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Septic Superficial Thrombophlebitis: a Major Threat from a Minor Lesion

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Septic Superficial Thrombophlebitis: a Major Threat from a Minor Lesion Septic superficial thrombophlebitis: a major threat from a minor lesion Bernard J. Mezon, md; Andrus J. Voitk, md Sites of insertion of peripheral intra¬ mon, its incidence correlates imper- fossa. CVP monitoring was discontinued venous catheters remain an important fectly with that of local infection with after 2 days and the established line used to administer fluids but often overlooked source of or without septicemia.3,4 Not only is no intravenous and and the obtained from culture of mate¬ medication. When drainage failed to oc¬ hospital-acquired septicemia growth cur the anastomosis be¬ most source of rial from at through biliary important staphylococcal many catheter tips sites cause of an de¬ thrombo¬ with unrecognized anomaly, septicemia. Septic superficial phlebitis, but culture of material scribed elsewhere,10 an end-to-side chole- phlebitis is characterized by severe from the tip at many clinically normal dochoenterostomy was fashioned 4 days local pain and is readily evident intravenous sites yields pathogenic or¬ after the first operation. The night after clinically. Care of the intravenous line ganisms, thus proving these sites to be the second operation the patient com¬ can prevent this complication. To be the source of septicemia. Staphylococcus plained of pain in his left arm and the it must be aureus is the cultured in more next morning his temperature was 39.2°C. diagnosed, suspected. pathogen Acute and Treatment consists of removal of the than 50% of instances; the others are superficial thrombophlebitis intravenous line and administration cellulitis surrounding the left cephalic mostly gram-negative bacilli,3'4 among vein were noted. The intravenous catheter of heparin and antibiotics effective which Klebsiella and Aerobacter pre¬ was removed and cultures made, blood against penicillinase-producing organ¬ dominate. This is in contrast to sepsis samples were taken for culture, and isms. Occasionally the vein must be associated with intravenous hyperali- therapy was begun with cloxacillin, 1 g IV ligated or, preferably, removed. mentation, in which Candida is the q4h, clindamycin, 300 mg IV q6h, and usual pathogen and gram-negative gentamicin, 40 mg IV q4h. Within 24 Le point d'insertion des catheters bacteria, often nonpathogenic species, hours the cellulitis subsided and the arm intraveineux demeure are was no longer painful. Blood and mate¬ peripheriques occasionally responsible.1,2 Staphy¬ rial from the catheter une source mais souvent lococcus is the causative tip grew penicillin- importante organism resistant S. aureus. and gen¬ oubliee de contractees a much more to Clindamycin septicemies often in septicemia due tamicin were stopped and cloxacillin was l'hopital, et la source la plus importante contaminated intravenous catheters than continued for 10 days. In 4 days' time he des septicemies a staphylocoques. La in septicemia due to other causes, the was afebrile and at the time of discharge thrombophlebite superficielle septique frequencies being 70% and 15 to 20%, the left arm and cephalic vein appeared est caracterisee par une douleur respectively, according to one group.3 normal. locale intense et elle est cliniquement When the intravenous line is being Comment: Pain associated with septic is so severe evidente. Des soins portes a la established, the risk of both thrombo¬ superficial thrombophlebitis tubulure intraveineuse and infection is increased that it may be a patient's sole complaint peut prevenir phlebitis by even after abdominal cette etre lack of immediately major complication qui, pour aseptic technique3,4 and undue surgery. In half the cases of septicemia diagnostiquee, doit etre suspectee. trauma to the vein;3 the type and size due to contamination of intravenous sites Le traitement consiste a retirer la of cannula6 and the material from in one study, local symptoms and signs tubulure intraveineuse et a administrer which the cannula is made are also im¬ were evident 1 to 2 days before the onset de I'heparine et des antibiotiques portant factors.7 After the catheter is of septicemia.4 The presence of intra- efficaces contre les microorganismes inserted, sepsis may occur because of venous-catheter-related thrombophlebitis in producteurs de penicillinase. A failure to anchor the catheter,45 careless undiagnosed sepsis warrants inclusion in the antibiotic of an effect¬ I'occasion on avoir a violation of the for administra¬ regimen agent peut ligaturer system ive organ¬ la de a I'enlever. tion of ade¬ against penicillinase-producing veine, ou, preference, medications5 and lack of isms. The response to appropriate anti¬ quate surveillance and maintenance.3,4 biotic therapy is usually rapid and uncom¬ Since the advent of intravenous hyper- The risk of septicemia increases the plicated. The gravity of this complication alimentation much attention has been longer the catheter is in place, but if of intravenous therapy is illustrated by the fatal outcome of