Post-injection thrombophlebitis in patients undergoing peripheral IV catheterization in a tertiary care hospital: incidence and risk factors

Abstract

p class="abstract"> Background: Intravenous catheters cause endothelial damage and trauma, which can predispose to venous thrombosis. Peripheral vein infusion thrombophlebitis occurs in 25- 35% of hospitalized patients with intravenous catheters and has both patient-related implications (e.g., sepsis) and economic consequences (e.g., extra nursing time). This study is designed to address this issue, by assessing the potential risk factors in those who have developed phlebitis, and deriving conclusions based on the same.
Methods: A total of 830 patients were observed over a period of 2 months. All details of the patient were collected. Thrombophlebitis was graded using Visual Infusion Phlebitis Score. Each case was compared with a matching control.
Results: 53 of 830 patients observed, developed thrombophlebitis giving an incidence of 6.4%. 92.5% had IV cannulation flushed after insertion. IV cannula had to be changed at least 2 times during the hospital stay. All had an average IV cannulation for 5 days. All had insertion of same size cannula (20G). Level 1 Phlebitis was identified in 64.15% patients, level 2 Phlebitis in 33.96% patients and Level 3 Phlebitis was seen 1.88% patients.
Conclusions: Significant association was noted between the number of times the catheter was changed since admission and administration of Potassium chloride and Certain Medications such as Piperacillin through the cannula.</p

Full text

International Journal of Scientific Reports | April 2020 | Vol 6 | Issue 4 Page 154
International Journal of Scientific Reports
Rai P et al. Int J Sci Rep. 2020 Apr;6(4):154-162
http://www.sci-rep.com
pISSN 2454-2156 | eISSN 2454-2164
Original Research Article
Post-injection thrombophlebitis in patients undergoing peripheral IV
catheterization in a tertiary care hospital: incidence and risk factors
Pranjal Rai, Vinaykumar Thati, Geeta Ghag, Vipul Nandu*
INTRODUCTION
The word Phlebitis comes from the Latin word Phlebo
meaning vein and -itis meaning inflammation. It basically
stands for inflammation of the vessel wall and its origins
can be dated back to when it was first described by John
Hunter.1 The term thrombophlebitis is used when the
venular inflammation is associated with formation of
thrombus within the same region.
Peripheral IV administration has almost become a
necessity (80%) in the indoor-patient department’s
today.2 Peripheral Catheterization is an invasive
procedure and requires an experienced clinician or nurse,
local sterilization methods and knowledge of common
precautions that need to be taken while giving the
therapy.
Due to lack of knowledge, reasonable care and skill,
thrombophlebitis has emerged as a very common
complication (3.7-67.24%) in hospitalized patients.3
Phlebitis is the development of an inflammatory reaction
in the vein, most commonly due to a thrombus. It
classically presents with clinical signs of pain, induration,
tenderness, swelling and/or erythema.
The reason why more light needs to be shed on this
subject is that not only does it increase the nursing cost
ABSTRACT
Background: Intravenous catheters cause endothelial damage and trauma, which can predispose to venous
thrombosis. Peripheral vein infusion thrombophlebitis occurs in 25- 35% of hospitalized patients with intravenous
catheters and has both patient-related implications (e.g., sepsis) and economic consequences (e.g., extra nursing time).
This study is designed to address this issue, by assessing the potential risk factors in those who have developed
phlebitis, and deriving conclusions based on the same.
Methods: A total of 830 patients were observed over a period of 2 months. All details of the patient were collected.
Thrombophlebitis was graded using visual infusion phlebitis score. Each case was compared with a matching control.
Results: 53 of 830 patients observed, developed thrombophlebitis giving an incidence of 6.4%. 92.5% had IV
cannulation flushed after insertion. IV cannula had to be changed at least 2 times during the hospital stay. All had an
average IV cannulation for 5 days. All had insertion of same size cannula (20G). Level 1 Phlebitis was identified in
64.15% patients, level 2 Phlebitis in 33.96% patients and Level 3 Phlebitis was seen 1.88% patients.
Conclusions: Significant association was noted between the number of times the catheter was changed since
admission and administration of Potassium chloride and Certain Medications such as Piperacillin through the cannula.
