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1. Phlebitis: treatment, care and prevention..................................................................................................... 1
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Phlebitis: treatment, care and prevention
Author: Higginson, Ray; Parry, Andrew

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Abstract: 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. [PUBLICATION ABSTRACT]
Full text: Headnote
How to prevent, identify and treat phlebitis in patients with a venous cannula
Headnote
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.
Keywords: Phlebitis/Venous catheter/ Infection control
In this article...
* Peripheral venous cannulation is a common procedure used 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
Peripheral 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;
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* 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 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).
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 micro-organisms 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
high-quality, 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 cross-infection, improve hospital hygiene and help combat
nosocomial infections (Burke, 2003).
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In addition, aseptic technique can help prevent the transmission of micro-organisms to wounds and other
susceptible sites (such as intravenous cannula 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 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).
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Phlebitis
Mechanical phlebitis
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Mechanical phlebitis occurs where the movement of a foreign object (cannula) within a vein causes friction and
subsequent venous inflammation (Stokowski et al, 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
osmolality of the substances have a significant effect on the incidence of phlebitis (Kohno et al, 2009) (Figs 2
and 3).
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 osmolality 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 (Carton et al, 2006).
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.
Signs and symptoms
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.
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 (VTP) scale.
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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 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).
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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.
The clinician's hands should be thoroughly washed, gloves worn and the patient's 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 osmolality 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).
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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 patient's 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.
Sidebar
* This article has been double-blind peer reviewed
Sidebar
5 key points
1 Peripheral venous cannulation is a common procedure
2 Phlebitis - or inflammation of the vein - can be caused by mechanical, chemical or infectious irritation at the
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cannula site
3 Careful placement and good hygiene can help to prevent phlebitis
4 There are two assessment tools to identify early signs of the condition
5 Vigilance can help to prevent rare but potentially severe complications such as sepsis
Sidebar
QUICK FACT
20-80% of patients with a peripheral venous cannulation develop phlebitis
References
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AuthorAffiliation
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.
Subject: Catheters; Hospitals; Blood clots; Antibiotics; Thrombosis; Microorganisms; Veins & arteries; Fluid;
Nurses; Nosocomial infections; Hygiene; Intravenous therapy;
MeSH: Catheterization, Peripheral -- adverse effects, Humans, Phlebitis -- diagnosis, Phlebitis -- etiology,
Phlebitis -- therapy, Catheterization, Peripheral -- methods (major), Infection Control -- methods (major),
Phlebitis -- prevention & control (major)
Publication title: Nursing Times
Volume: 107
Issue: 36
Pages: 18-21
Number of pages: 4
Publication year: 2011
Publication date: Sep 13-Sep 19, 2011
Year: 2011
Section: Nursing Practice: Review Phlebitis
Publisher: Emap Limited
Place of publication: London
Country of publication: United Kingdom
Publication subject: Medical Sciences--Nurses And Nursing
ISSN: 09547762
Source type: Magazines
Language of publication: English
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Document type: Feature, Journal Article
Document feature: Photographs References
Accession number: 21998938
ProQuest document ID: 1039305281
Document URL: http://search.proquest.com/docview/1039305281?accountid=25704
Copyright: Copyright Emap Limited Sep 13-Sep 19, 2011
Last updated: 2014-04-04
Database: ProQuest Public Health
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