Veterinary Vertex
Veterinary Vertex is a weekly podcast that takes you behind the scenes of the clinical and research discoveries published in the Journal of the American Veterinary Medical Association (JAVMA) and the American Journal of Veterinary Research (AJVR). Tune in to learn about cutting-edge veterinary research and gain in-depth insights you won’t find anywhere else. Come away with knowledge you can put to use in your own practice – along with a healthy dose of inspiration to remind you what you love about veterinary medicine.
Veterinary Vertex
Navigating IV Catheter Complications in Cats
What are the hidden risks of IV catheter complications in hospitalized cats, and how can we better manage them? Join us as we explore these critical questions with Dr. Kyle Granger, ECC resident at Colorado State University, who shares groundbreaking insights from his recent JAVMA article. Learn how smaller gauge catheters and greater body weights substantially elevate complication risks and why adopting human phlebitis grading scales could revolutionize veterinary catheter protocols. Discover the practical challenges veterinarians face when placing IV catheters in cats with difficult venous access and gain actionable advice on educating your staff to identify and manage these issues more effectively.
Feline JAVMA article: https://doi.org/10.2460/javma.23.12.0717
Canine JAVMA article: https://doi.org/10.2460/javma.23.05.0293
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Speaker 2:You are listening to Veterinary Vertex, a podcast of the AVMA Journals. In this episode we chat about how smaller gauge catheters and greater body weights are associated with increased risk of peripheral intravenous catheter complications in cats hospitalized in the critical care unit. With our guest, kyle Granger.
Speaker 3:Welcome to Veterinary Vertex. I'm Editor-in-Chief Lisa Fortier, and I'm joined by Associate Editor Sarah Wright. Today we have Kyle joining us. Kyle, thank you so much for taking time out of your very busy schedule to be with us here today.
Speaker 4:Anytime Happy to be here with you guys. Hello, I'm Kyle. I'm one of the ECC residents at the Colorado State University.
Speaker 3:Go Rams 1991.
Speaker 2:I should have known that was coming. I was waiting for it. Let's discover the impact of catheter size and body weight on IV catheter complications in cats. So, kyle, your JAVMA article discusses how smaller gauge catheters and greater body weights are associated with increased risk of peripheral intravenous catheter complications in cats hospitalized in the critical care unit. Can you share with our listeners the background on the study?
Speaker 4:Yeah, so in terms of like the background, there's absolutely a bare minimum of information out there about IV catheters in veterinary medicine, so cats and dogs predominantly.
Speaker 4:And when you look at human medicine, human medicine has, like all these guidelines for preserving catheters, wrapping catheters, monitoring catheters, and the nurses are very heavily involved in how we define catheter complications, and so there was only a few studies performed in veterinary medicine, and it just so happened that the previous study about IV catheter complications in cats and dogs was published by one of the authors on the paper, dr Zersen, kristen Zersen and Simpson, and so for both of those studies that they performed, they were finding all these different things.
Speaker 4:But when we look at the literature, there's not really a good catheter protocol that's detailed and assesses like what are the risks associated with a catheter protocol that's detailed and assesses like what are the risks associated with the catheter complication and things like that. And so when I came into my residency project, while it was like one of the things that gets assigned to you, I also have a list, like a giant list, of just research topics and ideas, and catheter complications was one of them, and so I was just like I'm very excited to actually participate in this, and from there it just kind of grew and took off. And then I had to separate it out into two studies because I was just like let's do all these things. And here we are.
Speaker 2:Yeah, it's awesome. It always starts like that. You're like, oh, I want to do all the things and you're like, wait, what can I accomplish in this one project? Like to create the one with these scripts, and then, yeah, stents and other things. But it's a really timely topic and important for clinicians to. Obviously no one likes placing IV catheter in cats. Maybe there are some people, but they're just so hard and their veins are so small, so I think it's really so tiny and, as you point out in this manuscript, though, you know it might be easier to do the smaller catheter, but maybe it's not always.
