Phlebitis: Identifying and preventing complications in at risk patients
Phlebitis: Identifying and preventing complications in at risk patients
Peripheral Venous Cannulation (IV Insertion) is the most common procedure carried out in hospital and outpatient settings to allow for administration of medications. Due to the frequency of IV use it is necessary that the nurse understands how to identify and react to phlebitis.
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Upon completion of this course, the course participant will be able to:
- Explain which circumstances can lead to an increased risk of phlebitis.
- Describe how to implement a phlebitis grading scale into standard practice.
- Identify patients who are at risk of phlebitis.
Peripheral venous cannulations, or intra venous insertions, are the most common procedure carried out in hospital and outpatient settings to allow for the administration of medications (Endacott, et al. 2009). Peripheral catheter phlebitis is caused by the inflammation of the vein and it is a common complication of IV therapy (Infusion Nursing Standards of Practice, 2000). Phlebitis is characterized by pain and tenderness along the internal vein, redness, swelling, and warmth at the insertion site. It is estimated that phlebitis may occur anywhere from 20-80% of the time following peripheral infusions. Further, phlebitis can occur up to 48 hours following an infusion, and it is believed that many cases go unreported or undiagnosed (INS). Therefore, it is essential that nurses be able to identify patients who are at risk of developing phlebitis and promptly intervene.
There are a variety of contributing factors that may increase a person’s risk of developing phlebitis. These are divided into extrinsic and intrinsic factors:
Extrinsic factors include:
- pH level
- Osmolality of the solution,
- Insertion of a catheter that is big or too long for vein size
- Skin preparation
- Frequency of dressing changes.
Intrinsic factors include:
- Previous trauma to the vein
- Patients history and present condition
- Overall condition of the veins
The type of delivery device should be carefully considered depending on the type of fluid to be administered, and the length of time that the therapy will last. For example, a newly diagnosed stage II breast cancer patient that is going to receive 11 weeks of chemotherapy may not be appropriate for a peripheral venous device. Peripheral venous devices are good for short term use only (Dougherty & Lister, 2008). The nurse should partner with the ordering provider in order to ask about the length of the therapy, so that the appropriate catheter or catheter recommendation can be made (INS). Before insertion of any vascular access device (VAD), the nurse should visually examine the potential venous sites. The patient may also be asked if he/she has had an intravenous device inserted previously and where it was inserted. This may give the nurse clues regarding previous trauma to a vein. Once a site is found, standard best practice should be followed. For example, hand washing, preparation of the site, etc.
Once the IV is started, regular monitoring of the infusion should occur, with the nurse being aware of three potential complications that may occur: mechanical, chemical, and bacterial.
Mechanical phlebitis may occur if the nurse does not select the correct size of the device. A device that is too large may cause friction on the internal lining of the vein causing inflammation. This is an avoidable complication if prior to insertion a thorough assessment of the access area has been done by feeling the pliability of the veins. A nurse should select the smallest access device for the vein.
Friction can also be avoided by correctly stabilizing the device to prevent unnecessary movement of the catheter in the vein. Once a catheter is inserted, the risk of inflammation from rubbing will be reduced if manipulation of the catheter is kept to a minimum.
Chemical phlebitis occurs when solutions irritate the endothelial lining of the vessel wall. The pH scale ranges from 0.0- 14.00. Current evidence indicates that a pH between 2.3 and 11.0 destroy human cells on contact. Nurses can use the knowledge that a solution will be potentially irritating in order to select the appropriate device. Devices should be selected that will allow for particulate matter to be infused. Solutions outside the range of 5-9 should be considered for infusing through a central device.
