Phlebitis in Vascular Access Management

Classification and Etiology

Phlebitis is an inflammation of a vein that can occur during or after intravenous therapy. Understanding its etiology is essential for both prevention and appropriate intervention. Phlebitis is categorized into four primary types based on causative factors.

1.1 Chemical Phlebitis

Chemical phlebitis results from endothelial inflammation or injury caused by the infusion of irritating substances. Contributing factors include:

Irritating Infusates: Certain medications and solutions are known to cause endothelial irritation. These include amiodarone, nicardipine, norepinephrine, levetiracetam, dextrose concentrations exceeding 10%, cancer chemotherapy agents, antibiotics (notably flucloxacillin and vancomycin), dobutamine, potassium chloride, and iron sucrose (Lv & Zhang, 2020; Simin et al., 2019; Van Boxtel et al., 2022). Evidence-based practice initiatives have successfully reduced the incidence of amiodarone-related phlebitis through protocol standardization, including peripheral site rotation schedules and dilution optimization (Murphy et al., 2020).

Infusate Characteristics: Solutions with extreme pH levels or high osmolarity pose increased risk. Particulate matter within infusates may also contribute to vessel irritation (Van Boxtel et al., 2022).

Infusion Parameters: Inadequate hemodilution, excessive infusion rates through short peripheral catheters, and an increased number of infused medications all elevate risk (Simões et al., 2022; Yasuda et al., 2022).

Procedural Factors: Skin antiseptic solution that has not fully dried prior to catheter insertion can be drawn into the vein during the insertion process, causing chemical irritation (Helm et al., 2019).

1.2 Mechanical Phlebitis

Mechanical phlebitis occurs when physical factors cause trauma or irritation to the vein’s endothelial lining. Key contributing factors include:

Catheter-to-Vein Ratio: A catheter that is too large relative to the vessel diameter creates friction and pressure against the vessel wall (Piper et al., 2018; Mielke et al., 2022).

Insertion Site and Technique: Catheter placement in areas of flexion, improper insertion angle, and suboptimal tip positioning increase mechanical stress on the vessel. Insertion trauma itself can initiate the inflammatory response (Heng et al., 2020).

Catheter Materials: Polytetrafluoroethylene (PTFE/Teflon™) catheters and stiffer catheter materials have been associated with higher rates of mechanical phlebitis. Advances in catheter materials may reduce these complications (Moureau et al., 2022; Karaoğlan et al., 2022).

Securement and Infusion Rate: Inadequate catheter securement allows catheter movement within the vessel, while rapid infusion rates can contribute to vessel wall irritation (Liu et al., 2022).

1.3 Infectious Phlebitis

Infectious phlebitis, also termed septic or suppurative thrombophlebitis, results from bacterial contamination through several pathways:

Extraluminal Contamination: This occurs when skin antisepsis is inadequate or when the catheter becomes contaminated during the insertion procedure (Helm et al., 2019).

Intraluminal Contamination: Bacteria may enter through the catheter hub during access or manipulation, or through contaminated fluids and medications (Koo et al., 2020).

Hematogenous Seeding: Infection originating elsewhere in the body can seed the catheter site through the bloodstream. This is more common in emergent insertions, when aseptic technique is compromised, or when dressings become contaminated (Helm et al., 2019).

1.4 Postinfusion Phlebitis

Postinfusion phlebitis manifests 48 to 96 hours after catheter removal and may result from any of the factors described above. Research has identified PIVC insertion in the emergency department as a significant risk factor for this complication. Reported rates of postinfusion phlebitis vary considerably, ranging from 1% to 23% across studies (Webster et al., 2015; Urbanetto et al., 2016; Urbanetto et al., 2017).

Patient-Related Risk Factors

Certain patient characteristics elevate the risk of developing phlebitis. Clinicians should assess these factors when planning vascular access and during ongoing care.

Immune and Infectious Status: Current infection and immunodeficiency compromise the body’s ability to maintain vessel integrity and fight contamination (Lv & Zhang, 2020).

Mobility: Reduced mobility limits blood flow and may increase catheter-related mechanical stress (Marsh et al., 2021).

Thrombotic Risk: A family history of deep vein thrombosis indicates potential for vessel-related complications (Simin et al., 2019).

Comorbidities: Various underlying health conditions may predispose patients to vascular complications.

Insertion Location: Catheter placement in the patient’s dominant arm increases movement and mechanical stress. Lower extremity insertion in adults carries elevated risk and should be avoided except in infants (Fan et al., 2023).

Demographic Factors: Female gender and age 60 years or older have been associated with increased phlebitis risk in multiple studies (Lv & Zhang, 2020; Suliman et al., 2020).

