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(Chest. 1999;115:1576-1580.)
© 1999 American College of Chest Physicians

Infusion Phlebitis in Patients With Acute Pneumonia*

A Prospective Study

Manuel Monreal , MD; Francisco Quilez , RN; Celestino Rey-Joly , MD; Soledad Rodriguez , RN; Nieves Sopena , MD; Carmen Neira , RN and Josep Roca , MD

* From the Servicio de Medicina Interna, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain.


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Study objectives: To prospectively assess the relative risk for phlebitis in a series of consecutive patients with pneumonia and to identify risk factors that predict an increased risk for phlebitis.

Setting: Internal medicine department of a tertiary teaching hospital.

Patients: Seven hundred sixty-six consecutive patients with acute pneumonia receiving IV therapy.

Interventions: Only the first catheter was taken into account. There were 308 short lines (a 51-mm, 18-gauge Teflon catheter); 307 midsized lines (a 28-cm, 16-gauge polyvinyl chloride catheter); and 151 long lines (71-cm, 14-gauge plain polyurethane catheter). Eighteen variables were prospectively evaluated in an open, nonrandomized study for their contribution to the occurrence of phlebitis.

Results: The overall phlebitis rate was 39%. Phlebitis developed in 53% of patients with short lines, in 41% of patients with midsized lines, and in 10% of patients with long lines, and these catheters remained in place an average (± SD) of 3.0 ± 2.4 days, 4.6 ± 3.4 days, and 7.8 ± 6.6 days, respectively. The variables that influenced the development of phlebitis, as determined by multivariate analysis, were the following: type of catheter; blood hemoglobin levels; and IV therapy with either corticosteroids or erythromycin.

Conclusions: According to our data, when the use of a catheter is expected to be required for <= 36 h, a short line can be used. If a longer duration is expected, a longer line is warranted. Ours is the first study in which the relationship between blood hemoglobin levels and phlebitis has been reported. Because the use of intravascular devices is increasingly common, a more complete knowledge of the factors that influence their acceptance has become essential.

Key Words: catheter • hemoglobin • pathophysiology • phlebitis • pneumonia • prediction


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Patients with acute pneumonia often require IV antibiotics, usually for at least 4 days. Infusion phlebitis, defined as the inflammation of a cannulated vein, is a common cause of pain and discomfort in these patients. Studies over the past 2 decades have shown that 20 to 70% of patients receiving peripheral IV therapy develop phlebitis.1 ,2 ,3 ,4 ,5 ,6

Many factors have been implicated in the genesis of phlebitis. These can be divided into chemical factors, such as irritant drugs and fluids, and physical factors, such as catheter material and the site and duration of cannulation. Nevertheless, a review of the literature shows great differences among authors in the perceived relative importance of these factors. The widely varying results reflect differences in patient population and in the methods for and the duration of cannulation. Furthermore, most of these studies have major limitations, such as small study samples, heterogeneous populations, the assessment of few risk factors, and incomplete statistical analyses. We designed a prospective study to examine the relative roles of a number of potential factors in the etiology of phlebitis in a large series of consecutive patients with acute pneumonia.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Catheters
Patients with acute pneumonia scheduled to have a peripheral IV catheter inserted for routine antibiotic therapy received the following types of catheters: (1) short lines using 51-mm, 18-gauge Teflon catheters (Abbocath-T; Abbott Laboratories; Montreal, Canada); (2) midsized lines using 28-cm, 16-gauge polyvinyl chloride catheters (Venocath-16; Abbott Laboratories); or (3) long lines using 71-cm, 14-gauge plain polyurethane catheters (Drucafix-Splittocan; Braun Palex; Melsungen, Germany). The study was carried out over 3 years in a 56-bed department of internal medicine in a university hospital. The approval of the Institutional Committee on Clinical Investigation was given, and, although individual consent was not required, an information sheet was given to all patients.

Definitions
The diagnosis of pneumonia was based on the presence of a pulmonary infiltrate observed on a roentgenogram plus at least two of the following three signs and symptoms: (1) a temperature > 37.81°C; (2) new onset of cough or increase in cough and sputum production in patients with COPD; and (3) a WBC count > 10 x 109/L or < 4 x 109/L.

Extravasation was defined as the exuding of fluid into subcutaneous tissues without resulting warmth, induration, or erythema. Infusion phlebitis was defined as the presence of a palpable cord or the presence of at least two of the following physical changes that occur at distances > 3 cm from the catheter insertion site along the course of a vein: warmth, erythema, tenderness, and induration. Plugging was defined as catheter dysfunction that requires removal of the catheter but without any of the other listed complications. Colonization of the catheter was defined as a positive result of a semiquantitative culture taken from the catheter (> 15 colony-forming units).

