What You Need to Know

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WHAT YOU NEED TO KNOW:

What is phlebitis?

Phlebitis is inflammation of the wall of your vein. Inflammation may be caused by damage to or infection of your vein. Phlebitis may occur in a vein in your arm or leg. Symptoms include pain, redness, and swelling near the vein. Symptoms may appear when you are receiving an IV medication, or 48 to 96 hours after you receive the medicine.

What increases my risk for phlebitis?

• An IV catheter placed in a vein in your arm or leg
• IV injections of amiodarone, vancomycin, ciprofloxacin, or chemotherapy medicines
• A condition that affects your blood vessels, such as varicose veins or venous insufficiency
• IV drug abuse

How is phlebitis treated?

Medicines may be given to decrease pain and swelling. Your IV catheter will be removed. Do the following to manage your symptoms:

• Apply a warm compress to your vein. This will help decrease swelling and pain. Wet a washcloth in warm water. Do not use hot water. Apply the warm compress for 10 minutes. Repeat this 4 times each day.
• Elevate your leg or arm above the level of your heart as often as you can. This will help decrease swelling and pain. Prop your leg or arm on pillows or blankets to keep it elevated comfortably.
• Wear pressure stockings if directed. Pressure stockings improve blood flow and help decrease pain and swelling. Pressure stockings can also help decrease your risk for blood clots in your legs. Wear the stockings during the day. Do not wear them overnight when you sleep.
  
• Do not inject illegal drugs. Talk to your healthcare provider if you use IV drugs and need help to quit.

When should I seek immediate care?

• Your leg or arm turns pale or blue.
• Your leg or arm feels hot or cold.
• Your arm or leg feels warm, tender, and painful. It may look swollen and red.

When should I contact my healthcare provider?

• You have a fever.
• You have more pain, swelling, or warmth near your vein.
• Your symptoms do not improve within 72 hours.
• You have questions or concerns about your condition or care.

Care Agreement

You have the right to help plan your care. Learn about your health condition and how it may be treated. Discuss treatment options with your healthcare providers to decide what care you want to receive. You always have the right to refuse treatment. The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.

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Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

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IV Complications – Medical Emergencies and Complications | Module 1: Advanced Pain Control and Sedation

Medical Emergencies and Complications

IV Complications

Complications of gaining I.V. may include infiltration, hematoma, an air embolism, phlebitis, extravascular drug administration, and intraarterial injection. Intraarterial injection is more rare, but as threatening.

Infiltration

Infiltration is the infusion of fluid and/or medication outside the intravascular space, into the surrounding soft tissue. Generally caused by poor placement of a needle or angiocath outside of the vessel lumen. Clinically, you will notice swelling of the soft tissue surrounding the IV, and the skin will feel cool, firm, and pale. Small amounts of IV fluid will have little consequence, but certain medications even in small amounts can be very toxic to the surrounding soft tissue.

Hematoma

A hematoma occurs when there is leakage of blood from the vessel into the surrounding soft tissue. This can occur when an IV angiocatheter passes through more than one wall of a vessel or if pressure is not applied to the IV site when the catheter is removed. A hematoma can be controlled with direct pressure and will resolve over the course of 2 weeks.

Air Embolism

Air embolism occurs as a result of a large volume of air entering the patient’s vein via the I.V. administration set. The I.V. tubing holds about 13 CCs of air, and a patient can generally tolerate up to 1 CC per kilogram of weight of air; small children are at greater risk. Air embolisms are easily prevented by making sure that all the air bubbles are out of the I.V. tubing; fortunately, it is an extremely rare complication.

Phlebitis and Thrombophlebitis

Phlebitis and thrombophlebitis occur more frequently. Phlebitis is inflammation of the vein which occurs due to the pH of the agent being administered during the administration of the I.V, while thrombophlebitis refers to inflammation associated with a thrombus. Both are more common on the dorsum of the hand than on the antecubital facia and may occur especially in hospitalized patients where an I.V. may be in for several days, where use of an angiocatheter, as opposed to a needle, can increase the risk of phlebitis, as the metal needle is less irritating to the endothelium. (Needles are generally used for short term IV access of less than three hours, while angiocaths are used for longer periods of time.) The infusate itself may cause phlebitis and may be irritating to the skin. Older patients are also more susceptible to phlebitis.

Treatment is generally elevating the site, providing warm compresses and administering non-steroidal agents to the patient. Anticoagulants and antibiotics are usually not required.

Extravascular Injection

Extravascular injection of a drug may result in pain, delayed absorption and/or tissue damage (if the pH of the agent being administering is too high or too low). If large volumes have been injected and the skin is raised and looks ischemic, then 1% procaine should be infiltrated. Procaine is a vasodilator, which will improve the blood supply both to the area and improve venous drainage away.

Intraarterial Injection

An intraarterial injection occurs rarely, but is much more critical. The most important measure is prevention, by making sure that the needle is inserted in a vein. Remember that veins are more superficial than arteries. If you cannulate an artery, there should be a pumping of bright red blood back into your angiocath, which would not be seen when you cannulate a vein. Intraarterial injection frequently causes arterial spasm and eventual loss of limb, usually from gangrene.

In the case of intraarterial injection, recognition is paramount; observe the color of the skin, observe capillary refill, and feel the radial pulse. Capillary refill, which is observed by squeezing a fingertip and then watching the red color return, is a reflection of perfusion. If capillary refill is decreased, then perfusion to that extremity is decreased. Treatment: In the case of intraarterial injection, it is the intravenous drugs which pose severe problems, rather than the I.V. solution. Leave the needle in the artery, and slowly inject approximately 10 CCs of one percent procaine. Procaine is a vasodilator. It is slightly acidic, with a pH of 5, and will counter the alkaline drugs that were just administered. Following treatment, the patient must be hospitalized, and may often require a sympathetic nerve block. An endarterectomy and heparinization may also be necessary to prevent further complications.

A Note About Oxygen

The number one emergency drug in the office is not epinephrine, or atropine, or diazepam for patients with seizures it is OXYGEN. Therefore it is important to always be prepared to ventilate the patient with 100% oxygen. Preparation includes knowing where your 100% oxygen source is (should be easily accessible), know that you have an ambubag and knowing how to deliver oxygen via positive pressure in the case of an emergency.