Similarly, high osmolality may cause chemical phlebitis. Human plasma osmolality is 290 mOsm/L. With normal ranges from 285-310. Normal saline solution is isotonic, 0.5% saline is hypotonic, whereas D5NS is hypertonic. It is worth noting that, intravenous fluid labeling has osmolality, but that labeling is not required for intravenous mixtures, such as antibiotics and chemotherapy agents. Certain drugs, such as cytotoxic drugs, can produce phlebitis despite being isotonic and pH neutral. Cytotoxic drugs can alter endothelial cell metabolism, causing cell cycle arrest, and inducing inflammatory responses. It is recommended that a nurse use the slowest infusion
possible, in the largest blood vessel.
- Cytotoxic drugs include various commonly used antibiotics naficillin, oxycillin, macrolides (erythromycin, azithromycin), quinolones (ciprofloxacin, levofloxacin), amphotericin B, Vancomycin, and antineoplastics (cladribine, mitomycin).
Few studies have been done on humans regarding trauma to the vein, however studies in animals reveal the following:
- In a 6 hour infusion through a peripheral vein, drugs with a pH of 4.5 had 100% phlebitic changes.
- A pH of 5.9 saw a mild to moderate phlebitis 50% of the time.
- A pH of 6.3 resulted in mild damage 20% of the time.
Bacterial or infective phlebitis occurs when there has been contamination to the IV solution or system. Contamination can be caused in a number of ways:
- During mixing of the solution, when sterile or aseptic technique was not followed.
- At the point of entry when skin preparation was inadequate or because ports and hubs were not cleaned properly.
Infection prevention standards must be followed when handling any vascular access device. Hand hygiene is a key component in positive outcomes with patients receiving any vascular access device. Institutional polices should be adhered to related to all aspects of infusion therapy.
The Infusion Nurses Standards of Practice recommends that a phlebitis scale be used to rate phlebitis according to the signs and symptoms present. There are two scales that are recommended by the Infusion nurses society. One is the Phlebitis Scale, the other is the Visual Phlebitis Scale.
The scale that the Infusion Nurses Society has designed for use when determining the severity of phlebitis rates the infusion site as either:
- no symptoms
- erythema at access site with or without pain
- pain at the access site with erythema and or edema
- pain at the access site with erythema and or edema streak formation and palpable venous cord
- Pain at the access site with erythema and or edema, streak formation palpable venous cord greater than one inch, and purulent drainage.
The Visual Phlebitis Scale rates the vein and has corresponding treatment. For detailed examples and samples of these scales please visit the Infusion Nurses Society website.
Before a vein is selected the nurse should carefully assess the IV site in order to ensure that none of the phlebitis symptoms are present. Should signs and symptoms of phlebitis be present, another site should be investigated. The nurse should then use a standard scale to assess the infusion for complications (phlebitis). Early recognition is critical with vesicant solutions.
The frequency of assessment will be dependent on the signs and symptoms of the person, and other clinical factors (type of fluid, patient’s age). The nurse should report the symptoms to the licensed independent provider. The nurse should not rely on infusion pumps to detect or prevent infiltration. Electronic pumps do not cause infiltrations or phlebitis, but they can exacerbate the condition or
problem. When the VAD is discontinued, the nurse should describe and document the visual inspection of the vein. This allows future nursing staff to determine if the vein suffered any potential symptoms of phlebitis.
In ambulatory care settings, both the patient and any family should be provided with instructions about the signs and symptoms of phlebitis. Additionally, they should be informed about the recommended procedure for handling a potential case of phlebitis occurring outside of the hospital.
Gallant P. Shultz AA (2006) Evaluation of a Visual Infusion Phlebitis Scale for Determining Appropriate Discontinuation of Peripheral Intravenous Catheters. Journal of Infusion Nursing; 29:6, 338-34.
Infusion Nurses Society (2011). Infusion Nursing Standards of Practice. Journal of Infusion Nursing; Supplement 34:15.
Dougherty and Lister. (2008). The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Oxford: Black Well Publications.
Endacott R. et. Al. (2009) Clinical Nursing Skills, Core and Advanced. Oxford: Oxford University Press.
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