Pediatric Considerations: Systematic review evidence suggests that overall phlebitis rates may be lower in pediatric patients compared to adults (Indarwati et al., 2020; Marsh et al., 2018).

Prevention Strategies

Effective prevention requires a multifaceted approach addressing device selection, insertion technique, infusate management, and ongoing care.

3.1 Vascular Access Device Selection

When infusates known to cause phlebitis are required, clinicians should consider the anticipated duration of therapy and total infusion time. For longer courses of irritating medications, a peripherally inserted central catheter (PICC) or other central vascular access device (CVAD) may be more appropriate than a peripheral catheter.

The choice of catheter size is critical: selecting the smallest gauge catheter appropriate for the intended therapy reduces catheter-to-vein ratio and associated mechanical irritation (Marsh et al., 2021; Karaoğlan et al., 2022). Insertion should target larger veins when possible, and areas of flexion should be avoided. For adult patients, lower limb insertion should be avoided; for neonates and non-mobilizing infants, this restriction does not apply (Zingg et al., 2023; Fan et al., 2023).

3.2 Insertion Technique and Skill

Research demonstrates that PIVC insertion by infusion or vascular access specialist teams results in greater first-attempt insertion success and lower complication rates. Organizations should consider dedicated insertion teams and ensure that clinicians performing vascular access procedures maintain appropriate competencies (Zingg et al., 2023).

3.3 Skin Preparation

Complete drying of antiseptic solution before catheter insertion is essential. Wet antiseptic can be drawn into the vein during insertion, causing chemical irritation. Clinicians must allow adequate time for the antiseptic to dry fully before proceeding.

3.4 Catheter Securement and Joint Stabilization

Proper securement technology prevents catheter movement within the vessel, reducing mechanical irritation. When catheters must be placed near joints, appropriate stabilization techniques should be employed to minimize flexion-related complications (Ayat-Isfahani et al., 2017; Berger et al., 2022).

3.5 Infusate Management

Collaboration with pharmacy can significantly reduce phlebitis risk. One study demonstrated that standardized drug administration measures supervised by a pharmacist—including attention to drug composition, administration rate, route selection, and compounding contraindications—were associated with reduced phlebitis rates in intensive care settings (Simões et al., 2022; Yasuda et al., 2022).

Vancomycin Considerations: Continuous vancomycin infusions should be administered via a CVAD rather than a peripheral or midline catheter. Research has documented thrombophlebitis in all patients receiving continuous vancomycin infusion via midline catheter, regardless of dilution, as confirmed by daily ultrasound assessment (Scarano et al., 2022).

Dilution Strategies: For medications associated with phlebitis, such as nicardipine, diluting the concentration may reduce incidence. One study demonstrated reduced nicardipine-related phlebitis in acute stroke patients through concentration dilution (Kawada et al., 2018).

In-Line Filtration: While infusate contaminants represent a potential cause of phlebitis, current evidence does not support routine use of in-line filters specifically for thrombophlebitis prevention. The patient populations most likely to benefit from filtration have not been clearly identified, and clinical study results remain uncertain. Further research is needed to establish beneficial effects, potential disadvantages, and cost-effectiveness (Van Boxtel et al., 2022).

3.6 Insertion and Maintenance Bundles

Implementation of PIVC insertion and maintenance bundles has shown effectiveness in reducing complications including phlebitis. Bundle elements typically address site selection, insertion technique, securement, dressing management, and ongoing assessment (Ray-Barruel et al., 2019; Gunasundram et al., 2021; Singh et al., 2021; Steere et al., 2019; Diwakar et al., 2021).

3.7 Emergency Insertion Considerations

Catheters inserted emergently under suboptimal aseptic conditions should be replaced when the patient is stabilized, within 48 hours of the original insertion. Adult patients with lower extremity catheters should have these relocated to an upper extremity site. For pediatric patients, catheters should be moved to a new proximal site or opposite side when feasible.

Assessment and Monitoring

4.1 Clinical Assessment

Regular assessment of vascular access sites is fundamental to early detection and intervention. Assessment frequency should be determined based on patient population, therapy type, and individual risk factors.

Signs and Symptoms: Clinicians should assess for swelling, erythema, leakage, palpable venous cord, purulent discharge, warmth, and pain or tenderness at the access site.

Pain as an Early Indicator: Pain at the insertion site may serve as an early warning sign of developing phlebitis. Clinicians should evaluate pain reports promptly and thoroughly (Simões et al., 2022; Mihala et al., 2018).

Patient Education: Patients should be instructed to report pain or tenderness at the vascular access site promptly, enabling early intervention.

