Phlebitis was more likely when infusion pumps were used, catheters were inserted near the elbow,

and drugs were administered more than three times daily. Phlebitis is a common complication of intravenous therapy and results in undue pain in patients and increases in costs to the health care system. A new study (conducted by nurses) investigated the factors that most frequently led to phlebitis and identified how advanced practice nurses could encourage prevention of the problem. The authors evaluated 568 intravenous catheter sites on 355 patients on a general surgery unit at a university hospital in Turkey. To determine possible factors related to phlebitis, the authors collected data on patients' age; sex; diagnosis; catheter size, location, and site; and types of fluids and medications infused. A phlebitis evaluation scale developed by the Infusion Nurses Society was used to categorize the degree of phlebitis observed, ranging from 0 (no phlebitis) to 4th degree * Grade 0 = No symptoms * Grade 1 = Erythema at access site with or without pain * Grade 2 = Pain at access site with erythema and/or edema * Grade 3 = Pain at access site with erythema and/or edema, streak formation, palpable venous cord * Grade 4 = Pain at access site with erythema and/or edema, streak formation, palpable venous cord > 1 inch in length, purulent drainage. More than half (54.5%) of the catheter sites had phlebitis. First-degree phlebitis (redness or pain at the site, or both) accounted for the majority (44.5%) of these cases. The most common site for phlebitis was the antecubital area, and phlebitis was observed more often when the same arm was used for subsequent catheter placements. Catheters inserted for less than 24 hours were less likely to cause phlebitis, as were isotonic fluid infusions. The authors also found that phlebitis was more likely to occur when medications were delivered through the catheter, especially four or more times a day, and when an infusion pump was used. Phlebitis may result in more serious complications, such as purulent thrombophlebitis, sepsis, and thrombosis formation, which lead to increased length of hospitalization, need for antibiotics, and possible surgical intervention. Several factors contribute to the development of phlebitis, including administration of irritating IV fluids or medications, injury to the inner lining of the vein by the catheter, and infection. It is important to implement strategies to reduce the risk of

phlebitis, monitor the IV site closely for evidence of phlebitis, and remove the IV catheter when signs and symptoms such as pain and erythema occur. Knowledge of contributing factors and application of associated INS standards help to reduce the risk of phlebitis. Avoid administering irritating infusion therapies through a peripheral IV catheter. Infusions not appropriate for peripheral administration include parenteral nutrition, continuous vesicant drug infusions, infusates with a pH of less than 5 or more than 9, and infusates with osmolality of more than 600 mOsm/L. A centrally placed catheter is indicated for irritating infusates. Remember that midline catheters are peripheral catheters and that these same guidelines apply. Antiseptic solutions used to prepare the site should be allowed to completely air-dry before placing the catheter. This practice avoids tracking the antiseptic into the vein and potentially causing irritation that leads to phlebitis. Minimize the risk for phlebitis caused by vein trauma. Use the smallest size catheter and the shortest length to accommodate the infusion therapy. Avoid areas of flexion and lower extremities (exception: infants) when placing peripheral catheters. Ensure that the catheter is stabilized in place. Catheter stabilization is now recognized as an important intervention in reducing the risk for phlebitis, infection, catheter migration, and catheter dislodgment. When the catheter is stabilized, there is less movement of the catheter in and out of the insertion site and less irritation of the vein by the catheter (see the "Speaking of Standards column" in the January/February 2007 issue). Minimize the risk for phlebitis caused by introduction of bacteria. Prepare the site with an antiseptic before venipuncture. Wash your hands and use aseptic technique during all infusion procedures. Monitor the site carefully and instruct patients to report any pain or discomfort at the site. The practice criteria under the Phlebitis Standard also recommend that sites be observed for 48 hours after removal to detect postinfusion phlebitis and that patients be given written instructions about signs and symptoms to report. Nurses should be vigilant about assessing patients with IV catheterization for phlebitis on a daily basis and educating staff on the potential risk factors. Based on these study results, site rotation, use of isotonic solutions when appropriate, and avoidance of the elbow area may be used as preventive strategies.

REFERENCES 1. Infusion Nurses Society. Infusion Nursing Standards of Practice. J Infus Nurs.2006;29(1S):S1-S92. 2. Centers for Disease Control and Prevention. Guidelines for the prevention of intravascular catheter-related infections. MMWR Morb Mortal Wkly Rep. 2002;(RR10):51. 3. Soiffer NE, Borzak S, Edlin BR, Weinstein R. Prevention of peripheral venous catheter complications with an intravenous therapy team: a randomized controlled trial. Arch Intern Med. 1998;158:473-477. 4. Catney MR, Hillis S, Wakefield B, et al. Relationship between peripheral intravenous catheter dwell time and the development of phlebitis and infiltration. J Infus Nurs.2001;24:332-341. 5. Uslusoy E, Mete S. J Am Acad Nurse Pract 2008;20(4):172-80.