EFFECTIVENESS OF MOIST ICE PACK VERSUS WARM GLYCERINE MAGNESIUM SULPHATE APPLICATION IN
REDUCTION OF PAIN AND INFLAMMATION AMONG PATIENTS WITH IV INFUSION AT GOVERNMENT HOSPITAL,
THUCKALAY, KANYAKUMARI DISTRICT.
Dissertation submitted to
THE TAMILNADU DR. M.G.R MEDICAL UNIVERSITY CHENNAI
In partial fulfillment of requirement for the degree of
MASTER OF SCIENCE IN NURSING
APRIL- 2012
EFFECTIVENESS OF MOIST ICE PACK VERSUS WARM GLYCERINE MAGNESIUM SULPHATE APPLICATION IN
REDUCTION OF PAIN AND INFLAMMATION AMONG PATIENTS WITH IV INFUSION AT GOVERNMENT HOSPITAL,
THUCKALAY, KANYAKUMARI DISTRICT.
BY
Mr. RAJAN P V
Dissertation submitted to
THE TAMILNADU DR. M.G.R MEDICAL UNIVERSITY CHENNAI
In partial fulfillment of requirement for the degree of
MASTER OF SCIENCE IN NURSING
APRIL- 2012
SRI. K. RAMACHANDRAN NAIDU COLLEGE OF NURSING
Affiliated To Tamil Nadu Dr. M.G.R. Medical University, K.R.Naidu Nagar, Sankarankovil, Tirunelveli District,
Tamil Nadu.
CERTIFICATE
This is a bonafide work of Mr. RAJAN P.V, M.Sc. (N).,(2010 – 2012 Batch) II Year student of Sri. K. Ramachandran Naidu College of Nursing, Sankarankovil, Pin code: 627 753. Submitted in partial fulfillment for the Degree of Master of Science in Nursing, Under Tamil Nadu Dr.M.G.R. Medical University, Chennai.
SIGNATURE:
___________________________Prof. (Mrs). N. Saraswathi, M.Sc. (N).,Ph.D (N).,
Principal, Head of the Department in Pediatric Nursing, Sri. K. Ramachandran Naidu College of Nursing, Sankarankovil, Tirunelveli-627 753
TamilNadu.
COLLEGE SEAL
A COMPARITIVE STUDY TO ASSESS THE EFFECTIVENESS OF MOIST ICE PACK VERSUS WARM GLYCERINE MAGNESIUM SULPHATE APPLICATION IN REDUCTION OF PAIN AND INFLAMMATION AMONG PATIENTS WITH IV INFUSION AT GOVERNMENT HOSPITAL, THUCKALAY, KANYAKUMARI DISTRICT.
APPROVED BY DISSERTATION COMMITTEE ON
PROFESSOR IN NURSING RESEARCH Prof.(Mrs).N. SARASWATHI,M.Sc (N),PhD Principal and Head of Department in Pediatric Nursing Sri. K. Ramachandran Naidu college of Nursing Sankarankovil (Tk), Tirunelveli (Dist).
CLINICAL SPECIALITY CO – GUIDE Mrs.V. Jaya, M.Sc(N)
Lecturer, Medical-Surgical Nursing Department, Sri. K. Ramachandran Naidu college of Nursing Sankarankovil (Tk), Tirunelveli (Dist).
MEDICAL EXPERT
Dr. V. ANTONY DAVID, MD Consultant Physician
Professor of Medicine,
KanyakumariGovt Medical College &Hospital, Asaripallam, Nagercoil.
Dissertation submitted to
THE TAMILNADU DR. M.G.R MEDICAL UNIVERSITY CHENNAI
In partial fulfillment of requirement for the degree of
MASTER OF SCIENCE IN NURSING
APRIL- 2012
ACKNOWLEDGEMENT
At the outset, it is my privilege to thank the Chairman andManaging Trustee, Sri. K. Ramachandran Naidu college of Nursing for giving me a chance to enrich my professional life.
My heartfelt gratitude to Prof. Mrs. N. Saraswathi, M.Sc(N), Ph.D, Principal, Sri. K. RamachandranNaidu college of Nursing for her mentorship by guidance, invaluable suggestions, and role modeling in the field of nursing research.
I am extremely grateful to my co-guide Mrs.V.Jaya,M.Sc(N), lecturer,Department of Medical Surgical Nursing, Sri. K. Ramanchandran Naidu college of Nursing for her effects in conceptualizing the study.
I am greatly indebted to Mrs.J. Sathya,MSc(N), Lecturer, Department of Medical Surgical Nursing, Sri. K. Ramanchandran Naidu college of Nursing for constant source of inspiration and encouragement, which was a key for the successful accomplishment of the study.
I acknowledge my genuine gratitude to Dr. V. Antony David, MD Consultant Physician, Professor of Medicine and Chief Civil Surgeon, Kanyakumari Govt.
Medical College and Hospital, Asaripallam, Nagercoil for his guidance and help extended during the course of the study.
I acknowledge my sincere thanks to Dr. K. Joseph Raj, Statistician, for his suggestions and guidance in data analysis.
My sincere thanks to Dr. ArulmozhiDuraippa, MBBS, DGO, Joint Director of Health services, Nagercoil, for granting the permission to conduct the study.
I express my heartfelt gratitude to the Matron, Staff nurses and all the patients of Govt. District Head Quarters Hospital, Thuckalay, Kanyakumari District who extended their cooperation for the study.
Immense thanks to all the inpatients with IV infusion site inflammation who agreed to participate and make this study success.
An ovation of thanks to Mr. J. Suresh,Hitech systems and Browsing for his patience, understanding and tireless effort in the timely completion of the manuscript.
I am thankful to the librarians of Sr. K. Ramachandran Naidu College of Nursing and TamilNadu Dr. M.G.R. Medical University for their cooperation in collecting the related literature for the study.
I will forever remain thankful to my parents Mr. P. Velukkannu and Mrs. T.
Rosammal without whom it would have been impossible for me to enter this profession and pursue this study.
I am deeply indebted to my brother Mr. V. Alwin, Mr. V. Arivazhagan, my friends Mr. P. Syed Khan, Mr. Edmund and my family members for their ever ready nature of unconditional support, encouragement and prayer which enabled me to complete study with renewed energy and vigour.
Above all I thank God Almighty for sustaining me with his grace every moment of my life and especially for the successful completion of this study.
TABLE OF CONTENTS
CHAPTERS TITLE PAGE
No.
I INTRODUCTION 1 – 13
Background of the study 1
Need for the Study 4
Statement of the problem 8
Objectives of the study 8
Hypotheses 9
Operational definitions 9
Assumptions 11 Delimitation 11
Projected Outcome 11
Conceptual frame work 12
II REVIEW OF LITERATURE 14 - 34
Review of related literature 14
III RESEARCH METHODOLOGY 35 - 44
Research design 35
Variables 36
Setting of the study 36
Population 36
Sample 37
Sample size 37
Sampling technique 37
CHAPTERS TITLE PAGE
No.
