Intra Venous

Access
Complications:
Trombophlebitis
M. Saifur Rohman, dr SpJP. PhD.
FICA
Dept. Cardiology and Vascular Medicine
Faculty of Medicine, Brawijaya University

Intravenous (IV)
Access Indications
90% of hospitalized patients receive
IV fluids and medications
Fluid and blood replacement
Drug administration
Obtaining venous blood specimens
for lab analysis

Place the constricting band.

Scott Metcalfe

Cleanse the venipuncture site.

Scott Metcalfe

Insert the intravenous cannula into the

vein.

Scott Metcalfe

Withdraw any blood samples needed.

Scott Metcalfe

Connect the IV tubing.

Scott Metcalfe

Turn on the IV and check the flow.

Scott Metcalfe

Secure the site.

Scott Metcalfe

Label the IV solution bag.

Scott Metcalfe

IV Access Complications

Pain
Local infection
Pyrogenic reaction
Allergic reaction
Catheter shear
Inadvertent arterial
puncture

Circulatory
overload
Thrombophlebitis
Thrombus
formation
Air embolism
Necrosis
Anticoagulants

Complications of IV Therapy
Classified according to their location
Local complication: at or near the
insertions site or as a result of
mechanical failure
Systemic complications: occur within the
vascular system, remote from the IV
site. Can be serious and life threatening

Local complications
Occur as adverse reactions or trauma to
the surrounding venipuncture site
Assessing and monitoring are the key
components to early intervention
Good venipuncture technique is the main
factor related to the prevention of most
local complications associated with IV
Therapy.
Local complications include: hematoma,
thrombosis, phlebitis, postinfusion
phlebitis, thrombophlebitis, infiltration,
extravasation, local infection, and veno
spasm.

Hematoma
Hematoma and ecchymosis demote
formations resulting from the
infiltration of blood into the tissues at
the venipuncture site
Related to venipuncture technique
Use of large bore cannula: Trauma to the
vein during insertion
Patients receiving anticoagulant therapy
and long term steroids

Hematoma
Subcutaneous hematoma is the most
common complication
Can be a starting point for other
complications: thrombophlebitis and
infection
Related to:
Nicking the vein
Discontinuing the IV without apply adequate
pressure
Applying the tourniquet to tightly above a
priviously attempted venipuncture site.

Hematoma
Signs and symptoms:
Discoloration of the skin
Site swelling and discomfort
Inability to advance the cannula all the
way into the vein during insertion
Resistance to positive pressure during
the lock flushing procedure

Hematoma Prevention
Use of an indirect method
Apply tourniquet just before
venipuncture
Use a small need in the elderly and
patients on steriods, or patients with
thin skin.
Use blood pressure cuff to apply
pressure
Be gentle

Hematoma Treatment
Apply direct, light pressure for 2-3
minutes after needle removed
Have patient elevate extremity
Apply Ice
Document

Thrombosis
Catheter-related obsturctions can be
mechanical or non-thrombotic
Trauma to the endothelial cells of the
venous wall causes red blood cells to
adhere to the vein wall, forms a clot
or Thrombosis
Drip rate slows, line does not flush
easily, resistance is felt
Never forcible flush a catheter

Thrombosis
Types of Thrombus or occlusion

Persistent withdrawal occlusion

Partial occlusion
Complete occlusion
Fibrin tail
Fibrin sheath
Mural thrombosis

Intraluminal vs. fibrin flap

trombus
Intaluminal thrombus

Fibrin Flap

Reopen the Pipeline, Hadaway C, Nursing. 2005, 35(8)

Total Occlusion
Probable cause: Intraluminal thrombus

Symptom:

Unable to infuse or aspirate

Partial Occlusion
Probable cause: Fibrin flap
Symptom: Unable to aspirate

Reopen the Pipeline, Hadaway C, Nursing.