Methods
Prior to insertion of the catheter, blood was drawn for blood counts. The choice of IV site for each patient was at the discretion of the physician and/or the nurse, as was the choice of a short, midsized, or long line. The insertion technique was standardized, and the same personnel placed all three types of lines. The skin was prepared with povidone-iodine. The catheter was inserted percutaneously without prior skin incision. The insertion site was covered with an adhesive dressing (Oper Por; Iberhospitex S.A.; Barcelona, Spain), and adhesive tape was applied to anchor the tubing of the giving set. The catheters were subsequently handled according to the normal practice of the attending medical and nursing staff. Each patient was seen daily by a member of the research team. The patient was questioned about pain at the insertion site, and the site was palpated. Catheters were removed when they were blocked and no longer functional, when they were causing distress, or when the patient was discharged. At the time of removal, the nursing staff was asked to record the reason for and time of removal. Colony counts were performed on the primary plates, and all organisms were identified by standard methods.

Study Design
The study was done to determine the relative risk for phlebitis with three different types of peripherally inserted catheters and to identify risk factors that predict an increased risk for phlebitis. Only the patient's first catheter was taken into account. The data collected at the time of insertion included details about the patient (age, gender, and associated diseases), data about the catheter (type of catheter and time of cannulation), data about the infusate (antibiotics, bronchodilators, or corticosteroids), and data about components of the blood (blood cells). IV antibiotic therapy consisted mainly of erythromycin and cephalosporins. Both drugs have been shown to increase the incidence of phlebitis.3 ,7 ,8

For categoric data, such as gender or presence of diabetes, the significance of differences was determined using the {chi}2 test or the Fisher Exact Test, and, for continuous data such as the patient's age or hemoglobin levels, significance was determined with the Student's t test. To assess which risk factors predicted the occurrence of phlebitis, variables were evaluated using the proportional hazards model.9 This was done with the aid of a specific statistical package (EGRET; Statistics, and Epidemiology Research Corporation, and Cytel Software Corporation; Seattle, WA).10


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Study Population
At the conclusion of the predetermined study period, a total of 766 patients had been included. There were 548 men and 218 women aged 15 to 98 years (mean age, 55 years). As previously noted, only the first catheter for a patient was studied. There were 308 patients with short lines (40%), 307 patients with midsized lines (40%), and 151 patients with long lines (20%). Patients with short lines were significantly older, and the use of IV drugs was not homogeneous among groups (Table 1 ).


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  		Table 1. Clinical Characteristics of Patients Entering in the Study

 
Complications of Catheter Use
Overall, phlebitis was the most common cause of catheter removal. Phlebitis was diagnosed in 300 of 766 patients (39%), as shown in Table 2 . The overall phlebitis rate was 53% in patients with short lines, 41% in those with a midsized lines (odds ratio [OR], 1.61; 95% confidence interval [CI], 1.16 to 2.25; p < 0.005), and 10% in patients with long lines (OR, 14.31; 95% CI, 7.19 to 29.15; p < 0.001). Catheters remained in place an average (± SD) of 3.0 ± 2.4 days in patients with short lines, 4.6 ± 3.4 days in patients with midsized lines (p < 0.001), and 7.8± 6.6 days in patients with long lines (p < 0.001). Most patients who developed phlebitis required the insertion of an additional catheter: 142 of 163 patients (87%) with short lines; 98 of 126 patients (78%) with midsized lines; and 8 of 11 patients (72%) with long lines.


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  		Table 2. Causes of Removal of the Catheter*

 
The extravasation rate was also significantly higher in patients with short lines compared to those with midsized lines (11% vs 6%, respectively [OR, 2.06; 95% CI, 1.10 to 3.88; p = 0.02]), while extravasation did not develop in patients with long lines (see also Table 2 ). Plugging occurred with equal frequency in patients with short and midsized lines but was rare in patients with long lines. Finally, subclavian venous thrombosis developed in three patients with long lines, and in one patient with a short line. The incidence of local colonization of the catheter was low and was comparable in the three catheter groups: 6.5% in patients with short lines; 5.1% in patients with midsized lines; and 7.9% in patients with long lines. None of the catheters studied was considered to have caused bacteremia.

Risk Factors for Phlebitis
The univariate analysis showed that the risk of phlebitis was inversely correlated to the length of the catheter but that risk increased with rising hemoglobin levels (Table 3 ). Furthermore, the phlebitis rate was significantly lower in HIV-infected patients as well as in patients receiving IV corticosteroids.


