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Nursing Practice

Review
Phlebitis

Keywords: Phlebitis/Venous catheter/


Infection control
This

article has been double-blind


peer reviewed

How to prevent, identify and treat phlebitis in patients with a venous cannula

Phlebitis: treatment,
care and prevention
In this article...
 eripheral venous cannulation is a common procedure used
P
in hospital to deliver fluid and medicine
Phlebitis (inflammation of the vein) can be caused by
chemical, mechanical or infectious irritation
Good practice with cannula insertion and infection control
should help to prevent the condition
Author Ray Higginson is chartered
biologist and senior lecturer in critical care,
and Andrew Parry is senior lecturer in
critical care; both at the Faculty of Health,
Sport and Science, University of
Glamorgan, Wales.
Abstract Higginson R, Parry A (2011)
Phlebitis: treatment, care and prevention.
Nursing Times; 107: 36, 18-21.
Peripheral venous catheter-associated
phlebitis is caused by inflammation to the
vein at a cannula access site. It can have a
mechanical, chemical or infectious cause.
Good practice when inserting a
cannula, including appropriate choice of
device and site, can help to prevent phlebitis.
Good infection control techniques are also
vital in preventing the condition.
There are two phlebitis scoring systems,
which should be used in routine practice
to identify and treat early signs of the
inflammation.

eripheral venous cannulation


(PVC) is a common procedure
carried out in hospital to allow
rapid and accurate administration of medication (Endacott et al, 2009).
However, the placement of an intravenous
cannula can have undesirable effects, the
most common of which is phlebitis.
Peripheral catheter-related phlebitis is
caused by the inflammation of the tunica
intima of a superficial vein. The inflammation is due to irritation of the tunica intima
by mechanical, chemical or bacterial

sources. If left untreated, it can lead to


infection or thrombus formation (Royal
College of Nursing, 2010).
It is estimated that in the UK 20-80% of
patients with a PVC develop phlebitis (Pandero et al, 2002). This broad range has also
been reported in studies from other countries (Uslusoy and Mete, 2008) and suggests poor identification of phlebitis or
poor reporting protocols.
It is essential for nurses to be able to
identify patients who are at risk of developing phlebitis. In turn, early recognition
will enable prompt intervention, minimising disruption to treatment.

Receiving intravenous therapy

Intravenous therapy is indicated for many


reasons. A significant number of patients
admitted into hospital receive some form
of intravenous therapy via PVC.
These include intravenous antibiotic
administration, intravenous fluids, intravenous pain relief and/or total parenteral
nutrition (TPN).
Intravenous delivery devices include:
Peripheral cannulas;
Peripheral midline catheters;
Peripherally inserted central catheters;
Skin tunnelled cuffed central catheters
(Hickman lines).
The type of intravenous delivery device
used depends on the type of fluid administered and the length of time intravenous
therapy will last. For example, peripheral
venous cannulas are indicated for

18 Nursing Times 13.09.11 / Vol 107 No 36 / www.nursingtimes.net

5 key
points

Peripheral
venous
cannulation is
a common
procedure
Phlebitis or
inflammation
of the vein can
be caused by
mechanical,
chemical or
infectious
irritation at the
cannula site
Careful
placement
and good hygiene
can help to prevent
phlebitis
There are
two
assessment tools
to identify early
signs of the
condition
Vigilance
can help to
prevent rare but
potentially severe
complications
such as sepsis