focused on sepsis associated with this it is in place for less than 48 hours sep¬ potentially compli¬ used ticemia probably will not occur.3,4 Con¬ cated major surgery because of a "minor" technique,12 while the commonly deviation in technique. peripheral vein has been neglected as a taminated intravenous solutions occa¬ source of life-threatening sepsis. It is sionally may be the cause of sepsis,8 al¬ Case 2 estimated that 20% of all though in most instances the solution septicemias A 27-year-old man was admitted to hos¬ are to in¬ has been found to be sterile9 and poor related contamination of pital with blunt chest injury and an acute dwelling intravenous catheters.3 One technique instead was implicated. abdomen. Laparotomy revealed hemato¬ group found that in 43% of hospital- The following two case reports illus¬ mas but no free bleeding or visceral acquired septicemias the inoculation trate how serious this complication may damage. Bilateral hemothoraces were site was an indwelling peripheral venous be. treated with closed chest tube drainage. catheter,4 and another group estimated Postoperative respiratory failure was the rate of catheter-induced bacteremia Case treated in the intensive care unit with en- reports dotracheal intubation and a in their to be ventilator. A large hospital 200/yr.5 Case 1 CVP catheter inserted in the left ante¬ Although thrombophlebitis is com- cubital fossa failed to function; it was used A 39-year-old man underwent pancre*- for administration of intravenous fluids aticoduodenectomy for chronic pancrea¬ and medication. From the departments of surgery, University titis localized to the head of the Two later his rose to of Manitoba, Winnipeg, and Soldiers' Memorial pancreas* days temperature Hospital, Orillia, Ont. During the operation a central venous 39°C and he complained of pain in his catheter was threaded into left where was evident. The Reprint requests to: Dr. A. Voitk, 34 Market pressure (CVP) arm, phlebitis St., Orillia, ON L3V 3C9 the left cephalic vein from the antecubital fever was attributed to pulmonary infec- 1128 CMA JOURNAL/JUNE 19, 1976/VOL. 114 tion and diagnostic investigations were colonies (Fig. 1), and culture grew penicil¬ To prevent this complication, one instituted while antibiotics were withheld. lin-resistant Staphylococcus, should not give therapy intravenously This case illustrates the im¬ The next day the intravenous line in the Comment: when other routes are adequate; in¬ left arm was removed because of a leak; portance of the clinician's heeding symp¬ dwelling catheters should be reserved note was made again of phlebitis. On the toms and looking for thrombophlebitis and of his 4th postoperative day he had cellulitis when dealing with septicemia in for situations in which prolonged ther¬ night is our chills and rigor, his temperature rising a patient receiving intravenous therapy. apy anticipated. Both cases illus¬ to 40 °C. If thrombophlebitis is detected, immediate trated the need to remove long cannulas Blood samples were taken for culture inclusion in the antibiotic regimen of an when no longer required. Careful pre¬ and treatment begun with gentamicin, 150 agent effective against penicillinase-produ¬ paration of the site and atraumatic in¬ mg IV q8h, and methicillin, 2 g IV q6h, cing organisms is indicated while culture sertion are important when intravenous the latter being chosen because cultured reports are awaited. If appropriate therapy lines are established. The catheter tracheal aspirates had grown penicillin- is delayed the patient may fail to respond should be firmly anchored and viola- resistant S. aureus. A spiking fever, with to even excessively high doses of the ap¬ tions of the line should be minimal and between 38 and con¬ propriate antibiotic. The clot will extend temperatures 40°C, carried out under tinued and inflammation of the left ce¬ beyond clinically apparent confines and aseptic conditions. phalic vein persisted. Gentamicin therapy the infection may establish itself within Daily application of a topical antibiotic was stopped when blood cultures yielded the clot, where antibiotics cannot penetrate. to the site prevents sepsis11 but even penicillin-resistant Staphylococcus. His pul¬ Treatment at this stage requires surgical this method is not considered safe be¬ monary function had improved and the removal of the source of sepsis. The salu- yond 96 hours.12 Although central left cephalic vein was now thought to be tary effect of this approach is illustrated venous catheters for hyperalimentation the source of sepsis. He was transferred by the prompt response in this patient. have been successfully and routinely to a ward and methicillin was replaced maintained infection-free for 3 weeks with 3 g IV was cloxacillin, q4h; heparin Discussion or such results can be also given. Cellulitis of the arm abated more, expected and his temperature decreased; the cephalic Although septic superficial thrombo¬ only with painstaking attention to the vein remained tender, however, and the phlebitis has received some attention in site and line at all times.13 Unless one is temperature continued to spike up to 38 °C.
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