How to prevent, identify and treat phlebitis in patients ...

Nursing Practice

Review

Phlebitis

Keywords: Phlebitis/Venous catheter/

Infection control

¡ñThis

article has been double-blind

peer reviewed

How to prevent, identify and treat phlebitis in patients with a venous cannula

Phlebitis: treatment,

care and prevention

In this article...

 eripheral venous cannulation is a common procedure used

P

in hospital to deliver fluid and medicine

Phlebitis (inflammation of the vein) can be caused by

chemical, mechanical or infectious irritation

Good practice with cannula insertion and infection control

should help to prevent the condition

Author Ray Higginson is chartered

biologist and senior lecturer in critical care,

and Andrew Parry is senior lecturer in

critical care; both at the Faculty of Health,

Sport and Science, University of

Glamorgan, Wales.

Abstract Higginson R, Parry A (2011)

Phlebitis: treatment, care and prevention.

Nursing Times; 107: 36, 18-21.

Peripheral venous catheter-associated

phlebitis is caused by inflammation to the

vein at a cannula access site. It can have a

mechanical, chemical or infectious cause.

Good practice when inserting a

cannula, including appropriate choice of

device and site, can help to prevent phlebitis.

Good infection control techniques are also

vital in preventing the condition.

There are two phlebitis scoring systems,

which should be used in routine practice

to identify and treat early signs of the

inflammation.

P

eripheral venous cannulation

(PVC) is a common procedure

carried out in hospital to allow

rapid and accurate administration of medication (Endacott et al, 2009).

However, the placement of an intravenous

cannula can have undesirable effects, the

most common of which is phlebitis.

Peripheral catheter-related phlebitis is

caused by the inflammation of the tunica

intima of a superficial vein. The inflammation is due to irritation of the tunica intima

by mechanical, chemical or bacterial

sources. If left untreated, it can lead to

infection or thrombus formation (Royal

College of Nursing, 2010).

It is estimated that in the UK 20-80% of

patients with a PVC develop phlebitis (Pandero et al, 2002). This broad range has also

been reported in studies from other countries (Uslusoy and Mete, 2008) and suggests poor identification of phlebitis or

poor reporting protocols.

It is essential for nurses to be able to

identify patients who are at risk of developing phlebitis. In turn, early recognition

will enable prompt intervention, minimising disruption to treatment.

Receiving intravenous therapy

Intravenous therapy is indicated for many

reasons. A significant number of patients

admitted into hospital receive some form

of intravenous therapy via PVC.

These include intravenous antibiotic

administration, intravenous fluids, intravenous pain relief and/or total parenteral

nutrition (TPN).

Intravenous delivery devices include:

? Peripheral cannulas;

? Peripheral midline catheters;

? Peripherally inserted central catheters;

? Skin tunnelled cuffed central catheters

(Hickman lines).

The type of intravenous delivery device

used depends on the type of fluid administered and the length of time intravenous

therapy will last. For example, peripheral

venous cannulas are indicated for

18 Nursing Times 13.09.11 / Vol 107 No 36 /

5 key

points

1

Peripheral

venous

cannulation is

a common

procedure

Phlebitis ¨C or

inflammation

of the vein ¨C can

be caused by

mechanical,

chemical or

infectious

irritation at the

cannula site

Careful

placement

and good hygiene

can help to prevent

phlebitis

There are

two

assessment tools

to identify early

signs of the

condition

Vigilance

can help to

prevent rare but

potentially severe

complications

such as sepsis

2

3

4

5

Coloured venogram

of phlebitis in leg

Microorganisms gain access to new hosts

via a variety of methods, with some

microbes using more than one method of

transmission. Microorganisms are not

able to move freely between hosts by themselves ¨C they require either direct physical

contact with a new host, or they use

another person, animal or inanimate

object, to gain access.

Understanding these direct and indirect modes of transmission is essential for

effective infection control (Box 1).

Clinical staff, especially those in close

physical contact with patients, can act as a

portal for disease-causing organisms,

facilitating their spread between patients

and the clinical environment. An unhygienic environment can harbour microorganisms and facilitate their contamination and spread (Randle et al, 2009).

