What is the management for a patient with erythema and tenderness at an intravenous (IV) site after IV placement for dehydration management?

Management of Peripheral IV Site Phlebitis

Remove the peripheral intravenous catheter immediately when a patient presents with pain, erythema, and tenderness at the IV insertion site, as these are clear signs of phlebitis. 1

Immediate Actions

The catheter must be removed without delay. The Infectious Diseases Society of America provides the highest level recommendation (A-I) that peripheral intravenous catheters with associated pain, induration, erythema, or exudate should be removed immediately. 1 This is non-negotiable—do not wait for culture results or attempt to salvage the line. 2

After removal:

• Visually inspect the insertion site to assess the extent of inflammation and document findings. 2
• If any exudate is present, submit samples for Gram staining and routine culture (and additional cultures for fungi and acid-fast organisms if the patient is immunocompromised). 1
• Clean the area with 2% chlorhexidine-based preparation or 70% alcohol. 2
• Apply appropriate dressing: use sterile gauze for weeping/oozing sites or transparent semi-permeable dressing for dry sites. 2

Why This Approach

The evidence is clear that phlebitis from short-term peripheral IV catheters carries very low risk of catheter-related bloodstream infection (CRBSI) or suppurative thrombophlebitis. 1 However, leaving the catheter in place serves no purpose and prolongs patient discomfort while risking progression to more serious complications. 2

A critical distinction: This patient has a peripheral IV catheter, not a central venous catheter. The CDC and IDSA guidelines differentiate management based on catheter type—central lines in hemodynamically stable patients without documented infection may be observed, but peripheral lines with phlebitis signs should always be removed. 1

Monitoring and Follow-up

• No systemic antibiotics are needed for uncomplicated peripheral IV phlebitis in an immunocompetent patient without fever or systemic signs of infection. 1
• Monitor the site for progression over the next 24-48 hours to ensure resolution. 2
• Elevate the affected extremity and consider applying warm compresses for symptomatic relief (though this is supportive care, not evidence-based treatment). 2

Placement of New IV Access

When new IV access is required:

• Use the opposite upper extremity or a site well away from the area of phlebitis. 2
• Select upper extremity sites rather than lower extremity in adults. 1, 2
• Consider a midline catheter or PICC if IV therapy is expected to exceed 6 days, as this reduces phlebitis risk. 1, 3, 2
• Replace peripheral IV catheters every 72-96 hours in adults to prevent recurrent phlebitis. 1, 2

Common Pitfalls to Avoid

• Do not delay catheter removal hoping the phlebitis will resolve with the line in place—it will not. 2
• Do not apply topical antimicrobial ointments to the insertion site, as this is not recommended and provides no benefit. 1, 2
• Do not place the new catheter in the same area where phlebitis occurred. 2
• Do not submerge the affected area in water until complete healing occurs. 2

When to Escalate Care

While this presentation appears to be uncomplicated phlebitis, escalate to more aggressive management if:

• Fever, hypotension, or systemic signs of infection develop, suggesting possible bloodstream infection. 1
• A palpable venous cord extends beyond the immediate insertion site, suggesting thrombophlebitis. 1
• Purulent drainage appears at the site. 1
• The patient is immunocompromised, warranting cultures and closer monitoring. 1

The intact distal pulses and absence of edema in this patient are reassuring signs that deep vein thrombosis is unlikely. 1