4
5

Coloured venogram
of phlebitis in leg

Infection control

Microorganisms gain access to new hosts


via a variety of methods, with some
microbes using more than one method of
transmission. Microorganisms are not
able to move freely between hosts by themselves they require either direct physical
contact with a new host, or they use
another person, animal or inanimate
object, to gain access.
Understanding these direct and indirect modes of transmission is essential for
effective infection control (Box 1).
Clinical staff, especially those in close
physical contact with patients, can act as a
portal for disease-causing organisms,
facilitating their spread between patients
and the clinical environment. An unhygienic environment can harbour microorganisms and facilitate their contamination and spread (Randle et al, 2009).
Infection control measures are essential
in the fight against disease-causing
microbes, and in the delivery of a highquality, effective healthcare service.
Good staff hygiene, hand hygiene and
adherence to universal precautions (Box 2)
are fundamental nursing skills that have
consistently been shown to reduce crossinfection, improve hospital hygiene and
help combat nosocomial infections
(Burke, 2003).
In addition, aseptic technique can
help prevent the transmission of microorganisms to wounds and other susceptible sites (such as intravenous cannula

fig 1-3. Types of phlebitis

Fig 1. Mechanical phlebitis:


possibly occurred due to cannula
proximity to wrist. Taken from
Macklin (2003)
Fig 2. Chemical phlebitis. Fig 3. Chemical phlebitis:
note the red track up the
Taken from Macklin
arm from chemical
(2003)
irritation of the vein

ports), and reduce the risk of cross-infection (Hart, 2007).


An aseptic technique is necessary when
performing any clinically invasive procedure, especially if the patient has an infectious disease. It is, of course, indicated
when delivering intravenous therapy, be it
cannula insertion, intravenous drug or
fluid administration (Randle et al, 2009).
Phlebitis has been linked with

box 2. Universal
infection control
measures
Handwashing
Patient skin preparation
Wearing gloves and aprons
Establishing a clean environmental
field
Using sterile equipment
Disposing of contaminated or soiled
equipment and linen appropriately
Safe disposal of sharps

Box 1. Modes of transmission


Direct contact

Indirect contact

Infected or colonised person-tosusceptible host: spread by direct


contact with infected or colonised skin,
mucous membranes or body fluids

Airborne: Some microorganisms can


survive for periods in the air

Fomite (inanimate object): hospital


objects such as medical equipment,
clothing, bedding, dressings and sinks can
act as a source of infection
Vector borne: microorganisms spread by
arthropods
Droplet spread: occurs when bacteria or
viruses travel, usually only a short distance,
on large respiratory droplets

inappropriate catheter insertion sites and


inappropriate catheter usage. In addition,
a poor standard of infection control has a
part to play and infection control and
hygiene standards are essential in the
treatment and prevention of the condition
(Uslusoy and Mete, 2008).

Phlebitis

Mechanical phlebitis
Mechanical phlebitis occurs where the
movement of a foreign object (cannula)
within a vein causes friction and subsequent venous inflammation (Stokowski
etal, 2009) (Fig 1).
It often occurs when the size of the cannula is too big for the selected vein (Martinho and Rodrigues, 2008). It has also
been suggested that placement of a cannula near a joint or venous valve will
increase the risk of mechanical phlebitis
due to irritation of the vessel wall by the tip
of the cannula (Macklin, 2003).
This type of phlebitis can be avoided by
selecting the smallest possible device for
the largest vessel (although some studies
such as Uslusoy and Mete (2008) have suggested that catheter size is not a significant
causative factor).
Consideration must also be given to the
nature of the intended IV therapy and
optimum cannula size for drug delivery.
For example, a large-bore cannula would
be appropriate for rapid fluid resuscitation
while a cannula with a smaller bore would
suffice for sliding scale insulin therapy.
Chemical phlebitis
Chemical phlebitis is caused by the drug or
fluid being infused through the cannula.
Factors such as pH and osmolarity of the
substances have a significant effect on the
incidence of phlebitis (Kohno et al, 2009)
(Figs 2 and 3).

www.nursingtimes.net / Vol 107 No 36 / Nursing Times 13.09.11 19

SPL

short-term use only (Dougherty and Lister,


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 administered (RCN, 2010).

