein.

Central venous catheter procedures have many associated complications that increase

morbidity& mortality rate, length of hospital stays, and healthcare costs. Problems related to

central venous catheters occur in nearly 15% of infected people, mainly are mechanical

complications, infectious complications, and thrombotic complications. Central venous pressure

can be influenced by numerous conditions including technical and physiologic factors.

Moreover, several efforts have been made to devise a simple, more comfortable, and

minimally invasive procedure to assess critically ill patients' fluid volume status like peripheral

venous catheters to measure central venous pressure from peripheral venous pressure.

Moreover, Peripheral venous catheter is one of the most frequently used medical devices in

the world. Peripheral venous catheters is a catheter that is placed in peripheral veins and has

several therapeutic uses. Still, they result in complications such as pain, hematoma, phlebitis, and

infiltration, leakage, extravasation, occlusion, blockage, and accidental removal. Bloodstream

issues related to peripheral venous catheters is not common. It produces in nearly 0.1% of the

intravenous or 0.5 per 1,000 catheter days.

Measuring peripheral venous pressure from peripheral venous catheters is a more

uncomplicated, safer technique, cost-effective, and substitute for central venous pressure

observation and therapeutic replacement, monitoring, and low morbidity complications.

This research was to compare peripheral versus central venous catheter pressure and

complications among critically ill patients.

Nowadays, data were collected over ten months from August 2018 to June 2019. Sixty

patients a purposive sample who meet inclusion criteria were selected from ICUs at King Saud

Medical City using one comparative design for the research; calculate the sample quantity based

on the power examining Bland -Altman formula (The Mean difference between CVP & PVP

(mmHg) = -2.4 ± 9.51).

In this research, the patient was chosen depend on the following range: Male or female

patients between the ages of 20 and 60—patients in the ICU with a central venous catheter

(subclavian vein). Although infected people were omitted based on exclusion criteria, including

patients with cardiac disorders and elderly, burn patients, patients with a femoral central line,

contraindicated patients to place the peripheral intravenous catheter, skin infection at the

intended insertion site, pregnant women and children.

In this current study, The tool was used after researching their recent literature review. It

contained one tool I Venous catheter assessment sheet utilized for data collection and divided

into four parts:

Part I demographic and clinical data, the patient's demographic characteristics, and clinical
data. It has age, gender, marital point, diagnosis, level of education, height, weight, and body

mass index. Part II venous catheter characteristics central and peripheral venous catheter clinical

features include the date of insertion, site of insertion, size of a line, time-consuming to

placement, uses of fluoroscopy with insertion. Part III: venous pressure monitoring follows up

sheet, which includes peripheral and central venous pressure. Venous pressure affected factors

section: mechanical ventilation mode; Fio2, tidal volume, PEEP, respiratory rate and pressure

support, medication vasopressor, patient position, and vital signs (rate of respiration, rate of heart

beat, oxygen saturation, blood pressure, average arterial pressure and temperature).

Part IV: venous catheter-related complications observation checklist used to observe

central venous catheter and peripheral venous catheter complications. Central venous catheter

and peripheral venous catheter complications consist of early and late complications. This study's

approval was taken from the ethical committee of field of nursing at King Abdul-Aziz University

in Jeddah and the ethical Committee at King Abdul-Aziz University hospital (KAUH) and

Research center of King Saud Medical City (KSMC) in Riyadh. Additional approval to facilitate

conducting a data collection for the study from the Research center from KSMC to ICU. Also,

authorization to carry out the task has taken from options setting's administration after explaining

the study's reason.

The study tool's validity, the data collection tool will be tested by five researchers in the

clinical-surgical field Faculty of nursing at King Abdul Aziz University to check the accuracy of

data, and the end product of objects. All five evaluators had an agreement on constructing the

measurement tool with "Kappa" value = 0.714 (P=0.035), and the minor corrections suggested

by a jury were adopted. The produced instruments reliability was checked by "Cronbach's alpha"

(α=0.90) test. "Intra-class correlation" (ICC) of these responses was observed to be "r =+0.90"
(P=0.000), which was statistically significant with Internal consistency.

Data was calculated through flow chart and collected at morning. Selected 60 patients for

the study admitted to the intensive care department at King Saud Medical City in Riyadh. The

researcher observed the data utilizing SPSS version 24.

Various tests were done to calculate data such as mean, range as well as standard deviation.

A t-test was performed to measure the qualitative data by relating two averages. Inferential

statistics ANOVA and Chi-Square test was done and measured and adopted a P<0.05 for tests of

significance. We also made Bland‐Altman plots by comparing PVP and CVP plotted against the

two measurements' mean. To envisage the correlation the regression equation formula was used

by the researcher.

The study results were presented in four parts: (a) Demographic and clinical data of the

study sample. (b) venous catheter characteristics. (c) venous pressure. (d) venous catheter

complications.

It was observed that the mean peripheral venous pressure during the three days was higher than

central venous pressure (11.5±2.5, 11.3±2.2, 10.8±4 vs. 10.5 ± 2.1, 10.6± 2.04, 9.9± 3.70,

respectively). The results also show no early complications from the central venous catheter as

well as peripheral venous catheter. Regarding late complications, the findings demonstrate that

catheter occlusion was the latest complications for peripheral venous catheter (33%), followed

by Extravasation and Infiltration grade 4 (28.4%).

In comparison, the most common late complications from central venous catheters were

catheter-related infection (5%). The results detected that three central venous catheters had

positive results regarding the bacteriological examination, with two of them were gram-positive
bacilli, and one had gram-negative bacilli. At the same time, the bacteriological examination for

peripheral venous catheter was negative.

Finally, the study's finding illustrates that using a peripheral venous catheter for measuring

peripheral venous pressure as a replacement to use middle venous pressure in ICU. It was

observed that the mean peripheral venous pressure during the three days was higher than central

venous pressure. Moreover, The higher mortality rate observe on central venous catheters than

peripheral venous catheters.

The majority of complication was an infection in Central venous catheters while peripheral

venous catheter had no infection. peripheral venous catheter have higher complications a rate

like occlusion of the catheter while zero in central venous catheters. Therefore, the researchers

recommend the beginning using treatment and adjustment of vascular approach devices by

introducing the catheter and elimination to approach the symptoms for the infections. It was

observed that the mean peripheral venous pressure during the three days was higher than central

venous pressure.