Keywords: Thrombophlebitis, Peripheral venous thrombosis, IV cannula, Infusion thrombophlebitis
Department of General Surgery, HBT Medical College and Dr. R. N. Cooper Hospital, Juhu, Mumbai, Maharashtra,
India
Received: 19 December 2019
Revised: 20 February 2020
Accepted: 21 February 2020
*Correspondence:
Dr. Vipul Nandu,
E-mail: dr.vipulnandu@gmail.com
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
DOI: http://dx.doi.org/10.18203/issn.2454-2156.IntJSciRep20201271

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International Journal of Scientific Reports | April 2020 | Vol 6 | Issue 4 Page 155
and time, along with putting the patient’s safety at risk,
but also can be used as a crude indicator to assess the
level of healthcare that is being provided at that
institution, especially at a tertiary care setup in India
where increasing patient burden is reciprocal to the
intentness and observation that is given to them by the
health-care providers.4
While there have been many studies demonstrating the
incidence and risk factors, lesser ones have tried to use
alternative interventional strategies to reduce the
symptoms of thrombophlebitis. Since there is limited data
to guide management of superficial thrombophlebitis, the
initial step includes discontinuing IV therapy through the
catheter, removing the catheter. Symptomatic treatment
includes elevation of the limb, providing cold compresses
and oral NSAIDs. Antithrombotic therapy remains a
cornerstone of therapy, for relieving symptoms and
reducing the risk of embolization. Heparin containing
ointments are used in many institutions for cases of
thrombophlebitis. The catheter site should be also
monitored for further complication, and antibiotics must
be initiated if there are any concerns for suppurative
thrombophlebitis.
This study is designed to address this issue, by assessing
the potential risk factors in those who have developed
phlebitis, and deriving conclusions based on the same.
The significance of this study is that using the derived
data, we will be able to determine, or at least suggest
ways so that the incidence of its development in future
patients can be reduced. Most of the studies previously
performed have been conducted in developed countries
like Germany and Turkey, and the same results cannot be
extrapolated to a developing nation like ours, where
many new factors might be needed to be taken into
consideration. This study, aims to address the problem in
an Indian background, through a government owned
tertiary care institute, where the same risk factors, along
with added presumed ones have been used to quantify the
problem, and to assess, indirectly, the quality of the
healthcare setting.
METHODS
A prospective observational study was carried out in an
HBT medical college, a tertiary care hospital from June
2017 to August 2017. Patients willing to participate in the
study between the age group of 12 to 60 years receiving
IV therapy in wards were included for the study. Patients
not willing to participate, pregnant women, elderly (>60
years of age) and children (less than 12 years) were
excluded from the study.
After taking permission from the institutional ethics
committee, and the head of institution, 830 participants
were clinically observed over a period of 2 months for the
development of thrombophlebitis during the course of
hospital stay in the surgical wards. Among these 53
participants developed thrombophlebitis along with their
53 age and sex matched controls without
thrombophlebitis were selected in the ratio of 1:1 during
the same period. Hence, a total 106 patients were selected
for the study.
Patients were screened during their stay and at the time of
their discharge, based on the inclusion and exclusion
criteria as mentioned above. A case record form was
prepared and used for collecting all preliminary details of
the patient, reason for admission, local symptoms of
thrombophlebitis (redness, induration, pain) at the
catheter site (if present) and systemic signs such as fever.
Thrombophlebitis was graded using visual infusion
phlebitis score suggested by infusion nurse’s society
(Table 1).
The case record form was also used for noting down the
site of peripheral catheter placement, the drugs
administered via the intravenous route, type of drug, its
concentration, frequency of administration, duration of
administration, duration of keeping the Intravenous line
empty after the drug is administered and whether the IV
line was administered in first attempt or not, whether
flushed after removing the line, how many times the
catheters were changed during admission, treatment
being given (if any) to them for remedying them of
thrombophlebitis.
The model of this study is a quantitative one, that is, it is
a systematic investigation concerning thrombophlebitis,
and the final objective is to apply the analysis of collected
data for making a definitive statement regarding the risk
factors, both patient and health administration related.
