https://doi.org/10.15218/ejnm.2022.12 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2022 Original Article Monitoring Peripheral Intravenous Catheters Complications in Pediatric Patients in Erbil City/Iraq ABSTRACT INTRODUCTION Peripheral intravenous (IV) catheterization (PIVC) is one of the most commonly used procedures in hospitalized children [1]. Each year worldwide, over a billion PIVCs are inserted in hospitalized children [2]. It is also calculated that above 80% of pa- tients undergo this procedure across hos- pitalization [1, 3]. The procedure is applied Backgrounds and Objectives: Although most problems of peripheral intravenous cathe- terization are inconsiderable and easily treated, some are dangerous and require rapid management. This study aimed to explore peripheral intravenous catheter-related com- plications and the quality of nursing care for dressing sites of peripheral intravenous catheterization among the pediatric population. Methods: The study was conducted at Raparin Teaching Hospital for Children inpatient units in Erbil City/Iraq, using an observational study design. A purposive sample from 296 hospitalized children with peripheral intravenous catheterization was chosen for this study. The data was collected using a special check List (PIVC-miniQ) developed for checking the signs and symptoms and the quality of care for the catheter insertion site. Furthermore, the obtained data on peripheral intravenous catheterization problems was evaluated for exploring grades of phlebitis using the Phlebitis Scale developed by the Infusion Nursing Society in 2011. The data was processed and analyzed using SPSS using descriptive statistical analysis (frequency, percentage) and inferential statistical tests (Chi-squared, contingency coefficient). The probability value of ≤0.05 was regarded as statistically significant. Results: Most (82.4%) of patients were recruited in the emergency unit, with the highest percentage (36.8%) were toddlers. More than two-thirds (72.3%) of participants were assessed within the first peripheral catheter insertion. Regarding overall grades of pa- tients’ peripheral intravenous catheterization complications (PIVC), less than a quarter (21.6%) were within the first grade, indicating being at risk for complications, and 6.8% were within the second grade, indicating slight phlebitis. Regarding the nursing care for PIVC site care, 62.5% of participants received fair care, and 22.3% received poor care. Conclusions: A quarter of observed children were at risk for having phlebitis and less than ten percent had slight phlebitis. About a quarter of patients received poor nursing care for the catheter insertion site. Most participants have not a documentation of pe- ripheral intravenous catheter insertion date on the dressing and on the patient's chart. Keywords: Quality of Care; Peripheral Intravenous Catheters; Complications. Norhan Zeki Shaker; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. (Correspondence: norhan.shaker@hmu.edu.krd ) 105 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Received: 25/05/2022 Accepted: 08/08/2022 Published: 30/11/2022 mailto:norhan.shaker@hmu.edu.krd https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.12 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2022 Original Article to assist in various managements, such as hydro-electrolytic imbalances, blood loss- es, and dysfunctions of multiple organs [4]. It can also be injected in some patients prophylactically before procedures and in unsteady patients for crisis use [5,3]. Although PIVC is common, the risk of com- plications is high [6] and sometimes can lead to local and systemic complications. These complications include hematoma, occlusion, phlebitis, thrombophlebitis, infil- tration, leakage, pain, edema and local in- fection [7,8]. While most problems are mi- nor and manageable, some can be life- threatening and necessitate immediate attention. The most frequently seen conse- quences are infections and mechanical is- sues such as occlusion, leakage, and dis- lodgment [9].Over a person's lifetime, par- ticularly if hospitalization starts in child- hood, informed and patient-focused IV care is vital [10]. Most of the post-insertion IV care and maintenance is handled by nurses, who frequently perform PIVC inser- tions [11]. As a result, nurses are crucial in monitoring and preventing PIVC problems and failure. The global trend of PIVC inser- tion studies and experiences are more than conservation. When maintenance of PIVC have important role in confirming catheter patency for many days [14]. The nurse must document using a