Superficial Vein Phlebitis: Treatment & Complications

Any vein can develop a blood clot.  Blood clots in the deep veins are called deep vein thrombosis, or DVT.  Blood clots in the superficial veins are called superficial vein thrombophlebitis…or SVT.  Commonly, however, it is known simply superficial vein phlebitis.

We are often contacted from patients or their referring physicians for treatment for superficial vein phlebitis.  These most commonly occur in varicose veins in the leg, but any superficial vein can develop a clot.

Clots in the superficial varicose veins of the legs can be a benign and self-limited problem. However, when the blood clot occurs in the larger superficial varicose veins, it can spread into the deep veins of the leg, referred to as a deep vein thrombosis (DVT) and potentially break off and move through the heart to the lungs, called a pulmonary embolism…or PE.  Therefore superficial vein phlebitis is considered a serious medical condition.

Generally the treatment of superficial vein phlebitis is to prevent spread to the deeper veins.  Sometimes this requires a blood thinner.  Patients should be seen by a qualified healthcare provider who can help determine the extent of the clot (usually with Ultrasound), then develop a short and long term treatment plan.

Findings on Physical Exam

Clots in the superficial veins most frequently occur in the legs in association with varicose veins. When a blood clot occurs in the arm, it is general associated with an IV placement.

Phlebitis refers to acute inflammation of the vein, and thrombo- refers to a clot in the vein. Clot itself is highly inflammatory.

When a person has superficial vein phlebitis, they will often have pain, tenderness, redness and what feels like a cord under the skin. This can be quite painful. This can look like an infection, although most are not infected with bacteria.  It can also look like a deep vein thrombosis.

Ninety percent of cases of phlebitis occur in people with pre-existing varicose veins. When varicose veins are not present, and the patient has not had a recent IV, then medical causes can be considered as well.

Clinical Course and Complications of Superficial Vein Phlebitis

Most clinical presentations are uncomplicated with typical findings of tenderness, firm skin, pain, and redness along the varicose vein. The degree of inflammation varies depending on the length of the vein affected. There is often a cord like feeling under the skin that feels like a small rope, with redness over this cord. Low-grade fever may be present in uncomplicated superficial thrombophlebitis, but high fever should increase suspicion for infection in the superficial thrombophlebitis.

Complications of superficial vein phlebitis can also occur. The biggest concern in the short term is spread from the superficial veins to the deep veins.  Long term, the phlebitis can re-occur. Rarely, infection can arise in the clotted veins, which is associated with high fever, and redness that extends well past the affected vein.  In these patients, IV antibiotics are required, and possibly removal of the infected vein.

The diagnosis of phlebitis and thrombosis of the lower extremity superficial veins is usually clinically apparent based upon the patient’s complaints and physical examination as described above, especially in patients with known risk factors.

The need for duplex ultrasound or further evaluation with laboratory or other studies depends upon the clinical scenario. Most feel that duplex examination is essential for patients with suspected superficial vein thrombosis due to the high rate of concurrent deep vein thrombosis (DVT), as well as to accurately make the diagnosis and define the location of the clot so the patient can be reevaluated if the symptoms worsen.

Treatment of Phlebitis

Treatment differs depending upon whether the thrombosis affects larger superficial varicose veins, as well as the greater, or small saphenous veins, and how close the clot is to the junctions with the deeper veins.  This can be determined by ultrasound.  Also if the condition seems to be worsening, that can mandate a different treatment approach.

For uncomplicated disease, treatment is primarily aimed at alleviating symptoms and preventing spread of clot into the deep venous system.  This is done with compression hose, exercise, leg elevation and non steroidal anti-inflammatory medications.

Usually a close follow up is planned, and follow up ultrasound is performed until it is clear the condition has resolved.  In some cases, anticoagulant medication is used stop the clotting process in an effort to prevent spread of the clot to the deeper veins.  This can include drugs like Xarelto and Eliquis, or shots like Low Molecular Heparin (Lovenox or Arixtra).

You and your care provider can discuss if anticoagulant medications are indicated, and if so, for how long.  Long term if the condition was triggered by large varicose veins, then you might consider discussing if your varicose veins should be treated with procedures like Closurefast, Venaseal, Varithena, or some form of sclerotherapy to help reduce the risk of recurrence in the future.

Generally, if you think you might have superficial vein phlebitis you should seek medical input, especially if the veins are red, hot, tender and hard and if the condition seems to be worsening.

Oregon’s Leading Vein Care Specialists

At Inovia Vein Specialty Centers we specialize in caring for patients with venous disorders such as varicose veins, deep venous thrombosis, and venous stasis ulcers.

If you are interested in learning more about vein treatment options, simply fill out our Online Appointment Request Form or call any of our clinics in Northwest Portland , Tigard, Happy Valley or Bend, Oregon.

Superficial Thrombophlebitis: Symptoms, Causes

Overview

What is phlebitis?

Phlebitis is a term used to describe veins that are painful, red and inflamed.

What is thrombophlebitis?

Thrombophlebitis means there is a blood clot in the vein (thrombosis or thromboembolism) that causes swelling and pain.

Superficial thrombophlebitis: If the vein that has the clot is just under the skin, it is called a superficial venous thrombosis or superficial thrombophlebitis. This type of clot does not usually travel to the lungs unless it reaches the deep veins. But, superficial thrombophlebitis can be painful and treatment may be needed.

Deep vein thrombosis (DVT): If the blood clot is in the veins deep in the body, it is called a deep vein thrombosis (DVT). This type of clot can travel to the lungs (pulmonary embolism) and block blood flow to the lungs. In severe cases, this can lead to death. Most DVTs require treatment right away.

Symptoms and Causes

What causes superficial thrombophlebitis?

Superficial thrombophlebitis can be caused by an injury to the arm or leg; having an intravenous (IV) line; or the cause may not be known.Potential risk factors are the same as for those who have deep vein thrombosis (DVT), and include:

• An inherited (family) condition that increases your risk of blood clots
• Cancer and some cancer treatments (chemotherapy)
• Limited blood flow because of an injury, surgery, or not moving
• Long periods of inactivity that decrease blood flow, such as:
  • Sitting for a long time, such as in a car, truck, bus, train or airplane
  • After surgery or a serious injury
• Pregnancy and the first 6 weeks after giving birth
• Being over age 40 (although clots can form at any age)
• Being overweight
• Taking birth control pills or hormone therapy, including for treatment for postmenopausal symptoms
• Placement of a central venous catheter or pacemaker

What are the symptoms of thrombophlebitis?