2005, 35(8)

Thrombosis
Types of Thrombus or occlusion
Thrombosis related to:
Hypertensive pt; blood backing up
Low flow rate
Location of the IV cannula
Compression of the IV line for an
extended period of time
Trauma to the wall of the vein

Thrombosis
Signs and Symptoms
Fever and Malaise
Slowed or stopped infusion rate
Inability to flush

Prevention

Use pumps and controllers to manage flow rate

Microdrip tubing for rate below50mL/hr
Avoid areas of flexion
Use filters
Avoid lower extremeties

Thrombosis
Treatment
Never flush a cannula to remove an
occlusion
Discontunue the cannula
Notify the physician and assess the site
for circulatory impairment

Document

Phlebitis
Inflammation of the vein in which the
endothelial cells of the venous wall
become irritated and cells roughen,
allowing platelets to adhere and
predispose the vein to inflamationinduced phlebitis
Tender to touch and can be very painful

Phlebitis
Mechanical:
To large a catheter for the size of the vein
Manipulation of the catheter: improper
stabilization

Chemical: vein becomes inflamed by

irritating or vessicant solutions or
medication

Irritation medication or solution

Improperly mixed or diluted
Too-rapid infusion
Presence of particulate matter

Phlebitis
Chemical (cont):
The more acidic the IV solution the
greater the risk
Additives: Potassium
Type of material
Length of dwell:
30% by day 2, 39-40% by day 3 (Macki and
Ringer)

The slower the rate of infusion the less

irritation

Chemical Phlebitis - Nafcillin

Phlebitis
Bacterial
Also called Septic phlebitis: least common
Inflammation of the intima of the vein
Contributing factors
Poor aseptic technique
Failure to detect breaks in the integrity of the
equipment
Poor insertion technique
Inadequate stabilization
Failure to perform site assessment
Aseptic preparation of solutions
Hand washing and preparing the skin

Phlebitis
Postinfusion
Inflamation of the vein 48-96 hr after
discontinued
Factors that contribute:

Insertion technique
Condition of the vein used
Type, compatibility, pH of solution used
Gauge, size, length, and material
Dwell time
Infrequent dressing change
Host factors: age, gender, age and presence of
disease

Phlebitis
Immune system causes leukocytes to
gather at the inflamed site
Pyrogens stimulate the
hypothalamus to raise body
temperature
Pyrogens stimulate bone marrow to
release more leukocytes
Redness and tenderness increase

Phlebitis
Signs and Symptoms

Redness at the site

Site warm to touch
Local swelling
Palpable cord along the vein
Sluggish infusion rate
Increase in basal temperature of 1degree C or
more

Prevention
Use larger veins for hypertonic solutions
Central lines for Infusions lasting longer than 5
days

Phlebitis Scale
0 No clinical symptoms
1- Erythema at access site with or without
pain
2- Pain at access site, with erythema and /
or edema
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, purulent drainage

Thrombophlebitis
Thrombophlebitis denotes a twofold
injury: thrombosis and inflammation
Related to:
Use of veins in the lower extremity
Use of hypertonic or highly acidic
infusion solutions
Causes similar to those leading to
phlebitis

Infusion Thrombophlebitis
Primarily an inflammatory process (vs.
thrombotic)
Incidence up to 20-25% with inpatients with PIV
Causes

Physical trauma
Chemical irritation
Thrombosis
Infection

Diagnosis
Clinical
Venous duplex

Develops quickly and spontaneously resolves in

days to weeks
Arch Intern Med 1998;158(2):151-6. Am J Med 2002; 113:146151

Thrombophlebitis
Signs and Symptoms
Sluggish flow rate
Edema in the limbs
Tender and cord like vein
Site warm to the touch
Visible red line above venipuncture site
Diminished arterial pulses
Mottling and cyanosis of the extremities

Thrombophlebitis
Prevention
Use veins in the forearm rather than the
hands
Do not use veins in a joint
Assess site q 4 hr in adults, q 2 hr in
children
Catheter securment
Infuse at rate prescribed
Use the smallest size catheter to do the
job
Proper dilution

Thrombophlebitis
Septic thrombophlebits can be
prevented:
Appropriate skin preparation
Aseptic technique in the maintance of
infusion
Proper hand hygiene
60% from patients skin
35% from the line itself
5% from hands