Speaker 4:You know the best, so I think this is, again, really important information for our listeners. So, that being said, what were some of the pivotal findings from this study? So, ironically enough, like isn't the title, and I wish that I could have named it something cool, you know, but I feel like it is like straight up front. You know, the smaller catheter gauge sizes as well as the increasing body weights in cats were the most prominent statistical findings. But, personally, like, the education of the nurses and the remaining staff when they were detecting and classifying phlebitis was a really big impact, because a good portion of catheters are always just removed because they say, oh, it's phlebitis, but we've never actually put a definition on what phlebitis is or grading system, rather on what phlebitis is and how it impacts when the catheter needs to be moved. And we just adopted the human kind of grading scale to our studies and it seemed to work out pretty well because they were sending me pictures of the catheters, just like I would grade this a grade four. I or I was like, oh my god, that's so cute.
Speaker 4:Yes, remove the catheter, uh, so it was quite interesting. It's more of a personal note on the personal knowledge of, like, the technicians, the nurses, the veterinary assistants, everyone involved in the study. It was really helpful for them to understand why a catheter would need to be moved or why it wasn't an issue that there was maybe a little bit of redness at the site. So that was personally my favorite. But smaller catheter gauges and increasing body weight yeah.
Speaker 3:Do you, kyle, when you, when the fat cat comes in, do you? Does everybody run for the hills? Or like, does somebody really want to tackle these?
Speaker 4:Kyle steps up and he's like I'll do that Usually actually the nurses here at Colorado, colorado state university. They're actually quite adept at getting catheters in like the over lease. I call them sexy succulent patients. They they are really good at finding the veins and making sure the catheter like stays put, and so we didn't have actually have that issue. But when a student was trying to do it in a fat cat not so long ago I did like I can step in and do it. It's fine, and I can show you the tricks and the tips for how to place the catheter because I've placed so many of them so as a doctor. That's rare. You'll rarely find like a doctor stepping in to do a catheter and I think that that was also something that I learned is the best techniques to perform catheter placement in cats and dogs.
Speaker 3:Yeah, the nurses are amazing, aren't they? Yes, I'm also very impressed that you kept good enough records to do this study. I think that's a real kudos to your whole team and your interest in IV catheter.
Speaker 4:Complications in cats oh yeah, if you ask anybody here, I love Excel. I am like a Excel Google Sheets kind of just like. Oh gosh, I love it so much. And so when collecting all the information we have, like the paper, that was easy for the nurses on the floor, especially like after hours and everything, where they would fill out those data collection forms and then they would just place them at my desk and then I would go through and type them in and I had to create a system for myself in order to make sure that they got in on time, otherwise I'd be like who was this patient? And I would have to go back, look at their records and everything and grab all that data. So it was definitely a process, but it was well worth it, because now we have, like this pretty good information out there for most clinicians to know, like if you have a smaller catheter gauge, but also if they are a bigger cat, you probably will find that they'll experience some catheter complications throughout hospitalization yeah, really great information.
Speaker 3:You clearly have a passion for this. What, when, did this start your research interest and what sparked your interest in IV catheter? Complications in cats.
Speaker 4:So it actually started during my rotating internship, where I saw that they were routinely replacing catheters, like every 72 hours, and when they would do that, I would look at the patients and go, but the catheter was working, but it's our protocol, so why is it our protocol?
Speaker 4:I would look at the patients and go, but the catheter was working, but it's our protocol, so why is it our protocol? And it was based off of the human paper in like, I think, 2009, where they found that bacterial phlebitis was more associated with capillary complications beyond 72 hours. But recent literature just displaces that after I looked it up, and so I couldn't find any of the information in veterinary medicine and I had always wanted to do something related to just the instruments in veterinary medicine, because there's not much about the things that we use in veterinary medicine out there. And sure enough I came in. They were like this is your project. I was like, oh, my goodness, you read my mind. This is amazing. So I decided that, yeah, this was the place for me and that's how pretty much it all got started, and it's still a to be continued.
Speaker 3:That's fantastic.
