http://doi.org/10.33698/NRF0129 – Prabhjot Kaur,Ramesh Thkayr ,Sukhpal Kaur,Ashish Bhalla
Abstract :Among hospitalized patients, intravenous therapy is the most common invasive procedure and is associated with phlebitis rate of between 2.3% and 60%. The current study was carried out to assess the risk factors leading to phlebitis amongst the peripheral intravenous cannulated patients. The study was conducted in Emergency Out Patient Department of a tertiary care hospital. Using consecutive sampling technique, 200 patients were studied who were scheduled for intravenous cannulation. The various risk factors studied were age, sex, size of cannula, site of insertion, hand washing and use of gloves etc. The IV site was studied prospectively for the presence and absence of phlebitis till the cannula remained in situ. Visual Infusion Phlebitis Scale was used to assess the grade of phlebitis. Approval to conduct the study was sought from the Ethics Review Committee of the Institute. Mean age (yrs) ± SD of the subjects was 41.37yrs ±15.81 with range of 18-87. 70% were male. Mean duration of cannula in situ was 2.66 days±0.75. Out of total 200 subjects 113(56.5%) developed phlebitis. There was significant relationship between the phlebitis and duration of cannula in situ, administration of antibiotics and electrolytes (c2 =21.74, 6.96, 14.18, p<0.01) respectively.
Key words :
Peripheral Intravenous Cannulation, Risk Factors, Phlebitis.
Correspondence at : Prabhjot Kaur
B12/32, Street No. 2
Cinema Road, Batala, Punjab.
Introduction
Intravenous (IV) devices are an important and common aspect of hospital practice for the administration of medications, nutrients, fluids, blood products and to monitor the hemodynamic status of a person1. Phlebitis is one of the common complications of IV therapy. Among hospitalized patients, 5% to 70% of patients receiving IV therapy develop phlebitis.2 Phlebitis refers to the subjective clinical manifestation at an access site with two of the following symptoms: redness, pain, swelling, palpable venous cord, thrombosis or streak formation. It can lead to infection or thrombus formation. Symptoms develop over hours to days and resolve in days to weeks.3
There are three different types of phlebitis including mechanical, chemical and infectious. Mechanical phlebitis occurs when a peripheral intravenous catheter is not secured properly, leading the catheter to change position within the vein.4 Chemical phlebitis is caused by highly vesicant irritants such as drugs. Drug irritation was indicated as the most significant predictor of phlebitis such as antibiotics, blood products, and glucose containing fluids.5,6
Infectious or bacterial phlebitis is caused when an infectious agent is introduced into the peripheral intravenous catheter. Infectious phlebitis can be caused by contamination of the catheter tip anytime during IV insertion. Infectious phlebitis may also occur if a cannula is left in place longer than recommended by the CDC.1,7,8 The center for disease control and prevention (CDC) recommends rotating the intravenous cannula every 72 to 96 hours to reduce the risk of infection and patient discomfor t associated with phlebitis.1
The gauze of the IV catheter has also been identified as another cause of phlebitis. Critically-ill patients require large bore IV catheters for immediate resuscitation efforts and are therefore at higher risk for developing phlebitis.9 Female sex, poor quality peripheral veins, inser tion of cannula in the lower extremity and the presence of underlying medical disease (cancer, immunodeficiency, diabetes mellitus) also increase the risk of peripheral vein infusion phlebitis.7 Other factors may include inexperience of the person inser ting the catheter, inser tion in the emergency room where establishing access quickly is often necessary, and other conditions such as neutropenia, malnutrition, immune-suppression, peripheral neuropathy and care and handling by an expert clinicians. 7,10,11,12
Phlebitis causes pain, sepsis, additional diagnostic investigations and treatments and may lead to the increased duration of hospitalization, patient’s stress level and financial burden as well as increasing staff workload. The current study was carried out to find out the risk factors related to phlebitis associated with peripheral IV catheters.
Materials and Methods
The study was conducted in Emergency medical and surgical Out Patient Department of Nehru hospital, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh. The study population consists of all patients admitted in emergency who require peripheral intravenous cannulation. Total 200 patients were studied by using consecutive sampling technique.
