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IV-related phlebitis, complications and length of hospital stay: 1

Article  in  British journal of nursing (Mark Allen Publishing) · November 1998

DOI: 10.12968/bjon.1998.7.21.5551 · Source: PubMed

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CLINICAL
IV-related phlebitis, complications
and length of hospital stay: 1
Abstract
This article, the first of two-parts, addresses the growing problem of
intravenous-related phlebitis in hospitalized patients, and the resultant
personal and financial costs to both patient and hospital. Literature on
the various types of phlebitis, the factors that increase the patient’s risk
of developing phlebitis, clinical indicators and severity grading scales,
and the complications of phlebitis are examined. Awareness of such factors
is considered instrumental in minimizing the incidence of intravenous-
related phlebitis. The second article in this series will present a study of
90 patients from a large teaching hospital, which was conducted to
determine the incidence and severity of intravenous-related phlebitis, risk
factors, associated complications, and the related length of hospital stay.
The impllcations of the results for current and future nursing care of
patients receiving IV therapy will be discussed, and recommendations for
safe practice will be made.
L
iterature evidence suggests that few hos-
pitals in Britain today are investigating
the risks and costs associated with intra-
venous (IV) therapy. Although hospitals are
placing a greater emphasis on quality, evi-
dence-based practice, and cost-effectiveness,
litigation arising from patient injury is on the
increase (Lipley, 1998; Tingle, 1998).
Use of the IV route has led to an increased
risk of adverse reactions and complications
(Parish, 1982; Hampton and Sheretz, 1988),
many of which can be life-threatening but are
preventable (Peters et al, 1984). Lamb (1995)
highlights the risk of the development of
damaging side-effects, which may arise from
the treatment itself, device-related complica-
tions or the clinical status of the patient, or be
caused by the administering clinician. IV-
related phlebitis can have long-term implica-
tions for both the patient and the hospital (De
Luca et al, 1975; Fricker, 1980). Early detec-
tion and prompt, consistent nursing interven-
tion can decrease its occurrence and severity
(Ervin, 1987).
Linda Campbell is
Intravenous Nurse Trainer, An estimated 25 million patients enter the
Medical Directorate, The health service each year and receive infusion
Royal Hospitals, Belfast
therapy via peripheral venous access (Angeles
and Barbone, 1994). Approximately 50% of
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Linda Campbell
these devices fail to deliver the prescribed IV
therapy course, one of the most common rea-
sons being phlebitis. The incidence of
phlebitis in hospitalized patients receiving IV
therapy has been reported to be as high as
80% (Feldstein, 1986). The Intravenous
Nurses Society’s (1990) standards of practice
state that an acceptable phlebitis rate in any
given patient population is 5% or less.
Review of the literature on this subject sug-
gests that phlebitis rates in most hospitals are
much higher than this ‘acceptable rate’, rang-
ing from 20 to 80% (Maki and Ringer, 1991;
Perucca and Micek, 1993; Angeles and
Barbone, 1994). One might therefore expect
that major advances would have been made
in the reduction of peripheral IV infusion-
related phlebitis. However, this expectation
has not been realized. In 1998, phlebitis rates
of between 20 and 80% in patients receiving
IV therapy via peripheral venous cannulae are
not acceptable.
While no human activity is free from risk,
the complication rates of peripheral venous
cannulation and phlebitis are unacceptable
when compared with the level of risks toler-
ated in other spheres (Peters et al, 1984).
Nursing research in this area (provided that it
is published) can determine why this rate is so
high and, if the recommendations are imple-
mented, provide the professional nurse with
the power to maintain a safe, cost-effective
environment for the hospitalized patient
(Ervin, 1987).
PHLEBITIS, THROMBOPHLEBITIS, AND
INFUSION-RELATED PHLEBITIS
Phlebitis is defined as inflammation of the
vein wall (Angeles and Barbone, 1994)
(Figure 1). Two complications that may
develop as a result of phlebitis are: infection
resulting from an accumulation of neu-
trophils; and thrombus, which may lead to
complete occlusion of the vein (throm-
bophlebitis) (Hecker, 1988).