• Swelling of the leg or arm (sometimes this happens suddenly)
• Pain or tenderness in the area of the clot
• Feeling of increased warmth in the area of the clot
• Red or discolored skin in the area of the clot

If thrombophlebitis causes pain or interferes with your daily activities, talk to your doctor about treatment options.

Diagnosis and Tests

How is superficial thrombophlebitis diagnosed?

Your doctor may suspect that you have superficial thrombophlebitis based on a physical exam. But, a vascular ultrasound is needed to confirm the diagnosis. An ultrasound is also important because about 20% of people with superficial thrombophlebitis also have a DVT.

Many times, patients who have superficial thrombophlebitis wait to see a doctor, thinking they have a muscle strain or sprain. In fact, without an ultrasound, the doctor may also think the problem is related to a muscle.

Management and Treatment

What are the treatment options for patients with superficial thrombophlebitis?

The main goal when you begin treatment for superficial thrombophlebitis is to control pain and inflammation.

Treatment includes:

For pain:

• Nonsteroidal anti-inflammatory pain medication (NSAIDs) such as ibuprofen
• Warm compresses

For inflammation and swelling:

• Leg elevation when you are resting
• Compression stockings
• Staying active and not sitting for too long

Other medical treatments:

Most times, treatment for patients with superficial thrombophlebitis includes only ways to manage pain and inflammation. But, if you are at risk of developing a DVT or have problems that affect the way your blood clots, you will likely need to take anticoagulation medication.

In most cases, superficial thrombophlebitis clears up within a few weeks.

When is surgery necessary for phlebitis?

If you have superficial thrombophlebitis and varicose veins, your doctor may talk to you about surgical treatment. The combination of these conditions puts you at greater risk of having superficial thrombophlebitis after the condition clears up. The best way to reduce this risk is to use surgery or endovenous therapy to take care of the varicose veins and keep them from returning. These procedures are performed by a vascular specialist in either the hospital or an outpatient surgery center.

Types of surgery include:

Endovenous ablation. A special catheter (long, thin tube) is placed in the saphenous vein (the longest vein in your body; it runs along the inside of your leg). The catheter is inserted by making a small puncture in your calf. Once it is in place, electric currents (radiofrequency) or laser energy is sent through the catheter to the area of the vein. This stops the backward blood flow in the vein that leads to varicose veins. Your doctor may also combine this procedure with another to remove large varicose veins through very small incisions (ambulatory phlebectomy).

Endovenous ablation is a less painful and less invasive alternative to surgical ligation and stripping, which is rarely used anymore.

Sclerotherapy. A solution is injected directly into the affected vein. The solution irritates the lining of the vessel, causing it to swell and stick together. Over time, the vessel turns into scar tissue that fades from view. This treatment is performed in the office by a vascular specialist or surgeon. It does not involve a hospital stay. Many times, the doctor will perform sclerotherapy along with endovenous ablation to take care of all varicose veins in the leg.

Your healthcare provider will talk to you about the best treatment for you.

Resources

Doctors vary in quality due to differences in training and experience; hospitals differ in the number of services available. The more complex your medical problem, the greater these differences in quality become and the more they matter.

Clearly, the doctor and hospital that you choose for complex, specialized medical care will have a direct impact on how well you do. To help you make this choice, please review our Miller Family Heart, Vascular & Thoracic Institute Outcomes.

Cleveland Clinic Heart, Vascular & Thoracic Institute Vascular Medicine Specialists and Surgeons

Choosing a doctor to treat your vascular disease depends on where you are in your diagnosis and treatment. The following Heart, Vascular & Thoracic Institute Sections and Departments treat patients with all types of vascular disease, including blood clotting disorders:

Section of Vascular Medicine: for evaluation, medical management or interventional procedures to treat vascular disease. In addition, the Non-Invasive Laboratory includes state-of-the art computerized imaging equipment to assist in diagnosing vascular disease, without added discomfort to the patient. Call Vascular Medicine Appointments, toll-free 800-223-2273, extension 44420 or request an appointment online.

Department of Vascular Surgery: surgery evaluation for surgical treatment of vascular disease, including aorta, peripheral artery, and venous disease. Call Vascular Surgery Appointments, toll-free 800-223-2273, extension 44508 or request an appointment online.

You may also use our MyConsult second opinion consultation using the Internet.

The Heart, Vascular & Thoracic Institute also has specialized centers and clinics to treat certain populations of patients:

Learn more about experts who specialize in the diagnosis and treatment of vascular and arterial disease.

Contact

If you need more information,click here to contact us, chat online with a nurse or call the Miller Family Heart, Vascular & Thoracic Institute Resource & Information Nurse at 216. 445.9288 or toll-free at 866.289.6911. We would be happy to help you.

Becoming a Patient

Treatment Options

Additional information about vascular treatment options can be found at:

Treatment Guides

Diagnostic Tests

Diagnostic tests are used to diagnose coronary artery disease and the most effective treatment method.

Webchats

Our webchats and video chats give patients and visitors another opportunity to ask questions and interact with our physicians.

Videos

Interactive Tools

Additional information and resources

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The inclusion of links to other websites does not imply any endorsement of the material on those websites nor any association with their operators.

Why choose Cleveland Clinic for your care?

Our outcomes speak for themselves. Please review our facts and figures and if you have any questions don’t hesitate to ask.

Injection Site Reactions – Managing Side Effects

Chemocare.com

Care During Chemotherapy and Beyond

Injection site reactions discussed here are local skin reactions that occur when
the drug escapes from the veins or IV catheter into the skin (extravasation).

Drugs That Cause Injection Site Reactions:

The drugs that can cause injection site reactions are divided into 2 types:
irritants and vesicants.

Irritants cause a short-lived and limited irritation to the vein:

• Symptoms are; tenderness, warmth, or redness along the vein or at the injection
  site.
• A variation to this is a hypersensitivity “flare reaction” at the injection site.
• Symptoms of this reaction are redness and itching at the injection site.
• Irritant chemotherapy agents include: bleomycin, carboplatin, carmustine, cisplatin,
  dacarbazine, denileukin difitox, doxorubicin, doxorubicin liposome, etoposide,
  ifosfamide, streptozocin, teniposide, thiotepa, vinorelbine.