Speaker 4:This next question is a little bit self-serving, but why did you choose to submit this very clinically important manuscript to JAVMA? We actually published a similar paper in JAVMA about dogs, and so it's more so that JAVMA does reach a wider audience, for, like the general practitioners too, as well as like the ER doctors and everything, and so while it is a catheter complication study in the critical care unit, it likely can be applied across the board for most patients, and we wanted to get the catheter protocol out there so that people knew exactly like what we were using here and why we saw fewer complications throughout their hospitalization. But now they have a pairing, so now you can find both cats and dogs via just one site, and I think that really helps for remembering where to find this information. And if we have it in one local hub, then by all means it works out better for everybody.
Speaker 3:Yeah, we really have a passion for bringing clinically important manuscripts to our Jabha readers. So thank you again, again, anytime. Kyle, earlier you mentioned to Sarah what you thought were some of the pivotal findings of your manuscript, but every time we do a study we're surprised by something. What surprised you in this study?
Speaker 4:So in our dogs paper about dogs with catheter complications, we found that the higher their Apple score was beyond 35, was pretty strongly correlated with the likelihood that they will have a catheter complication. And the Apple score is one of the many scoring systems in veterinary medicine that can help determine, like, how severely impacted this patient is, so their physiologic status at the time of admission or within the first 24 hours, and they use a bunch of different kind of clinical pathologic parameters but also physical exam parameters, and in the CATS paper we just didn't find it and we aren't sure exactly like why that difference exists. They do use different parameters in cats and dogs for the Apple score, but if they are sick then I would expect them to continue to have a higher Apple score and then experience more complications. But cats just don't read the book ever, and so it's one of those things of does it just coincide with history repeating itself? Of, yeah, cats don't read the textbook. So even if they are at their sickest don't read the textbook.
Speaker 4:So even if they are at their sickest, do we actually think that they will have a catheter complication? We don't know, but according to our study and the Apple scores that we did attain. Nah, and I thought that that was very, very interesting. That was a pivotal part of just like no, I did something wrong, my steps must be wrong, and I reanalyzed it a couple times before actually getting on moving over it, and so reanalyzed it a couple of times before actually getting on moving over it, and so I think that was probably the most surprising thing, and also how much time I had to dedicate to it. But hey, here we are.
Speaker 3:Yeah, I see more manuscripts coming like reassessing Apple score and what goes into it and what are the big parameters. Because maybe it just levels everything out if there's too many components going in. Because maybe it just levels everything out if there's too many components going in, yeah, what?
Speaker 4:are the next steps in your research into IV catheter complications.
Speaker 4:So I think that, from my standpoint, we have some literature out there for the peripheral IV catheter studies, but we don't really talk about like central catheters all that much and there's just a couple of papers, some produced with Silverstein as an author, but we haven't fully fleshed out or explored that either.
Speaker 4:As well as like arterial catheters, we don't talk about those much in veterinary medicine and I know that they can be routinely placed under anesthesia for procedures. And so what is the likelihood that a catheter complication can occur with an arterial catheter, especially like in the healthy versus non-healthy dogs? And that's a pretty good one, because we typically believe that the arterial catheters are prone to having dislodgement or malfunctions, like immediately after anesthesia, once they get into the critical care unit. But is it because of how we wrap those catheters? Is it because of phlebitis? Is it because of extravasation? We don't know. And so exploring those two catheters, those two types of catheters, will be extremely helpful in determining like, do we place these catheters early, do we secure them differently, do we use a different securing technique? And I think that that's the next step, especially for me.
Speaker 3:That's awesome, kyle. Ai is everywhere. Artificial intelligence Do you see a role for AI in helping you understand IV catheter complications?
Speaker 4:I don't think so, and here's why.
Speaker 4:And it's mostly because catheters required a great bit of just observation throughout the study, and so we have to like observe them, feel them, because most of the complications associated with like probitis uses a great deal of like oh, is there retinas at the side, do they have like a palpable venous, like vein there, and as well as, is it hot to the touch?