BRITISH JOURNAL OF NURSING, 1998, VOL 7, NO 21
CLINICAL
Figure 1. Coloured venogram showing the
inflammation of veins (phlebitis) in the leg of a
patient. The veins have been coloured orange
and appear misshapen, leading off randomly
(e.g. left of image). Phlebitis causes pain,
swelling and tenderness along the length of a
vein. Phlebitis can lead to abnormal formation
of clots in the veins (thrombophlebitis).
Figure 2. Coloured angiogram of thrombophlebitis in a vein in the leg (left, pink).
At right is a healthy leg with a normal vein. The white structure at left is bone.
Thrombophlebitis is inflammation of part of a vein, usually near the surface of the
body, along with clot formation in the affected segment. The condition can occur
after injury or a complication of blood vessel disorders like varicose veins.
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Many researchers consider thrombophlebitis
to be a progressive development or complica-
tion of phlebitis (Figure 2). Millam (1988) con-
sidered it to be similar to phlebitis, with the
additional complication of clot formation at the
cannula tip or along the inner wall of the vein.
Infusion-related phlebitis was defined by
Hecker (1988) as ‘local inflammation of veins
that are receiving infusions’. This definition
was supported by Maki and Ringer (1991)
who added that, as a result, patients who
received infusion therapy frequently suffered
pain and discomfort. In 1992, Hecker suggest-
ed that irritation of the venous endothelium by
the infusate resulted in venoconstriction. This
prevented blood from flowing through the vein
and diluting the infusate, the resultant effect
being intensification of the venous irritation.
Most investigators have concluded that
infusion-related phlebitis is primarily a ‘phys-
iochemical’ phenomenon; however, there may
be an infective cause. Leibovici (1989) found
that although infusion phlebitis was mainly
caused by physical and chemical stimuli,
infection at the site of insertion of the cannula
also accounted for approximately 10% of cases.
Post-infusion phlebitis is inflammation of a
vein that has been used for IV infusion, devel-
oping during or after infusion (Millam,
1988). From this definition, it can be seen
why many authors view post-infusion
phlebitis and infusion-related phlebitis as one
and the same.
CHEMICAL, PHYSICAL AND SEPTIC
PHLEBITIS
‘Chemical’ phlebitis
‘Chemical’ phlebitis is irritation of the vein
wall by a chemical irritant such as infusion
fluid (Haynes, 1989). Both a low pH and a
high osmolarity of IV solutions and medica-
tions are reported to be associated with the
development of chemical phlebitis (Harrigan,
1984; Hecker, 1988). Dextrose infused in high
concentrations is acidic and irritant, and
induces phlebitis (Hecker, 1992). Researchers
have shown that ‘buffering’ infusion solutions
(i.e. neutralizing them) reduces the rate of
phlebitis in the short term (Fronkalstrud et al,
1971; Bivins et al, 1979; Hecker et al, 1991).
Additives such as potassium chloride
(Larson and Hargiss, 1984; Adams et al,
1986) and various intravenously administered
drugs, such as antibiotics and cytotoxics,
BRITISH JOURNAL OF NURSING, 1998, VOL 7, NO 21
CLINICAL
‘
The venous can produce severe venous inflammation
(Gaukroger et al, 1988; Hecker, 1989). Maki
access device and Ringer (1991) reaffirmed these findings
needs to be smaller in their study of 714 patients.
in gauge than the The presence of particulates in infusion
fluid has been cited as a major cause of
lumen of the vein, to chemical phlebitis by many researchers
allow the blood to (Blackhouse et al, 1987; Barnett, 1992;
act as a ‘cushion’ Lundgren et al, 1993). Over the years, there
has been much discussion about the use of in-
between the cannula line IV filters in reducing infusion particulates.
and the internal Allcutt et al (1983) showed that in-line filtra-
lining of the tion delayed the onset of phlebitis; however,
the changes were not significant enough to
vein...Cannulae justify the use of filters. The role of in-line fil-
inserted into areas of ters is still a matter for debate, and researchers
joint flexion or (e.g. Wilson, 1994) emphasize that filters are
not a panacea for the problems of IV therapy.
rotation may slide
back and forth or ‘Physical’ phlebitis
roll inside the vein, ‘Physical’ phlebitis occurs when veins have
’
been traumatized by physical contact with
thereby irritating organic or inorganic materials, or the material
the vein wall... composition of the cannula used during IV
fluid administration (Tully et al, 1981).