standardized scale, the signs and symptoms of phlebitis, the interventions used, and the patient's reac- tion to treatment in the patient's charts. International data on prevalence and man- agement of PIVCs are lacking, although PIVC use is highly evident in hospitalized patients internationally [15]. In addition, there are no published studies in Iraq on PIVC among pediatric patients. The nation- al and international quality agency recom- mended strategies for prevention of PIVC complications including designated trained personnel to insert and maintain PIVCs, surveillance, hand hygiene, proper use of aseptic non-touch technique and recom- mendations regarding catheter site care and early removal when no longer neces- sary [16]. This study aimed to explore pe- ripheral intravenous catheter-related com- plications and nursing care for the dressing at the site of PIVC among the pediatric population in Erbil city and to determine the association between grades of PIVC complication and levels of nursing care for the PIVC site, inserted PIVC number, and children age. An observational design was used for con- ducting this study in 2022 at inpatient units (emergency, surgical, and neonatal care) of Riparian Teaching Hospital for Chil- dren (RTHCH) in Erbil city Kurdistan region, Iraq. The sample size estimation in this study has been calculated through this for- mula: n=Z2 P (1-P)/d2 [22,24]. When n is representing sample size, Z is the statistic corresponding to level of confidence, P is expected proportion in population (expected prevalence or based on previous studies), and d is precision or absolute er- ror. The level of confidence is 95%, preci- sion is 5%, and expected prevalence is 40 %. A sample size of 303 children with PIVC was recruited. The sample size was 296 after seven children were discharged be- fore 24 hours of hospitalization. The sam- ple included hospitalized children who re- quired at least one PIVC in RTHCH during the data collection period. Patients re- ferred from other hospitals with previously inserted PIVC were excluded from sample. Data were collected between April and July 2022. The researcher preformed the sam- ple selection during routine morning visits. Each patient was given a case number, and the PIVC followed after 24 hours to assess the complications and the failure. Each pa- tient needs ten to fifteen minutes for tak- ing the relevant information. Nurses were 106 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. METHODS https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.12 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2022 Original Article inferential data. The results were consid- ered statistically significant at p-value ≤0.05. Table 1 shows that the majority (82.4%) of participants were recruited from the emer- gency unit. The highest percentage (36.8%) were toddlers, and more than half (58.4) of the patients were male. More than two- thirds (72.3%) of participants were as- sessed within the first PIVC insertion, and more than three quarter (76.6) of inserted PIVCs size was 24 gauge of yellow color. Concerning the site of PIVC insertion, 64.2% of children had the cannula in their hands, and 64.2% on the right side. Re- garding the indication of insertion, almost all the children (99.3%) used it for medica- tion or receiving fluid. Table 2 reveals just above a quarter (26%) of patients had pain or tenderness, 26.7% had redness at the site of insertion, 67.6% complained of warmth at the site of insertion, 26.7% had swelling >1cm from the insertion site, 67.6% had hard vein beyond IV tip when palpated, and 21.3%had partial/complete dislodgement. Regarding IV dressing and connection, 66.6% had loose or lifting edg- es of the tape, 98.0% did not have PIVC insertion date documented on dressing, and 73% lack the date of PIVC insertion in the patient's chart. Table 3 shows the overall grades of PIVC complication. The highest percentage (71.6%) of participants were within grade zero indicating no com- plications, 21.6% were within the first grade indicating being at risk for complica- tions, and 6.8% were within second grade which indicates having slight phlebitis. Ta- ble 4 displays statistically significant associ- ations between grades of PIVC complica- tion and levels of nursing care for the PIVC site (p=0.04), and no statistically significant association with inserted PIVC number (p=0.24), and children’s age (p=0.183). not informed about the study. After a re- view of many previous articles, the re- searcher decided to use Peripheral Intrave- nous Catheter mini Questionnaire (PIVC- mini Q) https://doi.org/10.1186/s12913- 