The data was statistically analyzed using IBM SPSS
version 21.0 and microsoft office excel 2007. Continuous
data has been expressed as mean (standard deviation) and
median (interquartile range). The categorical data is
summarized as frequencies and percentages. The
normally distributed continuous variables were analyzed
by unpaired t-test and data failing to meet the normality
assumption was analyzed by Mann-Whitney U test.
Categorical data was analyzed using chi-square test and
fisher’s exact. P<0.05 were accepted as indicative of
statistical significance.
RESULTS
Duplex ultrasound examination has been considered a
screening tool of choice for evaluating superficial
thrombophlebitis as it is non-invasive and easy to
perform. However due to time constraints and the
absence of appropriate funding, we had to adhere to using
clinical manifestations and the VIPS as the mainstay to
diagnose and classify the patients.
The study included 830 participants who were clinically
observed over a period of 2 months for the development
of thrombophlebitis. Among these, only 53 participants
developed thrombophlebitis which gives an incidence of
6.4%.

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Average age of the cases and controls was 41.3 years and
40.5 years respectively. Among the cases, 23 (43.4%)
were females and 30 (56.6%) were males and among the
controls, 24 (45.3%) were females and 29 (54.7%) were
males. The various sites of IV cannulation in our study as
shown (Table 2).
Table 1: Visual infusion phlebitis score suggested by infusion nurse’s society.
Intravenous site appears healthy
0
No sign of phlebitis
Observe the cannula
One of the following is evident:
• Slight pain near IV site
• Slight redness near IV site
1
Possible first signs of
phlebitis
Observe the cannula
Two of the following are evident:
• Pain near IV site
• Erythema
• Swelling
2
Early signs of phlebitis
Re-site the cannula
All of the following are evident:
• Pain along the path of the cannula
• Erythema
• Induration.
3
Medium stage of phlebitis
• Re-site the cannula
• Consider treatment
All of the following are evident and extensive:
• Pain along the path of the cannula
• Erythema
• Induration
• Palpable venous cord
4
Advanced stage of phlebitis
and start of thrombophlebitis
• Re-site the cannula
• Consider treatment
All of the following are evident and extensive:
• Pain along the path of the cannula.
• Erythema
• Induration
• Palpable venous cord
• Pyrexia
5
Advanced stage of
thrombophlebitis
• Initiate treatment
• Re-site the cannula
Table 2: Risk factors based on site of catheterization and vein accessibility across cases and controls for the
development of thrombophlebitis: patient factors.
Factors
Cases
Controls
Site
N (%)
N (%)
Upper/left/basilic vein
3 (5.7)
5 (9.4)
Upper/left/cephalic
5 (9.4)
4 (7.5)
Upper/left/dorsal arch
17 (32.1)
18 (34)
Upper/left/median cubital vein
3 (5.7)
1 (1.9)
Upper/right/basilic vein
3 (5.7)
4 (7.5)
Upper/right/cephalic
5 (9.4)
4 (7.5)
Upper/right/dorsal arch
10 (18.9)
16 (30.2)
Upper/right/median cubital vein
5 (9.4)
1 (1.9)
Upper/right/multiple
1 (1.9)
0 (0)
Lower/right/dorsal arch
1 (1.9)
0 (0)
Vein visibility during IV catheterisation
Visible even without tourniquet
15 (28.3)
21 (39.6)
Seen after using tourniquet
17 (32.1)
11 (20.8)
Not visible even with tourniquet
21 (39.6)
21 (39.6)
# Chi-square test used, significance level <0.05.
All the patients had IV cannula in their upper limbs. Of
the 53 cases, 15 patients (28.3%) had veins visible even
without tourniquet application, 17 patients (32.1%) had
veins visible after tourniquet application and 21 patients
(39.6%) had no veins visible even after tourniquet
application, whereas, Of the 53 Controls, 21 patients
(39.6%) had visible veins without tourniquet application,
11 patients (20.8%) had visible veins after tourniquet

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application and 21 patients (39.6%) had no visible veins
even after tourniquet application, p value was 0.319. Of
the 53 cases, in 34 patients (64.2%) IV cannulation was
done in First attempt and 19 patients (35.8%) required
more than one attempt for IV cannulation, whereas, 35
patients (66%) out of 53 controls had IV cannulation
done in First attempt and 18 patients (34%) required
more than 1 attempts, p value was 0.839 (>0.05, not
significant) (Table 3). Of the 53 cases, in 49 patients
(92.5%) IV cannulation was followed by flushing of
cannula and in 4 patients (7.5%) IV cannulation was not
followed by flushing of cannula, whereas, all 53 patients
(100%) of controls had IV cannula flushed post insertion,
p value was 0.118 (Table 3).
