Studies in phlebitis. II. Early detection of amiodarone-induced phlebitis in a rabbit model.
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Amiodarone↗
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A prospective study of Staphylococcus aureus nasal colonization and intravenous therapy-related phlebitis.
BACKGROUND: Intravenous (IV) therapy-associated phlebitis is common, but its causes are ill defined. Some cases may be related to bacterial colonization of the skin surrounding the IV catheter, especially by Staphylococcus aureus. This prospective study examined the association of phlebitis with anterior nares S aureus carriage, as well as with other potential risk factors. METHODS: Selected demographic and clinical data and a nares culture were collected from patients on designated wards by us and from the IV therapy team at the time of initial IV catheter placement. Patients were followed up for signs and symptoms of phlebitis for the duration of the initial catheter's use and for up to two additional IV placements. Potential risk factors were compared for patients who developed phlebitis and those who did not by the Cox multivariate proportional hazards model. RESULTS: During 10 weeks, 273 men with a total of 416 catheter placements had fully evaluable data. Phlebitis occurred during 13.7% of the catheter placements. Nasal cultures yielded S aureus from 14.3% of the patients, but none of the IV team nurses. Surprisingly, S aureus nasal colonization was related (at borderline statistical significance) to a reduction in phlebitis risk. Location of the patient on a surgical ward, the presence of infection at any site, and a larger-gauge catheter were each significant independent risk factors for phlebitis. The highest risk of phlebitis appeared to have been within 12 to 24 hours of catheter placement. CONCLUSIONS: The primary finding of this study was that nasal colonization with S aureus did not increase the risk of developing IV catheter-associated phlebitis. Our rate of IV catheter-associated phlebitis was similar to that in other studies, but the factors predisposing to phlebitis differed somewhat from those in previous studies.
Catheterization, Peripheral↗
Risk factors for infusion-related phlebitis with small peripheral venous catheters. A randomized controlled trial.
OBJECTIVE: To identify risk factors for infusion-related phlebitis with peripheral intravenous catheters. DESIGN: A randomized trial of two catheter materials, with consideration of 21 potential risk factors. SETTING: A university hospital. PATIENTS: Hospitalized adults without granulocytopenia who received a peripheral intravenous catheter. INTERVENTIONS: House officers or ward nurses inserted the catheters, and each insertion was randomized to a catheter made of tetrafluoroethylene-hexafluoropropylene (FEP-Teflon) or a novel polyetherurethane without leachable additives (PEU-Vialon). MEASUREMENTS: Research nurses scored insertion sites each day for inflammation and cultured catheters at removal. RESULTS: The Kaplan-Meier risk for phlebitis exceeded 50% by day 4 after catheterization. intravenous antibiotics (relative risk, 2.00), female sex (relative risk, 1.88), prolonged (greater than 48 hours) catheterization (relative risk, 1.79), and catheter material (PEU-Vialon: FEP-Teflon) (relative risk, 0.73) strongly predicted phlebitis in a Cox proportional hazards model (each, P less than 0.003). The best-fit model for severe phlebitis identified the same predictors plus catheter-related infection (relative risk, 6.19), phlebitis with a previous catheter (relative risk, 1.54), and anatomic site (hand: forearm, relative risk, 0.71; wrist:forearm, relative risk, 0.60). The low incidence of local catheter-related infection was comparable with the two catheter materials (5.4% [95% CI, 3.8% to 7.6%] and 6.9% [CI, 4.9% to 9.6%]); none of the 1054 catheters prospectively studied caused bacteremia. CONCLUSIONS: Multiple factors, including the infusate and the duration of cannulation, contribute to the development of infusion-related phlebitis. The use of peripheral intravenous catheters made of PEU-Vialon appears to pose the same risk for catheter-related infection as the use of catheters made of FEP-Teflon, and PEU-Vialon can permit longer cannulation with less risk for phlebitis. The risk for catheter-related bacteremia with FEP-Teflon and PEU-Vialon catheters is sufficiently low that it no longer seems justifiable to recommend the use of small steel needles for most peripheral intravenous therapy.
