Introduction

Superficial venous thrombophlebitis (SVT) associated with peripheral venous cannulation is the most frequent complication of peripheral venous infusion, occurring in in 25% to 35% of hospitalized patients,1 which is much higher than the 5% incidence considered acceptable by the Intravenous Nurses Society’s guidelines.2

SVT can lead to serious medical complications that impact negatively both patients and healthcare institutions. Thrombophlebitis causes patient discomfort and occlusion of the intravenous catheters, both requiring removal and re-siting of the catheter. This generates unnecessarily delays in administration of intravenous therapy and more invasive venous access procedures with associated risks and ultimately prolongs hospital stay by 2-5 days.3 SVT does also significantly increase the risk of catheter-related bloodstream infections in up to 50% of patients.4,5 Furthermore, thrombosis associated with SVT can become infected, leading to suppurative thrombophlebitis in 0.2% to 2% of peripheral vein catheter insertions6,7 and sepsis. This is a serious complication that prolongs hospital stay and is associated with increased costs to an average of $4830 per episode in 1991 U.S. dollars.8

Pathogenesis

Local inflammation of the wall of the vein at the catheter site is considered to be the initiating event in a cascade that ultimately leads to thrombophlebitis. The venous endothelium can be injured by the chemical irritation caused by the infusate,8,9 physical trauma by the catheter,8–10 or microorganisms colonizing the cannula.8 Injury to the venous endothelium causes a prostaglandin-mediated activation of the inflammatory cascade and the coagulation pathway leading to thrombosis.11 Furthermore, inflammation of the endothelium causes venoconstriction at the catheter leading to local stasis of the blood which in turn promotes thrombosis and increased irritation of the endothelium by the infusate.12 Histopathologic studies confirm this cascade by showing that peripheral vein infusion thrombophlebitis is associated with swelling of the endothelial cells, leukocytic infiltration of the vein wall,11,13 and fibrin deposition and thrombus formation.13

Risk factors

Numerous studies8,14–44 have identified several risk patient-related, catheter-related, and healthcare-and-provider-related factors for the development of SVT that are summarized in Table 1.

Table 1.Risk factors associated with the development of superficial vein thrombophlebitis.
Risk Factors*
Patient-related Catheter-related Healthcare/provider-related
Female sex Longer duration Less experienced healthcare personnel
Medical comorbidities
- Diabetes mellitus
- Immunodeficiencies
- Malignancies
- Burns
-Trauma
- Previous thrombophlebitis
- Hemoglobin levels > 12.5
- Hypercoagulable states		 Material
- Teflon catheter > steel needle
- Fluorinated ethylene/Teflon >
Polyurethane/Vialon		 Placement by house staff > intravenous therapy team
Site of catheter infection
- Lower extremity > upper extremity
- Forearm/antecubital fossa >
wrist/dorsum of hand
- Forearm > antecubital fossa		 Intravenous infusate
- Antibiotics (Augmentin, aminoglycoside, dicloxacillin, erythromycin, benzylpenicillin, cefuroxime)
- Hypertonic solutions
- KCl
- Continuous intravenous infusion
- Amiodarone infusion
- Chemotherapy agents		 Less nursing care
Poor quality peripheral veins Larger bore Type of hospital
- General > specialized
Greater number of catheters Location of placement
- Emergency Department > ward
Bruising at the insertion site Higher number of insertion attempts
Greater number of catheters Poor anchorage of catheter with tape or dressing
Infected catheters Changing catheter site dressings more frequently than every 48 hours
Colonized catheters

* Modified from references 1 and 42

Female sex,8,14,16,32–36 medical comorbidities,8,16 poor quality peripheral veins,8 and insertion in the lower extremity, forearm, or antecubital fossa8,24,29,32–36 are thought to increase the risk of SVT.

