Effectiveness and Safety of Measures to Prevent Infections and Other Complications Associated With Peripheral Intravenous Catheters: A Systematic Review and Meta-analysis.

BACKGROUND: Peripheral intravenous catheters (PIVCs) contribute substantially to the global burden of infections. This systematic review assessed 24 infection prevention and control (IPC) interventions to prevent PIVC-associated infections and other complications. METHODS: We searched Ovid MEDLINE, Embase, Cochrane Library, WHO Global Index Medicus, CINAHL, and reference lists for controlled studies from 1 January 1980-16 March 2023. We dually selected studies, assessed risk of bias, extracted data, and rated the certainty of evidence (COE). For outcomes with 3 or more trials, we conducted Bayesian random-effects meta-analyses. RESULTS: 105 studies met our prespecified eligibility criteria, addressing 16 of the 24 research questions; no studies were identified for 8 research questions. Based on findings of low to high COE, wearing gloves reduced the risk of overall adverse events related to insertion compared with no gloves (1 non-randomized controlled trial [non-RCT]; adjusted risk ratio [RR], .52; 95% CI, .33-.85), and catheter removal based on defined schedules potentially resulted in a lower phlebitis/thrombophlebitis incidence (10 RCTs; RR, 0.74, 95% credible interval, .49-1.01) compared with clinically indicated removal in adults. In neonates, chlorhexidine reduced the phlebitis score compared with non-chlorhexidine-containing disinfection (1 RCT; 0.14 vs 0.68; P = .003). No statistically significant differences were found for other measures. CONCLUSIONS: Despite their frequent use and concern about PIVC-associated complications, this review underscores the urgent need for more high-quality studies on effective IPC methods regarding safe PIVC management. In the absence of valid evidence, adherence to standard precaution measures and documentation remain the most important principles to curb PIVC complications. CLINICAL TRIALS REGISTRATION: The protocol was registered in the Open Science Framework (https://osf.io/exdb4).

Impact of an interventional bundle on complications associated with peripheral venous catheters in elderly patients.

PURPOSE: Elderly patients admitted to geriatrics departments often require peripheral venous catheters (PVC), which should be inserted and maintained following a series of preventive recommendations. Our objective was to evaluate the impact of a training bundle comprising measures aimed at reducing complications associated with the use of PVC in elderly patients admitted to a tertiary teaching hospital. METHODS: We performed a prospective study of patients who received a PVC within 24 h of admission to a geriatrics department. After a 10-month pre-interventional period, we implemented an educational and interventional bundle over a 9-month period. Follow-up was until catheter withdrawal. We analyzed and compared clinical and microbiological data between both study periods. RESULTS: A total of 344 patients (475 PVC) were included (pre-intervention period, 204 patients (285 PVC); post-intervention period, 140 patients (190 PVC)). No statistically significant differences in demographic characteristics were observed between the study periods. The colonization and phlebitis rates per 1000 admissions in both periods were, respectively, 36.7 vs. 24.3 (p = 0.198) and 81.5 vs. 65.1 (p = 0.457). The main reason for catheter withdrawal was obstruction/malfunctioning (33.3%). Obstruction rate was higher for those inserted in the hand than for those inserted at other sites (55.7% vs. 44.3%, p = 0.045). CONCLUSIONS: We found no statistically significant differences regarding phlebitis and catheter tip colonization rates. It is necessary to carry out randomized studies assessing the most cost-effective measure to reduce complications associated with PVC.

Implementation of a midline catheter service in a regional setting.

Introduction: Midline catheters have been reported to be an effective and safe means of providing patients with intravenous access within the hospital and community setting. With minimal experience in the introduction of a midline service across the local health network, a regional hospital pursued this task. This observational study assesses the provision of a safe clinical framework for midline insertion, and the improvement of patient care and experiences by avoiding treatment interruptions and unnecessary cannulation attempts from failed traditional peripheral vascular access devices. Methods: From the introduction of the midline service in June 2018, outcome measures of all patients who received a midline over the following two-year period were documented including rate of line success, complication rates, dwell time, and the number of insertion attempts. Results: The midline service provided 207 lines over a two-year period with a total dwell time of 1,585 days. Project goals were achieved with 85% (Aim > 85%) of all lines completing treatment prior to removal. First attempt insertion was 86% (Aim > 80%) with a maximum insertion attempt of two. Rates of line-related complications were less than 8%, with five documented cases of phlebitis (2.5%) and one deep vein thrombosis with no infections documented. Conclusion: Despite limited resources, a successful midline service was introduced. Future expansion will see an increase in insertor numbers providing improved access to the service.