Physical trauma can result from the insertion of
a long, large-gauge cannula, into a short, nar-
row vein. The venous access device needs to be
smaller in gauge than the lumen of the vein, to
allow the blood to act as a ‘cushion’ between
the cannula and the internal lining of the vein
(Angeles and Barbone, 1994; Murchan et al,
1996). Cannulae inserted into areas of joint
flexion or rotation may slide back and forth or
roll inside the vein, thereby irritating the vein
wall (Angeles and Barbone, 1994).
Gaukroger et al (1988) highlight the poten-
tial risks associated with the insertion of can-
nulae in a ‘rough manner’, by an ‘unskilled
Table 1. Host factors that
predispose to the
development of phlebitis
Age
Gender
Presence of disease, e.g. blood
abnormalities
Diabetes mellitus
Severe debilitation
Level of activity
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person’, or ‘in a hurry’ as in an emergency sit-
uation. The experience of the person estab-
lishing venous access clearly influences the
risk of the patient developing phlebitis (Maki
and Ringer, 1991).
Poor anchorage of cannulae with tape or
dressing appears to increase the risk of devel-
opment of phlebitis (Von Dardel et al, 1986;
Hedstrand and Zaren, 1989). This theory was
supported by Lundgren et al (1993) who fol-
lowed up their study patients for 5 months after
discharge; pain was the most commonly report-
ed problem following removal of the cannula:
47% (n = 28) complained of pain between 5
and 9 days post-discharge, and 7% (n = 4)
experienced pain between 98 and 160 days
post-discharge.
Certain cannulae materials appear to
increase the risk of development of phlebitis
(Davies, 1998). Gaukroger et al (1988) com-
pared Teflon and Vialon cannulae in 700 sur-
gical patients. They found a 46% reduction in
thrombophlebitis when Vialon cannulae were
used. Maki and Ringer (1991), in a random-
ized, controlled clinical trial involving 714
patients, showed that Vialon cannulae were
substantially less phlebitogenic than were
Teflon cannulae.
‘Septic’ phlebitis
‘Septic’ phlebitis is phlebitis that develops as a
direct result of sepsis or infection (Stratton,
1982). In a small proportion of patients, a bac-
terial infection may cause phlebitis (Bennet and
Brachman, 1992). Septic or bacterial phlebitis
can progress to septicaemia if the cannula
remains in place (Jemison-Smith and Thrupp,
1982). Maki and Ringer (1991), in their study
of 1054 venous cannulae in 714 patients, found
that only a small proportion of those with infu-
sion-related phlebitis had cannula-related infec-
tion; however, approximately half of those with
cannula-related septicaemia had phlebitis.
Routine or scheduled replacement of IV
cannulae has been advocated as a means of
preventing phlebitis and catheter-related
infection (Ena et al, 1992). The incidences of
thrombophlebitis and bacterial colonization
of peripheral cannulae increase dramatically
when the cannulae are left in place for more
than 72 hours (Collin et al, 1975; Band and
Maki, 1980; Ena et al, 1992).
The use of dressings, and the type of dress-
ing used, have been reported to contribute to
the development of septic phlebitis, thrombo-
BRITISH JOURNAL OF NURSING, 1998, VOL 7, NO 21
 IV-RELATED PHLEBITIS, COMPLICATIONS AND LENGTH OF HOSPITAL STAY: 1

Figure 3. Physiology of cannula-induced phlebitis.

BRITISH JOURNAL OF NURSING, 1998, VOL 7, NO 21 1309

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CLINICAL
‘
phlebitis, and cannula-related infection in
As healthcare
many studies (Von Dardel et al, 1986;
professionals Hedstrand and Zaren, 1989). However, a
cannot look inside large study that looked at four different types
of dressing for sterile cannulae did not find
veins during IV
any significant difference in cannulae-related
therapy, they must infection rates between the dressings (Maki
rely on what they and Ringer, 1997).