Speaker 4:And so it will be really difficult for AI to incorporate themselves into that. However, on the flip side, when it comes to the clinical signs as well as like bloodwork abnormalities and using those scoring systems, if we do find that with those central arterial line catheter studies in the future that those scoring systems are very applicable, such as the case for, like our dogs with peripheral IV catheter complications, then AI could probably like we type in our stuff and then it'll probably spit out like ooh, you should probably put like a central line in this one, or ooh, you should probably estimate for more than one catheter on your estimate to the owner. So that way those costs are accounted for earlier on, at the very beginning of their hospitalization. So from a data analytics standpoint, absolutely, but from an actual, can we detect the catheter complication with AI? Probably not.
Speaker 2:That's a good distinction and also just really good information to think about for the future and for those of you just joining us. We're discussing IV catheter complications in cats with our guest Kyle Granger. So, kyle, as you said, you're an ACC resident at Colorado State. How has your advanced training prepared you to write this manuscript?
Speaker 4:We review so many manuscripts in our like journal club as well as like our board review, and so we are constantly looking at what do we look for in a paper, how do we write it to convey like accurately what we want to convey. And I think that that was that's really helpful, because in the beginning I can tell you like the first one was like a rough start, but then the second one was like so much easier to write because I just I just knew what I was looking for and I knew what I wanted to convey. And plus, like my co-authors, my mentors, they were also a pretty big help in developing the manuscript, because on the first one, with the dogs, one of the Zersen, she's very detail oriented. She went through every single reference that I had in the paper and was like how did you find this information? I don't even have access to this PDF. And I was like here it is. And then she would say, oh, I get what you're trying to say, but how about we rephrase it?
Speaker 4:As well as my other mentor, dr Q, who had a lot of inside information about the catheter complications in cats and papers that have been published, and she said you know, I don't think we can talk about their catheter protocols I know what it is but at the same time, we can't really directly compare them because they didn't write it in their papers and so I think that both of them, plus all of the reviewing and everything that we do on like a weekly basis, has been extremely helpful in determining, like, what's important in a paper and what's just oversaturating the market.
Speaker 2:Sounds like you have some great mentors, oh yeah. Now this next set of questions is going to be really important for our listeners. Now this next set of questions is going to be really important for our listeners.
Speaker 4:What is one piece of information the veterinarian should know before discussing IV catheter complications with a client catheters do not need to be routinely replaced and you can elect to replace them on a clinically indicated manner. That is probably the most important thing that I can pull from both papers is that dogs and cats in our papers had catheters in for longer than like 10 days did not see any signs of phlebitis infection or anything associated with it in both of those papers, and so the likelihood that you know I need to change this every single day or every three days is an old school way of thinking, and even in human medicine they rewrote the guidelines to say that in children you can change that to a on a clinically indicated manner, and I think that very much directly applies to veterinary medicine. Just from these two studies alone, and especially for for cats, because no one wants to wrangle a cat in order to get another catheter in. So if you can leave it alone, just leave it alone.
Speaker 2:I just have to say I wonder if that change would like decrease the incidence you know of, like cat bites or injuries or scratches absolutely, if we leave them alone they'll probably be okay yeah, so just since we you said you do do like a lot of journal clubs and obviously you're an ECC resident, so you're very well versed in the literature have you found anything about like how often like routine IV catheter maintenance should be performed? I remember during my internship we had flow sheets and be like every 24 hours you had to highlight the box for IV catheter maintenance to make sure you know everything was going well with it. But is there any evidence behind that?
Speaker 4:nope, none out there. Um, and that is something they're actually still exploring in human medicine and in veterinary medicine. We don't have much information about that. But I can say from personal experience in doing this study for cats unless, like the like catheter wrap and everything that you have associated, whatever your catheter bundle that you're using, if that is soiled then by all means that's the time to change it. But if it looks okay, it's flushing, okay, you're not getting like signs from your IV pump or IV infuser that you know this is occluded or you should probably check the catheter, then it's likely that it's a-okay and we don't have to unwrap it. But also we use the transparent dressing or the tegaderms and just honestly flipping it back, flipping the vet wrap and the cotton wrap back and looking directly at that insertion site, was extremely helpful and made really checking those catheters a lot easier. And so if that's the case, then it depends, Whatever your securing bundle you're using, try to throw one of those transparent bandages in there.