Improved Patient Safety and Quality Outcomes With Amiodarone Infusions.

BACKGROUND: Amiodarone is a common intravenous medication and a known irritant to the vessel wall when administered peripherally. LOCAL PROBLEM: Nurses identified an increase in phlebitis associated with peripheral amiodarone leading to multiple catheter replacements and interruptions in drug therapy. Central venous access is recommended by the manufacturer but not practical for a short-term infusion based on the risk to the patient, time, and cost. METHODS: A 4-phased approach was used to identify a more suitable peripheral intravenous catheter. INTERVENTIONS: A collaborative effort between bedside nurses and the vascular access team evolved to look at alternative products for peripheral intravenous catheters. RESULTS: The extended dwell peripheral catheter decreased phlebitis from 54% to 5%. It also decreased interruptions in drug therapy and improved patient comfort and satisfaction. CONCLUSIONS: A practice change was implemented utilizing extended dwell peripheral catheters for intravenous amiodarone and disseminated to other units.

Effectiveness of topical interventions to prevent or treat intravenous therapy-related phlebitis: A systematic review.

AIMS AND OBJECTIVES: To evaluate the effectiveness of topical interventions in the prevention or treatment of intravenous therapy-related phlebitis. BACKGROUND: Phlebitis is a severe inflammatory reaction that can be caused by intravenous therapy with hyperosmolar drugs. Although a variety of interventions are performed in several different countries, the most efficient method is yet to be established. DESIGN: A systematic review of randomised controlled trials (RCTs) was conducted. METHODS: Following the PRISMA checklist, we conducted a literature search using seven different databases using an individual strategy adapted for each. Studies in which any topical intervention was applied to prevent or treat intravenous therapy-related phlebitis which were published between 1998 and 2019 were analysed. RESULTS: Data were collected of 13 RCTs, which in total collected data from 2,015 patients during hospital treatments with different types of intravenous therapies, such as fluid replacement, antibiotics, chemotherapy and antiarrhythmic drugs. The effectiveness of different topical interventions such as the application of nonsteroidal anti-inflammatory drugs, Sesame indicum oil, heparin sodium formulations, Chamomilla recutita tea and ointment, and Rosmarinus officinalis ointment were identified. RELEVANCE TO CLINICAL PRACTICE: Although the studies suggest a potential to use phytotherapy agents as topical interventions, pharmaceutical preparations, main substrate, and pharmaceutical or phytotherapeutic origins are very different between studies. There are insufficient data to build a solid conclusion that lead us to recommend a specific topical intervention in the prevention or treatment of intravenous therapy-related phlebitis.

Epirubicin chemotherapy in women with breast cancer: Alternating arms for intravenous administration to reduce chemical phlebitis.

OBJECTIVE: To establish whether using alternating arms for peripheral intravenous epirubicin administration affects the severity or duration of epirubicin-induced phlebitis. METHODS: An observational study of women with breast cancer (n = 237) in a UK Cancer Centre. Data were analysed after receiving three treatment cycles according to the arm used for epirubicin administration: same, alternating or mixed arm (two consecutive cycles in one arm and one in the alternate arm). Phlebitis severity was graded by clinical staff after each treatment; participants also self-reported symptoms during treatment and for up to 6 months after. RESULTS: The alternating arm group experienced significantly less severe symptoms than the other arm use groups, 6% (4 of 64) compared with 34% (p < 0.001, odds ratio: 0.13 (95% CI: 0.043-0.38) alternating arm compared with same arm group). The alternating arm group reported less pain (p = 0.013), lower overall impact (p = 0.009), lower effect on function (p = 0.032) and shorter duration of symptoms (p = 0.001) than the other arm use groups. CONCLUSION: Using alternating arms for peripheral administration of epirubicin significantly reduces the severity and duration of chemical phlebitis and is recommended to improve patient experience and reduce the need for central venous access devices.

In-Line Filtration Reduces Postoperative Venous Peripheral Phlebitis Associated With Cannulation: A Randomized Clinical Trial.

