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Phlebitis

Submitted by Paula Wallis, IVNNZ Inc. Educator 2003 - 2005. Originally printed in IVNNZ Inc. Newsletter

Phlebitis is a complication that is frequently associated with IV therapy. A number of literature articles have written that phlebitis can occur in as much as 25-70% of patients.
Phlebitis is defined as the acute inflammation of the internal lining of the vein (Infusion Nursing Standards of Practice, 2000). Phlebitis is characterised by pain and tenderness along the course of the vein, redness and swelling and warmth can be felt at the insertion site.
There are a number of factors that can contribute to and increase the risk of phlebitis.

These factors include:

  • The infusion of drugs or solutions that are acidic or alkaline or have a high osmolarity
  • Trauma to the vein during insertion
  • Insertion into a vein that is too small
  • Using a vascular access device that is too big for the vein
  • Extended dwell time of the same IV site
  • Type of catheter material used
  • Patients history and present condition
  • Condition of the veins
  • Cannula stabilisation
  • Skin preparation/infection control
  • Frequency of dressing change

Phlebitis can be classified into three categories:

  • Mechanical
  • Chemical or infusion
  • Bacterial

Mechanical phlebitis occurs when the size of the cannula is too big for the selected vein causing unnecessary friction on the internal lining of the vein leading to inflammation. This type of phlebitis can be avoided by doing a thorough assessment of the patient prior to inserting an IV device and following the rule of selecting the smallest device for the largestvessel. Correct and adequate stabilisation of the cannula can prevent unnecessary movement of the line therefore preventing the friction from occurring. When manipulation of the cannula is reduced the risk of inflammation is also reduced. This type of phlebitis is commonly seen with PICC lines.

Chemical phlebitis is most commonly seen with peripheral IV devices when medications or solutions irritate the endothelial lining of the small peripheral vessel wall. The lower or higher the Ph of the medication or solution, the greater the risk of phlebitis occurring. The same occurs if there is an increase in the tonicity of a medication or solution. Chemical phlebitis is a rare occurrence in central venous catheters due to the larger size of the vessel and the increased blood volume through these vessels. Medications which have been incorrectly diluted or mixed result in particulate matter being infused; particulate matter is also another factor which increases the risk of chemical phlebitis.

Bacterial phlebitis is usually a precursor to an infection at the insertion site. It occurs due to contamination of the IV system allowing bacteria to enter the solution and then the patient. Contamination can be caused by compromised aseptic technique during mixing of medications or solutions, improper cleaning of connection ports and hubs during connecting of IV equipment and inadequate skin preparation during insertion.

An interesting point to make about phlebitis and PICC lines is that research has shown that female patients have a higher risk of phlebitis than male patients; Caucasians have also shown to have a higher incidence although the reason for the increased risk has not been determined (Maki and Ringer, 1991).

The Infusion Nurses Standards of Practice recommends that a phlebitis scale be used to rate phlebitis according to the signs and symptoms present. Below is the scale that the Infusion Nurses Society has designed for use when determining the severity of phlebitis.

Phlebitis Scale

Grade Clinical Criteria
0 No Symptoms
1 Erythema at access site with or without pain
2 Pain at access site with erythema and/or oedema
3

Pain at access site with erythema and/or oedema
Streak formation
Palpable venous cord

4

Pain at access site with erythema and/or oedema
Streak formation
Palpable venous cord > 1 inch in length
Purulent drainag

Prevention
Prevention of phlebitis involves many factors and the nurse should consider these factors the moment the patient receives an IV device.
Prevention measures include:
* Adhering to aseptic technique during insertion, dressing changes, mixing or drawing up of solutions or
medications, accessing ports or hubs on IV equipment
* Cannula site rotation
* Using the smallest gauge cannula in the largest vein
* Adequate securement of the IV device
* Close and regular monitoring of the IV site
* Patient education of the signs and symptoms of phlebitis
* IV device selection – When to Pick a PICC!
* Following guidelines on dilution of solutions to prevent particulate matter and to ensure that     the medication or solution doesn’t have too high or too low a pH or tonicity.

Jackson (1998) states that peripheral intravenous cannulation is one of the most prevalent invasive procedures in health care today. Problems such as phlebitis continue to affect patient care. Having an awareness of the types of phlebitis and the causes can improve patient care by preventing unnecessary and often expensive intravenous interventions.

References
Hankins J, Waldman Lonsway RA, Hedrick C, Perdue MB. The Infusion Nurses Society. Infusion Therapy in Clinical Practice. 2nd Edition, 2001. Ch. 8 Infection Control, 131-132.
Karadag A, Gorgulu S. Journal of IV Nursing. Effect of two short peripheral catheter materials on phlebitisdevelopment. 200, May/June, 23:3, 158-166.
Maki D., Ringer, M. Annals of Internal Medicine. Risk factors for infusion related phlebitis with small peripheral venous catheters: a randomised trial. 1991, 114:10, 845-54.
Mazzola, JR, Schott- Baer, D, Addy L. Journal of IV Nursing. Clinical Factors Associated with the development of phlebitis after insertion of a peripherally inserted central catheter. 1999, January/February, 22:1, 36-42.

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