Description and Etiology

Phlebitis is an inflammation of the delicate inner lining (the tunica intima) of the vein. It is

characterized by pain, inflammation, and tenderness along the vein and is a common

complication associated with PIVs. Phlebitis may result in other complications such as

thrombosis formation (thrombophlebitis) and potentially BSIs, although the link between

phlebitis and BSIs is not well established (Hadaway, 2012; Zingg & Pittet, 2009).

Phlebitis is attributed to damage from chemical irritation, mechanical trauma, and bacteria.

Chemical phlebitis results from infusate damage to the tunica intima. Certain characteristics of

medications/solutions are associated with vein damage when they are administered via a PIV

catheter (Infusion Nurses Society [INS], 2011a):

■ Dextrose content greater than 10%

■ Acidic or alkaline pH (i.e., <5 or >9)

■ High osmolarity (>600 mOsm/L)

Chemical damage to the vein may also result from failure to allow the skin antiseptic solution to

fully dry prior to catheter insertion. Vein irritation results when the antiseptic is pulled into the

vein during catheter insertion.

Mechanical vein trauma occurs when the catheter irritates or injures the endothelial cells lining

the vein wall. This may occur during insertion, when a large catheter is placed in a small vein or

at a point of flexion, or when a catheter lacks adequate stabilization, causing catheter movement

that irritates the vein wall. During placement of a midline peripheral catheter or a peripherally

inserted central catheter (PICC), mechanical phlebitis may result if the catheter is advanced too

rapidly into the vein. Symptoms occur soon after placement and tend to be transient. Catheter

removal is considered if the symptoms persist beyond 24 to 48 hours.

Bacteria can also cause phlebitis, and the consequences can be serious, including catheter-related

bloodstream infection (CR-BSI). Bacteria may be introduced through poor aseptic technique

during insertion or during catheter access or maintenance care. Phlebitis may not be evident

during peripheral catheter dwell time but appear after removal. This is called “postinfusion

phlebitis” and becomes apparent 48 to 96 hours after the catheter is removed. Types of phlebitis

are summarized in Table 9-1.

> Table 9-1 TYPES OF PHLEBITIS

Mechanical Phlebitis

Mechanical vein trauma occurs when the catheter irritates or injures the endothelial cells lining

the vein wall. This may occur during insertion, when a large catheter is placed in a small vein or

at a point of flexion, or when the catheter lacks adequate stabilization causing catheter movement

that irritates the vein wall.

Chemical Phlebitis

Chemical phlebitis results from infusate damage to the tunica intima. Infusates with a dextrose

content greater than 10%, an acidic or alkaline pH (i.e., <5 or >9), and a high osmolarity (>600

mOsm/L) cause vein damage when administered via a peripheral I.V. catheter. Also, failing to

allow the antiseptic solution to fully dry prior to catheter insertion may cause irritation when

antiseptic is pulled into the vein during insertion.

The type of catheter material may increase the risk of phlebitis. Several different materials are

used in the manufacture of catheters. Catheters made of silicone elastomer and polyurethane

have a smoother microsurface, are thermoplastic, are more hydrophilic, become more flexible

than polytetrafluoroethylene (Teflon) at body temperature, and cause less venous irritation.

Bacterial Phlebitis
Bacteria can cause phlebitis, and the consequences can be serious, including catheter-related

bloodstream infection. Bacteria may be introduced through poor aseptic technique during

insertion, or during catheter access or maintenance care. Suppurative or purulent

thrombophlebitis is characterized by the presence of purulent drainage in the vein. This serious

complication is associated with bloodstream infection and requires surgical removal of the vein.

NURSING FAST FACT!

Examples of three common I.V. solutions, and their pH and osmolarity:

Solution pH Osmolarity (mOsm/L)

5% dextrose in water 4.8 252

5% dextrose in water with 0.45% sodium chloride 4.6 406

0.9% sodium chloride 6.0 308

NURSING FAST FACTS!

Hand hygiene is critical in preventing health-care–associated infections and thus bacterial

phlebitis.

All equipment should be inspected for integrity, particulate matter, cloudiness, and any signs

indicating a break in sterility.

When inspecting the venipuncture site, if the skin is noted to be visibly dirty, it should be washed

with soap and water prior to skin antisepsis.

If there is excess hair at the site, hair can be clipped using a scissors or disposable head surgical

clippers.

The skin should not be shaved because microabrasions from shaving may increase the risk of

infection.

> Table 9-1 TYPES OF PHLEBITIS—cont’d

Postinfusion Phlebitis

Postinfusion phlebitis is associated with inflammation of the vein that usually becomes evident

within 48–96 hours after the cannula has been removed, so the site should be monitored for that

time period. On discharge, patients should be instructed on signs and symptoms of postinfusion

phlebitis and who to contact if it occurs (INS, 2011a, p. S65).

Host factors that may also contribute to risk of phlebitis include fragile vessels, a predisposition

toward thrombosis (hypercoagulable state), high hemoglobin levels, female gender, older age,

and underlying medical disease (e.g., diabetes, infectious diseases, cancer, immunodeficiency)

(Dychter, Gold, Carson, & Haller, 2012; Zingg & Pittet, 2009) (Table 9-2).