Criteria for sample selection 38
Development and description of the tool 38
Content validity 40
Reliability of the tool 40
Pilot study 40
Data collection procedure 42
Plan for data analysis 43
Protection of Human subjects 43
Summary 44 IV ANALYSIS AND INTERPRETATION OF
DATA 45 - 84
Organization of data 45
Presentation of data 47
V DISCUSSION 85 - 91
VI SUMMARY, CONCLUSION,
IMPLICATIONS, LIMITATIONS AND RECOMMENDATIONS
92 - 99
BIBLIOGRAPHY APPENDICES
LIST OF TABLES
TABLE
NO. TITILE PAGE NO.
1 (a) Frequency and percentage distribution of demographic variables of patients with IV infusion site inflammation with respect to age, sex, marital status, education, occupation and number of days of hospitalization.
47
1 (b) Frequency and percentage distribution of patients according to details of IV therapy with respect to disease condition, location, type of the IV cannnula, size of IV cannula, duration of therapy and rate of flow.
50
2 Frequency and percentage distribution of pre test level of pain in IV infusion site among Group A and Group B.
55
3 Frequency and percentage distribution of pre test level of inflammation in the IV infusion site among Group A and Group B.
57
4 Mean and standard deviation of pain and inflammation of group A and Group B with IV infusion site before the moist ice pack and warm glycerin magnesium sulphate application
59
5 Unpaired‘t’ test value showing the pre test level of pain for Group A and Group B with IV infusion site.
60
6 Unpaired‘t’ test value showing the pre test level of inflammation for group A and group B with IV infusion site.
61
7 Frequency and percentage distribution of post test level of pain in IV infusion site of Group A and Group B.
62
8 Frequency and percentage distribution of post test level of inflammation in the IV infusion site among Group A and Group B.
63
9 Mean and Standard Deviation of pain and inflammation of Group A and Group B patients with IV infusion site
66
after moist ice pack and warm glycerin magnesium sulphate application respectively.
10 Unpaired‘t’ test value showing the post test level of pain for group A and group B with IV infusion site.
67
11 Unpaired‘t’ test value showing the post test level of inflammation for group A and group B with IV infusion site.
69
12 Distribution of mean and Standard Deviation of pain and inflammation of group A with IV infusion site.
71
13 Distribution of mean and Standard Deviation of pain and inflammation of group B with IV infusion site.
72
14 Correlation between post test level of pain with inflammation for group A and group B with IV infusion site.
73
15 (a) Association of post test level of pain of group A with age, sex, marital status, education and location
75
15(b) Association of post test level of pain of group A with type, rate, duration and disease condition
76
16 (a) Association of post test level of pain of group B with age, sex, marital status, education and location.
77
16 (b) Association of post test level of pain of group B with type, rate, duration and disease condition.
78
17 (a) Association of post test level of inflammation of Group A with age, sex, marital status, education and location
79
17 (b) Association of post testlevel of inflammation of group A with type, rate, duration and disease condition
81
18 (a) Association of post test level of inflammation of group B with age, sex, marital status, education and location
82
18 (b) Association of post testlevel of inflammation of group B with type, rate, duration and disease condition
83
LIST OF FIGURES
FIGURE TITLE PAGE 1 Therapeutic Effect of warm and cold application in
reduction of pain and inflammation
7 2 Conceptual framework based on Orlando deliberative –
interactive model
13(a) 3 Schematic representation of research design 40 4 Schematic representation of research methodology 49(a) 5 Distribution of sample according to age in Group A 58 6 Distribution of sample according to age in Group B 58 7 Distribution of sample according to duration of IV therapy
in Group A.
59
8 Distribution of sample according to duration of IV therapy in Group B.
59
9 Percentage distribution of pre test level of pain on IV infusion site in Group A and Group B.
61
10 Percentage distribution of pre test level of inflammation on IV infusion site in Group A and Group B.
63
11 Percentage distribution of post test level of pain on IV infusion site in Group A and Group B.
69
12 Percentage distribution of post test level of inflammation on IV infusion site in Group A and Group B.
70
13 Comparison of post test level of pain of IV infusion site in Group A and Group B.
73
14 Comparison of post test level of inflammation of IV infusion site in Group A and Group B.
75
15 Correlation between post test levels of pain with inflammation for Group A and Group B.
79
LIST OF APPENDICES
APPENDIX TITLE A Letter seeking and granting permission to conduct the study B Letter seeking experts opinion for content validity of the tool
C Certificate of English editing
D Copy of the tool for data collection and scoring key E Self introduction to the patient
F Description of intervention
ABSTRACT
A comparative study to assess the effectiveness of moist ice pack versus warm glycerin magnesium sulphate application in reduction of pain and inflammation among patients with IV infusion atGovernment Hospital, Thuckalay, Kanyakumari district.
Objectives of the study were:
1. To assess the level of pain and inflammation among Group A and Group B with IV infusion.
2. To find out the effectiveness of moist ice pack application and warm glycerin magnesium sulphate application in reduction of pain and inflammation among Group A and Group B.
3. To compare the pre and post test level of pain and inflammation in IV infusion among Group A and Group B.
4. To correlate the post test level of pain andinflammation in IV infusion among Group A and Group B.
5. To associate the post test level of pain and inflammation with their selected demographic variables among Group A and Group B.
Research hypotheseswere tested at 0.05 level of significance:
H1: There was a significant difference in the pre and post test level of pain and inflammation amongGroup A.
H2: There was a significant difference in the pre and post test level of pain and inflammation among Group B.
H3: Therewas a significant difference in the post test level of pain and inflammation between Group A and Group B.
H4: There was a positive relationship between the posttest level of pain and inflammation in the IV infusion site among Group A and Group B.
H5: There was a significant association of posttest level of pain and inflammation among Group A and Group B with theirselected demographic variables.
The study was based on Orlando’s theory of the deliberative nursing process.
The quantitative approach was used. The study was conducted in the Inpatient wards of Government District Head Quarters Hospital, Thuckalay, Kanayakumari District.
The design adopted for this study was two group pre and post test quasi experimental research design to evaluate the effectiveness of moist ice pack versus warm glycerin magnesium sulphate application in reduction of pain and inflammation among patients with IV infusion site inflammation. The samples were selected usingpurposive sampling technique and the groups were allotted by tossing the coin.
The patientswho satisfy the inclusive criteria were included in the sampling framework. While tossing a coin head belongs to the Group A and the tail belongs to Group B. Sixty patients with IV infusion site inflammation were assigned to group A (n = 30) and group B (n = 30) for moist ice pack and warm glycerin magnesium sulphate application respectively.
Moist ice pack application was given to Group A patients in the form of gauze wrung out of ice water and allowed to remain for 15 minutes for three times with the interval of three hours at the temperature of 170C for 1 day. Warm glycerin magnesium sulphate application was given to group B patients in the form of gauze wrung out of warm glycerin magnesium sulphate and allowed to remain for 15minutes for three times with the interval of three hours at the temperature of 400C for 1 day. The pre and post assessment level of pain was obtained by using numerical rating pain scale and for inflammation was assessed by Visual Infusion Phlebitis score. Descriptive and inferential statistics was used to analyze the data.