BACKGROUND: Peripheral venous cannulation is an everyday practice of care for patients undergoing anesthesia and surgery. Particles infused with intravenous fluids (eg, plastic/glass/drugs particulate) contribute to the pathogenesis of peripheral phlebitis. The aim of this study is to demonstrate the efficacy of in-line filtration in reducing the incidence of postoperative phlebitis associated with peripheral short-term vascular access. METHODS: In this controlled trial, 268 surgical patients were randomly assigned to in-line filtration and standard care (NCT03193827). The incidence of phlebitis (defined as visual infusion phlebitis [VIP] score, ≥2) within 48 hours was compared between the 2 groups, as well as the onset and severity of phlebitis and the reasons for removal of the cannula. The lifespan of venous cannulae was compared for the in-line filter and no-filter groups through a Kaplan-Meier curve. RESULTS: The incidence of phlebitis within 48 hours postoperatively was 2.2% and 26.9% (difference, 25% [95% confidence interval {CI}, 12%-36%]; odds ratio, 0.05 [0.01-0.15]), respectively, for the in-line filter and no-filter groups (P < .001). From 24 to 96 hours postoperatively, patients in the no-filter group had higher VIP scores than those in in-line filter group (P < .001). Venous cannulae in the in-line filter group exhibited prolonged lifespan compared to those in the no-filter group (P = .01). In particular, 64 (47.8%) of cannulae in the in-line filter group and 56 (41.8%) of those in the no-filter group were still in place at 96 hours postoperatively. At the same time point, patients with a VIP score <3 were 100% in the in-line filter group and only 50% for the no-filter group. In-line filtration was a protective factor for postoperative phlebitis (hazard ratio, 0.05 [95% CI, 0.014-0.15]; P < .0001) and cannula removal (hazard ratio, 0.7 [95% CI, 0.52-0.96]; P = .02). CONCLUSIONS: In-line filtration has a protective effect for postoperative phlebitis and prolongs cannula lifespan during peripheral venous cannulation in surgical patients.

Reduction of Nicardipine-Related Phlebitis in Patients with Acute Stroke by Diluting Its Concentration.

BACKGROUND: Nicardipine is frequently used in the treatment of hypertension for patients with acute stroke; however, its dosing is complicated by a high risk of phlebitis. In the present study, we examined whether restricting nicardipine concentration under a specific value could reduce the incidence of nicardipine-related phlebitis in patients with acute stroke. METHODS: Intravenous nicardipine-related phlebitis was retrospectively analyzed. From July 2015, a simple proposition was made to dilute maximum intravenous nicardipine concentration to lower than 130 µg/mL. The maximum intravenous nicardipine concentration and the incidence of phlebitis were compared between patients treated from July 2014 to June 2015 (preproposition group) and patients treated from July 2015 to June 2016 (postproposition group). RESULTS: A total of 300 patients (preproposition group, 138; postproposition group, 162) were included. The postproposition group demonstrated significantly lower maximum intravenous nicardipine concentration (in µg/mL, 76.9, 47.6-104.5 versus 130.4, 69.8-230.8; P < .001) and incidence of phlebitis (9.9%, 16/162 vs. 30%, 42/138; P < .001) than the preproposition group. Multivariable logistic regression analysis revealed that the maximum intravenous nicardipine concentration lower than 130 µg/mL (odds ratio [OR] .15; 95% confidence interval [CI] .06-.35; P < .001) and National Institutes of Health Stroke Scale on admission (OR .95; 95% CI .91-.99; P = .007) were the statistically significant independent factors for phlebitis, which indicated the usefulness of the proposition to dilute maximum intravenous nicardipine concentration to lower than 130 µg/mL. CONCLUSIONS: The simple and appropriate proposition about nicardipine administration lowered maximum nicardipine concentration and reduced the incidence of nicardipine-related phlebitis in patients with acute stroke.

Remember the risks of intravenous therapy and know how to reduce them.

Nicola Brooks, Associate Dean, Faculty of Health and Life Sciences, De Montfort University, reflects on the potential problems that can occur with the administration of intravenous therapy.

Preventing bloodstream infection in IV therapy.

Healthcare-associated infections (HAI) are one cause of preventable harm to patients, and are a clinical, political and economic concern. Vascular access, via a peripheral or central vascular device, is a routine experience for most patients receiving hospital care and is increasingly commonplace in health care at home. Because it is so common, ensuring safe vascular access is an essential focus for all health professionals. All vascular access procedures are invasive, regardless of patient group, therapeutic rationale, the device used, route and site of insertion and particular technique. As such there are inherent risks of patient harm. Many of these risks are well known and include issues such as infiltration, extravasation, phlebitis and pain. Of particular importance is the relationship between intravenous (IV) therapy and infection and how best to prevent HAI, specifically in relation to IV therapy, bloodstream infections, catheter-related bloodstream infections and central-line associated blood stream infections. This article considers the interrelationship between IV therapy bloodstream infections and measures to prevent HAI and summarises key principles in this ongoing endeavour.

