How to manage phlebitis secondary to IV fluid management?

Management of Phlebitis Secondary to IV Fluid Management

The primary management of phlebitis secondary to IV fluid management requires immediate removal of the peripheral venous catheter if signs of phlebitis develop, including warmth, tenderness, erythema, and palpable venous cord. 1

Diagnosis of Phlebitis

• Evaluate catheter insertion sites daily by:
  • Palpation through the dressing to detect tenderness
  • Visual inspection if transparent dressing is used
  • Monitoring for signs of phlebitis:
    • Pain (most common symptom, present in 83% of cases)
    • Erythema and edema (present in 63% of cases)
    • Warmth
    • Palpable venous cord

Immediate Management

1. Remove the peripheral venous catheter - This is the most critical first step when phlebitis is identified 1
2. Apply warm compresses to the affected area to improve circulation and reduce inflammation
3. Elevate the affected limb to reduce swelling and discomfort
4. Consider antibiotic therapy if septic phlebitis is suspected (especially with signs of systemic infection) 2
   • Most causative organisms (80%) are gram-positive bacteria, particularly Staphylococcus aureus (41%) and Group A streptococcus (20%)

Prevention Strategies

Catheter Selection and Replacement

• Replace peripheral venous catheters in adults every 72-96 hours to prevent phlebitis 3, 1
• For pediatric patients, leave peripheral venous catheters in place until IV therapy is completed, unless complications occur 1
• Consider midline catheters for IV therapy expected to exceed 6 days 1
• Select appropriate catheter type based on duration of therapy:
  • 6-14 days: Midline catheter
  • 15-30 days: PICC line or non-tunneled central venous catheter
  • ≥31 days: Tunneled central venous catheter or implanted port 1

Insertion Site Selection

• Use upper extremity sites rather than lower extremity sites 1
• Avoid veins around the elbow as they increase the risk of phlebitis 4
• Replace catheters inserted during medical emergencies with compromised aseptic technique as soon as possible and within 48 hours 3, 1

Infusion Management

• Replace administration sets no more frequently than every 72 hours, unless catheter-related infection is suspected 3, 1
• Replace tubing used for blood, blood products, or lipid emulsions within 24 hours of initiating the infusion 3, 1
• Complete the infusion of lipid-containing solutions within 24 hours of hanging the solution 3
• Complete the infusion of lipid emulsions alone within 12 hours of hanging the emulsion 3
• Avoid using infusion pumps when possible, as they may increase the risk of phlebitis 4

Aseptic Technique

• Clean injection ports with 70% alcohol or an iodophor before accessing the system 3, 1
• Cap all stopcocks when not in use 3, 1
• Minimize contamination risk by accessing ports only with sterile devices 3, 1
• Do not submerge catheters under water; protect with impermeable cover during showering 3, 1

Risk Factors to Consider

Several factors increase the risk of phlebitis development:

• Chronic diseases 5
• Extended duration of catheterization 5
• Type of fluid used for infusion 5
• Multiple catheter insertions 4
• Use of infusion pumps 4
• Insertion in veins around the elbow 4

Special Considerations

• If septic phlebitis is suspected and septicemia persists after 24 hours despite conservative therapy, operative excision of the involved vein may be necessary 2
• For patients with advanced chronic kidney disease (CKD stage 3b or greater, eGFR <45 mL/min), tunneled small-bore central catheters are recommended instead of midline catheters to preserve peripheral veins 1
• Phlebitis can lead to serious complications including sepsis, prolonged hospitalization, increased patient stress, and higher healthcare costs 4

Common Pitfalls to Avoid

• Delaying catheter removal when signs of phlebitis appear
• Using steel needles for administration of fluids that might cause tissue necrosis if extravasation occurs 1
• Routinely applying prophylactic topical antimicrobial or antiseptic ointment to insertion sites 1
• Ignoring daily assessment of catheter insertion sites
• Failing to consider the type of fluid being administered as a risk factor for phlebitis 5