Vesicants cause an injection site reaction often referred to as a chemical
cellulitis:

• The reaction to vesicants initially looks like an irritation but may worsen,
  depending on the amount of vesicant that has leaked under the skin.
• Vesicants can cause redness and blistering. Larger amounts of vesicant leakage from
  the chemotherapy injection can lead to severe skin damage in a matter of days.
• Symptoms from leakage of vesicants may be delayed for up to 6-12 hours after chemotherapy
  injection.
• Complaints of itching are common in the absence of pain.
• Severity of the injection site reaction depends on the vesicant potential of the
  drug, the amount and concentration of the drug exposure, and the immediate measures
  taken once the extravasation occurs.
• Vesicant chemotherapy agents include: Dactinomycin, daunorubicin, doxorubicin, epirubicin,
  idarubicin, mechlorethamine, mitomycin, mitoxantrone, paclitaxel, streptozocin,
  tenoposide, vinblastine, vincristine, vinorelbine.

Symptom Management:

Prevention of extravasation is the key to managing these types of injection
site reactions:

The nurse or doctor giving these types of chemotherapy injections must be carefully
trained.

A central venous access device might be recommended such as:

• PICC line: Although still considered temporary, a PICC
  line can be inserted for chemotherapy injection and used for six weeks to a few
  months before it is discontinued. This involves the placement of a long plastic
  catheter into one of the larger veins of the arm. This procedure is a non-surgical
  outpatient procedure. A special x-ray, called fluoroscopy will confirm that
  the catheter is in the right place, reducing risk of infection site reaction.
  This option is ideal for multiple short infusions or continuous infusions given
  in a hospital or at home with a portable pump.
• Tunneled catheter: Tunneled catheters are placed through the
  skin in the middle of the chest. They are tunneled through the subcutaneous
  tissue (the layer of tissue between the skin and muscle) and inserted into the superior
  vena cava vessel at entrance of the right atrium of the heart. There is a
  dacron cuff about two inches from the part of the catheter that exits the skin in
  the chest. Scar tissue forms around the cuff to hold the catheter in place.
  These catheters are inserted in an outpatient surgical procedure and a special x-ray,
  called fluoroscopy, must be done to be sure the catheter is in the right place,
  reducing risk of leaking vesicants. These catheters can be left in place for
  chemotherapy injection for months or years with low incidence of infection.
  Dressing changes and maintenance is required. These catheters can have multiple
  lumens (entrances) for medications to be infused or for blood to be drawn.
  A single lumen has one entrance for medications, a double lumen has two entrances
  and a triple lumen (the most available) has three entrances. These catheters
  are most often used for extensive chemotherapy regimens such as bone marrow transplant
  procedures. Tunneled catheters are usually called by their brand names:
  Broviac^®, Groshong^®,
  and Hickman^®.
• Port-a-cath: A more permanent injection site option involves the
  placement of a port-a-cath. The port-o-cath is placed under the skin on the
  chest. The cathether is then inserted into the superior vena cava vessel at
  entrance of the right atrium of the heart. This catheter can be placed in
  radiology by an interventional radiologist or by a surgeon in the operating room.
  It is approximately a one-hour procedure. The useful lifetime of a port-a-cath can
  be as long as three to five years. The port-o-cath can be felt under the skin
  and the nurse can find the injection site by locating the edges of the
  port-o-cath and inserting (cannulating) a special needle (called a Huber needle)
  into the soft middle section. Medications can be given through the port-a-cath
  and blood can be drawn from it eliminating the need for a blood draw from the arm.
  The use of a portable pump and port-a-cath allows the medication to be given over
  several days in the home setting rather than as a patient in the hospital.
  There are no dressing changes required but there is some maintenance involved.

Things You Can Do To Prevent Injection Site Reactions:

• Notify your health care professional immediately if you experience pain or discomfort
  at the injection site.
• If you have redness or discomfort at the site after leaving the chemotherapy treatment
  facility, apply ice to the injection site and notify your healthcare professional
  of potential irritant or vesicant leakage.
• EXCEPT: If extravasation of a vinca alkaloid medication – vincristine,
  vinblastine or vinorelbine, then you would apply warm compresses and notify your
  health care professional of the possibility of injection site reaction.

Treatments or Drugs for Injection Site Reactions:

• Prevention of extravasation is the key to management of this problem.
• If one of the above medications has extravasated the health care professional will
  attempt to remove as much of the medication as possible from the injection site
  and discontinue the IV.
• Ice or heat (in the case of vinca alkaloid chemotherapies) will be applied to the
  injection site.
• There are various antidotes that may be given based on the chemotherapy that
  extravasated, and the amount of drug infused. The nurse or doctor will work
  with the chemotherapy pharmacist to decide if an antidote is available and appropriate
  to the situation.

When to Contact Your Doctor or Health Care Provider:

• If you have received an irritant or vesicant medication and notice redness, pain
  or blistering at the site of infusion.

Note: We strongly encourage you to talk with your health care professional
about your specific medical condition and treatments. The information contained
in this website about chemotherapy, injection site reaction and other medical conditions
is meant to be helpful and educational, but is not a substitute for medical advice.

Chemocare.com is designed to provide the latest information about chemotherapy to patients and their families, caregivers and friends. For information about the 4th Angel Mentoring Program visit www.4thangel.org

Peripheral IV in Too Long

Case Objectives

• Appreciate the complications associated with peripheral intravenous (IV) catheters.
• Describe the optimal sterile technique that should be used in placing peripheral IVs.
• Describe best practices for day-to-day management of peripheral IVs in the hospital.
• State how frequently peripheral IVs should be changed in adult patients.

Case & Commentary—Part 1:

A 75-year-old man with a history of coronary artery disease and congestive heart failure (CHF) was admitted to the hospital with a CHF exacerbation. He was given intravenous (IV) diuretics and improved over the first 4 days in the hospital. At this medical center, there was a standard protocol that called for all peripheral IV catheters to be replaced after 4 days to prevent infection. Because of edema in his extremities, placing a new peripheral IV was going to be difficult. The bedside nurse asked the covering physician if the peripheral IV could be extended for an additional day or two. The physician was planning on discharging the patient the next day, so the extension was approved.

There has been substantial focus on the risks associated with central venous catheters including catheter-related bloodstream infections. Yet, peripheral intravenous (IV) catheters are much more common in modern hospitals and also have associated risks. This case provides one example of the hazards of this seemingly benign medical device.