Peripheral IV Site Rotation Based on Clinical Assessment vs. Length of Time Since Insertion.

The difference in complication rates for phlebitis and infiltration between peripheral intravenous site rotation based on clinical assessment versus length of time since insertion was evaluated. Evidence was generated for a policy change that will impact the quality of patient care.

Devices and dressings to secure peripheral venous catheters to prevent complications.

BACKGROUND: A peripheral venous catheter (PVC) is typically used for short-term delivery of intravascular fluids and medications. It is an essential element of modern medicine and the most frequent invasive procedure performed in hospitals. However, PVCs often fail before intravenous treatment is completed: this can occur because the device is not adequately attached to the skin, allowing the PVC to fall out, leading to complications such as phlebitis (irritation or inflammation to the vein wall), infiltration (fluid leaking into surrounding tissues) or occlusion (blockage). An inadequately secured PVC also increases the risk of catheter-related bloodstream infection (CRBSI), as the pistoning action (moving back and forth in the vein) of the catheter can allow migration of organisms along the catheter and into the bloodstream. Despite the many dressings and securement devices available, the impact of different securement techniques for increasing PVC dwell time is still unclear; there is a need to provide guidance for clinicians by reviewing current studies systematically. OBJECTIVES: To assess the effects of PVC dressings and securement devices on the incidence of PVC failure. SEARCH METHODS: We searched the following electronic databases to identify reports of relevant randomised controlled trials (RCTs): the Cochrane Wounds Group Register (searched 08 April 2015): The Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 3), Ovid MEDLINE (1946 to March 7 2015); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, March 7 2015); Ovid EMBASE (1974 to March 7 2015); and EBSCO CINAHL (1982 to March 8 2015). SELECTION CRITERIA: RCTs or cluster RCTs comparing different dressings or securement devices for the stabilisation of PVCs. Cross-over trials were ineligible for inclusion, unless data for the first treatment period could be obtained. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies, assessed trial quality and extracted data. We contacted study authors for missing information. We used standard methodological procedures expected by Cochrane. MAIN RESULTS: We included six RCTs (1539 participants) in this review. Trial sizes ranged from 50 to 703 participants. These six trials made four comparisons, namely: transparent dressings versus gauze; bordered transparent dressings versus a securement device; bordered transparent dressings versus tape; and transparent dressing versus sticking plaster. There is very low quality evidence of fewer catheter dislodgements or accidental removals with transparent dressings compared with gauze (two studies, 278 participants, RR 0.40; 95% CI 0.17 to 0.92, P = 0.03%). The relative effects of transparent dressings and gauze on phlebitis (RR 0.89; 95% CI 0.47 to 1.68) and infiltration (RR 0.80; 95% CI 0.48 to 1.33) are unclear. The relative effects on PVC failure of a bordered transparent dressing and a securement device have been assessed in only one small study and these were unclear. There was very low quality evidence from the same single study of less frequent dislodgement or accidental catheter removal with bordered transparent dressings than securement devices (RR 0.14, 95% CI 0.03 to 0.63) but more phlebitis with bordered dressings (RR 8.11, 95% CI 1.03 to 64.02) (very low quality evidence). A small single study compared bordered transparent dressings with tape and found very low quality evidence of more PVC failure with the bordered dressing (RR 1.84, 95% CI 1.08 to 3.11) but the relative effects on dislodgement were not clear (very low quality evidence). The relative effects of transparent dressings and a sticking plaster have only been compared in one small study and are unclear. More high quality RCTs are required to determine the relative effects of alternative PVC dressings and securement devices. AUTHORS' CONCLUSIONS: It is not clear if any one dressing or securement device is better than any other in securing peripheral venous catheters. There is a need for further, independent high quality trials to evaluate the many traditional as well as the newer, high use products. Given the large cost differences between some different dressings and securement devices, future trials should include a robust cost-effectiveness analysis.

[Reducing the Incidence of Phlebitis Related to Intravenous Injection in Pediatric Patients].

