Phlebitis: Treatment, Care and Prevention

Keywords: Phlebitis/Venous catheter/ Nursing Practice Infection control Review ●This article has been double-blind Phlebitis peer reviewed How to prevent, identify and treat phlebitis in patients with a venous cannula Phlebitis: treatment, care and prevention

In this article... 5 key Peripheral venous cannulation is a common procedure used points in hospital to deliver fluid and medicine Peripheral 1venous Phlebitis (inflammation of the vein) can be caused by cannulation is chemical, mechanical or infectious irritation a common Good practice with cannula insertion and infection control procedure should help to prevent the condition Phlebitis – or 2inflammation of the vein – can Author Ray Higginson is chartered sources. If left untreated, it can lead to be caused by biologist and senior lecturer in critical care, infection or thrombus formation (Royal mechanical, and Andrew Parry is senior lecturer in College of Nursing, 2010). chemical or critical care; both at the Faculty of Health, It is estimated that in the UK 20-80% of infectious Sport and Science, University of patients with a PVC develop phlebitis (Pan- irritation at the Glamorgan, Wales. dero et al, 2002). This broad range has also cannula site Abstract Higginson R, Parry A (2011) been reported in studies from other coun- Careful Phlebitis: treatment, care and prevention. tries (Uslusoy and Mete, 2008) and sug- 3placement Nursing Times; 107: 36, 18-21. gests poor identification of phlebitis or and good hygiene Peripheral venous catheter-associated poor reporting protocols. can help to prevent phlebitis is caused by inflammation to the It is essential for nurses to be able to phlebitis vein at a cannula access site. It can have a identify patients who are at risk of devel- There are mechanical, chemical or infectious cause. oping phlebitis. In turn, early recognition 4two Good practice when inserting a will enable prompt intervention, mini- assessment tools cannula, including appropriate choice of mising disruption to treatment. to identify early device and site, can help to prevent phlebitis. signs of the Good infection control techniques are also Receiving intravenous therapy condition vital in preventing the condition. Intravenous therapy is indicated for many Vigilance There are two phlebitis scoring systems, reasons. A significant number of patients 5can help to which should be used in routine practice admitted into hospital receive some form prevent rare but to identify and treat early signs of the of intravenous therapy via PVC. potentially severe inflammation. These include intravenous antibiotic complications administration, intravenous fluids, intra- such as sepsis eripheral venous cannulation venous pain relief and/or total parenteral (PVC) is a common procedure nutrition (TPN). carried out in hospital to allow Intravenous delivery devices include: Prapid and accurate administra- » Peripheral cannulas; tion of medication (Endacott et al, 2009). » Peripheral midline catheters; However, the placement of an intravenous » Peripherally inserted central catheters; cannula can have undesirable effects, the » Skin tunnelled cuffed central catheters most common of which is phlebitis. (Hickman lines). Peripheral catheter-related phlebitis is The type of intravenous delivery device caused by the inflammation of the tunica used depends on the type of fluid adminis- intima of a superficial vein. The inflamma- tered and the length of time intravenous tion is due to irritation of the tunica intima therapy will last. For example, peripheral Coloured venogram by mechanical, chemical or bacterial venous cannulas are indicated for of phlebitis in leg

18 Nursing Times 13.09.11 / Vol 107 No 36 / www.nursingtimes.net short-term use only (Dougherty and Lister, fig 1-3. Types of phlebitis 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 adminis- tered (RCN, 2010).