Speaker 4:It keeps the insertion site kind of clean and dry, but also it gives you the opportunity to check that insertion site quite readily and change the bandages only when it's soiled or if they. Yeah, well, it's a cat, so you know they'll probably drag it through their own poop and litter and you're just like great. I got to change it now, and that can also apply for dogs, when they just decide to pee on their catheter wrap. So hey, here we are, but only change it when it's needed and just. We can leave the patients alone a lot more and they can feel more comfortable and acclimate to the hospital environment a lot more if we can give them the time to do so, without constantly interrupting their sleep to do these catheter changes and things like that.
Speaker 2:Great, thank you. Then, on the other side of the relationship, what's one thing clients should consider around IV catheter complications in cats.
Speaker 4:So sometimes cats, they will experience like a little bit of redness or some residual inflammation at the site of the IV catheter. Especially if they're over grooming the area, it can be irritating. Yes, there's also a little bit of that like ton of medical tape adhesive that can be there and they're trying to get it off, but it's just so close to the site itself that it starts to irritate it. And so if you just simply like clean the area with like a warm rag and then especially if they're like excessively licking the area, then everything will be a-okay. But if you see that swelling getting worse or anything like that, then bring them in so that we can re-inspect that site.
Speaker 4:I had that happen and it was outside of the study. So after the study period was over I had one cat who came in and they had a pretty nice like kind of area of just swelling. The cat did not care that it was there, but we put an e-collar on them and then said, like let's just clean the area like once or twice a day, and then after about 48 hours it cleared up. And so sometimes we just need to make sure that the owners are aware that even though the catheter is removed, they still feel something in that area, so don't let them over groom the area and try to keep the area dry and clean as much as possible.
Speaker 3:That way we can avoid a revisit to the ER for things that could just be managed at home. That sounds like a good thing for a telemedicine visit instead of bringing the cat back. Yes, and as we wind down, kyle, we have a little bit of time left, so we usually ask one of these few questions. I'm going to ask you two of them because we have time. When you begin a puzzle, do you start with the inside or do you do the exterior border pieces first?
Speaker 4:Neither. If there is a matching piece that I see, like almost instantaneously, I usually just put that together and then I try to match the pieces simultaneously. I usually just put that together and then I try to match the pieces and then I try to work, and I guess, like in this fashion, I work from the inside out to the borders, because the borders are usually easy for me to find. The I mean, the edges of the puzzle pieces are probably flat, so I just put those towards the edge and I don't care about them, and so it's. I make the matches first and then I move outwardly, but my brain is just so spastic. I like to say that ultimately, I piece them together in various ways, and so it's never the same way with a puzzle. I can tell you that.
Speaker 3:We've never gotten that answer before. We were trying to group by phenotype, so surgeons went on the outside medicine and general clinicians were in the inside. We're not so you. You're sporadic across the span, the span, the divide. The other question, kyle what's your favorite animal fact?
Speaker 4:I have several, but my favorite one is that everyone knows the sloth is so slow and it extends to like their entire metabolism and digestive tract too, because it takes them nearly a month to digest one leaf. One leaf, it's kind of heinous. Like you can speed it up a little bit, you know that's crazy.
Speaker 2:I love that question because it's always so fun. Everyone always talks about a different species, so it's like a really fun way to learn too. I'm ready for like a trivia night now. Invite me. Thank you again, Kyle. We appreciate you being here with us today and for submitting your manuscript to JAVMA.
Speaker 4:Anytime and happy to contribute to the literature, and thank you guys for allowing me to be interviewed, but also for having this podcast. I listen to it quite readily whenever it's there, because it gives me a quick synopsis of the paper and it's really helpful. So thank you guys for doing this and thank you for being there for us, as clinicians, to publish these papers.
Speaker 2:And to our listeners. You can read Kyle's article and print Javma or online using your favorite search engine. I'm Sarah Wright with Lisa 48. We want to thank each of you for joining us on this episode of the veterinary vertex podcast. We love sharing cutting edge veterinary research with you and we want to hear from you. Be sure to leave us a rating and review on Apple podcasts or whatever platform you listen to.