The major findings of the study were:
1. There was a significant difference in the pre and post test level of pain and inflammation of Group A. [Pain (t=11.26, P<0.05), Inflammation (t=18.66, P<0.05)]
2. There was a significant difference in the pre and post test level of pain and inflammation of Group B.[Pain (t=13.78, P<0.05), Inflammation (t=19.50, P<0.05)]
3. There was a significant difference in the post test level of pain and inflammation between Group A and Group B. [Pain (t=2.98, P<0.05), Inflammation (t=2.32, P<0.05)]
4. There was a positive relationship between the posttest level of pain and inflammation in the IV infusion site inflammation of Group A and Group B.
[Group A (r=0.75, P<0.05), Group B (r=0.70, P<0.05)]
5. In group A, the findings revealed that there was an association between the location of the cannula and post test level of inflammation at p value <0.05, which showed significance. In group B, the findings revealed that there was an association between the duration of IV therapy and post test level of inflammation at p value of <0.05 which showed significance and the other demographic variables and post test level of pain and inflammation at the IV infusion site did not show any statistical significance.
On the basis of the study findings, it is recommended that:
The following studies can be undertaken to strengthen the management of patients with IV therapy inflammation,
1. The study can be conducted in large sample for better generalization.
2. A descriptive study can be carried out to assess the factors leading to the development of IV infusion site inflammation.
3. A study to assess the effectiveness of structured teaching regarding the intravenous infusion therapy for staff nurses working in hospital.
4. A comparative study can be conducted to compare the use of warm glycerin magnesium sulphate application with other non pharmacological measures in reducing pain and inflammation of IV infusion site inflammation.
5. A study to assess the knowledge, skill and attitude of staff nurse in management and prevention of IV infusion site inflammation.
Recommendation based on the suggestions from the study subjects:
Encourage the students to get specialization in intravenous therapy, cannula insertion, maintenance and prevention of complications.
The educational institution must provide opportunities for nursing students to practice intravenous therapy infusion by hands on practice and to develop the skillful practice in selection of site, maintenance of IV cannula and prevention of complications.
Nursing administrator should ensure high standards of care are provided by nurses caring the patients with IV therapy by regular supervision, conduction of nursing audit and such quality assurance practices.
In service education and specialization programmes in IV cannulation, maintenance and prevention of complication can be arranged to enhance the skills of practice nurses.
The nurse administrator should formulate protocols, policies, guidelines and system of care given by nurses to patients receiving intravenous fluids along with adequate allocation of funds for continuing education programme.
Conclusion
Clients in group B who received warm glycerin magnesium sulphate application showed a highly significant decrease in the level of pain (P < 0.05) and inflammation (P < 0.05) on IVinfusion site inflammation to compare with clients in group A who received moist ice pack application. Warm glycerin magnesium sulphate application on IV infusion site significantly reduced the inflammation and pain and also enhanced the patient comfort and promoted speedy recovery.
CHAPTER – I
INTRODUCTION
BACKGROUND OF THE STUDY
The history of intravenous therapy originated with the discovery of circulation by William Harvey. The first practical application was by Dr. Thomas Latta, who used infusion of saline to treat the intractable diarrhea. Approximately 90% of patients in acute care setting receive some form of intravenous infusion therapy (JeniseWillin, 1999).
The intravenous infusion is an important aspect of therapy under both medical and surgical conditions. Physiologic homeostasis within the body requires the presence of an adequate supply of fluids. The fluids circulating within the body are composed of water, electrolytes, minerals and cells. Their imbalances may result from many factors like injury, surgery and different kinds of medical illnesses. These imbalances can be corrected by intravenous therapy. Intravenous therapy has become a life saving as well as life sustaining therapy and the intravenous therapy is increasingly being performed by nursing staff in hospitals. Nurses spend up to 2/3rd of their time for IV therapy related responsibilities. Therefore, initiating IV infusion is a challenging skill in nursing.
Administering drugs by the intravenous route has advantages. Often the nurse uses the intravenous route in emergencies when a fast acting drug must be delivered quickly. The intravenous routeis also best when constant therapeutic blood levels must be established. Some medications are highly alkaline and irritating to muscles and subcutaneous tissues. These drugs cause discomfort when given intravenously.
Infiltration occurs when a catheter (or) needle penetrates the vessel wall during venipuncture(or) later slip out of the vein and allows intravenous solution to flow into surrounding tissues. This is manifested as swelling from increased tissue fluid around the venipuncture site, pallor, warmth, decreased flow of rate, stop of flow and pain resulting from edema and increasing proportionately as the infiltration worsens. (Potter and Perry 2009).
The interior wall of a vein (the tunica intima) consists primarily of a single layer of tightly packed endothelial cells. Injury to (or) irritation of this layer causes the release of histamines, bradykinin and serotonin. These in turn initiates the pain response, dilatation of the vein and increasing blood flow to the area. Capillary permeability also increases, allowing fluids and proteins to leak into the interstitial space causing edema and tenderness. (DeniseMacklin 2003).
Factors associated with the development of infiltration are integrity and state of veins, insertion technique, cannula location, insertion into the bony extremity (or) movable joints, size of cannula, use of steel needles, infusion of certain drugs, duration of therapy, increased length of time over 24hrs, blood flow problems in the region, hyperosmolar parenteral fluids, pH acidic infusates, chemotherapeutic drugs and duration of soft tissue exposure to vesicants.
When infiltration occurs infusion must be discontinued and if necessary re- inserted into another extremity. To reduce discomfort caused by infiltration, the nurse should elevate the extremity, which promotes venous drainage and helps to decrease edema, and wrap the extremity in a warm towel for 20 minutes which increases circulation and reduces pain and edema. (Potter and Perry 2009).
Local responses to warm and cold occur through stimulation of temperature sensitive receptors in the skin. Impulses travel from the periphery to the hypothalamus and the cerebral cortex. The hypothalamus then initiates heat producing (or) heat reducing location of the body. The conscious sensations of temperature are aroused in the cerebral cortex. These interventions are effective by decreasing swelling through cold application, decreasing stiffness through warm magnesium sulphate application and increasing large diameter nerve fiber input to block small diameter pain fiber messages by cold and warm application. (C.
Delaune2000).
Managing an intravenous therapy regimen has become a common nursing responsibility and it is the part of extended role of nurses. While, due to advances in technology intravenous therapy is now relatively safe, it is still possible forserious complications to arise. Unfortunately, as Speechley and Toovey (1987) remarked, these complications are sometimes regarded as routineoccurrence (or) a mere
‘nuisance’, but to overlook or underestimate the potential risk of intravenous therapy is to lose site of the aim of therapy, which is to effectively replace fluid and electrolytes without causing the patient discomfort (or) further injury.
Warm glycerin magnesium sulphate application can act by the osmotic action of the Glycerin magnesium sulphate enabling the movement of fluid from the interstitial space with the skin acting as the membrane between Topical magnesium sulphate, has been used traditionally in the treatment of abscess, by causing vasodilation and resolving by pointing of pus. Glycerin acts as a solvent of magnesium sulphate and its hygroscopic action helps in reducing swelling due to
interstitial fluid. The warmth generated acts by vasodilatation to improve fluid reabsorption and can reduce swelling and pain.
NEED FOR THE STUDY
In keeping with the latest research, current guidelines from the Center for Disease Control and prevention [CDC] states that, even when no problem arisein association with catheter use, peripheral venous catheters should be replaced and sites rotated at least every 96 hrs. The practice of not changing a catheter because the patient shows no signs of complications such as infiltration, thrombophlebitis should be avoided, especially in patients who areneutropenic, immunosuppressed or malnourished as these condition delay the appearance of symptoms.(Center for Disease Control and Prevention 2011).