Catheterization, Peripheral↗
Three-phase study of phlebitis in patients receiving peripheral intravenous hyperalimentation.
We found clinical phlebitis in 57 of 88 patients with peripheral hyperalimentation (65%). To determine if this was a problem common to all intravenous fluid therapy at our hospital, we performed a point-prevalence study. The prevalence of phlebitis in nonhyperalimentation intravenous patients was 18% (84 of 456 patients). We then performed a randomized, prospective, double-blind trial of sham versus standard in-line filters to determine if bacteria or filterable particulate matter was responsible for phlebitis in the peripheral hyperalimentation group. The standard-filter group had a phlebitis rate of 74% compared with 64% in the sham-filter group. We then eliminated in-line filters and replaced the standard glucose-based solution with a glycerol-based peripheral hyperalimentation solution. The phlebitis rate decreased from 68% to 27% (p less than 0.001). In conclusion, phlebitis in peripheral hyperalimentation patients was probably due to chemical properties of the peripheral hyperalimentation solution rather than bacteria or particulates.
Amino Acids↗
Septic phlebitis: a neglected disease.
A review of 100 patients with peripheral septic phlebitis revealed that 54 per cent of the cases were due to intravenous catheters and 46 per cent were secondary to drug abuse. Eighty per cent of the involved veins were in the arm or neck. Pain was the most common symptom (83 per cent), with erythema and edema the most common physical signs (63 per cent). Eighty per cent of the causative organisms were gram-positive bacteria, usually Staphylococcus aureus (41 per cent) or Group A streptococcus (20 per cent). Complications were more common if septic phlebitis was due to intravenous therapy than drug abuse. No deaths were directly attributed to septic phlebitis. However, hospital stay after development of septic phlebitis was 14 days with a 56 per cent complication rate. The initial treatment of septic phlebitis should include prompt removal of the intravenous device, antibiotics, heat, and elevation. Because serious complications occur in a significant number of patients, operative excision of the involved vein should be performed if clinical deterioration occurs or if septicemia persists after 24 hours despite conservative therapy.
Arm↗
[General surgeon's approach to deep phlebitis of the leg].
The therapeutic problems of the general surgeon, faced with a case of deep phlebitis of the lower limbs, differ according to whether it is diagnosed before or after surgery. If possible, pre-surgical phlebitis should be treated before the operation. Heparinotherapy remains the basic treatment. But there are numerous arguments against, or for the modification of, its use : old age, haemorrhagic lesions, haemorrhagic risks during surgery, or simply great operational urgency. In all these cases, an elastic bandage is invaluable. Treatment of post-operative phlebitis is also based on the heparins, combined if necessary with antibiotics and corticoids, but these products can result in iatrogenic complications (ulcers, haemorrhage). It is often difficult to choose between embolic and haemorrhagic risks ; it is always easy to apply an elastic bandage which suffices in most cases to remove the inflammatory signs of the phlebitis. This problem is not so frequent since systematic prevention has made post-operative phlebitis more rare. The use of anticoagulants in vascular surgery seems to the authors to be not so much an effective therapeutic method as a method to be feaved close surveillance of coagulation is indispensable during treatment.
Aged↗
Final inline filtration: a means of decreasing the incidence of infusion phlebitis.
Infusion phlebitis is the most common complication of intravenous therapy. Six methods of reducing the incidence of infusion phlebitis including inline final filtration, buffers, heparin, hydrocortisone, heparin-hydrocortisone combinations, and frequent set changes were tested in a two part randomized prospective double-blind study of 266 surgical patients. Patients who received filtered fluids had a significantly decreased incidence of infusion phlebitis as compared with that of controls (P = 0.0000001). Of the other methods tested, only the heparin-hydrocortisone combinations achieved any significant decrease in phlebitis (P less than 0.5). Therefore, inline filtration is a highly effective means of decreasing the incidence of infusion phlebitis and should be considered as a routine part of intravenous therapy.