Diabetes mellitus in particular increases the thrombophlebitis risk by 40%,40 presumably due to diabetes-induced endothelial damage.40 Higher hemoglobin levels predispose patients to thrombophlebitis,26 likely through an increased risk for venous thromboembolism in general. In terms of site of cannulation, insertion into areas of joint flexion and rotation, such as the antecubital fossa, can cause the catheter to slide back and forth or roll inside the vein, leading to increased intimal trauma with subsequent inflammation and thrombophlebitis.19,21,41

Larger catheter size,14,18,25,30,33 longer duration,8,18,19,21,29,30 greater number of catheters inserted,31 bruising at the site,25 catheter material,8,17 type of infusate,16,21–24,31–35 and infected37 and colonized8 catheters increase the SVT risk. A catheter-to-vein ratio of >33.33% has been shown to increase risk of superficial thrombophlebitis, presumably by decreasing peri-catheter blood flow velocities and promoting venous stasis and subsequent thrombosis.44 Studies have shown that catheters colonized with skin flora are up to six times more likely to cause SVT.8

Less experienced providers inserting the catheter,6,8,15 placement by an intravenous therapy team,14,15 admission to a non-specialized hospital,28 insertion in the emergency room,19,22–24 higher number of insertion attempts,6 less nursing care,28 poor anchorage of catheters,8 and changing catheter site dressings more frequently than every 48 hours39 can increase the SVT risk.

Presentation and Diagnosis

Signs and symptoms of catheter-associated SVT can occur relatively quick and include local pain, tenderness, redness, warmth, swelling, palpable venous cord, induration, streak formation or red line, or purulence or exudate. Low-grade fever may be present in early stages of thrombophlebitis, whereas high-grade fevers and erythema extending beyond the cannulated vein suggest suppurative SVT.

Based on the severity of the signs and symptoms, numerous progressive scales have been developed, that generally revolve around 5 grades as shown in Table 2.

Table 2.Grading Scale for Peripheral Vein Infusion Thrombophlebitis Grade Clinical Criteria
Grade Clinical criteria
0 No symptoms.
1 Pain or erythema at intravenous site.
2 Pain at intravenous site with erythema or swelling.
3 Pain at intravenous site with erythema and swelling or a palpable venous cord.
4 Pain at intravenous site with erythema, swelling, and a palpable venous cord > 1 cm.
5 Purulent discharge at intravenous site, along with all the signs of grade 4 thrombophlebitis.

However, because the numerous differing scales have not been validated or psychometrically tested,43 it is important for nurses and physicians to be aware of and maintain a high index of suspicion for the signs and symptoms of SVT.

Treatment

Although no consensus exists on the SVT management, prompt removal of the catheter is generally performed when patients develop pain and erythema or swelling at the catheter site. This usually leads to a quick resolution of symptoms. If discomfort persist after catheter removal, conservative therapy is initiated and includes elevation of the affected site, cold compressions, analgesics, and non-steroidal anti-inflammatory medications, as well as medications to help maintain patency of the vein.42,45

Topical heparinoid or diclofenac gels appear to significantly reduce the intensity of clinical signs and symptoms and achieve higher complete resolution.45 As such, according to the 2008 guidelines of the American College of Chest Physicians these patients can be treated with an oral anti-inflammatory drug, topical diclofenac gel, or heparin gel until resolution of symptoms or for up to two weeks.46 These guidelines recommended against the use of systemic anticoagulation.

A venous duplex ultrasound is recommended in patients with spontaneous SVT because concomitant deep venous thrombosis (DVT) occurs in 6-36% of patients.47,48 However, because there are no data estimating the risks of concomitant DVT in peripheral catheter-induced SVT, the decision on obtaining a venous duplex sonogram should be guided by clinical judgment. Patients with SVT who do not respond to removal of the catheter and other conservative measures, or have progression of their symptoms, should undergo duplex ultrasonography to evaluate for progression or extension of thrombosis.

If symptoms persist after 48 hrs of conservative management, patient develops fever, erythema extends beyond the cannulated vein, or purulence develops at the cannulation site, blood cultures to evaluate for bacteremia, antibiotic therapy, and early surgical consultation are very important as these are signs of suppurative SVT. Although imaging evaluation with an ultrasound can help to identify an abscess when clinical signs are equivocal, the diagnosis is usually made clinically. In these patients, prompt surgical incision and drainage, excision of the involved vein, and the ligation of the surrounding veins should be performed.49–52 Intermittent stab incisions can be selectively used to minimize the size of the wound when a longer segment of vein is affected.53 The length of the proximal and distal ligation of the involved vein is determined based on the extent of the intraluminal thrombus or purulence.53 The wound should be left open for secondary closure.49,50,53 A lower threshold for surgical intervention is recommended in the presence of comorbidities.53 Continued antibiotic therapy is important because 60% of patients with septic thrombophlebitis have concurrent bacteremia, with Staphylococcus Aureus being the most common pathogen.53