Nursing Practice
Review

Assessment and classification

All patients with an intravenous access


device should have the access site checked

every shift for signs of phlebitis (LaRue


and Peterson 2011; Gallant and Schultz,
2006). A number of phlebitis scales and
assessment tools have been developed to
assist this, and the two most commonly
used in the UK are the Phlebitis Scale and
the Visual Infusion Phlebitis (VIP) scale.
The Phlebitis Scale was developed by
the Infusion Nurses Society (2006). Using a
grading scale from 0-4, it has proven to be
a quick, easy and useful tool. It is shown in
Box 3.
The tool recommended by the Royal
College of Nursing is the Visual Infusion
Phlebitis scale first developed by Jackson
in 1998 (Box 4). The VIP scale has been
shown to be a valid and reliable measure
|| ||||

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||

||

QUICK
FACT
||||

The commonest symptoms of any form of


phlebitis are erythema and swelling along
the venous track, leading to hardened, cord
-like veins (Endacott et al, 2009). The area
can feel warm and patients may experience
pain or discomfort during drug administration (nurses should assess if this pain
persists between administrations).
Difficulty in injecting or regular infusion pump occlusion would also indicate
phlebitis. Any exudate oozing from the
insertion site would also be suggestive of
phlebitis, in particular infective phlebitis
(Macklin, 2003). Pyrexia and haemodynamic deterioration of an unknown origin
should prompt investigation into cannula
infection and potential systemic sepsis.

Source: Infusion Nurses Society (2006)

|||||

Signs and symptoms

Grade 0 No symptoms
Grade 1 Erythema at access site with
or without pain
Grade 2 Pain at access site with
erythema and/or oedema
Grade 3 Pain at access site with
erythema and/or oedema, streak
formation, palpable venous cord
Grade 4 Pain at access site with
erythema and/or oedema, streak
formation, palpable venous cord
greater than one inch in length and
purulent drainage

|||

Infective phlebitis
Infective phlebitis is caused by the introduction of bacteria into the vein. It may
start as an inflammatory response to cannula insertion, allowing bacteria to colonise the inflammatory debris (Malach et
al, 2006).
Poor practices during drug administration and a higher frequency of drug administration have been found to increase the
risk of infective phlebitis (Uslusoy and
Mete, 2008).
Another risk factor is poor skin
cleansing technique before cannula insertion. Malach et al (2006) found the bacterial growth on removed cannula tips were
those commonly associated with normal
skin flora.
Infective phlebitis can have significant
ramifications for the patient due to the
potential development of systemic sepsis.

box 3. Phlebitis Scale

|||

Antibiotics are reported to increase the


incidence of chemical phlebitis due to
their low pH (Macklin, 2003). With a large
proportion of hospitalised patients
receiving IV antibiotics, nurses need to be
vigilant when administering this therapy.
Isotonic fluids have been found to lower
rates of phlebitis, while hypertonic fluids
increase the incidence of phlebitis by initiating the inflammatory response (Uslusoy
and Mete, 2008).
TPN is hypertonic but its osmolarity
can be adjusted without affecting the
pharmacodynamics of the solution,
which, alongside the addition of drugs
such as heparin, has been shown to
increase the life of a fine bore midline cannula (Catton et al, 2006).

2080%

of patients with a
peripheral venous
cannulation develop
phlebitis

for determining when an intravenous


catheter should be removed (Gallant and
Schultz, 2006). The VIP score is recommended in the Infusion Nursing Standards
of Practice (INS, 2011).
These phlebitis assessment scales are
used to inform clinical practice and decision making, indicating to clinicians the
first stages of phlebitis and when intravenous cannulas should be replaced (Creed
and Spears, 2010). They can help reduce the
progression of phlebitis through early
detection.

Phlebitis reduction measures

The incidence of phlebitis can be reduced


by use of simple measures. Good practice
during insertion will also extend the life of
the cannula.