Infection control Microorganisms gain access to new hosts Fig 1. Mechanical phlebitis: via a variety of methods, with some possibly occurred due to cannula microbes using more than one method of proximity to wrist. Taken from transmission. Microorganisms are not Macklin (2003) able to move freely between hosts by them- selves – they require either direct physical Fig 2. Chemical phlebitis. Fig 3. Chemical phlebitis: contact with a new host, or they use Taken from Macklin note the red track up the another person, animal or inanimate (2003) arm from chemical object, to gain access. irritation of the vein Understanding these direct and indirect modes of transmission is essential for ports), and reduce the risk of cross-infec- inappropriate catheter insertion sites and effective infection control (Box 1). tion (Hart, 2007). inappropriate catheter usage. In addition, Clinical staff, especially those in close An aseptic technique is necessary when a poor standard of infection control has a physical contact with patients, can act as a performing any clinically invasive proce- part to play and infection control and portal for disease-causing organisms, dure, especially if the patient has an infec- hygiene standards are essential in the facilitating their spread between patients tious disease. It is, of course, indicated treatment and prevention of the condition and the clinical environment. An unhy- when delivering intravenous therapy, be it (Uslusoy and Mete, 2008). gienic environment can harbour micro- cannula insertion, intravenous drug or organisms and facilitate their contamina- fluid administration (Randle et al, 2009). Phlebitis tion and spread (Randle et al, 2009). Phlebitis has been linked with Mechanical phlebitis Infection control measures are essential Mechanical phlebitis occurs where the in the fight against disease-causing movement of a foreign object (cannula) microbes, and in the delivery of a high- box 2. Universal within a vein causes friction and subse- quality, effective healthcare service. infection control quent venous inflammation (Stokowski Good staff hygiene, hand hygiene and measures et al, 2009) (Fig 1). adherence to universal precautions (Box 2) It often occurs when the size of the can- are fundamental nursing skills that have ● Handwashing nula is too big for the selected vein (Mar- consistently been shown to reduce cross- ● Patient skin preparation tinho and Rodrigues, 2008). It has also infection, improve hospital hygiene and ● Wearing gloves and aprons been suggested that placement of a can- help combat nosocomial infections ● Establishing a clean environmental nula near a joint or venous valve will (Burke, 2003). field increase the risk of mechanical phlebitis In addition, aseptic technique can ● Using sterile equipment due to irritation of the vessel wall by the tip help prevent the transmission of micro- ● Disposing of contaminated or soiled of the cannula (Macklin, 2003). organisms to wounds and other suscep- equipment and linen appropriately This type of phlebitis can be avoided by tible sites (such as intravenous cannula ● Safe disposal of sharps selecting the smallest possible device for the largest vessel (although some studies such as Uslusoy and Mete (2008) have sug- Box 1. Modes of transmission gested that catheter size is not a significant Direct contact Indirect contact causative factor). Consideration must also be given to the Infected or colonised person-to- Airborne: Some microorganisms can nature of the intended IV therapy and susceptible host: spread by direct survive for periods in the air optimum cannula size for drug delivery. contact with infected or colonised skin, For example, a large-bore cannula would mucous membranes or body fluids be appropriate for rapid fluid resuscitation Fomite (inanimate object): hospital while a cannula with a smaller bore would objects such as medical equipment, suffice for sliding scale insulin therapy. clothing, bedding, dressings and sinks can act as a source of infection Chemical phlebitis Vector borne: microorganisms spread by Chemical phlebitis is caused by the drug or arthropods fluid being infused through the cannula. Factors such as pH and osmolarity of the Droplet spread: occurs when bacteria or substances have a significant effect on the viruses travel, usually only a short distance, incidence of phlebitis (Kohno et al, 2009) on large respiratory droplets (Figs 2 and 3). SPL

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Antibiotics are reported to increase the The clinician’s hands should be thor- incidence of chemical phlebitis due to box 3. Phlebitis Scale oughly washed, gloves worn and the their low pH (Macklin, 2003). With a large patient’s skin adequately cleansed. proportion of hospitalised patients Grade 0 No symptoms Good clinical practice must be observed receiving IV antibiotics, nurses need to be Grade 1 Erythema at access site with when administering intravenous drugs, vigilant when administering this therapy. or without pain starting at the point of reconstituting and Isotonic fluids have been found to lower Grade 2 Pain at access site with drawing up the drug. This standard of rates of phlebitis, while hypertonic fluids erythema and/or oedema practice must continue to the administra- increase the incidence of phlebitis by initi- Grade 3 Pain at access site with tion phase, with particular attention paid ating the inflammatory response (Uslusoy erythema and/or oedema, streak to cannula sites of patients on frequent and Mete, 2008). formation, palpable venous cord intravenous therapy, as regular use of the TPN is hypertonic but its osmolarity Grade 4 Pain at access site with cannula site increases the risk of bacterial can be adjusted without affecting the erythema and/or oedema, streak phlebitis (Uslusoy and Mete, 2008). pharmacodynamics of the solution, formation, palpable venous cord The appropriate cannula should be which, alongside the addition of drugs greater than one inch in length and selected for the vein. The site should also such as heparin, has been shown to purulent drainage be carefully selected, to avoid any bony increase the life of a fine bore midline can- prominences, joints and venous valves nula (Catton et al, 2006). Source: Infusion Nurses Society (2006) that would cause the cannula to move within the vein lumen. Infective phlebitis After insertion, the cannula should be Infective phlebitis is caused by the intro- every shift for signs of phlebitis (LaRue dressed to minimise movement in the vein duction of bacteria into the vein. It may and Peterson 2011; Gallant and Schultz, lumen, which could lead to mechanical start as an inflammatory response to can- 2006). A number of phlebitis scales and phlebitis. nula insertion, allowing bacteria to colo- assessment tools have been developed to Evidence suggests that the addition of nise the “inflammatory debris” (Malach et assist this, and the two most commonly drugs such as heparin and hydrocortisone al, 2006). used in the UK are the Phlebitis Scale and can reduce the incidence of phlebitis Poor practices during drug administra- the Visual Infusion Phlebitis (VIP) scale. (Ikeda et al, 2004); patients on intravenous tion and a higher frequency of drug admin- The Phlebitis Scale was developed by steroid therapy have a lower incidence of istration have been found to increase the the Infusion Nurses Society (2006). Using a phlebitis (Kohno et al, 2009). However, this risk of infective phlebitis (Uslusoy and grading scale from 0-4, it has proven to be applies only to the administration of anti- Mete, 2008). a quick, easy and useful tool. It is shown in neoplastic drugs and so is limited to Another risk factor is poor skin Box 3. patients receiving cancer chemotherapy. cleansing technique before cannula inser- The tool recommended by the Royal To avoid chemical phlebitis, the possi- tion. Malach et al (2006) found the bacte- College of Nursing is the Visual Infusion bility of bringing drug pH or osmolarity in rial growth on removed cannula tips were Phlebitis scale first developed by Jackson line with physiological ranges should be those commonly associated with normal in 1998 (Box 4). The VIP scale has been explored (Kuwahara et al, 1999). For skin flora. shown to be a valid and reliable measure example, patients undergoing antibiotic Infective phlebitis can have significant or potassium therapy have a higher phle- ramifications for the patient due to the || ||| bitis risk due to the low pH of these solu- || | | | | 20–80% potential development of systemic sepsis. | | tions and neutralising such solutions may