NOTE > Peripheral phlebitis can prolong hospitalization unless treated early.

INS Standard If phlebitis occurs, the nurse should determine the potential etiology of the

phlebitis—chemical, mechanical, bacterial, or postinfusion phlebitis—and implement

appropriate interventions for midline catheters and PICCs. Remove the short peripheral catheter

(INS, 2011a, p. S65).

> Table 9-2 FACTORS INCREASING RISK FOR PHLEBITIS

1. Catheter material

Teflon (less favorable thrombogenic properties)

2. Catheter size

Larger-gauge catheters take up more space in the vein and allow less blood flow around catheter

3. Insertion factors

Placed in emergency room/emergent situations

Placed by inexperienced staff

Placed in lower extremity

4. Increasing duration of catheter placement in adults

5. Infusate characteristics

pH <5 or >9

High osmolarity (>600 mOsm/L)

6. Host factors

Fragile vessels

Predisposition toward thrombosis (hypercoagulable state)

High hemoglobin levels

Female gender

Older age

Underlying medical disease (diabetes, infectious diseases, cancer, immunodeficiency, poor-

quality peripheral veins)

Signs and Symptoms

Inspection of the affected site reveals a similar appearance regardless of the underlying cause

(Fig. 9-2). Local signs and symptoms associated with phlebitis include:

■ Redness at the site

■ Site warm to touch

■ Local swelling

■ Palpable cord along the vein

■ Sluggish infusion rate

■ Possible fever

INS Standard The nurse should use a standardized phlebitis scale that is valid, reliable, and

clinically feasible (see Table 9-3 for an example).

A clinically feasible calculation for the phlebitis rate is performing a point-prevalence study,

which measures phlebitis at one point in time (INS, 2011a, p. S66):

Number of phlebitis incidents x 100

=Percent of peripheral phlebitis
Total number of PIV lines

> Table 9-3 PHLEBITIS SCALE

Grade Clinical Criteria`

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

in length, purulent drainage

Source: INS (2011a), with permission.

Prevention

The risk for phlebitis is reduced by the following:

1. Assess the appropriateness of the infusate characteristics and the duration of infusion for PIV

therapy.

2. Consider a midline catheter or CVAD (e.g., PICC) for:

a. Infusion therapies anticipated to last longer than 1 week and/or

b. Infusates with a pH less than 5 or greater than 9, or with osmolarity greater than 600 mOsm/L,

or for dextrose concentrations in excess of 10%.

3. Perform proper hand hygiene and use aseptic technique with all I.V. procedures.

4. Wear clean gloves during PIV insertion and maintain aseptic technique with catheter insertion.
5. Prepare the skin with an antiseptic and allow it to fully dry prior to catheter insertion. Do not

touch skin after antisepsis.

6. Choose the smallest cannula appropriate for the infusate.

7. Infuse solutions at the prescribed rate. Do not attempt to catch up on delayed infusion time.

8. Avoid placing PIV catheters in areas of flexion (e.g., wrist).

If an area of flexion must be used, use a joint stabilization device.

9. Ensure that the catheter is adequately stabilized in place to minimize catheter movement

within the vein.

10. Assess the site at least every 4 hours for signs of complications, more frequently when

administering irritating infusates, when the patient is sedated or has cognitive limitations and

cannot report changes, and/or when the PIV is placed in a high-risk location such as an area of

flexion (Gorski, Hallock, Kuehn, et al., 2012).

NURSING FAST FACT!

Be aware that solutions that are highly acidic (pH <5), highly alkaline (pH >9), or

hyperosmolar (>600 mOsm/L) or have a high dextrose concentration (>10%) are associated

with a higher risk of phlebitis.

Treatment

Standard treatment of phlebitis is the application of warm compresses to the affected site. In

addition, INS (2011b) recommends the following actions:

■ Determine the potential etiology, whether chemical, mechanical, bacterial, or postinfusion

phlebitis. Additionally, use this information in planning for ongoing venous access. For example,

if the etiology is likely an irritating infusate, consider the need for an alternate plan, such as a

PICC.
■ Remove the PIV and replace as clinically indicated.

■ Restart the infusion in the opposite extremity, using a fresh administration set.

■ Monitor the site for postinfusion phlebitis for 48 hours.

■ Provide patient education about postinfusion phlebitis, including instructions about its signs

and symptoms, and who to contact if it occurs.

Documentation

Document the site assessment, the phlebitis rating (1, 2, 3, or 4), whether the licensed

independent practitioner (LIP) was notified, and the treatment provided. Document the

discontinuation of the PIV catheter and the location of the new I.V. site. Document all observable

symptoms and the patient’s subjective complaints, such as “feels tender to touch” and “it hurts.”

Document the actions taken to resolve the problem and the time of LIP notification.

NURSING FAST FACT!

If the inflammation is the result of bacterial phlebitis, a much more serious condition may

develop if the patient is not treated. Untreated bacterial phlebitis can lead to septicemia.