Buffers↗
[Phlebitis of infectious etiology].
Various infections are sometimes at the origin of phlebitis. Because of the different therapeutic consequences, this etiology should be considered whether it is a case of deep phlebitis of a limb, migratory recurrent phlebitis, or the type of phlebitis called "iron wire". The principal diseases that may lead to phlebitis are : tuberculosis, typhoid fever, rickettsiosis, and streptococcal, staphylococcal, and pneumococcal infections. Certain viruses may have a role but so far there is no formal proof. Focal pathology of dental or tonsillar origin involves in some cases an aseptic venous lesion. Bacterial or mycotic suppurative thrombophlebitis related to an intravenous catheter is the price paid for the use, often unnecessarily, of this method of perfusion.
Bacterial Infections↗
Peripheral parenteral nutrition: effect of a standardized compounded mixture on infusion phlebitis.
The incidence and severity of infusion phlebitis was evaluated prospectively in 142 surgical patients who received peripheral parenteral nutrition (PPN) for a total of 700 days. In a first study phase 83 patients were given PPN for a total of 424 days. All nutrient solutions were delivered over a 12-h period from a 3-litre bag and the infusion sites rotated daily. These methods resulted in an incidence of phlebitis of 18 per cent, 75 per cent of the patients being fed successfully by PPN until resumption of oral nutrition. In an attempt to assess the importance of the method of delivering nutrient solutions, the next 59 patients were randomized to receive PPN as a compounded mixture or by a conventional technique with simultaneous infusion from separate bottles. Infusion phlebitis was significantly more frequent (P less than 0.001) in patients infused with separate bottles. There was no difference between the groups with regard to duration of nutrition or the need to establish central venous access. We conclude that PPN is a safe and cost-effective means of providing total parenteral nutrition in most surgical patients. The use of compounded mixtures significantly reduces the incidence of phlebitis without increasing total costs.
Aged↗
Retinal phlebitis in the Irvine-Gass syndrome.
We reviewed the pathology records from January 1965 through July 1975 for aphakic eyes. After exclusion of unsuitable cases, ten eyes (nine patients) with cystoid macular edema and 142 eyes without cystoid macular edema were studied. Clinical ophthalmic records were available for five of the ten eyes with the Irvine-Gass syndrome. Histologic sections were examined, revealing a significant correlation between the Irvine-Gass syndrome and retinal phlebitis, which has not been reported previously, as well as cyclitis and vitritis. Anterior segment operative complications tended to be more prevalent in eyes with the Irvine-Gass syndrome than in those without the Irvine-Gass syndrome, although the assocation was not statistically significant (P less than .1). Retinal trypsin digestion showed the phlebitis to be distributed posteriorly within primary and secondary retinal veins, frequently occurring near points of bifurcation. The changes in permeability seen in the Irvine-Gass syndrome may be due to this retinal phlebitis and to a generalized inflammation-induced increase in capillary permeability. The case of the phlebitis is not known.
Adult↗
Effectiveness of Topical Huzhang Sanhuang with Standard Nursing for Chemotherapy-Induced Phlebitis: Randomized Controlled Study.
Chemotherapy-induced phlebitis (CIP) is a common complication of peripheral intravenous chemotherapy that can cause pain, local inflammation, treatment interruption, and diminished quality of life. This randomized controlled trial evaluated the efficacy and safety of the topical Huzhang Sanhuang (HZSH) formula, combined with standard nursing care, in managing CIP. Ninety-four hospitalized patients with CIP (grade I or higher) were randomly assigned in a 1:1 ratio to receive either topical HZSH formula plus standard nursing care (experimental group, n = 47) or 50% magnesium sulfate wet dressing plus standard nursing care (control group, n = 47) for 14 days. Prespecified outcomes included phlebitis grade, visual analog scale (VAS) pain score, high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), symptom resolution time, and safety indicators. By Day 14, patients in the experimental group demonstrated significantly greater improvement in phlebitis severity than those in the control group (risk ratio for grade ≥ II, 0.42; 95% confidence interval, 0.20-0.87; P = 0.012). The experimental group also showed significantly larger reductions in VAS pain scores, hs-CRP levels, and IL-6 concentrations (all P < 0.01). Kaplan-Meier analysis further demonstrated faster resolution of multiple local symptoms in the experimental group. Treatment adherence was high in both groups, and no serious adverse events or major safety concerns were observed. These findings indicate that the topical HZSH formula, combined with standard nursing care, is a safe and effective integrative nursing intervention that accelerates clinical recovery, alleviates local symptoms, and reduces the inflammatory burden in patients with chemotherapy-induced phlebitis.