20 Nursing Times 13.09.11 / Vol 107 No 36 / www.nursingtimes.net

The clinicians hands should be thoroughly washed, gloves worn and the
patients skin adequately cleansed.
Good clinical practice must be observed
when administering intravenous drugs,
starting at the point of reconstituting and
drawing up the drug. This standard of
practice must continue to the administration phase, with particular attention paid
to cannula sites of patients on frequent
intravenous therapy, as regular use of the
cannula site increases the risk of bacterial
phlebitis (Uslusoy and Mete, 2008).
The appropriate cannula should be
selected for the vein. The site should also
be carefully selected, to avoid any bony
prominences, joints and venous valves
that would cause the cannula to move
within the vein lumen.
After insertion, the cannula should be
dressed to minimise movement in the vein
lumen, which could lead to mechanical
phlebitis.
Evidence suggests that the addition of
drugs such as heparin and hydrocortisone
can reduce the incidence of phlebitis
(Ikeda et al, 2004); patients on intravenous
steroid therapy have a lower incidence of
phlebitis (Kohno et al, 2009). However, this
applies only to the administration of antineoplastic drugs and so is limited to
patients receiving cancer chemotherapy.
To avoid chemical phlebitis, the possibility of bringing drug pH or osmolarity in
line with physiological ranges should be
explored (Kuwahara et al, 1999). For
example, patients undergoing antibiotic
or potassium therapy have a higher phlebitis risk due to the low pH of these solutions and neutralising such solutions may
help prevent phlebitis (Kuwahara et al,
1999), although this is not usually done by
nurses.
Similarly, TPN infusions have a high
osmolarity, increasing the risk of chemical
phlebitis (Kuwahara et al 1999). Adjusting
the osmolarity of TPN solutions (if possible) can also help prevent phlebitis.

Complications

Early phlebitis at an intravenous site usually resolves after a cannula is removed or


resited (Rickard et al, 2010).
Complications are rare but can occur;
these include infection, thrombosis, and
recurrent superficial thrombophlebitis
(Loewenstein, 2011).
One of the most serious complications
although fortunately rare is septic
thrombophlebitis, a condition characterised by venous thrombosis and inflammation in the presence of bacteraemia
(Mermel et al, 2009).

Employ techniques to help


you achieve your objectives
Anne Marshall

p33

Box 4. Visual Infusion Phlebitis scale


Appearance

Score

Stage

IV site appears healthy


Action: observe cannula

No signs of phlebitis

One of the following signs is evident


Slight pain near IV site or
Slight redness near IV site
Action: observe cannula

Possibly first signs


of phlebitis

Two of the following are evident


Pain at IV site
Redness
Swelling
Action: resite cannula

Early stage of phlebitis

All of the following signs are evident


Pain along path of cannula
Redness around site
Swelling
Action: resite cannula and consider
treatment

Medium stage of phlebitis

All of the following signs are evident and


extensive
Pain along path of cannula
Redness around site
Swelling
Palpable venous cord
Action: resite cannula and consider
treatment

Advanced stage of
phlebitis or start of
thrombophlebitis

All of the following signs are evident and


extensive
Pain along path of cannula
Redness around site and swelling
Palpable venous cord
Pyrexia
Action: initiate treatment/resite cannula

Advanced stage
thrombophlebitis

Source: Jackson (1998)


Treatment

The treatment of phlebitis will depend to


some extent on the severity of inflammation and presence of a thrombus. Moderate
phlebitis will usually resolve itself. A
patient with phlebitis with a VIP score of 2
or more will require their cannula to be
removed or resited.
The initial treatment for any form of
phlebitis is to stop the infusion and
remove the PVC (Webster et al, 2010). This
should be done with consideration for the
patients needs; if, for example, the patient
is haemodynamically unstable, the PVC
should only be removed once a new PVC
has been sited.
An affected limb should be elevated to
minimise inflammation and an antiinflammatory cream or gel can be directly
applied to the area (Reis et al, 2009).
Anti-inflammatory analgesics can be
prescribed to treat both the inflammation
and the pain associated with phlebitis.

Conclusion

Many patients in hospital require PVC as


part of their medical management and
care. A recognised associated risk factor is
phlebitis.
Nurses are well placed to assess for the
presence of phlebitis and act accordingly.
By observing good practice both during
and after peripheral catheter insertion,
complication rates of phlebitis can be
reduced and patient care improved.NT
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