What is the management of infusion-related phlebitis in a child?

Management of Infusion-Related Phlebitis in Children

Remove the peripheral venous catheter immediately when phlebitis is identified—this is mandatory, not optional. 1, 2, 3

Immediate Assessment and Catheter Removal

• Identify phlebitis by clinical signs: warmth, tenderness, erythema, palpable venous cord, or swelling at the IV site 1, 3
• Remove the catheter as soon as any of these signs develop—do not delay removal hoping symptoms will resolve with the catheter in place 1, 2, 3
• Visually inspect the site after catheter removal to assess the extent of inflammation 1
• If exudate is present, submit samples for Gram staining and culture, particularly in immunocompromised children 1

Local Site Care

• Clean the affected area with an appropriate antiseptic:
  • Preferably use 2% chlorhexidine-based preparation 1
  • Alternatively use 70% alcohol 1
• Apply appropriate sterile dressing based on site condition:
  • Use sterile gauze for weeping or oozing sites 1
  • Use transparent semi-permeable dressing for dry sites 1
• Do not submerge the affected area in water until healing is complete 1

Monitoring

• Evaluate the phlebitis site daily for progression of tenderness, erythema, warmth, and swelling 3
• Monitor for signs of infection including fever, purulent drainage, and systemic symptoms 3

Placement of New IV Access

• Use upper extremity sites only for subsequent IV therapy—avoid lower extremity placement as this increases phlebitis risk 1, 3, 4
• Avoid placing new catheters in the same area where phlebitis occurred 1
• In pediatric patients, leave catheters in place until IV therapy is completed unless complications occur—do not routinely replace catheters at scheduled intervals as recommended in adults 2
• Consider using a midline catheter or PICC when IV therapy is expected to exceed 6 days 1

Prevention Strategies for Future IV Insertions

• Select catheters based on intended purpose and duration of use 1
• Ensure experienced nurses perform catheter insertion, as insertion by novice nurses increases phlebitis risk 4
• Avoid steel needles for administration of fluids and medications that might cause tissue necrosis if extravasation occurs 1
• Keep dressings clean and dry—contaminated dressings increase phlebitis risk 4
• Consider using in-line filters (1.2-1.5 mm for lipid emulsions or all-in-one mixes; 0.22 mm for aqueous solutions) as particulates in infusion fluid contribute to phlebitis development 5

Critical Pitfalls to Avoid

• Do not leave the catheter in place once phlebitis develops—this is the most common error and increases risk of progression and infection 1, 2, 3
• Do not apply topical antimicrobial or antiseptic ointment to the phlebitis site—this provides no benefit and is not recommended 1, 3
• Do not routinely apply prophylactic topical antimicrobial ointment to insertion sites of peripheral venous catheters 1

Special Considerations for Thrombophlebitis

If the child develops symptomatic catheter-related superficial vein thrombosis (thrombophlebitis extending beyond simple phlebitis), anticoagulation may be considered in specific circumstances:

• When the catheter is still functioning and the child continues to need venous access 5
• When symptoms progress despite catheter removal 5
• However, in most pediatric patients with superficial vein thrombosis, no anticoagulation is appropriate after catheter removal 5