Infection control measures are essential

in the fight against disease-causing

microbes, and in the delivery of a highquality, effective healthcare service.

Good staff hygiene, hand hygiene and

adherence to universal precautions (Box 2)

are fundamental nursing skills that have

consistently been shown to reduce crossinfection, improve hospital hygiene and

help combat nosocomial infections

(Burke, 2003).

In addition, aseptic technique can

help prevent the transmission of microorganisms to wounds and other susceptible sites (such as intravenous cannula

? Teresa Heithaus

Infection control

fig 1-3. Types of phlebitis

Fig 1. Mechanical phlebitis:

possibly occurred due to cannula

proximity to wrist. Taken from

Macklin (2003)

Fig 2. Chemical phlebitis. Fig 3. Chemical phlebitis:

note the red track up the

Taken from Macklin

arm from chemical

(2003)

irritation of the vein

ports), and reduce the risk of cross-infection (Hart, 2007).

An aseptic technique is necessary when

performing any clinically invasive procedure, especially if the patient has an infectious disease. It is, of course, indicated

when delivering intravenous therapy, be it

cannula insertion, intravenous drug or

fluid administration (Randle et al, 2009).

Phlebitis has been linked with

box 2. Universal

infection control

measures

¡ñ Handwashing

¡ñ Patient skin preparation

¡ñ Wearing gloves and aprons

¡ñ Establishing a clean environmental

field

¡ñ Using sterile equipment

¡ñ Disposing of contaminated or soiled

equipment and linen appropriately

¡ñ Safe disposal of sharps

Box 1. Modes of transmission

Direct contact

Indirect contact

Infected or colonised person-tosusceptible host: spread by direct

contact with infected or colonised skin,

mucous membranes or body fluids

Airborne: Some microorganisms can

survive for periods in the air

Fomite (inanimate object): hospital

objects such as medical equipment,

clothing, bedding, dressings and sinks can

act as a source of infection

Vector borne: microorganisms spread by

arthropods

Droplet spread: occurs when bacteria or

viruses travel, usually only a short distance,

on large respiratory droplets

inappropriate catheter insertion sites and

inappropriate catheter usage. In addition,

a poor standard of infection control has a

part to play and infection control and

hygiene standards are essential in the

treatment and prevention of the condition

(Uslusoy and Mete, 2008).

Phlebitis

Mechanical phlebitis

Mechanical phlebitis occurs where the

movement of a foreign object (cannula)

within a vein causes friction and subsequent venous inflammation (Stokowski

et al, 2009) (Fig 1).

It often occurs when the size of the cannula is too big for the selected vein (Martinho and Rodrigues, 2008). It has also

been suggested that placement of a cannula near a joint or venous valve will

increase the risk of mechanical phlebitis

due to irritation of the vessel wall by the tip

of the cannula (Macklin, 2003).

This type of phlebitis can be avoided by

selecting the smallest possible device for

the largest vessel (although some studies

such as Uslusoy and Mete (2008) have suggested that catheter size is not a significant

causative factor).

Consideration must also be given to the

nature of the intended IV therapy and

optimum cannula size for drug delivery.

For example, a large-bore cannula would

be appropriate for rapid fluid resuscitation

while a cannula with a smaller bore would

suffice for sliding scale insulin therapy.

Chemical phlebitis

Chemical phlebitis is caused by the drug or

fluid being infused through the cannula.

Factors such as pH and osmolarity of the

substances have a significant effect on the

incidence of phlebitis (Kohno et al, 2009)

(Figs 2 and 3).

/ Vol 107 No 36 / Nursing Times 13.09.11 19

SPL

short-term use only (Dougherty and Lister,

2008). If intravenous therapy is indicated

for longer periods, central venous access

will be required. Likewise, central access is

required if cytotoxic and/or hypertonic

solutions are to be intravenously administered (RCN, 2010).

Nursing Practice

Review

Assessment and classification

All patients with an intravenous access

device should have the access site checked

every shift for signs of phlebitis (LaRue

and Peterson 2011; Gallant and Schultz,

2006). A number of phlebitis scales and

assessment tools have been developed to

assist this, and the two most commonly

used in the UK are the Phlebitis Scale and

the Visual Infusion Phlebitis (VIP) scale.