The practice of infusion therapy had become such a considerable component of nursing practice that in 1981 congress proclaimed January 25th as National Intravenous Nurses Day. The Intravenous Nurses Society (INS) is the professional organization that establishes standards of practice to promote excellence in intravenous nursing to ensure the highest quality, cost effective care for all individuals requiring infusion therapy (INS 2000).
Today’s hospitals rely on IV catheters as essential tools to deliver IV medications, blood products, and nutritional fluids to patients. Approximately 90% of all patients entering the hospital environment for care have some form of intravenous therapy during their hospital stay. Administering vital medications to these patients through the use of IV catheters can be complicated by localized phlebitis. Reported incidence of phlebitis ranged from 10% to 90% of peripheral IVs with symptoms occurring within eight hours of placement.
RegoFurtado,L.C,(2011) conducted a study to determine the incidence and predisposing factors of phlebitis related to peripheral IV cannulae and its predisposing factors in a General Surgery department. A total of 171 patients and 286 peripheral cannulae were monitored. The average incidence of phlebitis was 61.5%, and factors such as diabetes and tobacco consumption were identified as relevant to the development of phlebitis. Other elements identified as predisposing to the development of phlebitis include administration of KCl, the dwell time of the peripheral cannula, and the anatomical location of the cannula. Phlebitis associated with peripheral cannulae is still a current problem requiring knowledgeable staff who can prevent, recognize and act appropriately in a timely manner to minimize its severity.
The nurse practicing in today’s world is faced with a myriad of duties and responsibilities involving specialized skills and techniques. IV infusion therapy is one of the major responsibilities of the nurse in her day to day practice and an area that is continually expanding.
Intravenous sites are selected to accommodate the intended solution. The nurse should inspect and palpate the site for edema, erythema, warmth, indurations (hardness), pain and discomfort. When palpating the site, the nurse will find that an infiltrated area is warm/cool and the skin may have blanched appearance. The site of the infiltration is to be monitored quickly because usually fluid reabsorbs within 24hrs.
Pain at the intravenous site is the primary warning that more serious complications may ensue. Since pain is subjective, it is extremely important for the nurse to assess, intervene and evaluate each patient’s discomfort on an individual
basis.Edema may indicate an infiltration has occurred. The extremity should be compared with the opposite hand or arm if thesite seems edematous.
The application of warm or cold may relieve pain through a ‘counter – irritant’
effects as well as by direct effect on peripheral and free nerve endings [Lehmann and De lateur1989].Before applying warm or cold therapies, the nurse has to assess the patient’s physical condition for signs of potential intolerance to heat and cold. The nurse is legally responsible for safe administration of warm and cold application.
Li Weihong (2009) stated that the topical glycerin magnesium sulphate application on IV phlebitis, significantly reduced the pain and swelling within 24 hours, but bruising skin still left.
Isabel (2010) reported that the topical application of glycerin sulphate on peripheral cannula related phlebitis, reduced the size of erythema and rate of phlebitis within 5 days.
Aylayava (2010) reported that local cold application significantly reduced the severity of skin burns and pain after transthoracic cardioversion.
Olavi V Airaksinen (2003) stated the local application of cold reduced the pain and severity of soft tissue injuries.
Both of these nursing interventions (warm and cold application)have therapeutic effect inreducing pain and severity of inflammation as follows.
Fig.1. Therapeutic effect of warm &cold application in reduction of pain and inflammation
Warm glycerin magnesium sulphate application can act by the osmotic action of magnesium sulphate enabling the movement of fluid form the interstitial space with the skin acting as the membrane between Topical Magnesium sulphate has been used traditionally in the treatment of abscess by causing vasodilation and resolving by
COLD APPLICATION
VASOCONSTRICTION
REDUCES CAPILLARY WALL PERMEABILITY AND ESCAPE OF EXTRACELLULAR FLUIDS
DECREASES BLOOD FLOW
DECREASES SWELLING INCREASES
BLOOD VISCOSITY
DECREASES CELL METABOLISM
DECREASES NERVE CONDUCTION VELOCITY
DECREASES SENSITIVITY OF NERVE FIBERS AND RECEPTORS
INDUCES NUMBNESS/ PARESTHESIA
DECREASES LOCAL PAIN WARM APPLICATION
VASODILATION
IMPROVES BLOOD FLOWTO THE INJURED PART
INCREASES CAPILLARY PERMEABILITY PROMOTES DELIVERY OF OXYGEN AND NUTRIENTS
INCREASES TISSUE METABOLISM
PROMOTES REMOVAL OF WASTE PRODUCTS AND PAIN PRODUCING PROSTAGLANDIN
REDUCES MUSCLE SPASM /STIFFNESS AND PROMOTES MUSCLE RELAXATION
REDUCES PAIN AND INFLAMMATION
pointing of pus. Glycerin acts as a solvent of magnesium sulphate and its hygroscopic action helps in reducing swelling due to interstitial fluid. The warmth generated acts by vasodilation to improve fluid reabsorption and can reduce swelling and pain.
Because of the similar therapeutic effect of these two interventions especially inreducing pain andinflammation of intravenous infiltration site, it makes lot of confusion among nurses to practice the ideal choice of intervention which promotes patient comfort by relieving pain andinflammation. This made the investigator to be more interested to compare the effectiveness of warm glycerinmagnesium sulphate and most ice pack application in reducing painand inflammation of intravenous infusion site inflammation. This research found useful to identify the ideal method of intervention infusion site inflammation which helps to relieve the discomfort and promote the comfort of the patient with intravenous infusion site inflammation.
STAEMENT OF THE PROBLEM
A comparative study to assess the effectiveness of moist ice pack versus warm glycerin magnesium sulphate application in reduction of painand inflammation among patients with IV infusion at Government Hospital, Thuckalay, KanyakumariDistrict.
OBJECTIVES
1. To assess the level of pain and inflammation among Group A and Group B with IV infusion.
2. To find out the effectiveness of moist ice pack application and warm glycerin magnesium sulphate application in reduction of pain and inflammation among Group A and Group B.
3. To compare the pre and post test level of pain and inflammation in IV infusion among Group A and Group B.
4. To correlate the post lest level of pain and inflammation in IV infusion among Group A and Group B.
5. To associate the post test level of pain and inflammation with the selected demographic variables among Group A and Group B.
RESEARCH HYPOTHESES
Hypotheses will be tested at p < 0.05 level:
H1: There will be a significant difference in the pre and post test level of pain and inflammation among Group A.
H2: There will be a significant difference in the pre and post test level of pain and inflammation among Group B.
H3: Therewill be a significant difference in the post test level of pain and inflammation between Group A and Group B.
H4: There will be a positive relationship between the posttest level of pain and inflammation in the IV infusion site inflammation among Group A and Group B.
H5: There will be a significant association of posttest level of pain and inflammation among Group A and Group B with their selected demographic variables.
OPERATIONAL DEFINITIONS
Assess
It is the process of systematically collecting, validating and analyzing data regarding pain and inflammation among patients with IV infusion.