Humans↗
Filtration and infusion phlebitis: a double-blind prospective clinical study.
The effect of final filtration on the incidence of infusion phlebitis was studied in a prospective, double-blind investigation involving 146 postoperative patients. The incidence of infusion phlebitis was found to be significantly reduced when an inline, 0.45-mum membrane filter was used. The greatest reduction of infusion phlebitis was in the filter groups receiving unbuffered solutions and no set change over the 72 hours of therapy. Buffering the infusion fluid or 24-hour change of the administration set did not have any effect on reducing the incidence of phlebitis. Antibiotic therapy appeared to have a slightly beneficial effect only when inline filters were employed. A significant rise in white blood cell count and an increase in sedimentation rate were observed in the patients receiving unfiltered fluids. It is recommended that inline final filters should be a part of routine intravenous therapy.
Adolescent↗
[Physical methods in the treatment and prevention of deep phlebitis of the leg].
By the term "physical methods" the author envisages primarily walking, wearing an elastic support, and rest with the legs raised. Physical methods for the prevention and cure of phlebitis were worked out by two French surgeons between the two wars but have been rapidly replaced by coagulant treatment. Now these methods have been reduced, in most cases, simply to a "fight against haemostasis" by means of verbal instructions and with no relation to the original methods : in many cases the methods are not known to the younger generation of physicians because they have not been taught them. Several factors are leading to renewed interest in these methods : on the one hand the undeniable dissatisfaction with anticoagulant therapy, and on the other hand the many experiments that, in the last 15 years, have led to an understanding of the mode of action of the physical methods. These experiments are reviewed in the present article. From the practical point of view, improvements in materials have led to improvements in the range of bandaging techniques. The authors looked back at the original publications, that is to say to the publications of Chalier and of Nard, who described methods, which have been much referred to, that were quite exacting. The different types of bandaging for the prevention and cure of thrombosis are illustrated by numerous pictures. In the curative treatment of phlebitis, there are three essential indications for the use of physical methods : contraindications for anticoagulants, their failure, and the prevention of sequelae. In the prevention of phlebitis, the raising of the legs when seated, a factor in a quasi-experimental stasis, must give way to mobilization - very early and very frequent walking. It is the opinion of specialists in phlebitis, who have used these methods over many years, that the physical methods, which are also physiological, are a valuable complement to biological methods. Their effectiveness is, however, a function of the rigour with which they are applied : --as regards degree : the support must be applied in the correct dosage, as, for example, must heparin and digitalin ; --as regards staff : the patient and his associates must collaborate closely, and nursing staff are indispensable ; --as regards skill : the faith of the physician alone can overcome the doubts or scepticism of others.
Bandages↗
[Vasomotor substances and anti-inflammatory agents in the treatment of phlebitis].
Intrafemoral injections of substances known as "vasodilators" are still of the utmost value in the treatment of deep phlebitis as are the anti-inflammatory drugs, particularly in their injectable forms (Butazolidine, Ketazone). The indications are : cases of phlebitis that are just developing ; failure of anticoagulants ; and contraindications to the use of anticoagulants, notably phlebitis during pregnancy. As always in the treatment of phlebitis, therapeutic results are only complete and lasting if an effective support bandage is also applied.