Treatment
Infusion Thrombophlebitis
Heparin gel vs. placebo 126 inpatients
Resolution at 7 days in 44% with heparin vs. 26% with
placebo

Topical diclofenac vs. systemic diclofenac vs.

placebo
Positive response 60% in both treatment groups vs. 20%
with placebo at 48 hours

Heparinoid cream vs. piroxicam gel vs. placebo

68 pts with infusion-related or spontaneous
thrombophlebitis
No difference in symptoms at 14 days

Topical essaven gel vs. placebo 23 pts

Significant improvement in symptoms with gel
Med
2000;114:371373.
J Clin Pharmacol systemic
1999;54:917921.
Clin
No(Barc)
controlled
trialsEurevaluating
Ann Chir Gynaecol 1990; 79:9296. Angiology 2001; 52(S3):S63S67

anticoagulation

Infusion Thrombophlebitis
ACCP 2008 Guidelines
Symptomatic infusion
thrombophlebitis:
Oral diclofenac or another NSAID (Grade
2B), OR
Topical diclofenac gel (Grade 2B), OR
Heparin gel (Grade 2B)

Until resolution of symptoms or for

up to 2 weeks.
We recommend against the use of
systemic anticoagulation (Grade 1C).
Chest 2008;133;454-545

Infiltration
Related to:
Puncture of the distal vein wall during
access
Puncture of the vein wall by mechanical
friction
Dislodgement of the catheter from the
intima of the vien
Poor securment
High delivery rate
Overmanipulation

Infiltration
The inadvertent administration of a
non-vesicant solution into
surrounding tissue
Dislodgment of the catheter from the
vein
Second to phlebitis as a cuase of IV
therapy morbidity

Infiltration
Signs and Symptoms
Coolness of the skin around site
Taut skin
Dependent edema
Absence of blood return
Pinkish blood return
Infusion rate slows

Infiltration
Complications fall into 3 catagories
Ulceration and possible tissue necrosis
Compartment syndrome
Reflex sympathetic dystrophy syndrome

Infiltration

Cellulitis from PIV

Extravasation
Inadvertent administration of a
vesicant solution into surrounding
tissue
Vesicant is a fluid or medication that
causes the formation of blisters, with
subsequent sloughing of tissues
occurring from the tissue necrosis

Extravasations related to:

Puncture of the distal wall
Mechanical friction
Dislodgement of the catheter

Examples of Vesicants

Phenergan pH is 4 to 5.5
Dilantin pH is 12 (Drano has a pH of 14)
High concentration KCL pH is 5 to 7.8
Calcium gluconate pH is 6.2
Amphotericin B pH is 5.7 to 8
Dopamine pH is 2.5 to 5
Nipride pH is 3.5 to 6
10%, 20% or 50% dextrose pH is 3.5 to
6.5
Sodium bicarbonate pH is 7 to 8.5

Extravasations
Signs and Symptoms
Complaints of pain or burning
Swelling proximal to or distal to the IV
site
Puffiness of the dependent part of the
limb
Skin tightness at the veinpuncture site
Blanching and coolness of the skin
Slow or stopped infusion
Damp or wet dressing

Extravasations
Prevention:

Use of skilled practitioners

Knowledge of vesicants
Condition of the patients veins
Drug administration technique

If continuous give in CVAD

Only with brisk blood return of 3-5 cc
Use of a free flow IV
Do not use a pump on vesicants given peripherally
Assess for blood return frequently

Extravasations (cont)
Prevention (cont)
Site of venous access
Condition of the patient
Vomiting, coughing, retchin
Sedated
Unable to communicate

Treatment

Extravasation

Dilantin Extravasation

Other Complications
Local infection:
Microbial contamination of the cannula
or the infusate
Thrombus becomes infected

Venous Spasm: a sudden involuntary

contraction of a vein or an artery
resulting in temporary cessation of
blood flow through a vessel

Take Home Message

Well prepare
Choose the best venous access for
proper fluid
Antiseptic and aseptic procedure
Be aware of complication
Treat complication earlier