Table 3: Risk factors based on technique of catheterization across cases and controls for the development of
thrombophlebitis: procedural factors.
Factors
Cases
Controls
P value
IV catheterization at first attempt#
N (%)
N (%)
Yes
34 (64.2)
35 (66)
0.839
No
19 (35.8)
18 (34)
IV flushed after insertion$
Yes
49 (92.5)
53 (100)
0.118
No
4 (7.5)
0 (0)
Number of times catheter changed during indoor stay@
2 (2)
0 (0)
<0.0005*
Duration during which IV line kept empty@
5 (5)
5 (5)
0.580
Local treatment given#
Ice pack application
20 (37.7)
0 (0)
-
Local heparin
1 (1.9)
0 (0)
Both local heparin and ice pack
1 (1.9)
0 (0)
None
31 (58.5)
53 (100)
Duration of IV catheterization (in days) @
4
5
0.969
Total
53 (100)
53 (100)
#Chi-square test used, $Fisher exact test used, *significant at 0.05 level. @median (Interquartile Range). Mann Whitney U test used.
Table 4: Risk factors based on IV canula properties and drugs administered across cases and controls for the
development of thrombophlebitis: equipment/drug related factors.
Factors
Cases
Controls
P value#
Cannula size@
20 G
20 G
0.223
KCl administered through IV catheter
Yes
6 (11.3)
0 (0)
0.027*
No
47 (88.7)
53 (100)
Total
53 (100)
53 (100)
Piperacillin and tazobactam
Given
12 (22.6)
2 (3.7)
0.004121
Not given
41(77.4)
51(96.3)
Total
53 (100)
53 (100)
#Chi-square test used, *significant at level <0.05, @median (Interquartile Range).
Among the 53 cases, on an average IV cannula had to be
changed at least 2 times during the hospital stay, whereas,
in 53 controls, none of them needed to change the
cannula during the hospital stay. P value was <0.0005
(Table 3).
On an average all the cases and controls had an average
IV cannulation for 5 days, p value was 0.580. It was also
noted that 37.7% of the cases were given ice pack,
ointment was given to only 1 case (1.9%), and both
ointment and ice pack was given to 1 case (1.9%).
Remaining cases (58.5%) were not given any local
treatment. Both the cases and controls had insertion of
same size cannula (20G). P value was 0.223 (>0.05, not
significant) (Table 4). Of the 53 cases, 6 patients (11.3%)
were administered IV KCL injection through the canula
and 47 (88.7%) were not administered, whereas, of the 53
controls, all 53 patients (100%) were not given IV KCL
injection through the cannula, p value was 0.027 (Table
4). Of the 53 cases, 12 patients (22.6%) were
administered piperacillin and tazobactam injection
through the canula and 41 patients (77.4%) were not
administered, whereas, of the 53 controls, 2 patients
(3.7%) were administered piperacillin and tazobactam
injection through the cannula and 51 patients (96.3%)
were not administered the injection, p value was 0.004
(Table 4). Of the 53 cases, level 1 phlebitis was identified
in 34 patients (64.15%), level 2 phlebitis was identified in

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18 patients (33.96%) and level 3 phlebitis was seen 1
patient (1.88%) (Figure 1).
Figure 1: Visual infusion phlebitis score among the
cases.
Of the 53 cases, maximum patients, 9 patients (17.1%)
were suffering from cholecystitis, followed by 4 patients
(7.6%) each suffering from appendicitis and vague pain
in abdomen, followed by 3 patients (5.7%) suffering from
cellulitis. Of the 53 controls, maximum patients 12
patients (22.8%) were suffering from appendicectomy,
followed by 9 patients (17.1%) each suffering from
cholecystitis, followed by 7 patients (13.2%) each
suffering from liver abscess and head injury.