Prevention

Prevention remains the cornerstone of minimizing the occurrence of SVT. Multidisciplinary and multi-professional guidelines have been developed to provide evidence-based recommendations for preventing SVT within a larger goal of preventing catheter-related infections. (Table 3)

Table 3.Guidelines for prevention of superficial venous thrombophlebitis (adapted from 2,54,55).
Area Recommendations
Educating, training, and staffing Educate healthcare personnel regarding the indications for catheter use, proper procedures for the insertion and maintenance of catheters, and appropriate infection control measures.
Periodically assess knowledge of and adherence to guidelines for all personnel involved in the insertion and maintenance of catheters.
Designate only trained personnel who demonstrate competence for the insertion and maintenance of catheters.
Ensure appropriate nursing staff levels.
Use initiatives in which multifaceted strategies are “bundled” together to improve compliance with evidence-based recommended practices.
Care of catheters and sites Use an upper-extremity site for catheter insertion. Replace a catheter inserted in a lower extremity site to an upper extremity site as soon as possible.
In pediatric patients, the upper or lower extremities or the scalp (in neonates or young infants) can be used as the catheter insertion site.
Select catheters based on the intended purpose and duration of use, known infectious and non-infectious complications (e.g., phlebitis and infiltration), and experience of individual catheter operators.
Use a midline catheter or peripherally inserted central catheter instead of a short peripheral catheter when the duration of intravenous therapy will likely exceed six days.
Evaluate the catheter insertion site daily by palpation through the dressing to discern tenderness and by inspection if a transparent dressing is in use. Gauze and opaque dressings should not be removed if the patient has no clinical signs of infection. If the patient has local tenderness or other signs of possible thrombophlebitis, an opaque dressing should be removed, and the site inspected visually.
Remove peripheral venous catheters if the patients develops signs of phlebitis (warmth, tenderness, erythema, or palpable venous cord), infection, or a malfunctioning catheter.
There is no need to replace catheters more frequently than every 72-96 hours to reduce risk of infection and phlebitis in adults.
Replace catheters in children only when clinically indicated.
Remove any catheter that is not essential.
Use a transparent, semi-permeable dressing to cover the catheter site.
Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled.
Do not use topical antibiotic ointment or creams on insertion sites.
Encourage patients to report any changes in their catheter site or any new discomfort to their provider.
Hand hygiene and aseptic technique Perform hand hygiene procedures, either by washing hands with conventional soap and water or with alcohol-based hand rubs. Hand hygiene should be performed before and after palpating catheter insertion sites as well as before and after inserting, replacing, accessing, repairing, or dressing a catheter.
Maintain aseptic technique for the insertion and care of catheters.
Prepare clean skin with an antiseptic (70% alcohol, tincture of iodine, an iodophor or chlorhexidine gluconate) before catheter insertion.
Antiseptics should be allowed to dry according to the manufacturer's recommendation prior to placing the catheter.
Wear clean gloves, rather than sterile gloves, for the insertion of catheters, if the access site is not touched after the application of skin antiseptics.
Wear either clean or sterile gloves when changing the catheter site dressing.
When adherence to aseptic technique cannot be ensured (i.e., catheters inserted during a medical emergency), replace the catheter as soon as possible (i.e., within 48 hours).

Major areas of emphasis include educating, training, and staffing; care of catheters and sites; and ensuring hygiene and aseptic technique.

As part of a routine practice, the peripheral venous catheters are removed just before patients leave the hospital. Since thrombophlebitis can still develop, it is important to warn the patient about signs of phlebitis after being discharged from the hospital.

Conclusions

Superficial thrombophlebitis associated with peripheral venous catheters remains the most frequent complication of peripheral venous infusion and leads to serious medical complications that impact negatively both patients and healthcare institutions. Our review shares evidence-based information on the pathophysiology, risk factors, clinical presentation, treatment, and prevention of infusion-related superficial thrombophlebitis. Healthcare providers should integrate this information into their care for patients receiving therapy via peripheral venous catheters.