019-4497-z:, this tool is developed by Hovik et al., and tested for reliability in measuring rates of PIVC problems. The tool included four sections. The first sections reveals phlebitis related signs and symp- toms at/around insertion site (9 items: PIVC pain or tenderness, redness, swelling, warmth, purulence, hardness of tissue, streak/red line along vein, palpable hard vein beyond IV tip, and partial/complete dislodgement). The second section reveals PIVC dressing, and IV connection related to PIVC failure (5 items: dressing soiled with blood or fluids, loose or lifting dressing edges, dressing fixed with tape only, blood in the line, and absence of insertion date on PIVC dressing). The third area consisted of 1 item, lack of documentation of PIVC in patient chart. The fourth section consisted of 1 item, indication for PIVC use. Each problem that accounts for 1 point. Overll score (0-16) reflects PIVC quality [17]. Furthermore, the obtained data on PIVC problems was evaluated for exploring grades of phlebitis using the Phlebitis Scale developed by the Infusion Nursing Society in 2011 that has already obtained validity and inter-rater reliability [15]. The official permission to conduct the study was ob- tained from the Erbil General Directorate of Health. The College of Nursing/Hawler Medical University research ethics com- mittee evaluated and approved the study protocol. Verbal informed consent for par- ticipation in the study was obtained from all mothers of children. The data were ana- lyzed using the statistical package for social science (SPSS, Version 23). Statistical tests frequency and percentage were used for categorical data. Chi-squared and nominal contingency coefficient were used for 107 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. RESULTS https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.12 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2022 Original Article 108 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 1: Characteristics of Children with PIVC at RCHTH (296) Item Category F. (%) Patient unit Emergency 244 (82.4) NCU 14 (8.1) Surgical 28 (9.5) Age/months Newborn < 1 m 13 (4.4) Infant 1-<12 m 91 (30.7) Toddler 12 -<36 m 109 (36.8) Preschool 36- < 60 m 83 (28) Gender Male 173 (58.4) Female 123 (41.6) Number of inserted PIVC in current hospitalization 1st 214 (72.3) 2nd 46 (15.5) ≤ 3rd 36 (9.2) Insertion Environment Emergency unit 234 (79) Surgical unit 33 (11.2) NCU 29 (9.8) Insertion site Right 184 (62.2) Left 112 (37.8) PIVC size (gauge) 24 G yellow 227 (76.7) 22 G Blue 69 (23.3) PIVC site Hand 190 (64.2) Wrist
 38 (12.8) Forearm 11 (3.7) Antecubital fossa 12 (4.1) Foot 42 (14.2) Head and neck 1 (0.3) Upper arm 2 (0.7) Reason for PIVC insertion Medication or fluid 294 (99.3) Unknown indication 2 (0.7) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.12 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2022 Original Article 109 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 2: Distribution of participants (n=296) children according to the assessed signs and symptom of PIVCs complications Signs and symptoms NO YES F. (%) F. (%) PIVC site assessment Pain/tenderness on palpitation 219 (74) 77 (26) Redness >1 cm from insertion site 228 (77) 68 (23) Swelling >1 cm from insertion site 217 (73.3) 79 (26.7) Warmth 96 (32.4) 200 (67.6) Purulence 296 (100) 0 (0) Streak/ red line along vein 290 (98) 6 (2) Induration/ hardness of tissues >1 cm 240 (81.1) 56 (18.9) Palpable hard vein beyond IV tip 96 (32.4) 200 (67.6) Partial/ complete dislodgement PIVC 233 (78.7) 63 (21.3) IV dressing and connection assessment Soiled with blood or fluids 273 (92.2) 23 (7.8) Loose or lifting edges 99 (33.4) 197 (66.6) Tape only 149 (50.3) 147 (49.7) Blood in line 167 (56.4) 129 (43.6) PIVC insertion date not documented on dressing 6 (2) 290 (98) Indication for PIVC Medication and Fluid 2 (0.7) 294 (99.3) Documentation Date of PIVC insertion In patient chart is lacking 80 (27) 216 (73) Table 3: Distribution of participants among the levels of PIVC complications Grades of PIVC complication F (%) Grade 0 (without clinical signs; healthy) 212 (71.6) Grade 1 (presence of erythema on the insertion of the catheter with or without pain; at risk for complication) 64 (21.6) Grade 2 (pain at the site of insertion of the catheter with erythema and/or edema; slight phlebitis). 