Moist ice pack application
Application of moist cold therapy over IV infusion inflammation in the form of gauze wrung out of ice water at 170 C temperature and allowed to remain for 15minutes for 3times with the interval of 3 hours for 1 day.
Warm glycerin magnesium sulphate application
Application of warm glycerin magnesium sulphate therapy over IV infusion inflammation with the use of clean cloth soaked in warm glycerin magnesium sulphate solution at 400 C temperature and allowed to remain for 15 minutes for 3 times with the interval of 3 hours for 1 day.
Effectiveness
It refers to the reduction in the level of pain and inflammation in the intravenous infusion site.
Pain
It refers to an unpleasant experience felt by the patient due to improper intravenous infusion as measured by the numerical rating pain scale.
Inflammation
If refers to local tissue redness, swelling, induration, warmth and venous cord formation at the site of intravenous infusion which are measured by the Visual infusion phlebitis score scale.
ASSUMPTIONS
1. Patient with IV infusion site may experience pain and inflammation.
2. Moist ice pack and warm glycerin magnesium sulphate application over IV infusion site may reduce pain and inflammation.
DELIMITATIONS
The study is delimited to a period of 4 weeks only.
The study is limited to the patients who are admitted in Govt hospital, Thuckalay during the period of data collection.
The study is limited to a sample of 60.
PROJECTED OUTCOMES
1. The findings of the study will help the nurses to plan and use the best application therapy in reducing the pain and inflammation of patients with IV infusion site inflammation.
2. Administration of moist ice pack application or warm glycerin magnesium sulphate application will reduce pain, inflammation and prevent the development of complications associated with the IV infusion therapy
CONCEPTUAL FRAMEWORK
Conceptual frame work is based on Orlando’s theory of the Deliberative nursing process.
Orlando was one of the earliest nurse theorists and one of the first person to develop nursing theory inductively from the empirical study of the nurse practice.
Orlando’s theory radically shifted the nurse’s focus from the medical diagnosis to nursing diagnosis i.e., to find and meet the client’s immediate needs.
Orlando’s nursing process composed of the following basic elements.
1. The behavior reaction of client 2. Reaction of the nurse
3. The nursing action, which are designed for the patient benefit.
Orlando says nurses should help to relieve physical and mental discomfort and should not add to the patient distress.
In this theory, nursing process is used by nurse to meet the client’s need for help, meeting the need, improves the client’s behavior. Client behavior can be verbal expression by language such a complaints, requests, demands (or) non-verbal manifested physiologically such as edema, skin colour, tear in the eyes, motor activity, (or) vocally such as crying, moaning and facial expressions. Nurse reacts to the client behavior and acts accordingly, after completion of the nursing action;which is evaluated for its effectiveness.
Client behaviour
Client need is to relieve the pain and inflammation which is caused byIV infusion site inflammation. The client who cannot resolve this need feels helpless, and the person behavior reflects the feelings. Behaviour can be verbalin which the client admits that he/she has painand inflammation (or) it may be non-verbal that is manifested by observation of physiological changes in the IV infusion site inflammation as erythema, swelling, tenderness, warmth and hardness.
Nurse reaction
Nurse perceives the client’s behavior and feels that the client has some need to be met and validating the same by communicating with client and by assessing the condition of IV infusion site inflammation, by using numerical rating pain scale to assess the level of pain and visual infusion phlebitis score for the severity of inflammation.
Nurse action
After verifying and identifying the need of the client, the nurse activity is planning and implementing the nursing action for meeting the client’s need (or) improving client’s behavior. Here, the nurse action is moist ice pack application for Group A and warm glycerin magnesium sulphate application for Group B; both are in the form of moisttherapy and then assessed the effectiveness of both application in reduction of pain and inflammation of IV infusion site inflammation. Ifsignificant reduction of pain and inflammation, the investigator maintain the comfort of the patient with the same intervention.If insignificant, the investigator recommends further plan for the client behavior.
CHAPTER – II
REVIEW OF LITERATURE
This chapter is designed to review the literatures, which are used to support this study.
The review of literature entails the systemic identification, reflection, critical analysis and report of existing information in relation to the problem of interest.
Review of research topic serves several purposes. A familiarity of previous study is useful in suggesting research topics in identifying aspects of a problem about which more research is being done.
The investigator reviewed literature available on IV infiltration and associated inflammation development, complications and management, and the effect of warm glycerin magnesium sulphate and moist ice pack application in reducing pain and inflammation.
REVIEW OF RELATED LITERATURE This is classified under three sections.
Section A: Studies related to development of IV infiltration and associated inflammation.
Section B: Studies related to management of IV infiltration and associated inflammation.
Section C: Studies related to effectiveness of warm glycerin magnesium sulphate and moist ice pack application in reducing pain and inflammation.
Part – I: Review of related literature
Section A: Studies related to development of IV infiltration and associated inflammation
TabotSGetal(2011) conducted a retrospective study on Pediatric compartment syndrome caused by intravenous infiltration in children’s hospital, Boston. Three infants (mean age, 9 months) were identified. Each patient had a large volume of IV fluid delivered into the subcutaneous tissue through a pump infusion system. In all cases, the sensor failed to alarm and disables the system, and problem was identified only after routine nursing evaluation of the IV site. Findings included the following:
tissue blanching, decreased capillary refill, and severely restricted active/passive motion of the affected extremity. They concluded that routine nursing evaluation remains the gold standard for detection of these events.
Rickand CMetal(2010) conducted a randomized controlled trail on routine resite of peripheral intravenous devices every 3 days did not reduce complications compared with clinically indicated resite in Griffith university hospital,Nathan Queensland. After ethics approval, 362 patients (603 IVDs) were randomized to have IVDs replaced on clinical indication (185 patients) or routine change every 3 days (177 patients). IVD complications rates were 68 per 1000 IVD days (clinically indicated) and 66 per 1000 IVD days (routine replacement) (P=0.86; HR 1.03; 95 CI, 0.74-1.43). Time to first complication per patient did not differ between groups (KM with log rank, P=0.53). IV therapy duration did not differ between groups (P=0.22), but more (P=0.004) IVDs were placed per patient in the routine replacement (mean, 1.8) than the clinical indication group (mean, 1.5), with significantly higher hospital costs per patient (P<0.001). They concluded that overall complication rates appear
similar, clinically indicated resite would achieve saving in equipment, staff time and patient discomfort.
Kohno E et al (2009) conducted a study to assess the effectiveness of corticosteroids on phlebitis induced by intravenous infusion of antineoplastic agents among rabbits in Kansai medical university hospital, Osaka. Vinorelbine(VNR) and doxorubincin(DXR) were diluted with normal saline to prepare test solutions at concentrations of 0.6mg/ml and 1.4mg/ml, respectively. Each test solution was infused into the auricular veins of rabbits. VNR is often used with dexamethasone(DEX) and DXR is co-administered with prednisolone(PSL). Two days after infusions, the veins were evaluated histopathologically. They concluded that pre-treatment with DEX may be a useful method for preventing phlebitis due to VNR, and that co-infusion PSL has the potential to prevent phlebitis caused by DXR.
