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Description and Etiology
Description and Etiology
Description and Etiology
Phlebitis is an inflammation of the delicate inner lining (the tunica intima) of the vein. It is
characterized by pain, inflammation, and tenderness along the vein and is a common
complication associated with PIVs. Phlebitis may result in other complications such as
thrombosis formation (thrombophlebitis) and potentially BSIs, although the link between
phlebitis and BSIs is not well established (Hadaway, 2012; Zingg & Pittet, 2009).
Phlebitis is attributed to damage from chemical irritation, mechanical trauma, and bacteria.
Chemical phlebitis results from infusate damage to the tunica intima. Certain characteristics of
medications/solutions are associated with vein damage when they are administered via a PIV
Chemical damage to the vein may also result from failure to allow the skin antiseptic solution to
fully dry prior to catheter insertion. Vein irritation results when the antiseptic is pulled into the
Mechanical vein trauma occurs when the catheter irritates or injures the endothelial cells lining
the vein wall. This may occur during insertion, when a large catheter is placed in a small vein or
at a point of flexion, or when a catheter lacks adequate stabilization, causing catheter movement
that irritates the vein wall. During placement of a midline peripheral catheter or a peripherally
inserted central catheter (PICC), mechanical phlebitis may result if the catheter is advanced too
rapidly into the vein. Symptoms occur soon after placement and tend to be transient. Catheter
bloodstream infection (CR-BSI). Bacteria may be introduced through poor aseptic technique
during insertion or during catheter access or maintenance care. Phlebitis may not be evident
during peripheral catheter dwell time but appear after removal. This is called “postinfusion
phlebitis” and becomes apparent 48 to 96 hours after the catheter is removed. Types of phlebitis
Mechanical Phlebitis
Mechanical vein trauma occurs when the catheter irritates or injures the endothelial cells lining
the vein wall. This may occur during insertion, when a large catheter is placed in a small vein or
at a point of flexion, or when the catheter lacks adequate stabilization causing catheter movement
Chemical Phlebitis
Chemical phlebitis results from infusate damage to the tunica intima. Infusates with a dextrose
content greater than 10%, an acidic or alkaline pH (i.e., <5 or >9), and a high osmolarity (>600
mOsm/L) cause vein damage when administered via a peripheral I.V. catheter. Also, failing to
allow the antiseptic solution to fully dry prior to catheter insertion may cause irritation when
The type of catheter material may increase the risk of phlebitis. Several different materials are
used in the manufacture of catheters. Catheters made of silicone elastomer and polyurethane
have a smoother microsurface, are thermoplastic, are more hydrophilic, become more flexible
than polytetrafluoroethylene (Teflon) at body temperature, and cause less venous irritation.
Bacterial Phlebitis
Bacteria can cause phlebitis, and the consequences can be serious, including catheter-related
bloodstream infection. Bacteria may be introduced through poor aseptic technique during
thrombophlebitis is characterized by the presence of purulent drainage in the vein. This serious
complication is associated with bloodstream infection and requires surgical removal of the vein.
phlebitis.
All equipment should be inspected for integrity, particulate matter, cloudiness, and any signs
When inspecting the venipuncture site, if the skin is noted to be visibly dirty, it should be washed
If there is excess hair at the site, hair can be clipped using a scissors or disposable head surgical
clippers.
The skin should not be shaved because microabrasions from shaving may increase the risk of
infection.
Postinfusion phlebitis is associated with inflammation of the vein that usually becomes evident
within 48–96 hours after the cannula has been removed, so the site should be monitored for that
time period. On discharge, patients should be instructed on signs and symptoms of postinfusion
Host factors that may also contribute to risk of phlebitis include fragile vessels, a predisposition
toward thrombosis (hypercoagulable state), high hemoglobin levels, female gender, older age,
and underlying medical disease (e.g., diabetes, infectious diseases, cancer, immunodeficiency)
(Dychter, Gold, Carson, & Haller, 2012; Zingg & Pittet, 2009) (Table 9-2).
NOTE > Peripheral phlebitis can prolong hospitalization unless treated early.
INS Standard If phlebitis occurs, the nurse should determine the potential etiology of the
appropriate interventions for midline catheters and PICCs. Remove the short peripheral catheter
1. Catheter material
2. Catheter size
Larger-gauge catheters take up more space in the vein and allow less blood flow around catheter
3. Insertion factors
5. Infusate characteristics
pH <5 or >9
6. Host factors
Fragile vessels
Female gender
Older age
Inspection of the affected site reveals a similar appearance regardless of the underlying cause
(Fig. 9-2). Local signs and symptoms associated with phlebitis include:
■ Local swelling
■ Possible fever
INS Standard The nurse should use a standardized phlebitis scale that is valid, reliable, and
0 No clinical symptoms
3 Pain at access site with erythema and/or edema, streak formation, and palpable venous cord
4 Pain at access site with erythema and/or edema, streak formation, palpable venous cord >1 inch
Prevention
1. Assess the appropriateness of the infusate characteristics and the duration of infusion for PIV
therapy.
b. Infusates with a pH less than 5 or greater than 9, or with osmolarity greater than 600 mOsm/L,
3. Perform proper hand hygiene and use aseptic technique with all I.V. procedures.
4. Wear clean gloves during PIV insertion and maintain aseptic technique with catheter insertion.
5. Prepare the skin with an antiseptic and allow it to fully dry prior to catheter insertion. Do not
7. Infuse solutions at the prescribed rate. Do not attempt to catch up on delayed infusion time.
9. Ensure that the catheter is adequately stabilized in place to minimize catheter movement
10. Assess the site at least every 4 hours for signs of complications, more frequently when
administering irritating infusates, when the patient is sedated or has cognitive limitations and
cannot report changes, and/or when the PIV is placed in a high-risk location such as an area of
Be aware that solutions that are highly acidic (pH <5), highly alkaline (pH >9), or
hyperosmolar (>600 mOsm/L) or have a high dextrose concentration (>10%) are associated
Treatment
Standard treatment of phlebitis is the application of warm compresses to the affected site. In
phlebitis. Additionally, use this information in planning for ongoing venous access. For example,
if the etiology is likely an irritating infusate, consider the need for an alternate plan, such as a
PICC.
■ Remove the PIV and replace as clinically indicated.
■ Restart the infusion in the opposite extremity, using a fresh administration set.
■ Provide patient education about postinfusion phlebitis, including instructions about its signs
Documentation
Document the site assessment, the phlebitis rating (1, 2, 3, or 4), whether the licensed
independent practitioner (LIP) was notified, and the treatment provided. Document the
discontinuation of the PIV catheter and the location of the new I.V. site. Document all observable
symptoms and the patient’s subjective complaints, such as “feels tender to touch” and “it hurts.”
Document the actions taken to resolve the problem and the time of LIP notification.
If the inflammation is the result of bacterial phlebitis, a much more serious condition may
develop if the patient is not treated. Untreated bacterial phlebitis can lead to septicemia.