20 (6.8) Total 296 (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.12 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2022 Original Article The current study was designed to explore peripheral intravenous catheter-related complications through assessment of the signs and symptoms related to PIVC com- plications among purposive sample of 296 children with PIVCs at Riparian Teaching Hospital for Children in Erbil city. The cur- rent study found that majority of partici- pating children were hospitalized in the emergency unit, and the highest percent- age of them were toddlers. The mean age was 23.08 ± 19.25 weeks and 58.4% were male. Another researcher conducted a study with 98 children and found, the mean age was 5.2 ± 4.7 years and the 50% of them were of the male gender [3]. In recent study most of patients were as- sessed within the first PIVC insertion, and lowest percentage of them were within third or more inserted PIVCs. Unluckily, after the PIVC inserted more than 50% of these will fail before finishing the treat- ment [16].The Infusion Nursing Society has abolished the practice of replacing cathe- ters after every 72 hours and suggests that catheters should only be removed or re- placed when they are no more required or 110 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 4: Association between grades of complication with quality of nursing care, inserted PIVC number, and child’s age Variables Grade 0 Grade 1 Grade 2 Total P-Value Quality of nursing care for the PIVC site Good 36 7 2 45 0.04 S Fair 134 37 14 185 Poor 42 20 4 66 Total 212 64 20 296 Inserted PIVC number 1st 162 41 7 210 0.24 NS 2nd 32 16 6 54 3rd &> 18 7 7 32 Total 212 64 20 296 Child age /month < 1 6 4 3 13 0.183 NS 1-<12 62 22 7 91 12-<36 86 20 3 109 36- 60 58 18 7 83 Total 212 64 20 296 Figure 1 : shows levels of nursing care for PIVC site care. The highest percentage (62.5%) of participants were received fair care at the site of PIVC dressing, and 22.3% received poor care. Figure 1: Levels of nursing care for the PIVC site dressing care DISCUSSION https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.12 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2022 Original Article observed children were within first grade having erythema on the catheter insertion site with or without pain indicating they were at risk for complication. This finding is similar with another studying showing the most frequent symptom at the inser- tion site was pain and tenderness [18]. The minority of children was within second grade having pain at the catheter insertion site with erythema and/or edema indi- cating slight phlebitis. One study reports complications among 111(51.9%) of PIVC subjects [3] and another stated the report- ed rates of phlebitis at 13%, extravasation at 28%, and bacterial colonization at 11% [19]. Regarding nursing care for the PIVC site, the current study finding shows that about a quarter of patients were suffering from poor nursing care for the PIVC dress- ing site. This finding is consistent with an- other study which found that PIVC compli- cations were common in pediatric depart- ments and are often associated with mis- use of device [3].There was a statistically significant association between grades of PIVC complication and levels of nursing care for the PIVC site and inserted PIVC number. There was no statistically signifi- cant association between grads of PIVC complication and children’s age and site of PIVC insertion. In contrast, another stated that age, hospitalization in surgery unit, insertion in antecubital vein have role in development of phlebitis study [20]. Re- sults from another study revealed that younger ages are risk factors for PIVC com- plications in children [21]. A quarter of observed children were at risk for having phlebitis and less than ten per- cent had slight phlebitis. About a quarter of patients received poor nursing care for the PIVC insertion site, which leads to PIVC complications. Most participants did not have the PIVC insertion date documented have impaired function [15]. The incidence of PIVC failure in pediatric patients is still high, despite the global and vital role in health care. A systematic review of 32 studies confirmed that an average of 34% of PIVC in pediatric patients fail before the completion of the therapies, with infiltra- tion as the most frequent complication [14].Moreover, in the current study, the majority of participants have the PIVC in- sertion for receiving medication or fluid, as mentioned in another study where 67.8% of PIVC insertions were used for drug ad- ministration [3].Regarding the signs and symptoms of PIVC complications, the cur- rent study found more than a quarter of the monitored children were complaining of pain and redness at the site of PIVC site. This finding agrees with a study done by Zempsky who found that PIVC is a primary cause of procedure