Doellman D et al(2008) stated in an article , “Infiltration and extravasation:
update on prevention and management” that infiltration and extravasation therapy involving unintended leakage of solution into the surrounding tissue. Consequences range from local irritation to amputation. While immediate action using appropriate measures (i.e., dilution, extraction, antidote, and supportive treatments) can decrease the need for surgical intervention, many injuries may be prevented by following standard policy and procedures.
Dougherty L(2007) stated in an article, “Extravasation: prevention, recognition & management” that infiltration and extravasation are complications that can occur during intravenous therapy administered via either peripheral or central venous access devices. Both can result in problems with the siting of future venous access devices, nerve damage, infection and tissue necrosis. The nurse is the key to
reduce the risk of infiltration and extravasation, through her knowledge and skill in cannulation and the IV administration of drug by bolus injection or infusion. The nurse must also be able to recognize the early signs and symptoms of infiltration and extravasation.
Kagal EM, Rayan GM (2004) conducted a retrospective study on the complications of peripheral intravenous catheters in hand and forearm with the aim of identifying the most common sites for developing infiltration. The records of 67 patients from Komagone city hospital were reviewed. By using mean and standard deviation, the study found that , there were 56 minor complications which comprises of 26 intravenous infiltration, out of 11 major complications as phlebitis, 6 skin necrosis, 2 compressive nerve lesion, digital stuffiness are twoand compartment syndrome is one.
Sobieska M etal (2003) conducted a descriptive study to identify the risk factors of intravenous related complications with 40 patients. By using observation check list the signs and symptoms were assessed which reveals that, the type of infusates, duration of cannulation more than 3 days (50%), IV antibiotics (12%), female sex (12%), catheter material PEO – vialon and Teflon (6%), anatomic site forearm related (12%) and wrist (8%).
VandenbosFetal (2003) conducted a descriptive study on incidence and complication of intravenous infusion with the aim of identifying the IV related complications. The samples were 550 patients with IV cannula from Nice University Hospital, among whom 219 were women (46%) and 331 were men (54%).The chi- square findings show that 54 (13.6%) had thrombophlebitis, 50(13.2%) had infiltration and 9(2.3%) had swelling and local infection.
Milkulis DJ etal (2002) conducted a descriptive study to assess the complications of peripheral IV cannula among 60 post operative patients, with the aim to identify the risk factors that causes peripheral IV complication such as infiltration. The observational check list was used to measure the signs and symptoms of complication. The chi-square findings show that the most cannula were placed on the upper side of the hand and unsatisfactory fixation (23 cases). The usage of fructose – glucose, antibiotics, anticoagulants were given as risk factors for the development of IV related complications.
Catney MR etal (2001) conducted a descriptive study on peripheral intravenous complications and its risks with the aim to identify the relationship between peripheral intravenous catheter dwell time and the development of phlebitis and infiltration in medical surgical units of Iowa city. Log rank test were used to test for an association between the covariates and the time until failure. The correlation findings show that, the total differences in the estimated failure rates item. The catheter lasting 6 days versus a new catheter inserted for another 3 days is 1.3%
because the conditional failure probability estimates for days 4, 5 and 6 are slightly higher than for day 1,2and 3.
Chukhrav AM. Grekor LG (2000) conducted a descriptive study on complications of peripheral vein with the aim to identify the causes of complications and its incidence with 50 inpatients, Toronto Research institute, Toronto. By using mean and standard deviation, the findings stated that infiltration and extravasation (62%), subcutaneous hematoma (21%), spontaneous rupture of vein (6%), obliteration of vessel(2%), superficial phlebitis(2%), external bleeding (0.5%) and the cause is due to incorrect techniques of insertion, placement and administration of IV solution.
O’ Grady NP etal (2000) conducted a comparative study on field started Vs Hospital started IVs with the aim to compare the risk of complications of IV cannula is high in field started IVs (OR) in Hospital started IVs. Among 88 patients in Mercy Hospital, Portland there were 10 occurrence of infiltration out of which 6 were associated with field started IVs. The study concluded that all field started IVs should be discontinued and restarted at hospital admission if not possible could be left in place for upto72 hours then discontinued.
Tully J.L Friedland GH etal(2000) conducted a comparative study on complications of intravenous therapy with steel needles and Teflon catheters with 954 cannula insertions. The risk of phlebitis was significantly greater with Teflon catheters (18.8% with Teflon Catheters, 8.8% with steel needles) steel needles were significantly associated with infiltration (17.9% with Teflon catheters, 40.1% with steel needles). The overall rate of complications was significantly greater for the group in which steel needles were used (53.8% versus 64.0%), basically due to the increased risk of infiltration with steel needles.
Graham DR, Keldermans MM etal (1999) conducted a descriptive study on infectious complications among patients receiving home intravenous therapy with peripheral, central or peripherally placed central venous catheters in Springfield clinic, Illinois, with 300 patients from two hospital based home IVT services over 29 months, 6 bacteremias (one death), 2 subclavian thrombosis, 13 catheter site infections, and 1 additional death occurred. Among PICC patients mean duration of therapy was 24 days (0-67) and was completed in 51 patients, others completed therapy with standard peripheral catheters a mean of 6 days later. Complications included 17 obstructions by clot, 11 cases of phlebitis, 6 catheter fractures, 5
punctures, 2 accidental removals and 1 infiltration. They concluded that home IVT is safe via many means of access with few infections than with hospital care. Such infections may be termed “nosohusial”.
Homes and Holmen (1998) conducted a descriptive study to identify the risk associated with duration of IV catheter in development of infiltration, with 100 samples in VA medical center, Iowa City. Correlation findings shows that the IV catheter removed and restarted after 72 hours carried less risk of developing complication than the therapy continued to 96 hours.
Reilly JJ, Neifield JP (1997) conducted a descriptive study on clinical course and management of accidental adriamycin extravasation in Indiana University Medical center, Indiana. Among 10 patients with adriamycin infiltration 7 patients suffered skin ulceration as 3 had severe functional impairment due to joint contractures. They concluded that adriamycin should not be infused near joints and surgical excision of ulcers is advocated if healing is prolonged. Proper local therapies as well as early attention to proper splinting and physical therapy can help reduce ultimate functional disability.
Hunter ES, Bell E etal (1995) stated in the article “relationship of local IV complications and the methods of intermittent IV access” that Infiltration, infection and thrombophlebitis were considered the most frequent complications of IV therapy.
The purpose of the study was to determine the incidence of complications during IV infusion which depends on whether the IV tubing is directly connected to the infusion device or the tubing connected to the latex part of an IV lock using a needle. They concluded that direct connection of tube to the infusion device had the higher incidence of complication.
Martinez JA etal (1994) conducted a prospective study of 569 IV cannula including 492 peripherally inserted cannula in a country hospital. 11.5% of patients developed extravasation and mean time situ was 3.0 days. The chi-square findings showed that contributing factors were age above 65 years, female sex, insertion of cannula into back of hand and drug like aminophylline and not using heparin.
Yucha CB, Hastings- Tolsma M, Szererenvi NM (1993) conducted a descriptive study on differences among intravenous extravasation of using common solutions. They statedthat frequent complications of intravenous therapy are extravasation (infiltration) of the infused fluid into the interstitial tissues. By using Correlation, the study compared the infiltration intentionally made using different IV solutions, regarding surface assessment and the volume of infiltrate as quantified by magnetic resonance imaging. Solutions differed significantly concerning pain, surface area, indurations and volume at the site of infiltration.