The frequency of change of administration
can see, feel and
sets has also been cited as a contributory fac-
ask, i.e. detectable tor in septic phlebitis. Following a large out-
changes in skin break of IV-related infection in a hospital in
Davenport in 1972, the Department of
colour, texture,
Health and Social Security (DHSS) stipulated
temperature and that fluid administration sets should be
sensitivity, to changed every 24 hours. This was enforced,
despite the fact that the cause of the contam-
identify the
’
ination was found to be faulty autoclaving
development equipment during manufacture (DHSS,
of phlebitis. 1972). The standards were set, with little firm
clinical or experimental evidence to support
them (Blackhouse et al, 1987).
The optimal interval for routine replacement
of IV administration sets has been examined in
three well-controlled studies: Snydman et al
(1987), Josephson et al (1985), and Maki and
Ringer (1987). Data from each of these studies
show that replacing the administration sets no
more frequenly than 72 hours after initiation of
use is not only safe, but also cost-beneficial.
Replacing administration sets and cannulae
simultaneously every third day can achieve sub-
stantial cost savings (Maki and Ringer, 1987).
OTHER FACTORS ASSOCIATED
WITH PHLEBITIS
Phlebitis may be associated with a number of
host factors (Nichols et al, 1983; Table 1).
According to Nichols et al (1983), these fac-
tors predispose the subject to the develop-
ment of microemboli, which can lodge at the
needle site and result in thrombophlebitis.
These factors also render the patient more
vulnerable to microorganisms introduced into
the IV system. Scally et al (1992) noted that
veins that have become fragile as the result of
the ageing process or repeated cannulation
increase the risk of phlebitis.
Female gender has been shown to increase
the risk of phlebitis in some studies (Tully et
al, 1981; Tager et al, 1983; Maki and Ringer,
1991). Dibble et al (1991) showed that, out
of 514 patients, more women had symptoms
of phlebitis than men, suggesting that if the
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same size cannula was placed in the back of a
female’s hand as in a male’s hand, then the
length of the cannula would extend beyond
the wrist in the female, causing increased risk
of irritation to the vein, leading to phlebitis.
Maki and Ringer (1991) suggested that indi-
viduals may vary in their ‘biological vulnerabili-
ty’ to the development of phlebitis, based on
their finding that patients who developed
phlebitis with a first cannula were more likely to
develop severe phlebitis with a second. However,
they could not offer an explanation for this find-
ing and concluded that the ‘pathobiological’
basis for such vulnerability is unknown. Further
research in this area is needed.
CLINICAL INDICATORS OF PHLEBITIS
AND SEVERITY GRADING SCALES
As healthcare professionals cannot look
inside veins during IV therapy, they must rely
on what they can see, feel and ask, i.e.
detectable changes in skin colour, texture,
temperature and sensitivity, to identify the
development of phlebitis. The absence of a
good blood flow and the presence of a poor
infusion rate have also been cited as clinical
indicators of phlebitis (Wright et al, 1985).
Observation of the patient for clinical signs
and symptoms of phlebitis is therefore the key
to preventing serious venous damage.
The order of occurrence and significance of
the clinical indicators ‘pain’ and ‘redness’
have been studied extensively. Dibble et al
(1991), in their study of 514 patients receiv-
ing IV therapy, found that pain was the most
common symptom, occurring in 133 patients
(64.9%), whereas redness occurred in only 71
(34.6%) patients. Aisenstein (1981) and
Nichols et al (1983) also identified pain at the
IV site as the first symptom of phlebitis.
According to the Intravenous Nurses Society’s
(1990) nursing standards of practice, the
presence of pain alone does not indicate
phlebitis, but the presence of pain at the inser-
tion site may be a precursor to phlebitis.
Other clinical indicators of phlebitis include
warmth or stiffness of the skin around the
cannula site, or a palpable venous cord above
the cannula site (Goodinson, 1990). Swelling
may occur around the site of the cannula and
the vein may feel hard. There may also be evi-
dence of ‘tracking’ — red lines running up the
arm from a spreading venous or lymphatic
infection (Campbell, 1997) (Figure 3).