Of the 53 cases, 11 patients (20.8%) had chronic diseases,
whereas, 42 patients (9.2%) did not have chronic
diseases. Of the 53 controls, 9 patients (17%) had
chronic diseases, whereas, 44 patients (83%) did not have
chronic diseases. Applying Chi-Square test to the above
contingency table, we get an X2 value of 0.2465. The p
value is 0.6195. Hence the result is not significant at
p<0.05 There is no significant statistical difference
between the two groups in relation to the presence of a
chronic disease.
DISCUSSION
Phlebitis and thrombosis of the lower extremity
superficial veins (i.e., superficial thrombophlebitis) is
generally a benign, self-limited disorder; however, when
the larger axial veins are involved (i.e., superficial vein
thrombosis SVT), propagation into the deep vein system
(i.e., deep vein thrombosis DVT) and even pulmonary
embolism can occur.5,6
The results of our study showed the incidence of phlebitis
to be 6.4% which is higher than the rate suggested by the
CDC (5%).7 It is close to the results obtained by Arias-
Fernandez et al, (5.6%) and is significantly higher than
the results obtained by Webster et al (1.8%) and in the
study by Urbanetto et al (1.25%).8-10 Higher values were
also obtained in the study by Atay et al (31.8%), the
study by Karadag and Gorgulu (36.5%), by Karadeniz et
al (67.2%), by Cicolini et al (15.4%), and in the study by
Oliveira et al (11.9%).11-15
There was no direct relationship identified between the
gender of the cases and development of phlebitis. This is
contradictory to the results obtained by Nyika et al, where
the male gender has been demonstrated as a risk factor
for development of phlebitis.16 A point prevalence study
by Washington, Georgita et al however showed the
female gender to be a risk factor.17 Similar to the results
obtained by Abolfotouh et al.18
In a study done previously to calculate the incidence of 8
signs (swelling, erythema, leakage, palpable venous cord,
purulent discharge, and warmth) and symptoms (pain and
tenderness) used for the diagnosis of phlebitis with
peripheral intravenous catheters, or short peripheral
catheters, and the level of correlation between them., it
was found that most signs and symptoms of phlebitis
occurred only occasionally or rarely; the incidence of
tenderness was highest (5.7%). Correlations were mostly
low; warmth correlated strongly with tenderness,
swelling, and erythema.19
If the patient has a history of deep vein thrombosis, then
the risk of upper extremity thrombosis due to
catheterization increases.20 It has also been noted that
many congenital or acquired pro-thrombotic states have
been associated with increased risk for catheter induced
venous thrombosis.21 Malignancies have also been
proposed as a potential cause of thrombophlebitis in
catheterized patients.22
Previous studies done on the subject of incidence and risk
factors for phlebitis has shown that the clinical
assessment of phlebitis in patients poses a lot of difficulty
due to the low agreement with phlebitis diagnosis.8 A
study published in 2001 described the incidence of
phlebitis in patients who were undergoing peripheral
intravenous therapy. The result of the study demonstrated
that 10 cases developed phlebitis within 72 hours. And in
3 cases, even though infusion site was clear at the time of
catheter removal, post infusion phlebitis still developed
within 24 hours.23
Atay et al in an independent prospective observational
study have demonstrated that phlebitis was observed in
31.8% individuals receiving peripheral IV therapy, and a
large number of them (79.2%) were identified to be level
I phlebitis. In addition, in our study, while no relationship
was found between the development of phlebitis and the
age, site of IV catheter, catheter number, and use of
antibiotics, there was a significant relationship between
the presence of chronic disease, duration of
catheterization and type of fluid used and the
development of phlebitis. This study in many ways is
similar to the one conducted in Zimbabwe as mentioned
previously.10
0
5
10
15
20
25
30
35
40
Number of cases

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Majority of the cases in our study were diagnosed with
level 1 phlebitis (64.15%) which is similar to the results
obtained by Cicolini et al, (94.4%) and by Atay et al,
(79.2%) in their respective studies.12,15 Although, as per
the study done by Nyika et al, the most common stage
diagnosed was level 4, and as per the study by Urbanetto
et al the most common stage was grade 3 in patients of
post-infusion phlebitis and grade 2 in patients having
phlebitis with catheter in place.10,16
In our study, there was no statistically significant