Shree Devi (1990) conducted a descriptive study on complications of IV therapy in children with the aim to find out the frequency and type of complication and determine the role of various factors in the causation of complications in Pediatric Department of Choithram Hospital and Research Center, Indore by using observational check list. Chi-square was used to identify the factors associated with the complications. The findings suggested that the life of IV was best at the elbow site and the complicationswerehigher at foot and ankle site, Elbow (20%) hand and wrist (49%), foot and ankle (31%)
Section B: Studies related to management of IV infiltration and associated inflammation.
Alley MS etal (2010) stated in an article, “Wireless application in IV infiltration detection system” that the IrDA based point of care system for the detection of intravenous infiltration. The system was used for monitoring patients under infusion therapy. It was optimized for portability by incorporating the battery source and wireless communication. The IrDA protocol provided source data communication between the electronic modules of the system and the PDA carried by the nurses. The PDA was used for initiating the actions of the electronic module and for data transfer. Security was provided by the specially designed software and hardware.
Thigpen JL, (2009) stated in an article, “Peripheral IV extravasation: Nursing procedure for initial treatment” that tissue extravasation resulting from intravenous infiltration can occur as a complication of neonatal intensive care with varying degrees of morbidity. Serious extravasation can result in pain, infection, disfigurement, prolonged hospitalization, increased hospital costs, and possible litigation. Although most infiltrates resolve spontaneously after the IV catheter is removed. IV extravasations and tissue sloughing do occur in NICU patients. Specific therapies are based on assessment of the degree of the injury. The goal in managing tissue damage after IV extravasation is to improve tissue perfusion and prevent progression tissue necrosis. This article presents an initial approach to nursing care for peripheral IV infiltration to guide clinicians in management of this complication. This approach is based on clinical experience, descriptive studies, and report from expert committees.
HadawayL (2007) stated in an article, “Infiltration and extravasation” that Infusion Nurses Society’s national standards of practice require that a nurse who administers IV medication or fluid knows its adverse effects and appropriate interventions to take before starting the infusion. A serious complication is the inadvertent administration of a solution or medication into the tissue surrounding the IV catheter- when it is a no vesicant solution or medication, it is called extravasation.
Both infiltration and extravasation can have serious consequences; the patient may need surgical intervention resulting in large scars; experience limitation of function, or even require amputation. Another long term effect is complex regional pain syndrome, a neurologic syndrome require long term pain management. These outcomes can be prevented by using appropriate nursing interventions during IV catheter insertion and early recognition and intervention upon the first signs and symptoms of infiltration and extravasation.
Mc Cullen KL etal (2006) conducted a retrospective study on review of risk factors for extravasation among neonates receiving peripheral intravascular fluids in St. John Hospital, Detroit. The setting and subjects were among randomly selected medical records of 25 neonates admitted to a neonatal intensive care unit from January 2003 through April 2004 who experienced peripheral intravascular infiltration were examined. The neonatal tissue extravasation tool was created to reflect common descriptive variables of the neonatal population and infused solutions used in their care. Charts 15 female and 10 male infants 24 to 39.6 weeks old were reviewed. Extravasation was not significantly related to age, weight, or sex. The most common IV medications were TPN (n=19) and calcium (n=18). The site of the infiltrate were the arm (n=16), foot/leg (n=5), scalp (n=3), (one not recorded). Stages 0 (absence of redness, pain, swelling; flushes with ease) (n=11) and 4 (severe
swelling, blanching, pain, skin break down, etc) (n=6) were the most common stages.
They concluded that the intravascular solutions causing the most extensive damage from extravasation were similar to those reported in other studies.
Lehr VT etal (2005) stated in an article “Management of infiltration injury in neonates using duoderm hydro active gel”, that neonates are at increased risk of injury from infiltration intravenous fluids because of small vessel size and immature skin structure. Until recently, hyaluronidase injection was used to prevent tissue injury following IV infiltration in neonates. Amorphous hydro gels have been used as wound dressings for sloughly or necrotic wound in a variety of clinical setting. Hydro gels facilitate auto debridement of the by rehydrating slough and enhancing the rate of autolysis. They reported their experience using duoderm hydro active gel for management of injury secondary to the infiltration of TPN solution and lipid emulsion in these neonates.
Wilkins CE Emmeroth AJ (2004) conducted a experimental study to assess the management of extravasation with the aim of identifying the management of infiltration with hyaluronidase in reducing pain and edema among 38 neonates of regional neonatal units of St. Mary’s Hospital Whitworth park, Manchester. Face assessment scale for pain and observation check list for edema was used as tool for data collection. By using mean and standard deviation, they conclude that exposing the wounds to the air, use of hyaluronidase and saline for occlusive dressing was effective.
Yosowite P etal (2003) conducted a descriptive study on peripheral intravenous infiltration necrosis with the aim of identifying the risk factors in relation to development of infiltration, necrosis in Nagano Medical center, Japan. Out of 14
patients, 8 patients received IV solution containing calcium salts and remaining 6 patients received 10% dextrose. 5 patients developed severe disfigurement (or) impaired limb function. The management includes debridement -8(57.5%), early skin grafting -4 (28.5%) and secondary reconstruction – 2 (14%). They concluded that the nurses who administering these drugs may believe that infiltration may come serious sequelae.
Kumar RJ, Pegg SP (2002) conducted a retrospective study on management of extravasation injuries with the aim of identifying the effectiveness of appropriate management in reducing complications. By reviewing the hospital years, among this 2 from isotonic dextrose esaline and other 7 from variety of solutions, parenteral nutrition and soda bicarbonate, etc. Out of them 5 patients were treated conservatively and 4 were managed by delayed debridement and split skin grafting, found that the final result were satisfactory in all 9 patients. Chi-square was used to associate the demographic data with the findings. They concluded that the management of extravasation injuries should be as conservative as possible.
Willsey DB etal (2002) conducted a descriptive study on compartment syndrome of the upper arm after pressurized infiltration of intravenous fluid with the aim to identify the factors contributing complications and morbidity conducted at Massachusetts General Hospital, Boston city with 40 patients. Patient record was used as tool to collect the data. Chi-square was used to associate the contributing factors with complications. They conducted that early recognition, diagnosis and intervention with surgical fasciotomy averted potential complication and morbidity.
Casanova D, Bardot J (2001) Conducted a experimental study on emergency treatment of accidental infusion with the aim to assess the effectiveness of saline flush
and liposuction as a management of infiltration with 14 new children in Yokohane pediatric ward. The intervention was treating the patient with gaults procedure consisting of saline flush out and liposuction. The finding showed that there was no skin impairment in 11cases and 3 cases of skin necrosis healed spontaneously. This demonstrates that it is important to dilute and remove the toxin from subcutaneous tissue to avoid skin necrosis at the site of extravasation.