The Phlebitis Scale was developed by

the Infusion Nurses Society (2006). Using a

grading scale from 0-4, it has proven to be

a quick, easy and useful tool. It is shown in

Box 3.

The tool recommended by the Royal

College of Nursing is the Visual Infusion

Phlebitis scale first developed by Jackson

in 1998 (Box 4). The VIP scale has been

shown to be a valid and reliable measure

|| ||||

||||||

||

||

QUICK

FACT

||||

The commonest symptoms of any form of

phlebitis are erythema and swelling along

the venous track, leading to hardened, cord

-like veins (Endacott et al, 2009). The area

can feel warm and patients may experience

pain or discomfort during drug administration (nurses should assess if this pain

persists between administrations).

Difficulty in injecting or regular infusion pump occlusion would also indicate

phlebitis. Any exudate oozing from the

insertion site would also be suggestive of

phlebitis, in particular infective phlebitis

(Macklin, 2003). Pyrexia and haemodynamic deterioration of an unknown origin

should prompt investigation into cannula

infection and potential systemic sepsis.

Source: Infusion Nurses Society (2006)

|||||

Signs and symptoms

Grade 0 No symptoms

Grade 1 Erythema at access site with

or without pain

Grade 2 Pain at access site with

erythema and/or oedema

Grade 3 Pain at access site with

erythema and/or oedema, streak

formation, palpable venous cord

Grade 4 Pain at access site with

erythema and/or oedema, streak

formation, palpable venous cord

greater than one inch in length and

purulent drainage

|||

Infective phlebitis

Infective phlebitis is caused by the introduction of bacteria into the vein. It may

start as an inflammatory response to cannula insertion, allowing bacteria to colonise the ¡°inflammatory debris¡± (Malach et

al, 2006).

Poor practices during drug administration and a higher frequency of drug administration have been found to increase the

risk of infective phlebitis (Uslusoy and

Mete, 2008).

Another risk factor is poor skin

cleansing technique before cannula insertion. Malach et al (2006) found the bacterial growth on removed cannula tips were

those commonly associated with normal

skin flora.

Infective phlebitis can have significant

ramifications for the patient due to the

potential development of systemic sepsis.

box 3. Phlebitis Scale

|||

Antibiotics are reported to increase the

incidence of chemical phlebitis due to

their low pH (Macklin, 2003). With a large

proportion of hospitalised patients

receiving IV antibiotics, nurses need to be

vigilant when administering this therapy.

Isotonic fluids have been found to lower

rates of phlebitis, while hypertonic fluids

increase the incidence of phlebitis by initiating the inflammatory response (Uslusoy

and Mete, 2008).

TPN is hypertonic but its osmolarity

can be adjusted without affecting the

pharmacodynamics of the solution,

which, alongside the addition of drugs

such as heparin, has been shown to

increase the life of a fine bore midline cannula (Catton et al, 2006).

20¨C80%

of patients with a

peripheral venous

cannulation develop

phlebitis

for determining when an intravenous

catheter should be removed (Gallant and

Schultz, 2006). The VIP score is recommended in the Infusion Nursing Standards

of Practice (INS, 2011).

These phlebitis assessment scales are

used to inform clinical practice and decision making, indicating to clinicians the

first stages of phlebitis and when intravenous cannulas should be replaced (Creed

and Spears, 2010). They can help reduce the

progression of phlebitis through early

detection.

Phlebitis reduction measures

The incidence of phlebitis can be reduced

by use of simple measures. Good practice

during insertion will also extend the life of

the cannula.

20 Nursing Times 13.09.11 / Vol 107 No 36 /

The clinician¡¯s hands should be thoroughly washed, gloves worn and the

patient¡¯s skin adequately cleansed.

Good clinical practice must be observed

when administering intravenous drugs,

starting at the point of reconstituting and

drawing up the drug. This standard of

practice must continue to the administration phase, with particular attention paid

to cannula sites of patients on frequent

intravenous therapy, as regular use of the

cannula site increases the risk of bacterial

phlebitis (Uslusoy and Mete, 2008).