4.2 Standardized Assessment Tools

Organizations should adopt a standardized phlebitis scale or definition and apply it consistently. However, clinicians should recognize the limitations of existing assessment tools. Studies have documented low interrater reliability for commonly used signs, symptoms, and scales in phlebitis assessment. The type, number, and severity of signs and symptoms that define phlebitis vary among published studies. Further research is needed to develop valid and reliable assessment instruments (Göransson et al., 2017; Marsh et al., 2020; Ray-Barruel et al., 2020; Marsh et al., 2015).

4.3 Replacement Intervals

Evidence supports clinically indicated replacement of PIVCs rather than routine scheduled replacement. Systematic review and meta-analysis have found no clear difference in thrombophlebitis rates between these approaches (Webster et al., 2019; Vendramim et al., 2020).

4.4 Comparative Device Outcomes

Meta-analysis data indicate that phlebitis incidence does not differ significantly between midline catheters and PICCs, which may inform device selection decisions (Lu et al., 2022).

4.5 Postinfusion Monitoring

Following PIVC removal, the site should be monitored for postinfusion phlebitis for 48 hours or until discharge. Patients and caregivers should receive written instructions describing signs and symptoms of phlebitis and guidance on whom to contact if symptoms develop (Webster et al., 2015; Urbanetto et al., 2016).

4.6 Emerging Assessment Technologies

Technological advances may enhance future phlebitis detection capabilities:

Ultrasound: Serial ultrasonographic assessments show promise for early recognition of peripheral intravenous catheter failure and associated venous changes (Bahl et al., 2021; Goel et al., 2020).

Infrared Thermography: This technology may offer objective identification of early phlebitis development through detection of increased temperature differences at the access site. Studies suggest it may be a promising technique, though further validation is needed (Doesburg et al., 2019; Mielke et al., 2022).

Intervention and Management

5.1 Peripheral Intravenous Catheters

Upon identification of signs or symptoms of phlebitis, the PIVC should be removed (Zingg et al., 2023; Marsh et al., 2015). The interprofessional team should collaborate to determine the need for continued vascular access and appropriate alternative access when indicated.

5.2 Midline Catheters and PICCs

Transient mechanical phlebitis may occur after midline catheter or PICC insertion. Management of this self-limiting condition includes ensuring proper catheter securement, applying heat to the affected area, elevating the limb, and monitoring for 24 hours postinsertion. If signs and symptoms persist beyond this period, catheter removal should be considered.

5.3 Symptomatic Relief

Several interventions may provide comfort and reduce phlebitis symptoms:

Physical Measures: Application of warm or cold compresses and limb elevation can provide symptomatic relief (Annisa et al., 2017; Gauttam & Vati, 2016).

Pharmacologic Options: Analgesics may be administered as needed, and anti-inflammatory agents may be considered (Goulart et al., 2020).

Topical Treatments: Various topical interventions have been studied for phlebitis prevention and treatment, including nonsteroidal anti-inflammatory drugs, glycerine, aloe vera, and chamomile. However, systematic review has not established clear evidence of efficacy for these agents (Goulart et al., 2020; Garcia-Expósito et al., 2022; Charan & Chaurasia, 2018; Babaieasl et al., 2019).

5.4 Chemical Phlebitis Management

When chemical phlebitis is suspected, clinicians should re-evaluate the need for ongoing vascular access and consider alternatives including different medications, slower infusion rates, greater infusate dilution, or transition to central vascular access (Kawada et al., 2018).

5.5 Infectious Phlebitis Management

When infectious phlebitis is suspected or purulent drainage is present, the following actions are indicated:

1. Remove the catheter immediately
2. Obtain cultures of purulent exudate and catheter tip
3. Document site assessment findings thoroughly
4. Monitor for signs of systemic infection
5. Anticipate that surgical intervention may be required in severe cases

A retrospective pediatric study reported that antibiotic and anticoagulation therapy achieved resolution of septic thrombophlebitis in 57% of patients (Koo et al., 2020).

Surveillance Considerations: For healthcare facilities in the United States conducting central line-associated bloodstream infection (CLABSI) surveillance following National Healthcare Safety Network (NHSN) protocols, matching cultures from purulent drainage at a non-central line site are relevant for determining CLABSI attribution in public reporting metrics (CDC, 2023).

Documentation and Quality Improvement

Accurate documentation of phlebitis incidents, interventions, and outcomes supports quality improvement efforts and enables organizations to identify patterns and implement targeted prevention strategies. Documentation should include assessment findings, suspected etiology, interventions performed, and patient response to treatment.

References

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This document is intended as an educational resource for clinical professionals. Clinical judgment should always be exercised in applying these guidelines to individual patient situations. Organizations should adapt these recommendations to their specific practice settings and patient populations.

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