BACKGROUND & PROBLEMS: Peripheral venous catheter (PVC) is commonly used to provide nutrition and medicine to pediatric inpatients. Phlebitis is a common side effect of PVC insertion. Over 90% of pediatric patients in the paedi-atric medical ward at the Chang Gung Memorial Hospital (CGMH) receive PVC insertion, with an incident rate of phlebitis of 5.07%. Common cause factors of phlebitis are: insufficient sterilization time, inappropriate methods used to fix the PVC, the use of fixtures that loosen easily, high re-fix rates, and inadequate wound care after catheter removal. PURPOSE: The purpose of this project was to reduce the incidence rate of PVC-insertion-related phlebitis in children from 5.07% to 2.5%. RESOLUTION: A one-week clinical observation identified the re-inserting / re-fixing of existing PVCs as the principal cause of phlebitis in the CGMH paediatric ward. Therefore, the researchers modified the catheter care bundle based on a review of the literature and the suggestions of clinical pediatric experts. Modifications included applying 2% chlorhexidine to sterilize the insertion site; using a new, non-woven fabric splint to fix the PVC site; providing cartoon-themed waterproof dressings for the first bath after the removal of the PVC; and setting standard operating procedures (SOPs) for PVC insertion and catheter removal. RESULTS: After applying these modifications, the incident rate of phlebitis in children with PVC insertions decreased from 5.07% to 2.08%. CONCLUSIONS: The application of 2% chlorhexidine reduces the waiting time for sterilization; the purpose-designed splint strengthens the fixation of the PVC; and the development of the SOPs for PVC insertion and post-removal catheter care reduces the risk of phlebitis. The combination of these strategies effectively reduces the incidence of phlebitis and improves the nursing care quality.

The Effectiveness of Clinically Indicated Replacement of Peripheral Intravenous Catheters: An Evidence Review With Implications for Clinical Practice.

BACKGROUND: Current clinical guidelines from the Centers for Disease Control and Prevention (CDC; 2011) state that peripheral intravenous catheters are to be replaced every 72-96 hr to prevent infection and phlebitis in the adult patient. It is unclear whether this practice reduces the incidence of phlebitis or other infections. AIM: The aim of this study was to examine levels I and II evidence to determine if replacing peripheral intravenous catheters only when clinically indicated compared to every 72-96 hr increases the adult patient's risk for infection or phlebitis. METHODS: The following patient or population, intervention, comparison, outcome question was used to search the literature databases PubMed, ClinicalKey, ProQuest, Ovid SP, and CINAHL: In the adult patient requiring a peripheral vascular catheter (P), does replacing the catheter only when clinically indicated (I) compared to replacing the catheter every 72-96 hr (C) increase the occurrence of phlebitis and infection (O)? A set of specific search criteria along with critical appraisal tools was used to identify relative studies. RESULTS: Four level II randomized controlled trials with no less than 155 subjects, and two level I meta-analyses reviewing a total of 13 research studies indicated that the replacement of peripheral intravenous catheters only when clinically indicated does not increase patient risk of phlebitis or infection when compared to the current practice of routine replacement between 72 and 96 hr in the adult patient population. LINKING EVIDENCE TO ACTION: The current practice of replacing peripheral intravenous catheters every 72-96 hr does not decrease the incidence of phlebitis or infection when compared to replacing catheters when clinically indicated in the adult population. By translating this research into current practice, healthcare costs and nursing care time will decrease, and unnecessary invasive procedures would be eliminated thereby increasing patient safety and satisfaction.

IV cannula securement: protecting the patient from infection.

The use of venous cannulas to administer intravenous therapy is a common clinical intervention within the hospital setting. Once in situ, IV cannulas must be securely fixed in order to prevent their movement or displacement; as unsecured cannulas pose significant health risks, such as mechanical phlebitis and an increased risk of infection. This article explores some of the complications associated with inappropriately secured IV cannulas, along with a discussion on common securement devices.

[Methods of preventing phlebitis induced by infusion of fosaprepitant].