difference between the groups in relation to whether the
vein was visible at the time of catheter insertion, or
whether the IV catheterization was successful in first
attempt or not. Thus, we can establish that neither of
these variables are risk factors for the development of
phlebitis. Also, no significant risk was identified in those
patients in whom the intravenous catheter was not flushed
after insertion. The study results however, obtained by
Nyika et al, show that 72.7% patients in whom catheters
were never flushed had developed thrombophlebitis.16
The no. of days of catheter dwell time was not a
significant risk factor for the development of phlebitis in
our study. Catney et al, in their study concluded that the
dwell time of catheters can be extended beyond 72 hours
under certain conditions.24 Ansel, Brenda and Boyce et al,
recommend keeping the IV Catheters in situ until a
clinical reason warrants their removal.26 Homer et al, in
their study also deduced that restarting the catheters after
72 hours instead of simply continuing the original
catheter does reduce the risk of development of phlebitis
within the next 24 hours.26 The CDC recommends
changing the peripheral IV catheters every 72-96 hours to
reduce the risk of catheter related infection and
phlebitis.27
A related study to this tried to assess whether the
indwelling time has any correlation to the development of
phlebitis and described that drug irritation was the most
significant predictor of phlebitis and infiltration rates in
this study. The total difference in the estimated failure
rates for the catheter lasting 6 days versus a new catheter
inserted for another 3 days is 1.3%. Because the
conditional failure probability estimates for days 4, 5, and
6 are slightly higher than for days 1, 2, and 3,
consideration may be given to extending the dwell time
of a peripheral IV catheter beyond 72 hours under certain
circumstances.24
It was found that the number of times the peripheral IV
catheter was changed since admission was itself a risk
factor for development of superficial thrombophlebitis.
This finding is also in accordance with similar results
obtained by Nyika et al, in their study.16 Maki et al have
described phlebitis with a previous catheter as having a
relative risk of 1.54 for the development of phlebitis in
the future.27
There was no significant association between the
development of phlebitis and the time for which the
catheter was empty after the infusion of the drug or fluid
had stopped had stopped. Nyika et al, in their study, have
reported that continuous infusion was a positive risk
factor for the development of phlebitis.16
The size of the catheter is a risk factor since for a similar
sized vein, a large diameter centrally placed catheter will
pose a greater risk than a smaller diameter catheter.26 In
our study, cannula size was not been identified as a
positive risk factor for the development of phlebitis. This
is similar to the findings of Zavareh et al and the result of
the metanalysis by Chang et al.26,24 In the study by
Webster and Marsh et al, it was found that 22-gauge
catheters are a positive risk factor for the development of
phlebitis (HR, 1.43; 95% CI, 1.02-2.00).9 Similarly,
Nyika et al, have identified 18-gauge catheters as risk
factors for development of phlebitis (75%).16 Singh et al,
have identified 20 gauge catheter as a relative risk and
Tripathi et al have estimated increased complications
being associated with 24-gauge catheters.30,31
Another factor is catheter infection, which may occur
directly from the patient’s flora or a remote site.32 Using
sterile techniques while inserting and timely removal of
indwelling catheters can reduce the incidence of catheter
related infections.33
A meta-analysis and systematic review by Chang et al
has tried to show the influence of catheterization site,
gauge and duration of infusion on the development of
phlebitis. This showed no statistical difference between
the use of catheters of gauges less than or more than 20.
There was no statistical difference between the
occurrence of phlebitis at catheters inserted in the
antecubital fossa and catheters inserted at other sites on
the upper limb. There was also no statistical difference in
the development of phlebitis in the catheters inserted for
more than 96 hours and those inserted for 96 hours or
less. The last statement contradicts the study mentioned
previously where catheter failure rates were higher in
those with indwelling time over 72 hours.25
The closest study compared to ours in recent years was
one conducted in Zimbabwe, which was a descriptive
one, conducted on 46 adult inpatients to check for the
incidence of phlebitis using a systematic random sample.