Peripheral IV catheters allow reliable and convenient delivery of life-saving medications for hospitalized patients. Placement of a peripheral IV catheter, however, is often a painful experience for patients. For staff with limited experience in placing peripheral IV catheters, multiple attempts may be required, especially for those with difficult venous access. So the decision to extend the peripheral IV catheter by the covering physician in the present case is perfectly understandable.

Nevertheless, peripheral IVs can be associated with multiple complications. Phlebitis (inflammation of the vein where the IV is placed) complicates IV therapy in 2.3%–60% of cases in different series.(1-3) The typical clinical presentation is pain and redness at the IV site. While most cases of phlebitis are noninfectious (just inflammation of the vein), this can progress to suppurative soft tissue infections (cellulitis, abscess, or tissue necrosis). Although rare (incidence rate: 0.06 cases per 1000 bed-days), this complication can cause serious morbidity.(4) Another serious complication is peripheral IV catheter–related bacteremia, which occurs in 0.1% cases (0.5 per 1000 IV catheter-day), although the frequency is lower than that of central line–associated bacteremia (4. 4%, 2.7 per 1000 catheter-day).(1,5)

In an effort to decrease the risk of catheter-related infections, scheduled replacement of peripheral IV catheters every 48–72 hours or every 72–96 hours has been widely used.(3,6-8) Despite the popularity of this practice, there is no strong evidence supporting it.(3,7,9) Based on findings that rate of phlebitis is not significantly different between peripheral IV catheters left in place for 72 hours versus 96 hours (10), the Centers for Disease Control and Prevention (CDC) recommends against replacing the peripheral IV catheter more frequently than every 72–96 hours.(6)

On the other hand, it should also be kept in mind that once peripheral IV catheter–related infectious complications do occur, infected catheters should be removed as soon as possible to prevent them from becoming a source of bloodstream infection. After inserting IV catheters, the site should be inspected daily, either at the time of changing dressing or by palpation through an intact dressing. (6,11) Erythema, tenderness, or other evidence of local inflammation should prompt the removal of the IV catheter.(6) In any case, it is imperative for the attending physician to inspect the IV catheter site to make sure that no early signs of phlebitis go unrecognized (4) before making the decision to extend the peripheral IV catheter.

In the case above, if the IV were functioning and the site lacked evidence of inflammation, it seems reasonable to extend the IV to 96 hours, particularly in light of the difficulty of placing a new IV and the potential pain to the patient.

Case & Commentary—Part 2:

The next day the patient was worse and required ongoing hospitalization. The peripheral IV was kept in place for 2 more days. On hospital day 6, the patient developed erythema around the IV site. With concerns for infection, the IV was removed and a new peripheral IV was placed. Later that day, the patient developed fever and chills. Blood cultures drawn at the time grew methicillin-resistant Staphylococcus aureus (MRSA), most likely secondary to the infected peripheral IV catheter. Subsequently, the patient complained of back pain and a magnetic resonance imaging (MRI) of the spine revealed an epidural abscess, which on aspiration grew MRSA. He required 6 weeks of IV antibiotics for the MRSA bacteremia and epidural abscess. The patient ultimately recovered and was discharged to home.

There is no mention whether the physician or the nurse inspected this patient’s catheter site at 96 hours, but by 144 hours, cellulitis had developed at the catheter site. Sadly, the unexplained clinical deterioration of this patient—who was scheduled to be discharged—was likely caused by peripheral IV catheter infection. The local soft tissue infection led to MRSA bacteremia and then to an epidural abscess. Fortunately, after aggressive therapy and a prolonged course, the patient eventually recovered. The extra cost of MRI, imaging-guided aspiration of epidural abscesses, 6-week IV antimicrobial therapy, as well as the prolonged hospitalization, is likely to be in the hundreds of thousands of dollars, not to mention the patient dissatisfaction and potential for litigation. This case therefore highlights the serious costs—both clinical and economic—that can be associated with peripheral IV catheter infections.

Case & Commentary—Part 3:

In response to this event, the medical center involved developed a strict policy under which peripheral IVs must be changed every 3 days. They can be extended for 1 additional day with a physician’s order but no longer. In addition, the medical center changed some of the nursing documentation to include the date of peripheral IV insertion and a description of the site during each shift.

It appears the medical center took some steps to try to prevent future peripheral IV infections. But, are these the highest-yield interventions? What should be learned from this case and what should be changed?

In this case, there were multiple issues with the IV management. The process of insertion was probably a difficult one in the presence of edema in the extremities, and staff with limited experience may have been unable to maintain good aseptic technique. In addition, there was inadequate and delayed recognition of the catheter infection; by the time it was recognized on day 6, cellulitis and bloodstream infection had already developed. These may have been due to a lack of expertise in day-to-day management of IVs and IV sites.

Best Practices for Management of Peripheral IVs

There are system interventions that can help prevent IV catheter complications. A randomized controlled trial demonstrated that a dedicated IV therapy team of registered nurses specially trained for inserting IV catheters and inspecting catheter sites significantly reduced both local and bacteremic complications of peripheral IV catheters.(11) Moreover, a large prospective study of 3165 patients also showed that deployment of well-trained IV teams can effectively prevent peripheral IV catheter infection.(12)

The insertion site, method of insertion, catheter type, and maintenance protocol all seem to matter as well. In adults, upper extremities are the preferred site for catheter insertion. (6) Using an insertion site in lower extremity has been found to be an independent risk factor for catheter-related soft tissue infection.(4) For skin disinfection before the insertion of IV catheter, 2% alcoholic chlorhexidine is more effective than 10% povidone-iodine in the prevention of catheter-related infections.(13,14) Teflon or polyurethane catheters have fewer infectious complications than catheters made with polyvinyl chloride or polyethylene.(2,6) After placement of an IV catheter, the catheter site should be covered by either sterile gauze or a sterile transparent semipermeable dressing.(6,15) The use of a continuous infusion to maintain IV catheter patency is an independent risk factor for microbiologically-proven catheter infection (12) and catheter-related soft tissue infection.(4) The use of a closed intermittent infusion system with a plastic cap that can be cleansed before drug injection is safer. For IV catheters not used for infusion of blood product or lipid emulsions, the IV administration sets in continuous use, including secondary sets and add-on devices, should be changed no more frequently than every 96 hours, but at least every 7 days. (6,16) Adoption of the above-stated simple, inexpensive, and evidence-based practices is the best approach to prevent similar events in the future.