At our hospital, we use aprepitant for nausea and vomiting when administering highly emetic anticancer agents, according to "Guidelines for the Appropriate Use of Antiemetic Agents" given by the Japan Society of Clinical Oncology. We initiated the intravenous administration of fosaprepitant for better compliance compared with aprepitant; however, we observed phlebitis after the infusion of fosaprepitant. Therefore, we investigated measures to reduce phlebitis associated with the infusion of fosaprepitant. For the first premedication, fosaprepitant (150 mg) was dissolved in 100 mL of saline and administered for 30 minutes; 1 of 2 patients showed grade 4 phlebitis. For the modified premedication, fosaprepitant, dexamethasone, and 5- HT(3) antagonist were dissolved in 100 mL of saline and administered for 30 minutes. The modified premedication was administered to a total of 27 patients; 5 patients developed mild phlebitis (grade 1), but infusion could be continued by treating their phlebitis with a hot pack. We used a combination of dexamethasone and 5-HT(3) antagonist with fosaprepitant as a modified premedication in order to avoid drug-induced vascular damage, which resulted in the pH decreasing to 6.20-7.55 (close to neutral) and a shorter infusion time.

[Risk Factors for Oxaliplatin-Induced Phlebitis and Venous Pain, and Evaluation of the Preventive Effect of Preheating with a Hot Compress for Administration of Oxaliplatin].

Venous pain induced by oxaliplatin(L-OHP)is a clinical issue related to adherence to the Cape OX regimen. To prevent LOHP- induced venous pain, we provided nursing care to outpatients who were administered a preheated L -OHP diluted solution using a hot compress. We retrospectively evaluated the risk factors for colorectal cancer patients who had L -OHP induced phlebitis and venous pain. Furthermore, the preventive effect of nursing care was compared between inpatients and outpatients from January 2010 to March 2012. At the L-OHP administration site, any symptoms were defined as phlebitis, whereas pain was defined as venous pain. A total of 132 treatment courses among 31 patients were evaluated. Multivariate logistic regression analysis revealed that both phlebitis and venous pain were significantly more common in female patients (adjusted odds ratio, 2.357; 95%CI: 1.053-5.418; and adjusted odds ratio, 5.754; 95%CI: 2.119-18.567, respectively). The prevalence of phlebitis and venous pain did not differ between inpatients and outpatients (phlebitis, 61.3% vs 67.7%; venous pain, 29.0%vs 19.4%). These results suggest that administration of L-OHP via a central venous route should be considered in female patients.

[Effect of pharmacotherapy on course of postoperative period after endovenous thermal ablation].

The authors assessed the effect of a micronized purified flavonoid fraction (MPFF) on the course of the postoperative period after endovenous thermal ablation (EVTA). The patients of the Study Group matching by the main studied parameters to the Control Group patients were given the MPFF according to the suggested regimen for 7 days. The obtained results were analysed by means of questionnaires (CIVIQ, VCSS, VAS) and ultrasound angioscanning. The obtained findings were statistically processed by means of the program Statistica 6.0 and reliability of the results was assessed with the help of the Student t-test. Patients of the both groups showed complete stable obliteration of the target veins. No statistically significant differences of the items of the questionnaires CIVIQ and VCSS at the beginning of the study and at the last examination were revealed, differences were noted on days 2-14 after EVTA and were not statistically significant (p>0.05). Phlebotrophic therapy in the postoperative period after EVTA helps to decrease phlebitic alterations in the coagulated vein, to improve motor activity and mental psychoemotional state of the patients.

Aloe vera for prevention and treatment of infusion phlebitis.