The visual infusion phlebitis score was used for
assessment. It was found that most participants came
under the classification of stage 4 phlebitis. Other risk
factors identified included the male gender,
immunosuppression, number of catheters inserted, site of
catheterization, and catheter dwell time, catheter gauge,
and securement, regularity of flushing and continuous
infusion.16
Other factors that are culprits for thrombophlebitis,
include chemical irritation from infused drugs as well as
the catheter material. Some common causes include

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potassium chloride, antibiotics such oxacillin and
vancomycin, some chemotherapeutic drugs, and
hypotonic (<250 mosmol/kg) or hypertonic solutions
(>350mosmol/kg).34
The administration of KCL has long been associated with
the potential risk of causing thrombophlebitis.35-36 In our
study, there is a statistically significant association
between the infusion of KCL through the peripheral
intravenous catheter and the development of phlebitis.
Ervin Susan in her study demonstrated a positive
association between the administration of KCL and the
development of phlebitis.35 The reason for this could be
the fact that potassium chloride is an irritant to the
endothelium, which may cause damage to the cells of the
endothelial lining and make them prone to inflammation
and subsequent thrombophlebitis. Dragana et al in their
survey also obtained similar results.36
In our study, there was a statistically significant
difference with the administration of piperacillin and
tazobactam through the peripheral IV catheter. Infusion
of medication has been documented as a potential cause
of development of thrombophlebitis in multiple
studies.9,18,24,30,36 Among these, beta lactams, especially
benzyl-penicillin and flu-cloxacillin have been noted in
previous studies as risk factors.36,39 Thus, it is not
surprising to find piperacillin as another irritant
medication in our study as a significant risk factor. The
reason behind this could be the fact that the drug itself
behaving as an irritant, has a mechanism of irritating the
endothelial lining, similar to potassium chloride.
There was no statistically significant difference to the
development of phlebitis between the comparison groups
in relation to the presence of chronic disease. The results
obtained by Atay et al show that the presence of chronic
disease has a statistically significant correlation to
phlebitis.11 Zavareh et al in their study have shown
diabetes mellitus as a relative risk factor.26
It was also observed that after the development of
phlebitis, while 22 patients were either given ice pack,
heparinoid ointment or both, more than half (31) patients
were not given any remedial measure. This might be a
crude indicator of the quality of healthcare that is being
administered at the institution.
Newer modalities for management of thrombophlebitis
such as use of notoginseny have been studied, but the
results are not conclusive enough to recommend it as a
standard for management without further evidence.37
Experimental studies have been carried out in animal
models testing the effectiveness of newer methods such
as Mirabilite and Chinese medicine treatment, but
without conclusive human trials, the prospect remains
unexplored and enigmatic.38,39
CONCLUSION
Based on our study results, we can say that post-injection
thrombophlebitis affects patients regardless of the age,
sex and diagnosis. Most cases are level 1 or level 2
according to VIPS grading system. While no relationship
was found between the visibility of vein at the time of
insertion of the catheter, whether inserted in first attempt
or not, whether flushed or not, time for which catheter
was left empty after infusion, dwell time, cannula size
and the presence of a chronic disease, in relation to the
development of phlebitis, significant association was
noted between the number of times the catheter was
changed since admission and administration of potassium
chloride and certain medications such as piperacillin
through the cannula.
Through this study, we were also able to estimate the
standard of healthcare that is being offered at our
institution. The fact that more than half the patients were
not offered any remedy for alleviating their symptoms
suggests a big lapse in the quality of nursing that is being
provided at our hospital.
Since the incidence rate is above the recommended rate
by CDC, we can try using certain preventive measures
such as removing peripheral catheters after 72 hours
electively as suggested by the CDC, to avoid post-
injection thrombophlebitis. KCl and Antibiotics should
be diluted appropriately and infused at a slower rate, or
whenever possible, given through a centrally placed IV
catheter. There needs to be an institutional management
algorithm to tackle this problem, so that appropriate
treatment is provided to each case of phlebitis and
thereby future complications can be avoided. Nurses need
to be further sensitized to this problem, since in a south
Asian country like India, complexion may lead to a
misdiagnosis on the visual infusion phlebitis scale, and
thrombophlebitis may be missed, and at the same time
heavy patient load in the in-patient department may
further numb the nursing staff to their distress.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: The study was approved by the
institutional ethics committee
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Cite this article as: Rai P, Thati V, Ghag G, Nandu
V. Post-injection thrombophlebitis in patients
undergoing peripheral IV catheterization in a tertiary
care hospital: incidence and risk factors. Int J Sci Rep
2020;6(4):154-62.