All of this brings us back to where we began: What is the optimal frequency to change peripheral IV catheters? As described above, there is no strong evidence in support of routinely changing catheters at 72 hours. We do know that longer (greater than 48 hours) catheter dwelling time is a risk factor for phlebitis.(1,2) In a prospective study of 3165 patients, however, the majority of phlebitis cases were culture-negative, suggesting the local inflammation was not caused by infection, and that extending the scheduled catheter replacement interval from 48–72 hours to 72–96 hours did not significantly increase the risk of microbiologically proven catheter infection.(12) A recent Cochrane review found no conclusive evidence of benefit in changing IV catheters every 72–96 hours in comparison with clinically indicated replacement in terms of the rates of IV catheter–related complications. (3,7,17) However, the two clinical trials reviewed were statistically underpowered for examining whether the risk of catheter-related bacteremia increases in clinically indicated replacement group.(6,10) A longer replacement schedule or clinical indicated replacement strategy has benefits in patient comfort and cost-savings, which need to be weighed against the potential harm of increased risk of catheter infection, especially bacteremia. In the absence of well-trained IV teams, replacement only when clinically indicated carries the risk of delayed recognition of catheter infection by inexperienced staff, until the development of serious consequences, as illustrated in the present case. In adult patients, replacement of peripheral IV catheters at 72–96 hour intervals is more comfortable for patients as well as less expensive than routine 48–72 hours exchanges, without significant increase in infection risk.(6)

The medical center attributed this adverse event to nonadherence to standard operating procedure, and in response, strictly enforced a scheduled replacement of peripheral IV catheters every 72–96 hours, which is consistent with the CDC recommendations. (6) This straightforward solution, although commendable, may not be enough to prevent future events. Efforts should be directed toward enhancing expertise in IV catheter insertion and maintenance, rather than focusing on the replacement schedule.(12) To ensure best practice, the institution should consider using well-trained IV teams (6,11,12), which is the most effective way to reduce peripheral IV catheter–related infectious complications.(8)

Take-Home Points

To reduce the risk of peripheral IV catheter–related infectious complications, the following are the best evidence-based practices:

• Use IV therapist teams for peripheral IV catheter insertion and day-to-day management.
• Place the IV catheter in upper extremities.
• Use 2% alcoholic chlorhexidine for skin disinfection before the insertion of peripheral IV catheter.
• Use intermittent flushing to maintain the peripheral IV catheter patency.
• Replace peripheral IV catheters every 72–96 hours, but not more often, in adult patients.

Chi-Tai Fang, MD, PhD

Associate Professor

Institute of Epidemiology and Preventive Medicine

National Taiwan University

Faculty Disclosure: Dr. Fang has declared that neither he, nor any immediate member of his family, has a financial arrangement nor other relationship with the manufacturers of any commercial products discussed in this continuing medical education activity. The commentary does not include information regarding investigational or off-label use of pharmaceutical products or medical devices.

References

1. Tager IB, Ginsberg MB, Ellis SE, et al. An epidemiologic study of the risks associated with peripheral intravenous catheters. Am J Epidemiol. 1983;118:839-851. [go to PubMed]

2. Maki DG, Ringer M. Risk factors for infusion-related phlebitis with small peripheral venous catheters. A randomized controlled trial. Ann Intern Med. 1991;114:845-854. [go to PubMed]

3. Webster J, Osborne S, Rickard C, Hall J. Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database Syst Rev. 2010;(3):CD007798. [go to PubMed]

4. Lee WL, Liao SF, Lee WC, Huang CH, Fang CT. Soft tissue infections related to peripheral intravenous catheters in hospitalised patients: a case-control study. J Hosp Infect. 2010;76:124-129. [go to PubMed]

5. Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc. 2006;81:1159-1171. [go to PubMed]

6. O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis. 2011;52:e162-e193. [go to PubMed]

7. Webster J, Clarke S, Paterson D, et al. Routine care of peripheral intravenous catheters versus clinically indicated replacement: randomised controlled trial. BMJ. 2008;337:a339. [go to PubMed]

8. Maki DG. Improving the safety of peripheral intravenous catheters. BMJ. 2008;337:a630. [go to PubMed]

9. Bregenzer T, Conen D, Sakmann P, Widmer AF. Is routine replacement of peripheral intravenous catheters necessary? Arch Intern Med. 1998;158:151-156. [go to PubMed]

10. Lai KK. Safety of prolonging peripheral cannula and i.v. tubing use from 72 hours to 96 hours. Am J Infect Control. 1998;26:66-70. [go to PubMed]

11. Soifer NE, Borzak S, Edlin BR, Weinstein RA. Prevention of peripheral venous catheter complications with an intravenous therapy team: a randomized controlled trial. Arch Intern Med. 1998;158:473-477. [go to PubMed]

12. Lee WL, Chen HL, Tsai TY, et al. Risk factors for peripheral intravenous catheter infection in hospitalized patients: a prospective study of 3165 patients. Am J Infect Control. 2009;37:683-686. [go to PubMed]

13. Maki DG, Ringer M, Alvarado CJ. Prospective randomised trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters. Lancet. 1991;338:339-343. [go to PubMed]

14. Darouiche RO, Wall MJ Jr, Itani KM, et al. Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med. 2010;362:18-26. [go to PubMed]

15. Maki DG, Stolz SS, Wheeler S, Mermel LA. A prospective, randomized trial of gauze and two polyurethane dressings for site care of pulmonary artery catheters: implications for catheter management. Crit Care Med. 1994;22:1729-1737. [go to PubMed]

16. Gillies D, O’Riordan L, Wallen M, Morrison A, Rankin K, Nagy S. Optimal timing for intravenous administration set replacement. Cochrane Database Syst Rev. 2005;(4):CD003588. [go to PubMed]

17. Rickard CM, McCann D, Munnings J, McGrail MR. Routine resite of peripheral intravenous devices every 3 days did not reduce complications compared with clinically indicated resite: a randomised controlled trial. BMC Med. 2010;8:53. [go to PubMed]

Inflammation of the Superficial Veins in Dogs

Phlebitis in Dogs

Phlebitis is characterized by a condition known as superficial thrombophlebitis, which refers to an inflammation of superficial veins (or veins close to the surface of the body). Phlebitis is generally due to an infection or because of thrombosis — the formation of a clot (or thrombus) inside a blood vessel, which in turn obstructs the flow of blood in the body.

