Phlebitis is medical term which means veins’ inflammation. The two types of phlebitis have been discovered:
superficial phlebitis and deep vein thrombosis(DVT). Superficial phlebitis occurs in superficial veins under the skin and mainly in peripheral veins of the extremities, while DVT is inflammation happens due to clotting in deep veins and mainly in central veins (1). Superficial phlebitis is one of the complication of the peripheral venous cannulation for infusion, which is procedure done in the hospitals to establish a venous access for delivering the medications. In 1993 study of intravenous infusion related phlebitis was done on thirty-five hospitals and 6,256 infusion sites data were obtained (2). The results were around thirty four percent of complications of infusion occurred, and approximately six percent of the complications were phlebitis despite good nursing care and insertion techniques (2). Other study was conducted in hospital in the western Brazilian Amazon about peripheral intravenous catheter phlebitis on 122 sample and the results were: around sixty seven percent complication from peripheral intravenous catheter, and 31.1 percent were phlebitis (3). Moreover, according to Nursing Practice Review Phlebitis article, patients who were on peripheral venous cannulation 20%-80% of them had incidence of phlebitis (4). Types of peripherally intravenous delivering medications are 1- peripheral cannulas, 2- peripherally inserted central catheter (PICC) and 3-peripheral midline catheter (4). The types are used according to the period of intravenous treatment and types of medications administered (4). Furthermore, for short period of treatment peripheral cannula is indicated while in central cannula is used for long term treatment and for hyperosmolar, cytotoxic and extreme acidic/basic solutions (4).
Sign and symptoms of superficial phlebitis’s is developing from erythema to palpable cored, pain, streak formation and/or purulent discharge, and the sign and symptoms are graded from 0-4:0 has no clinical signs and if symptoms to 4 has more progressive symptoms Tablet number 1 (4-5).
Tablet number 1
Phlebitis caused by Peripheral venous cannulation increases with present of risk factors that are related to patient, duration of infusion and cannula (6). Risk factors related to patients are 1-age: as age increase the risk of having phlebitis in increases and 2- female gender (6). A study has been conducted about incidence and of phlebitis from peripheral intravenous cannula in surgery department in Divino Espirito Santo Hospital use Chi-squareed test showed 63.6% from 55 patients with age of more than or equal 60 had phlebitis, and female gender who had phlebitis were 66.9% while males were 56% (7). However, the p values of age and gender is 0.3 and 0.06 which is clinically insignificant (7). Other patients related risk factor’s p value from the same previous study is having underlying disease like diabetes with p value of 0.003 and smoking with p value of 0.03, and both are clinically significant (6-7). Duration of treatment by peripheral venous cannula is also considered as risk factor for iv infusion phlebitis. Recommendation by Centers for disease control (CDC) guideline suggests no more four days (approximately 96h) peripheral IV catheter should be use in the same site, and the site should be changed every three to four days (72-96 h) (8). Material of cannula made of is also a risk factor increase phlebitis incidence. Maki and Ringer obtained a result from study of phlebitis cases after using Vialone was 30% lesser than after using Teflone (8-9-10). In addition, in 2002 Tagalakis study showed 30- 45% decrease in phlebitis cases after using polyurethen comparing with Teflon (10).Moreover, the gauge or size of catheter is risk factor as decreased the gauge number (increased diameter) the risk of phlebitis increases, and in the surgery department in Divino Espirito Santo Hospital study was clinically significant with p value of 0.031 with sample size of 286 (7). Choosing the inappropriate Site of cannula insertion can increase the risk of phlebitis incidence. An anatomic site that associated with high incidence of phlebitis was obtained from the study was done in surgery department in Divino Espirito Santo. Patients with the cannula in antecubital fossa have around 80% phlebitis higher than other sites such as wrist with 53% and forearms with 57% cases of phlebitis (7).
Types of phlebitis can be classified in to three categories according to its etiology:1- mechanical phlebitis, 2-bacterial phlebitis and 3-chmical phlebitis (4). Mechanical phlebitis occurs when there are frictions between the catheter or cannula and vein’s wall (4). The frictions increase when placing the cannula in highly movable places near to the joints, and using large size cannula (4). Bacterial phlebitis happens when there is contaminated cannula or poor hygiene practice, and it will develop to systemic sepsis (4). Chemical phlebitis is related to the medications physicochemical characteristics that are infused Ex. extremely high or low PHs and high osmolarity . The most common medications that cause phlebitis are antibiotics mainly levofloxacine & azithromycine and potassium chloride due to their lower PH and rapid administration (10). Amiodarone in a study showed forty percent of the sample have induced phlebitis because of rapid administration and, dose volume and its acidic nature (11). TPN with high osmolarity have high risk of casing chemical phlebitis (4). There are many other medications that are believed to cause phlebitis however there are not enough studies on them. Therefore, our aim in this research is to find out which medications are causing phlebitis.