A validated questionnaire was used to collect the data. Information was obtained regarding patient’s identification, demographic profile and co-morbid illness of the patient. Procedure observation sheet was prepared to collect data about the peripheral cannula and practices related to IV cannulation. It includes the items like cannula size, anatomic site of insertion, vein used for cannulation, type of dressing used to secure the cannula, number of attempts, hand washing, use of gloves. It was used at the time of peripheral intravenous cannulation. Continuing care sheet was prepared to record the subsequent observation of the patient related to peripheral cannulation. It includes the items as presence or absence of phlebitis, grade of phlebitis present, temperature of patient, and fluids and medication given during follow up. The subjects were daily assessed for the presence and absence of phlebitis
Standardized Visual Infusion Phlebitis Scale developed by Andrew Jackson (1998) was used to assess the grade of phlebitis.13 The score range from 0 indicating no symptoms of phlebitis to 5 with signs of purulent drainage, redness, and a palpable cord greater than 3 inches. All peripheral intravenous cannulae were assessed for the presence of severity of phlebitis as per the visual infusion phlebitis scale on subsequent visits till the cannula remained in situ. A pilot study was conducted to assess the feasibility of the study and relevant modifications were made. Approval to conduct the study was sought from the Ethics Review Committee of the Institute. An informed written consent was obtained from each patient. Peripheral intravenous cannulation was done as per the
procedure protocol. Procedure observation sheet was introduced at the time of peripheral intravenous cannulation. The peripheral IV cannulation was done by the staff nurses of emergency ward according to the procedure protocol. The continuing care sheet was filled during the follow up period for the presence and absence of phlebitis and fluid and medications given to the patients. The patient was studied prospectively for the presence and absence of phlebitis. If the peripheral Intravenous cannula was not present then date, time and reason for removal of the cannula was documented and follow up was terminated. The data was analyzed using descriptive and inferential statistics with the help of SPSS version 16.
Results
Total 349 patients were enrolled for the study. 149 study subjects were not studied because of the removal of cannula due to different reasons like insertion of central line, death and LAMA etc. Finally 200 subjects were studied, 115 (57.5%) and 85(42.5%) were from emergency medicine and emergency surgery OPD respectively. Among them only 113 (56.5%) developed phlibitis.
Demographic profile of the subjects
The subjects were in the range of 18 to 87 years with the mean age of 41.37yrs±15. More than half (70%) were male. 50.5% of the subjects were under matric. Majority (81.5%) were married. 55% belonged to rural area. (Table 1)
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Table 1: Demographic data of the subjects N=200
* Mean Age (yrs) ± = 41.37 ± 15.81
Incidence of phlebitis
Fig. 1 shows the incidence of phlebitis amongst the study subjects. Out of 200 study subjects, 113 (56%) developed phlebitis. The various factors were patient’s age, sex, size of cannula, site of insertion, practice of hand washing, and use of gloves, etc
Fig. 1: Incidence of phlebitis among the study subjects
Risk factors of phlebitis amongst the study subjects
Different risk factors related to phlebitis were studied. As per the patient related factors, the incidence of phlebitis was more in the male subjects (57.1%). As per the catheter insertion site related risk factors it was observed that phlibitis was more in the patients when the catheter was inserted in the vein of wrist (76.2%) as compared to veins of hand (52.7%) asn fore arm (41.5%). Duration of catherter in situ was directly proportional to the development of phlebitis and this different was statistically significant (P<0.01). Hand washing, use of gloves and the securement device used to fix the canula did not have any significant impact on the development of phlebitis.
Table 2: Risk factors of phlebitis amongst the study subjects N=200
| Patient specific factors | Presence of
n(%) |
phlebitis | c 2, df p-value | |
| Age (yrs)
<20 years (n=20) |
10(50.0) | 1.36, 3 | ||
| 21-40 years (n=93) | 54(58.7) | 0.72 | ||
| 41-60 years (n=64) | 38(59.4) | |||
| 60+ (n=23) | 11(47.8) | |||
| Sex | ||||
| Male | (n=140) | 80(57.1) | 0.08,1 | |
| Female | (n=60) | 33(55.0) | 0.78 | |
| Catheter specific factors Catheter site | ||||
| Forearm | (n=118) | 49(41.5) | 2.09,2 | |
| Hand | (n=91) | 48(52.7) | 0.35 | |
| Wrist | (n=21) | 16(76.2) | ||
| Catheter size
16 G |
(n=7) |
3(42.9) |
2.69, 3 |
|
| 18 G | (n=79) | 42(53.2) | 0.441 | |
| 20 G | (n=112) | 66(58.9) | ||
| 22 G | (n=2) | 2(100.0) | ||
| Duration of catheter | ||||
| £2 days | (n=85) | 32(37.6) | 21.74,2 | |
| 3 to 4 days | (n=91) | 60(65.9) | 0.00* | |
| >4 days | (n=25) | 21(84.0) | ||
| Others’
Hand washing |
||||
| Done | (n=9) | 5(55.5) | 0.003, 1 | |
| Not done | (n=191) | 108(56.5) | 0.95 | |
| Use of gloves
Yes |
(n=169) |