The appropriate cannula should be

selected for the vein. The site should also

be carefully selected, to avoid any bony

prominences, joints and venous valves

that would cause the cannula to move

within the vein lumen.

After insertion, the cannula should be

dressed to minimise movement in the vein

lumen, which could lead to mechanical

phlebitis.

Evidence suggests that the addition of

drugs such as heparin and hydrocortisone

can reduce the incidence of phlebitis

(Ikeda et al, 2004); patients on intravenous

steroid therapy have a lower incidence of

phlebitis (Kohno et al, 2009). However, this

applies only to the administration of antineoplastic drugs and so is limited to

patients receiving cancer chemotherapy.

To avoid chemical phlebitis, the possibility of bringing drug pH or osmolarity in

line with physiological ranges should be

explored (Kuwahara et al, 1999). For

example, patients undergoing antibiotic

or potassium therapy have a higher phlebitis risk due to the low pH of these solutions and neutralising such solutions may

help prevent phlebitis (Kuwahara et al,

1999), although this is not usually done by

nurses.

Similarly, TPN infusions have a high

osmolarity, increasing the risk of chemical

phlebitis (Kuwahara et al 1999). Adjusting

the osmolarity of TPN solutions (if possible) can also help prevent phlebitis.

Complications

Early phlebitis at an intravenous site usually resolves after a cannula is removed or

resited (Rickard et al, 2010).

Complications are rare but can occur;

these include infection, thrombosis, and

recurrent superficial thrombophlebitis

(Loewenstein, 2011).

One of the most serious complications

¨C although fortunately rare ¨C is septic

thrombophlebitis, a condition characterised by venous thrombosis and inflammation in the presence of bacteraemia

(Mermel et al, 2009).

¡°Employ techniques to help

you achieve your objectives¡±

Anne Marshall

p33

Box 4. Visual Infusion Phlebitis scale

Appearance

Score

Stage

IV site appears healthy

Action: observe cannula

0

No signs of phlebitis

One of the following signs is evident

¡ñ Slight pain near IV site or

¡ñ Slight redness near IV site

Action: observe cannula

1

Possibly first signs

of phlebitis

Two of the following are evident

¡ñ Pain at IV site

¡ñ Redness

¡ñ Swelling

Action: resite cannula

2

Early stage of phlebitis

All of the following signs are evident

¡ñ Pain along path of cannula

¡ñ Redness around site

¡ñ Swelling

Action: resite cannula and consider

treatment

3

Medium stage of phlebitis

All of the following signs are evident and

extensive

¡ñ Pain along path of cannula

¡ñ Redness around site

¡ñ Swelling

¡ñ Palpable venous cord

Action: resite cannula and consider

treatment

4

Advanced stage of

phlebitis or start of

thrombophlebitis

All of the following signs are evident and

extensive

¡ñ Pain along path of cannula

¡ñ Redness around site and swelling

¡ñ Palpable venous cord

¡ñ Pyrexia

Action: initiate treatment/resite cannula

5

Advanced stage

thrombophlebitis

Source: Jackson (1998)

Treatment

The treatment of phlebitis will depend to

some extent on the severity of inflammation and presence of a thrombus. Moderate

phlebitis will usually resolve itself. A

patient with phlebitis with a VIP score of 2

or more will require their cannula to be

removed or resited.

The initial treatment for any form of

phlebitis is to stop the infusion and

remove the PVC (Webster et al, 2010). This

should be done with consideration for the

patient¡¯s needs; if, for example, the patient

is haemodynamically unstable, the PVC

should only be removed once a new PVC

has been sited.

An affected limb should be elevated to

minimise inflammation and an antiinflammatory cream or gel can be directly

applied to the area (Reis et al, 2009).

Anti-inflammatory analgesics can be

prescribed to treat both the inflammation

and the pain associated with phlebitis.

Conclusion

Many patients in hospital require PVC as

part of their medical management and

care. A recognised associated risk factor is

phlebitis.

Nurses are well placed to assess for the

presence of phlebitis and act accordingly.

By observing good practice both during

and after peripheral catheter insertion,

complication rates of phlebitis can be

reduced and patient care improved. NT

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/ Vol 107 No 36 / Nursing Times 13.09.11 21

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