BRITISH JOURNAL OF NURSING, 1998, VOL 7, NO 21
 IV-RELATED PHLEBITIS, COMPLICATIONS AND LENGTH OF HOSPITAL STAY: 1
It is unfortunate that very often phlebitis is
not detected until the more advanced symp-
toms appear, e.g. induration (hardness) or a
palpable venous cord. By this stage it is often
too late to save the vein and, as a result, the
vein, superficial fascia and skin all sustain
injury. However, the use of phlebitis severity
grading scales to aid early detection of
phlebitis has successfully saved many a vein
and prolonged the use of the cannula.
It is important to have a uniform scale that
measures the degree of phlebitis (Perucca and
Micek, 1993). Phlebitis continues to develop,
despite specialized insertion techniques,
meticulous cannula care, and frequent assess-
ment and monitoring of the site. A uniform
phlebitis scale ensures greater accuracy in
performing site assessments, and provides cri-
teria for standardizing documentation.
Several scales have been developed over the
last 20 years to assess the severity of phlebitis.
These are based on the presence or absence of
certain clinical indicators (De Luca et al,
1975; Maddox and Rush, 1977; Intravenous
Nurses Society, 1990). The three main scales,
which are all similar and have been adapted
over the years, are:
● The Dinley scale (Dinley, 1976)
● The Maddox scale (Maddox and Rush,
1977)
● The Baxter scale (Baxter Healthcare Ltd,
1988).
All three scales grade phlebitis according to
severity, starting at ‘0’ for no symptoms, and
going up to ‘5’ for all symptoms. The Baxter
and Maddox scales are very similar, except
that pain and erythema have been given equal
status in the more recent Baxter scale because
of the results of phlebitis studies carried out
since Maddox, where erythema has been
found to be present simultaneously with, or
before, the development of pain.
The use of these scales as a measuring tool
in everyday IV site care has been shown, in
various studies, to be both relevant and bene-
ficial, the incidence of phlebitis being signifi-
cantly reduced (Gaukroger et al, 1988;
Dibble et al, 1991; Kerrison and Woodhull,
1994; Stonehouse, 1996).
COMPLICATIONS ASSOCIATED
WITH PHLEBITIS
Phlebitis can lead to thrombophlebitis —
inflammation of the vein along with the pres-
BRITISH JOURNAL OF NURSING, 1998, VOL 7, NO 21
‘
ence of thrombi. Occlusion of the vein may Phlebitis may
result, leading to extravasation, i.e. leakage of
fluids into the tissues (Haynes, 1989). If this
lead to sepsis;
occurs, venous access is limited in the affected septicaemia, acute
arm, and at worst can lead to seriously impaired bacterial
function in the upper limb, or even embolism
(Gaukroger et al, 1988; Weinstein, 1993).
endocarditis, and
The limited venous access may cause an even death can
unnecessary delay in the patient’s current treat- result...Clearly,
ment, lengthening his/her stay in hospital; this
can have repercussions (especially financial)
prevention of
for both the patient and the hospital (De Luca phlebitis is the
et al, 1975; Fricker, 1980). The very minimum answer to the
distress that the patient can expect to suffer
with phlebitis is pain, and this is unique for
problem. However,
each individual (Lundgren et al, 1993). first the incidence
Phlebitis may occur as a result of sepsis and severity of
(Gaukroger et al, 1988) or it may lead to sepsis;
septicaemia, acute bacterial endocarditis, and
phlebitis need to be
even death can result (Gaukroger et al, 1988; assessed, and the
’
Perucca and Micek, 1993; Weinstein, 1993). associated risk
Clearly, prevention of phlebitis is the
answer to the problem. However, first the
factors identified.
incidence and severity of phlebitis need to be
assessed, and the associated risk factors iden-
tified. Only then can the potential complica-
tions of phlebitis be addressed, and the impli-
cations that these may have for the patient’s
length of stay in hospital be ascertained.
The second article in this series will present
a quantitative study that determined the inci-
dence and severity of IV-related phlebitis in 90
patients in a large teaching hospital over a 2-
month period. The implications of the results
for the current and future nursing care of
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