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  		Table 3. Influence of Several Variables on the Development of Phlebitis*

 
The multivariate analysis confirmed the influence of the catheter type. The hazard ratio of phlebitis developing in patients with midsized lines was 0.382 compared to those with short lines, and the hazard ratio in patients with long lines was 0.042 (Table 4 ). The influence of hemoglobin levels was also confirmed: the hazard ratio of phlebitis developing in patients in the third quartile (12.5 to 13.9 g/dL) was 1.814 compared to those in the first quartile (< 10.5 g/dL). The hazard ratio of phlebitis developing in patients in the fourth quartile (> 13.9 g/dL) was 2.295. By contrast, HIV-infected patients were no longer at a lower risk, probably because of hemoglobin levels being low in these patients. Finally, the risk of phlebitis significantly decreased in patients receiving IV corticosteroids (hazard ratio, 0.465) but increased in those receiving erythromycin (hazard ratio, 1.535), as shown in Table 4 .


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  		Table 4. Influence of Several Variables on the Development of Phlebitis*

 

   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
The most common complication of IV therapy is phlebitis, which leads to much patient discomfort and requires the removal of the catheter, the insertion of a new catheter in a different site, and, often, local treatment and analgesic drugs. During prolonged hospitalization, repeated episodes of phlebitis can lead to difficulties with venous access and may result in more invasive procedures, such as central venous catheter placements or cutdowns, being performed.

It is now well established that the etiology of phlebitis is multifactorial. Several years ago, phlebitis was believed to be caused primarily by irritant infusion.11 ,12 ,13 ,14 Consequently, prophylaxis was instituted by using short cannulation times, adding buffers, and using in-line membrane filters to remove microparticulate components present in the infusion fluids. Some years later, the role of the catheter material in the pathogenesis of phlebitis was demonstrated,3 ,15 ,16 ,17 ,18 ,19 and efforts were directed to achieve more flexible and less adherent catheters. Nevertheless, no studies concerning the influence of blood components on the development of phlebitis have been undertaken.

First, we agree with most authors that long lines produce much lower rates of phlebitis and longer durations of cannulation, whereas short lines have to be removed more often because of phlebitis.4 ,5 ,20 Short IV catheters are the mainstay of IV therapy: they are easy for students, residents, and IV team personnel to insert and are relatively inexpensive. But our data suggest that for therapy that is expected to last > 36 h midsized lines are preferred. Percutaneously inserted central catheters are costly, require the use of fluoroscopy or angiography, are associated with additional complications such as deep venous thrombosis (three episodes in our series), and have the potential risk of local or systemic infection.

Second, we also confirm that the administration of IV antibiotics substantially increases the risk for phlebitis.3 ,7 ,8 In agreement with other studies,21 ,22 ,23 we found that adding corticosteroids to the infusate reduces the risk for phlebitis. Interestingly, despite a lower frequency of phlebitis with the midsized and long lines, there was a higher frequency of the use of antibiotics, which are known to be irritants, and a lower frequency of the use of steroids, which are possibly protective agents. This situation can probably be explained by the fact that most physicians prefer to insert long lines in those patients who will receive certain drugs.

However, our most striking finding was the relationship between higher hemoglobin levels and the risk for phlebitis. This is the first study in which such an association has been reported. The mechanism of catheter-related phlebitis is not well understood and may include vessel damage, rheologic abnormalities, and local activation of coagulation.24 ,25 ,26 ,27 We hypothesize that, by lowering the flow of blood in veins, a high hematocrit would reduce the dilution of irritant infusates and, thereby, predispose patients to phlebitis. However, it must be demonstrated whether there is a causative relationship between the two conditions or whether this relationship is just an epiphenomenon. Further studies are needed to confirm the influence of hematocrit on phlebitis development, which may lead to a better understanding of the pathogenesis of such a common complication. Because the use of intravascular devices is increasingly common, a more complete knowledge of the factors that influence their acceptance has become essential.


   Footnotes
 
Correspondence to: Manuel Monreal, MD, Servicio de Medicina Interna, Hospital Universitari Germans Trias i Pujol, 08916 Barcelona, Spain; e-mail: mmonreal@ns.hugtip.scs.es

Abbreviations: CI = confidence interval; OR = odds ratio

Received for publication July 30, 1998. Accepted for publication January 28, 1999.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Tully, JL, Friedland, GH, Baldini, LM, et al (1981) Complications of intravenous therapy with steel needles and Teflon catheters: a comparative study. Am J Med 70,702-706[CrossRef][ISI][Medline]
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  11. Bivins, AB, Raap, PR, De Luca, PP, et al (1979) Final in-line filtration: a mean of decreasing of infusion phlebitis. Surgery 85,280-284
  12. Tager, IB, Ginsberg, MB, Ellis, SE, et al (1983) An epidemiologic study of the risks associated with peripheral intravenous catheters. Am J Epidemiol 118,839-851[Abstract/Free Full Text]
  13. Falchue, HK, Peterson, L, McNeil, JB (1985) Microparticulate-induced phlebitis: its prevention by in-line filtration. N Engl J Med 312,78-82[Abstract]
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