i.v. essentials

Phlebitis: An irritating

KELLI ROSENTHAL, RN,BC, APRN,BC, CRNI, MS President and Chief Executive Officer • ResourceNurse.Com • Oceanside, N.Y.

IN THE PREVIOUS ISSUE of Nursing isn’t allowed to dry before venipuncture and made Incredibly Easy!, I reviewed infiltra- ends up being tracked into the . Bacterial tion and extravasation, complications of phlebitis may occur from contamination of intravenous (I.V.) therapy that can happen the catheter during insertion or from poor despite your best efforts. Now let’s look at skin antisepsis or during catheter manipula- What’s in another complication: phlebitis. tion. your I.V. bag? It could This is so irritating! What’s going on? Defined as “inflammation of a vein,” At a cellular level, when you introduce a cause phlebitis occurs for various reasons: catheter into a vein, the vein’s endothelial phlebitis! ■ The lining of the vessel is irritated by cells are injured, which triggers a small the presence of a foreign body (such as an clot to form and seal the puncture. The I.V. catheter). vasoactive substances that are released— ■ The catheter comes histamine and bradykinins—cause physi- into contact with the vein cal and chemical reactions within the vein wall, injuring it. and surrounding tissues. The result is ves- ■ An irritating medica- sel dilation, increased blood flow, and red- tion or solution is being ness and warmth. infused (chemical Greater permeability allows a phlebitis). fluid and protein shift from the intravascular ■ Bacterial contamina- space to the interstitial space, resulting in tion occurs (bacterial edema and discomfort around the I.V. site. If phlebitis). you don’t remove the cannula, phlebitis will The most frequent cause worsen with prolonged dwell time. of phlebitis is mechanical irri- The patient may develop a low-grade tation. This generally results fever from the leukocytes gathering at the from placing a large catheter inflamed site, which release pyrogens into in a small vein, improperly the bloodstream. The phlebitic process can securing the cannula, or using continue for an additional 72 hours after an insertion technique that catheter removal. causes trauma. The risk of phlebitis increases with the Chemical phlebitis occurs length of catheter dwell time. The Centers when the pH of the solution for Disease Control and Prevention recom- being infused is too low or too mends that you leave a peripheral cannula high (less than 5 or more than in place for no more than 96 hours for 9), when the osmolality adults. of the solution is too high (over 500 It gets worse mOsm/liter), or when On catheter removal, you may see pus at the skin prepping solution the puncture site. If you do, culture the

62 Nursing made Incredibly Easy! January/February 2004 site even in the absence of signs of sys- temic infection, such as fever or chills. The Use care with these affected vein may become septic, hard- drugs ened, and swollen with pus and may re- The following drugs are prone to causing quire surgical debridement, maybe even phlebitis: vein resection. • antibiotics Septicemia (a systemic bloodstream infec- • hypertonic dextrose solutions (>10%) tion) or endocarditis may also occur. Because • cancer damage to the vein lining causes phlebitis, • vasoactive medications patients are at risk for thrombus formation at • solutions containing calcium and potassi- the site, which can lead to , um supplements. deep vein , or .

What to watch for ter a medication peripherally or whether Often, the first sign of phlebitis is discom- the patient needs a central line (see Use fort at the infusion site or along the ve- Care with These Drugs). nous pathway. If your patient can talk, ask him to tell you if the I.V. site becomes un- Resolving the crisis comfortable. If he can’t communicate ver- Whatever the reason for phlebitis, your bally, watch for clues such as withdrawing nursing care should include promptly re- or grimacing when you’re palpating the moving the I.V. cannula as soon as the pa- site during routine site checks. tient complains of discomfort, monitoring As phlebitis progresses to thrombo- vital signs and the infusion site, notifying phlebitis, expect to see redness along the the patient’s health care provider, and ap- vein or around the insertion site, warmth, plying heat from a continuous, regulated slowing of the infusion, pain, a palpable source. cord along the venous pathway, and low- Report phlebitis as an adverse patient grade fever. outcome. Document all suspected cases of phlebitis using the Infusion Nurses Society Decisions, decisions Phlebitis Scale or per institutional policy You can prevent many instances of (see Grading Phlebitis). Continue to monitor phlebitis by choosing the proper site, can- the site until all signs of phlebitis have nula, and cannula securement technique. resolved. ■ For instance, con- sider using a catheter securement device if patient Grading phlebitis movement is likely Grade Clinical Criteria to result in “piston- 0 • No symptoms ing” at the site. 1 • at access site with or without pain Also understand how the process of 2 • Pain at access site with erythema and/or edema phlebitis occurs in 3 • Pain at access site with erythema and/or edema response to too- • Streak formation concentrated, too- • Palpable venous cord dilute, or pH- 4 • Pain at access site with erythema and/or edema extreme drugs and • Streak formation solutions. Check an • Palpable venous cord >1 inch (2.5 cm) in length I.V. drug book or • Purulent drainage ask your pharmacist Source: Infusion Nurses Society Phlebitis Scale if you’re unsure whether to adminis-

January/February 2004 Nursing made Incredibly Easy! 63