related pain in the hospital [18]. The current study revealed that two-thirds of the participants had a hard vein beyond the IV tip when palpat- ed. Monreal et al., listed the criteria of phlebitis which includes symptoms of pain, erythema, swelling, and palpable throm- bosis of the cannulated vein [23].Regarding IV dressing and connection assessment, the current study reveals that more than two-thirds of PIVC had loose or lifting edges of the tape. In addition,, many participants have no PIVC insertion date documented on the dressing, and most of them lack documentation of the date of PIVC insertion in the patient's chart. Simi- larly, another study found that the most dominant overall problem was lack of doc- umentation of PIVC (26.8%) [17]. Concern- ing the levels of PIVC complication which explored the grades of phlebitis using the Phlebitis Scale developed by the Infusion Nursing Society [15], the results reveal that most of the participants were free from complications (grade zero). At the same time, less than a quarter of 111 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. CONCLUSION https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.12 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2022 Original Article in ill neonates. Neonatal Network J. 2001; 20(5), 33–38. [7] Danski MTR, Oliveira GLR, Johann DA, Ped- rolo E, Vayego SA. Incidence of local compli- cations in peripheral venous catheters and associated risk factors. Acta Paul Enferm. 2015; 28(6):517-23. DOI: 10.1590/1982- 0194201500087. [8] Batista OMA, Moreira RF, Sousa AFL, Moura MEB, Andrade D, Madeira MZA. Local com- plications of peripheral intravenous therapy and associated factors Rev Cubana Enferm, 2018; 34(3). Available from: http:// www.revenfermeria.sld.cu/index.php/enf/ article/view/1246/374. [9] Pettit J, 
 Wyckoff M, Peripherally Inserted Central Catheters: Guideline for Practice, National Association of Neonatal Nurses. U.S. Second edition. 2007; ISBN 978-0- 9787636-3-3, Available from: www. NANN.org [10] Hallam C, Weston V, Denton A, Hill S, Boden- ham A, Dunn H, & et al. Development of the UK vessel health and preservation (VHP) framework: A multi-organizational collabo- rative. Journal of Infection Prevention. 2016; 17(2), 65–72. https:// doi.org/10.1177/1757177415624752. [11] Alexandrou E, Ray-Barruel G, Carr P J, Frost S, Inwood, S, Higgins N, and et al. Use of short peripheral intravenous catheters: Characteristics, management, and outcomes worldwide. Journal of Hospital Medicine. 2018; 13(5). available from: https:// doi.org/10. 12788/jhm.3039. [12] Almeida TJC, Miranda JOF, Santos LM, Santa- na RCB, Camargo CL, Nascimento Sobrinho CL. Peripheral venous accesses in hospital- ized children: a photographic study. Journal of Nursing UFPE on line. 2016; 10(2): 701-7. [13] Costa AB da, Medeiros LNB de, Neves AD, Barbosa MMB, Souza e Silva RGS, Siqueira RM de. Nursing technicians and peripheral venous catheterization in pediatrics. Journal of Nursing UFPE on line. 2020; 14: e244663 DOI: https://doi.org/10.5205/1981- 8963.2020.244663. [14] Indarwati F, Munday J, Keogh S. Nurse knowledge and confidence on peripheral intravenous catheter insertion and mainte- nance in pediatric patients: A multicenter cross-sectional study, Journal of Pediatric Nursing. 2022; 62: 10–16. PMID: 34798582 DOI: 10.1016/j.pedn.2021.11.007 on the dressing and in their medical chart. Nurses should give more im- portance to the PIVC site dressing and documentation. Further, studies need in this field for exploring the quality of post- PIVC insertion care, and the risk factors of PIVC complication among pediatric patients. The author would like to acknowledge the collaboration of all children and mothers at RTHCH in Erbil city who par- ticipated in the study, also special thanks for Mr. Malik F. Saber a graduated nurse for contribution in data collection. Nothing to declare. [1] Waitt C, Waitt P, Pirmohamed M. Intrave- nous therapy. Postgraduate Medical Jour- nal. 2004; 80(939): 1–6. [2] Alexandrou E., Ray-Barruel G., Carr P. J., Frost S., Inwood Sh., Higgins N., Alberto L., and et al , International prevalence of the use of peripheral intravenous catheters Journal of Hospital Medicine. 2015;10(8): 560-3. [3] Abdelaziz R B, Hafsi H, Hajji H, Boudabous H A, Chehida A B, Mrabet A Kh, and et al, peripheral venous catheter complications in children: predisposing factors in a multi- center prospective cohort study, Bio Medi- cal Centre Pediatrics. 2017; 17:208 DOI 10.1186/s12887-017-0965-y. [4] Bolcato M, Russo M, Donadello D, Rodri- guez D, Aprile A. 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