Superficial venous thrombophlebitis is the most common form of this condition, and is usually localized in one area.

Conversely, deep tissue thrombophlebitis is associated with clinical signs of sepsis, in which a bacterial infection occurs due to the presence of pathogenic organisms and their toxins in the blood or tissues. This type of thrombophlebitis is also associated with deep tissue thromboembolism, in which a clot or thrombus formed in one part of the body breaks free and migrates to another blood vessel, where it causes blockage.

Phlebitis can affect both dogs and cats. If you would like to learn more about how this disease affects cats, please visit this page in the PetMD health library.

Symptoms and Types

The main symptom of phlebitis is a localized inflammation, which is characterized by warmth, swelling, pain, hardened vessels, or a redness of the skin known as erythema. If at least two of the aforementioned signs are present, this can be taken as a sign of local inflammation. Drainage or fever may also be present, both being associated with the body’s response to such infections.

Causes

There is no specific age, breed, or gender of dog that is known to be more susceptible to the development of phlebitis. However, very young or elderly dogs may be at higher risk simply due to a less developed or poorly functioning immune system.

Other characteristics that are considered risk factors for the development of phlebitis include obesity, lack of mobility, poor vein quality, chronic heart or kidney disease, pregnancy, and/or an immunodeficiency disorder in which the dog’s immune system does not function properly.

The main cause of phlebitis is intravenous (IV) catheter use. Poor catheter quality or care may lead to bacterial colonization of a catheter, which can then infect the dog. Catheters are often used during surgery, or in emergency situations for treating trauma victims.

Diagnosis

A number of diagnostic procedures are necessary for properly diagnosing phlebitis. The Doppler test is an inexpensive means for testing blood flow in the dog’s veins, and may reveal any blood circulation irregularities and blockage. Blood cultures may also indicate signs associated with systematic inflammations. Additional diagnostic techniques may include x-ray imaging and urine analysis.

Treatment

If infection is suspected, antibiotic treatment will be the most likely treatment. The specific antibiotic prescribed to your dog will depend on the location of the infection, as well as the suspected contaminants behind the infection (if no culture is available at the time). Additional medications may help to make your dog more comfortable by alleviating related symptoms.

Living and Management

After the initial treatment, antibiotic therapy should be adjusted based on the follow-up culture tests. Certain veins, known as phlebotic veins, should be avoided for IV therapy or blood collection until your dog has completely recovered. With proper antibiotic treatment, the most severe cases may still take up to three weeks to resolve.

Prevention

Because the main cause of phlebitis is poor quality catheters or improper catheter care, this is the primary area to target when thinking about prevention. Any IV catheter sites should be cleaned regularly with antimicrobials and treated with antimicrobial ointment, in order to avoid bacterial infection that may lead to phlebitis. Sterile dressings should be used, and catheters should be changed within 24 hours, especially if they were placed in an emergency situation. Longer catheters may reduce the incidence of phlebitis.

90,000 Treatment in Israel – the official website of the Rambam hospital

A complex medical problem led to a double blockage of the arteries that supply blood to the brain. The patient was admitted to the hospital paralyzed and in a life-threatening condition. As a result of treatment in “Rambam”, Elena was able to move again

A few days ago, 61-year-old Elena Solof suddenly felt unwell. The patient was taken to the emergency room of the Rambam hospital. Her left side of her body was completely paralyzed and she did not understand what was happening around.A quick examination revealed that the blood clot had blocked the flow of blood to the patient’s brain, causing a life-threatening stroke. On average, Rambam Hospital treats about 1,500 stroke patients annually. Time is an important factor in stroke, often life and death.

Most cases of stroke (about 85%) are ischemic, as in the case of Solof, the rest with hemorrhage. When an ischemic stroke occurs, a blood clot-dissolving drug is administered intravenously in many hospitals for the first four and a half hours after the stroke.But in many cases, additional intervention is necessary to save the patient’s life: a complex and accurate extraction of the blocking thrombus is the only way to increase the possible time for providing assistance to six, and sometimes up to eight hours. Such treatment exists only in a few medical centers in Israel, in particular, in the “Rambam”.

In Solof’s case, it was discovered that she was suffering from a complex medical problem resulting in a blockage of the carotid arteries that supply blood to the brain and neck.Over the years, the patient developed a narrowing of the carotid artery. This led to the development of blood clots, one of them came off and hit the branching point of the artery, blocking the blood supply. This situation is a real challenge for the medical team.

“This,” says Dr. Ethan Avergal, who performs stenting at Rambam, “is a really difficult operation. In the first step, we introduced a balloon with a stent to widen the artery in the lower part. When the blockage in the first place was removed, we moved to the upper part of the artery, where there is a thrombus that blocked the blood supply to the patient’s brain.With the help of a special stent, we were able to remove the blood clot. The patient, undergoing the procedure under sedation, began to respond to the treatment already on the operating table and was able to move the left side of her body, which had been paralyzed up to this point. Treatment in Rambam is carried out by a team of professional doctors – specialists in many fields, including those working in other departments. Together we manage to save lives. ”

After stenting, Solof fully regained consciousness, began to move without difficulty and be aware of what was happening.

Rambam, the largest hospital in the north of the country, became the leader in the treatment of stroke in Israel when an emergency stroke treatment protocol was developed there. With the help of a specially created diagnostic team, Rambam specialists from the first second manage to provide life-saving treatment in the shortest possible time, meeting world standards. Rambam Hospital was also the first in northern Israel to perform brain stenting and other complex surgeries to expand life-saving opportunities in certain cases.Rambam has a team of multidisciplinary stroke specialists, including specialists in neurology, neurosurgery, circulatory system surgery, cardiology, neuroradiology and physiotherapy.

In order to receive qualified assistance from our team of doctors, foreign patients just need to contact the international department of the Rambam hospital and we will be happy to help you as soon as possible.

Signs of infection / Threats / Kaspersky.antivirus.lv

Therapeutic plasmapheresis and ozone therapy

PLASMAFERESIS is the removal of harmful substances from the blood.