BACKGROUND: Up to 80% of hospitalised patients receive intravenous therapy at some point during their admission. About 20% to 70% of patients receiving intravenous therapy develop phlebitis. Infusion phlebitis has become one of the most common complications in patients with intravenous therapy. However, the effects of routine treatments such as external application of 75% alcohol or 50% to 75% magnesium sulphate (MgSO4) are unsatisfactory. Therefore, there is an urgent need to develop new methods to prevent and alleviate infusion phlebitis. OBJECTIVES: To systematically assess the effects of external application of Aloe vera for the prevention and treatment of infusion phlebitis associated with the presence of an intravenous access device. SEARCH METHODS: The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator (TSC) searched the Specialised Register (last searched February 2014) and CENTRAL (2014, Issue 1). In addition the TSC searched MEDLINE to week 5 January 2014, EMBASE to Week 6 2014 and AMED to February 2014. The authors searched the following Chinese databases until 28 February 2014: Chinese BioMedical Database; Traditional Chinese Medical Database System; China National Knowledge Infrastructure; Chinese VIP information; Chinese Medical Current Contents; Chinese Academic Conference Papers Database and Chinese Dissertation Database; and China Medical Academic Conference. Bibliographies of retrieved and relevant publications were searched. There were no restrictions on the basis of date or language of publication. SELECTION CRITERIA: Randomised controlled trials (RCTs) and quasi-randomised controlled trials (qRCTs) were included if they involved participants receiving topical Aloe vera or Aloe vera-derived products at the site of punctured skin, with or without routine treatment at the same site. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted the data on the study characteristics, description of methodology and outcomes of the eligible trials, and assessed study quality. Data were analysed using RevMan 5.1. For dichotomous outcomes, the effects were estimated by using risk ratio (RR) with its 95% confidence interval (CI). For continuous outcomes, mean differences (MD) with 95% CIs were used to estimate their effects. MAIN RESULTS: A total of 43 trials (35 RCTs and eight qRCTs) with 7465 participants were identified. Twenty-two trials with 5546 participants were involved in prevention of Aloe vera for phlebitis, and a further 21 trials with 1919 participants were involved in the treatment of phlebitis. The included studies compared external application of Aloe vera alone or plus non-Aloe vera interventions with no treatment or the same non-Aloe vera interventions. The duration of the intervention lasted from one day to 15 days. Most of the included studies were of low methodological quality with concerns for selection bias, attrition bias, reporting bias and publication bias.The effects of external application of fresh Aloe vera on preventing total incidence of phlebitis varied across the studies and we did not combine the data. Aloe vera reduced the occurrence of third degree phlebitis (RR 0.06, 95% CI 0.03 to 0.11, P < 0.00001) and second degree phlebitis (RR 0.18, 95% CI 0.10 to 0.31, P < 0.00001) compared with no treatment. Compared with external application of 75% alcohol, or 33% MgSO4 alone, Aloe vera reduced the total incidence of phlebitis (RR 0.02, 95% CI 0.00 to 0.28, P = 0.004 and RR 0.43, 95% CI 0.24 to 0.78, P = 0.005 respectively) but there was no clear evidence of an effect when compared with 50% or 75% MgSO4 (total incidence of phlebitis RR 0.41, 95% CI 0.16 to 1.07, P = 0.07 and RR 1.10 95% CI 0.54 to 2.25, P = 0.79 respectively; third degree phlebitis (RR 0.28, 95% CI 0.07 to 1.02, P = 0.051 and RR 1.19, 95% CI 0.08 to 18.73, P = 0.9 respectively; second degree phlebitis RR 0.68, 95% CI 0.21 to 2.23, P = 0.53 compared to 75% MgSO4) except for a reduction in second degree phlebitis when Aloe vera was compared with 50% MgSO4 (RR 0.26, 95% CI 0.14 to 0.50, P < 0.0001).For the treatment of phlebitis, Aloe vera was more effective than 33% or 50% MgSO4 in terms of both any improvement (RR 1.16, 95% CI 1.09 to 1.24, P < 0.0001 and RR 1.22, 95% CI 1.16 to 1.28, P < 0.0001 respectively) and marked improvement of phlebitis (RR 1.97, 95% CI 1.44 to 2.70, P < 0.001 and RR 1.56, 95% CI 1.29 to 1.87, P = 0.0002 respectively). Compared with 50% MgSO4, Aloe vera also improved recovery rates from phlebitis (RR 1.42, 95% CI 1.24 to 1.61, P < 0.0001). Compared with routine treatments such as external application of hirudoid, sulphonic acid mucopolysaccharide and dexamethasone used alone, addition of Aloe vera improved recovery from phlebitis (RR 1.75, 95% CI 1.24 to 2.46, P = 0.001) and had a positive effect on overall improvement (marked improvement RR 1.26, 95% CI 1.09 to 1.47, P = 0.0003; any improvement RR 1.23, 95% CI 1.13 to 1.35, P < 0.0001). Aloe vera, either alone or in combination with routine treatment, was more effective than routine treatment alone for improving the symptoms of phlebitis including shortening the time of elimination of red swelling symptoms, time of pain relief at the location of the infusion vein and time of resolution of phlebitis. Other secondary outcomes including health-related quality of life and adverse effects were not reported in the included studies. AUTHORS' CONCLUSIONS: There is no strong evidence for preventing or treating infusion phlebitis with external application of Aloe vera. The current available evidence is limited by the poor methodological quality and risk of selective outcome reporting of the included studies, and by variation in the size of effect across the studies. The positive effects observed with external application of Aloe vera in preventing or treating infusion phlebitis compared with no intervention or external application of 33% or 50% MgSO4 should therefore be viewed with caution.