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The commonest symptoms of any form of | phlebitis nurses. phlebitis are erythema and swelling along Similarly, TPN infusions have a high the venous track, leading to hardened, cord for determining when an intravenous osmolarity, increasing the risk of chemical -like veins (Endacott et al, 2009). The area catheter should be removed (Gallant and phlebitis (Kuwahara et al 1999). Adjusting can feel warm and patients may experience Schultz, 2006). The VIP score is recom- the osmolarity of TPN solutions (if pos- pain or discomfort during drug adminis- mended in the Infusion Nursing Standards sible) can also help prevent phlebitis. tration (nurses should assess if this pain of Practice (INS, 2011). persists between administrations). These phlebitis assessment scales are Complications Difficulty in injecting or regular infu- used to inform clinical practice and deci- Early phlebitis at an intravenous site usu- sion pump occlusion would also indicate sion making, indicating to clinicians the ally resolves after a cannula is removed or phlebitis. Any exudate oozing from the first stages of phlebitis and when intrave- resited (Rickard et al, 2010). insertion site would also be suggestive of nous cannulas should be replaced (Creed Complications are rare but can occur; phlebitis, in particular infective phlebitis and Spears, 2010). They can help reduce the these include infection, thrombosis, and (Macklin, 2003). Pyrexia and haemody- progression of phlebitis through early recurrent superficial thrombophlebitis namic deterioration of an unknown origin detection. (Loewenstein, 2011). should prompt investigation into cannula One of the most serious complications infection and potential systemic sepsis. Phlebitis reduction measures – although fortunately rare – is septic The incidence of phlebitis can be reduced thrombophlebitis, a condition character- Assessment and classification by use of simple measures. Good practice ised by venous thrombosis and inflamma- All patients with an intravenous access during insertion will also extend the life of tion in the presence of bacteraemia device should have the access site checked the cannula. (Mermel et al, 2009).

20 Nursing Times 13.09.11 / Vol 107 No 36 / www.nursingtimes.net “Employ techniques to help you achieve your objectives” Anne Marshall p33