Anti-Inflammatory Agents↗
Double-blind study to investigate methods to prevent cephalothin-induced phlebitis.
Methods which might be useful in preventing cephalothin-induced phlebitis following intravenous administration of the buffered drug were investigated. One hundred and twenty adult orthopedic patients were assigned randomly to either a control group or one of five treatment groups. The treatment regimens studied were: addition of hydrocortisone phosphate 10 mg to each liter of intravenous fluid; addition of heparin 1,000 units to each liter of intravenous fluid; addition of heparin 500 units and hydrocortisone phosphate 1 mg to each liter of intravenous fluid; addition of heparin 1,000 units and hydrocortisone phosphate 10 mg to each liter of intravenous fluid; and filtration of intravenous solutions through a 0.22-mum inline filter. All patients in the study received intravenous buffered cephalothin at a dosage of 1 g every six hours for a minimum of 48 hours. Phlebitis was assessed every 12 hours according to predetermined criteria. Significant differences were found in the incidence of phlebitis at 48 hours between the control group and the last three study groups (see above). It is concluded that postinfusion phlebitis following cephalothin administration can be reduced by the concomitant addition of heparin and hydrocortisone to the intravenous solution or by the use of an inline 0.22-mum final filter.
Adolescent↗
Phlebitis associated with the intravenous use of cephalothin and cephapirin.
The frequency and severity of phlebitis associated with cephalothin and cephapirin was compared in a double-blind study in 82 surgical patients with 149 different infusion sites. After treatment with the coded drug products, the status of each patient's veins was evaluated daily by i.v. therapists. Cephapirin was associated with a slightly lower rate of phlebitis, but the difference was not significant. For both drugs, the duration of therapy did not appear to have an effect on the rate of phlebitis. Scalp vein needles were associated with a lower rate of phlebitis than plastic catheters, but the difference was not significant.
Cephalosporins↗
[Painful manifestations of the sequelae of phlebitis].
Pain may be absent from the various manifestations making up a post-phlebitis syndrome but when it is present it varies considerably from one patient to another. Thus the very common feeling of heaviness, generally not painful, may be perceived as being painful by certain patients either because of the particular severity of the feeling or because of a low pain threshold in certain cases. Since no method for the objective measurement of pain exists, the assessment of this symptom and of its severity remains highly subjective, most often based upon statements by the patients. However, in practice a distinction can be drawn between the following: Pain related to venous stasis: a simple feeling of heaviness most often but which, in certain patients, may take on a painful connotation. Among such "stasis" pains, particular mention must be made of venous intermittent claudication, a progressive feeling of calf tension during walking which becomes increasingly painful and finally forces the sufferer to stop. This symptom is generally linked to the obstruction of a large collecting vein. Pain accompanying a leg ulcer usually results from secondary infection. Mention may be made of the role of inflammatory lesions developing around the trophic problem and which may encompass nerves, in particular the internal saphenous nerve. Although classical, causalgia type pain is certainly rarer. Demyelinisation of peripheral nerves has been suggested as being at its origin. Once again, the role of inflammatory processes linked to secondary infection appears to be notable. The treatment of pain in a post-phlebitis patient must take the greatest possible account of the pathophysiology of the post-phlebitis syndrome responsible: disinfection of a leg ulcer, treatment of venous stasis by elastic support, or by surgery or sclerosing injections. Sympathectomy has been suggested in causalgia type pain. In fact, this operation has scarcely any indications in post-phlebitis syndrome.
Humans↗
Double-blind comparison of phlebitis produced by cefazolin versus cephalothin.
In a double-blind study with each patient as his own control, 1 g of cefazolin and 2 g of cephalothin were administered intravenously every 6 h to 20 patients in opposite arms for a period of 48 h each. The degree of phlebitis was significantly more severe with cephalothin than with cefazolin (P < 0.05); however, neither the incidence of phlebitis nor the time of onset of phlebitis was significantly different between the two drugs.
Adult↗