95(56.2) |
0.037, 1 |
|
| No | (n=31) | 18(58.1) | 0.85 | |
| Securement device | ||||
| Leucoplast | (n=34) | 22(64.7) | 3.66, 2 | |
| Dynaplast | (n=140) | 80(57.1) | 0.30 | |
| Paper tape | (n=26) | 11(42.3) | ||
*statistically significant
Development of phlebitis as per administration of fluids and medications:
The patients with peripheral IV cannula were studied prospectively for the fluids and medications administered through the cannula. Out of the total 113 subjects who developed phlebitis, 77% and 41% of the study subjects had phlebitis where antibiotics and electrolytes were used respectively and was found to be highly significant (p<0.005). 1/3rd of the study subjects had developed phlebitis where three or more other drugs were used like analgesics, antipyretics, diuretics, H2 receptor antagonist, etc. 87.6% of the subjects who received crystalloids developed phlebitis (P>0.05). (Table 3)
Table 3: Development of phlebitis as per administration of fluids and medications
N=113**
| Variable | Presence of
Value |
phlebitis | c 2, df p-value |
| Antibiotics | |||
| Yes | 87(76.9) | 6.97, 1 | |
| No | 26(23.1) | 0.00* | |
| Electrolytes | |||
| Yes | 46(40.7) | 14.18, 1 | |
| No | 67(59.3) | 0.00* | |
| Ionotropes | |||
| Yes | 17(15.0) | 0.40,1 | |
| No | 96(85.0) | 0.53 | |
| Other drugs | |||
| No or 1 drug | 26(23.0) | 1.67, 3 | |
| 2 drugs | 33(29.2) | 0.89 | |
| Three drugs | 37(32.7) | ||
| 4 or more drugs | 17(15.1) | ||
| Crystalloids | |||
| Yes | 99(87.6) | 1.39,1 | |
| No | 14(12.4) | 0.24 | |
| Colloids | |||
| Yes | 15(13.3) | 0.001, 1 | |
| No | 98(86.7) | 0.97 | |
*statistically significant ** Subject who developed phlebitis were taken
Discussion
Among hospitalized patients, intravenous therapy is the most common invasive procedure and is associated with a phlebitis rate of between 2.3% and 60%.14 It is well established that the etiology of phlebitis is multifactorial. The overall phlebitis rate in the study was 56% which was fond to be consistent with the findings of Zamanzadeh V et al15.
The incidence of phlebitis in the present study was more in males as compared to females. This may be due to more number of males in study but Tager et al16 and Cornely et al17 found that gender is not a risk factor whereas Kegel et al12 Maki ringer7 and Nassaji M18 found female gender to be an associated risk factor for the development of these complications. In contrast to other studies4, the incidence of phlebitis in patients > 60 years old was lower than those < 60 years old in both the groups because the inflammatory response in the elderly is often impaired, sign and symptoms of phlebitis may be subtle Moreover, the number of elderly was significantly less compared to adult population.
The various practices related to peripheral intravenous cannulation were studied. In the present study there were almost equal number of subjects who washed their hands or doned gloves before cannulation whereas Hirchmann et al19 had reported that in comparison of simple hand washing, disinfection of hands before the insertion or wearing of gloves resulted in fewer complications related to peripheral venous catheterization.
The catheter specific risk factors studied were cannula size, anatomic site of insertion, vein used for cannulation, catheter site dressing, type of fluid and medications administered through cannula. Large bore catheters generally cause more phlebitis due to greater mechanical irritation. The study results were consistent with the findings of Nassaji ZM18 that didn’t show catheter bore as a risk factor for phlebitis in both the groups. One of the possible reason may be that very large bore catheters were not used in study subjects whereas in contrast to other studies large bore catheters increased the risk of phlebitis. Poor anchorage of cannulae with tape or dressing appears to increase the risk of the development of phlebitis which was inconsistent with the present study findings.
Several factors determine the likelihood of developing phlebitis. Chemical phlebitis occurs due to injury to the vein wall by chemical irritants such as infusion fluids both a low pH and high osmolarity of intravenous fluids and medications are reported to be associated with chemical phlebitis. Additives such as potassium chloride, antibiotics and cytotoxic drugs can produce severe venous inflammation.20,21
In present study findings, cannulae were used for the rapid administration of large number of fluids and drugs but the study didn’t show any significant difference between the administration of antibiotics, electrolytes and ionotropes whereas Catney et al22 reported drug irritation as one of the most important risk factor for the development of phlebitis and infiltration. There was significant difference between the use of combination of IV fluids like 0.9% NS, 5% dextrose, Dextrose NS, etc and additive drugs like analgesics, antipyretics, H2 receptor antagonist etc and phlebitis in between the groups which was found to be consistent with findings of Maki and Ringer.6,7
The present study findings revealed duration of cannula in situ and the administration of antibioitics and electrolytes to be the most common risk factors of phlebitis.
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