Endacott R et al (2009) Clinical Nursing Skills, Core Box 4. Visual Infusion Phlebitis scale and Advanced. Oxford: Oxford University Press. Gallant P, Schultz AA (2006) Evaluation of a visual Appearance Score Stage infusion phlebitis scale for determining appropriate IV site appears healthy 0 No signs of phlebitis discontinuation of peripheral intravenous catheters. Journal of Infusion Nursing; 29: 6, 338-345. Action: observe cannula Hart S (2007) Using an aseptic technique to reduce One of the following signs is evident 1 Possibly first signs the risk of infection. Nursing Standard; 21: 47, 43-48. Ikeda S et al (2004) Use of heparin to lower the ● Slight pain near IV site or of phlebitis incidence of phlebitis induced by anti-neoplastic ● Slight redness near IV site agents used in ovarian cancer. Journal of Obstetric Action: observe cannula Gynaecology Research; 30: 6, 427-429. Infusion Nurses Society (2006) Infusion Nursing Two of the following are evident 2 Early stage of phlebitis Standards of Practice. Hagerstown, MD: ● Pain at IV site JP Lippincott. ● Infusion Nurses Society (2011) Infusion nursing Redness standards of practice. Journal of Infusion Nursing; ● Swelling Supplement 34: 1s. Action: resite cannula Jackson A (1998) Infection control: a battle in vein infusion phlebitis. Nursing Times; 94: 4, 68-71. All of the following signs are evident 3 Medium stage of phlebitis Kohno E et al (2009) Effects of corticosteroids on ● Pain along path of cannula phlebitis induced by intravenous infusion of ● Redness around site antineoplastic agents in rabbits. International Journal of Medical Sciences; 6: 4, 218-223. ● Swelling Kuwahara T et al (1999) Experimental infusion Action: resite cannula and consider phlebitis: tolerance pH of peripheral vein. Journal treatment of Toxicological Sciences; 24: 2, 113-121. LaRue G, Peterson M (2011) The impact of dilution All of the following signs are evident and 4 Advanced stage of on intravenous therapy. Journal of Infusion extensive phlebitis or start of Nursing: 34, 2, 117–123. Loewenstein R (2011) Treatment of superficial ● Pain along path of cannula thrombophlebitis thrombophlebitis. New England Journal of ● Redness around site Medicine; 364: 4, 380. ● Swelling Macklin D (2003) Phlebitis, a painful complication ● of peripheral IV catheterization that may be Palpable venous cord prevented. American Journal of Nursing; 103: 2, Action: resite cannula and consider 55-60. treatment Malach T et al (2006) Prospective surveillance of phlebitis associated with peripheral intravenous All of the following signs are evident and 5 Advanced stage catheters. American Journal of Infection Control; extensive thrombophlebitis 34: 5, 308-312. ● Pain along path of cannula Martinho RFS, Rodrigues AB (2008) Occurrence of phlebitis in patients on intravenous amiodarione. ● Redness around site and swelling Einstein; 6 (4), 459-462. ● Palpable venous cord Mermel LA et al (2009) Clinical practice guidelines ● Pyrexia for the diagnosis and management of intravascular catheter-related infection: update by the Infectious Action: initiate treatment/resite cannula Diseases Society of America. Clinical Infectious Source: Jackson (1998) Diseases; 49: 1, 1-45. Pandero A et al (2002) A dedicated intravenous cannula for postoperative use: effect on incidence and severity of phlebitis. Anaesthesia; 57: 921-925. Treatment Conclusion Randle J et al (2009) Oxford Handbook of Clinical The treatment of phlebitis will depend to Many patients in hospital require PVC as Skills in Adult Nursing. Oxford: Oxford University some extent on the severity of inflamma- part of their medical management and Press. Reis PED et al (2009) Pharmacological tion and presence of a thrombus. Moderate care. A recognised associated risk factor is interventions to treat phlebitis, systematic review. phlebitis will usually resolve itself. A phlebitis. Journal of Infusion Nursing; 32: 2, 74-79. patient with phlebitis with a VIP score of 2 Nurses are well placed to assess for the Rickard CM et al (2010) Routine resite of peripheral intravenous devices every 3 days or more will require their cannula to be presence of phlebitis and act accordingly. did not reduce complications compared removed or resited. By observing good practice both during with clinically indicated resite: a randomised The initial treatment for any form of and after peripheral catheter insertion, controlled trial. BMC Medicine; 8: 53 doi:10.1186/1741-7015-8-53. phlebitis is to stop the infusion and complication rates of phlebitis can be Royal College of Nursing (2010) Standards for remove the PVC (Webster et al, 2010). This reduced and patient care improved. NT Infusion Therapy. London: Royal College of Nursing. should be done with consideration for the Stokowski G et al (2009) The use of ultrasound to patient’s needs; if, for example, the patient References improve practice and reduce complication rates in Burke JP (2003) Infection control – a problem for peripherally inserted central catheter insertions: is haemodynamically unstable, the PVC patient safety. New England Journal of Medicine; final report of investigation.Journal of Infusion should only be removed once a new PVC 348: 651-656. Nursing; 32: 3, 145–155. has been sited. Catton JA et al (2006) The effect of heparin in Uslusoy E, Mete S (2008) Predisposing factors to peripheral intravenous nutrition via a fine-bore phlebitis in patients with peripheral intravenous An affected limb should be elevated to midline: a randomised double-blind controlled trial. catheter: a descriptive study. Journal of the minimise inflammation and an anti- Clinical Nutrition; 25: 394-399. American Academy of Nurse Practitioners; 20: inflammatory cream or gel can be directly Creed F, Spiers C (2010) Care of the Acutely Ill 172-180. applied to the area (Reis et al, 2009). Adult: an Essential Guide for Nurses. Oxford: Webster J et al (2010) Clinically-indicated Oxford University Press. replacement versus routine replacement of Anti-inflammatory analgesics can be Dougherty L, Lister S (2008) The Royal Marsden peripheral venous catheters. Cochrane Database of prescribed to treat both the inflammation Hospital Manual of Clinical Nursing Procedures. Systematic Reviews; Issue 3, Art No: CD007798. and the pain associated with phlebitis. Oxford: Blackwell Publications. DOI: 10.1002/14651858.CD007798.pub2.

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