Cedidi C, Hierner R, Berger A (2001)stated in the article ‘plastic surgical management in tissue extravasation of cytotoxic agent in the upper extremity’. It was on survey report that 18 patients who suffered with a significant extravasation injury and treated surgically. All patients were informed late (mean 22 days after the event to clinic with soft tissue defect over the dorsum of the hand, forearm and cubital fossa area). They underwent debridement, temporary wound coverage and skin grafting (or) coverage with local flap with a mean of 15 days hospitalization. Correlation was used to identify between days and the findings. They concluded that early referral of patients with extravasation can reduce tissue of illness and cost.
Littenberg B, Thompson L. (2001) conducted a prospective study on gauze Vs. plastic for peripheral intravenous dressing among 301 acutely ill medical inpatients in Stanford University Medical Center, California. Catheters were dressed with dry clean gauze or one of two brands of transparent plastic. The gauze dressing remained in place significantly longer (47 hours median) than either Uniflex (39 hours) of Tegaderm (32 hours) transparent plastic dressings (p=0.026). Catheters were removed for complications (inflammation, mechanical failure 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 venipuncture sites seen less often
with gauze, inflammation occurred later (p=0.002) and with lesser severity. Dry gauze dressing resulted in longer catheter life, lower complications rates, and less expense than transparent plastic dressings for peripheral intravenous catheters.
Handler EG (2000) has presented a case report on superficial compartment syndromes of the foot after infiltration of intravenous fluid at Department of Pediatrics and Rehabilitation Medicine, University of Wisconsin-Madison. This is a report of a four –year old boy with a spinal cord injury resulting in paraplegia who developed a compartment syndrome of the foot due to intravenous fluid extravasation.
The patient required surgical decompression and subsequent skin grafting. This case report demonstrates that the normal warning signs indicative of intravenous fluid infiltration such as pain or perception of pressure are not applicable in patients with spinal cord injuries and that warning symptoms may not be a reliable means for monitoring infiltration. Intravenous lines placed in the affected limb of these patients must be frequently visualized and evaluated.
Tsavaris NB etal (1999) conducted a comparative study on infiltration and effective management with the aim to evaluate the effectiveness of conservative approach to treatment in order to minimize necrosis from extravasation with 53 patients out of this 21 having old lesion and 32 with recent extravasation. In old lesion a keratolytic ointment was initially applied where as in new lesion.
Betamethasone was applied to the lesion with a tight bandage and was replaced.
Paired‘t’ test was used to compare the effectiveness of keratolytic ointment and betamethasone. They concluded that application of conservative measures in extravasation area from chemotherapy may avoid tissue necrosis and reconstructive surgery.
Heliskov J, Kleiber C (1998) has conducted a study on a randomized trial of heparin and saline for maintaining intravenous locks in neonates with the aim to determine the effects of saline, heparin 2 units (U) per ml saline, and heparin 10U/ml saline flush solutions on the duration of intravenous (IV) locks and the incidence of IV infiltration in neonates at University of Iowa Hospitals with 90 Neonates. By using correlation the result shows there were no statistical or clinical differences between the 3 groups for duration neither of IV nor for incidence of complications. They concluded that the use of heparin in IV lock flush solution did not affect the duration of IV locks nor the incidence of infiltration in neonates.
Von Heimburg D, Pallua N (1998) conducted a comparative study on early and late treatment of iatrogenic injection damage with the aim of comparing the effectiveness of early and late treatment of infiltration. Out of 32 patients with infiltration 8 patients referred within 24 hours and the IV material has removed and saline flush out and they did not develop soft tissue defect or skin necrosis. The other 24 patients were referred late (mean 19 days after injury) and they underwent debridement, temporary wound coverage and skin grafting and complete healing occurred after 52 days only. Paired and unpaired‘t’ shows that the removal of cytotoxic substances by saline flush out and early notification of symptoms and treatment reduces the incidence of complications.
Willsey DB, Peterfreund RA (1997) has presented a case report on compartment syndrome of the upper arm after pressurized infiltration of intravenous fluid in Department of Anesthesia and Critical care, Massachusetts General Hospital, Boston USA. A case of upper extremity compartment syndrome resulting from pressurized infusion of crystalloid through an intravenous catheter placed in the
emergency ward. Chi-square was used to associate the factors with complications which are early recognition, diagnosis and intervention with surgical fasciotomy averted potential complications and morbidity.
Tsavaris (1992) conducted a comparative study to evaluate the effectiveness of conservative approach as treatment of drug extravasation and avoiding reconstructive surgery with the aim of comparing the effectiveness of two therapies.
63 patients were separated in to two groups. Group A were treated with hydrocortisone and dexamethazone, Group B additionally with sodium thiosulphate.
In that the group B which received additionally sodium thiosulphate healing time was about half that for group A.Paired‘t’ test was used to compare the data between group A and group B. They concluded that application of conservative measures during chemotherapy may prevent tissue necrosis due to drug infiltration and need for subsequent reconstructive surgery.
Section C: Studies related to effectiveness of warm glycerin magnesium sulphate and moist ice pack application in reducing pain and inflammation.
Drygas KA etal (2011) conducted a study to evaluate the effect of cold compression therapy(CCT) on postoperative pain, lameness, range of motion of the stifle joint, and swelling following tibial plateau leveling osteotomy(TPLO) in dog.
The design used was randomized, blinded, placebo-controlled clinical trail.34 client- owned dogs with unilateral deficiency of a cranial cruciate ligament undergoing TPLO. Dogs were assigned to 2 groups. Group 1 (n=17dogs) received CCT in the 24 hour period following TPLO. Group 2 (n=17dogs) received no CCT. Degree of lameness, range of motion, and circumference of the stifle joint were measured before surgery and 1, 14, and 28 days after surgery. A modified composite Glasgow pain
scale, Visual analogue scale, and pain threshold score were used to evaluate signs of pain before surgery and 1, 14 and 28 days after surgery. Logistic regression and linear regression analysis were used to compare the measured variables. They concluded CCT decreased signs of pain, swelling, and lameness and increased stifle joint range of motion in dogs during the first 24 hrs after TPLO.
Tauzin-Fin P etal (2010) conducted a randomized, double-dummy study was undertaken to compare the effects of magnesium sulphate(MgSo4) administered by the intravenous vs the infiltration route on postoperative pain and analgesic requirements in Boredeaux hospital, Codex. 40 ASA I &II men scheduled for radical retro pubic prostatectomy under general anesthesia were randomized into two groups (n=20 each). Two medication sets A and B were prepared at the pharmacy. Each set contained a mini bag of 50ml solution for IV infusion and a syringe of 45ml for wound infiltration. Group Mg So4 IV patients received set A with 50mg/kg MgSo4 in the mini bag and 190 mg ropivacaine in the syringe. Group MgSo4/L received set B with isotonic saline in the minibag and 190mg ropivacaine+750mg MgSo4 in the syringe. IV infusion was performed over 30 min at induction of anesthesia and the surgical wound infiltration was performed during closure. Pain was assessed every 4 hr using a 100-point visual analogue scale. Postoperative analgesia was standardized using IV paracetamol (1gm/6hr) and tramadol was administered via a patient- controlled analgesia system. They concluded that co-administration of MgSo4 with ropivacaine for postoperative infiltration analgesia after radical retro pubic prostatectomy produces a significant reduction in tramadol requirements.
Ushida T etal (2009) conducted a study to assess the effectiveness of intradermal administration of magnesium sulphate and magnesium chloride produces