Our blood consists of cells: red and white blood cells, platelets, and plasma – the liquid part of the blood in which fats, proteins, carbohydrates, hormones, vitamins, waste products of cells, toxins and microbes are dissolved.During plasmapheresis, 450 ml is taken from the patient. blood, then it is centrifuged. In this case, the blood cells settle, and together with the saline solution, they are returned to the patient. And the resulting plasma will be removed, and with it all the harmful substances.

The effectiveness of Plasmapheresis is based on three factors: cleansing, strengthening the immune system and improving blood flow.

First, harmful substances are removed from the body: first those that are currently in the blood, then those that enter the blood from organs and tissues, and so on until they are completely cleaned.

Secondly, in response to the removal of plasma, the body mobilizes all its defense mechanisms, strengthens the immune system.

Thirdly, the purified blood becomes less viscous, moreover, plasmapheresis removes excess cholesterol.

In patients, Plasmapheresis improves well-being, stops the development of diseases, removes from the blood the remnants of drugs and substances that caused the disease.

After the procedure, a healthy person feels that his body is much better able to withstand stress, the effects of unfavorable ecology, alcohol, nicotine and other harmful substances.The age-related aging of the skin, the formation of wrinkles and edema is stopped: after all, plasmapheresis is a healing that comes from the inside and equally affects all systems and organs of our body.

And with the help of Plasmapheresis, many diseases are cured that cannot be cured without it by any other means, for example, rheumatoid arthritis, multiple sclerosis, sepsis and other severe damage to systems and organs.

With the help of Plasmapheresis, it is possible to effectively treat allergies and autoimmune diseases, remove the effects of chemotherapy in oncology, treat chronic intoxication with drug addiction, alcoholism, etc.

Plasmapheresis is used to reduce the concentration of proteins, lipids, hormones, toxins, antigens, antibodies, immune complexes in the plasma. As a result of the Plasmapheresis procedure, the blood is freed from salts and other harmful substances that accumulate in the body. There is a “rejuvenation” of the body as a whole.

Plasmapheresis helps in the following cases:

1. Dermatology (eczema, psoriasis, allergies, acute or chronic urticaria, dermatitis, furunculosis)
2. Gastroenterology (all forms of hepatitis, high cholesterol levels, chronic cholecystitis and chronic cholecystitis and stomach and duodenal ulcer)
3. Neurology (multiple sclerosis, myasthenia gravis)
4. Endocrinology (diabetes mellitus, obesity, hyperthyroidism)
5. Respiratory diseases (chronic bronchitis, bronchial asthma)
6. Chronic fatigue syndrome

and

7. Gynecology (infections, chronic inflammatory diseases of the uterus and appendages, menstrual irregularities, infertility, miscarriage, preparation for IVF, gestosis of pregnant women, climacteric syndrome)
8. Rheumatoid arthritis, arthrosis, arthritis
9. Hypertension, coronary heart disease

Administration of the city of Bryanka, Luhansk People’s Republic

Post-injection abscess is one of the types of abscesses that occurs after any injection of drugs.Such an abscess after an injection, whether intramuscular or intravenous injection, is manifested by the development of a painful inflammatory element with purulent contents. The main number of post-injection abscesses occurs during injections on their own, at home.

Causes of post-injection abscess

The main reason for the formation of post-injection abscess is considered to be ignoring the rules of disinfection during the injection. So, bacteria can enter the patient’s skin through unwashed hands, through non-sterile syringes or an injected solution, from poorly treated skin of the person who is undergoing the procedure.There are other known risk factors that can lead to an abscess after injection:
• Improper administration of medication solutions.
• Long courses of injections performed in the same area of ​​the body.
• Small muscle layer against a background of increased fatty layer.
• Damage to the vessel during injection, when interstitial hemorrhage occurs, followed by the formation of an abscess after the injection.
• Patient’s lack of hygiene.
• Dermatitis and other diseases of the skin, especially in areas where injections are routinely given.
• Severely weakened immunity, autoimmune pathologies, allergic diseases.
• Continuous bed rest, resulting in poor circulation of blood.

Terms of abscess occurrence: from 2 days or more. Most often, there are post-injection abscesses of the buttocks, thighs, less often – on the elbow, in the subscapularis and forearm.

Symptoms of post-injection abscess development:
• the appearance of a painful induration in the injection area;
• pains, at first mild and disturbing on palpation and movement, and then constant, intense, pulsating;
• swelling, redness of the skin over the area of ​​compaction, and subsequently – its cyanosis;
• increased body temperature;
• general weakness, sweating.

If this happens, then a visit to a doctor should not only be mandatory, but also immediate: a correctly performed injection should not have the reaction described above.
For any type of abscess after an injection, an immediate surgical opening of the inflamed focus is performed. Only with surgical intervention is it possible to completely remove the purulent capsule and heal the wound until it is completely cleansed. After the operation of opening the abscess, antibacterial treatment is prescribed.

Complications and consequences of post-injection abscesses
If the purulent process is not treated or treated incorrectly, then the amount of pus in the capsule can reach such a level when its walls cannot withstand and break through.Purulent contents enter nearby tissues: extensive phlegmonous inflammation is formed, which over time can be complicated by the appearance of fistulas and perforations.
In advanced situations, septic lesion can develop – a generalized infectious disease caused by the ingress of bacteria from a localized focus into the general bloodstream. Another common name for sepsis is blood poisoning, which is considered a serious pathology. Also, the ingress of pathogenic flora into the circulatory system can result in the development of osteomyelitis, in which purulent-necrotic processes are observed in bone tissue, bone marrow and nearby soft tissues.

Prevention
The following rules should be used as preventive measures:
• only disposable syringes and needles should be used for injections;
• with frequent injections, it is necessary to change the injection site;
• Do not administer an injection solution intended for intravenous or subcutaneous infusion, for intramuscular injection;
• Do not administer a drug that is known not to be sterile, or is unusable, or contains impurities or sediment;
• immediately before the administration of the drug, the skin should be disinfected at the injection site with 700 alcohol;
• during the injection, do not touch the needle with your fingers, even if they have been treated with a disinfectant liquid;
• after the administration of the drug, it is necessary to massage the injection site with an alcohol cotton swab for better distribution and absorption of the drug into the muscular system of the body;
• After the injection, monitor the injection site for several days.If a seal has formed around it, this indicates the onset of the inflammatory process;
• Do not inject if interstitial hemorrhage has formed on this site the day before;
• Do not mix several drugs in one syringe if you are not sure that they are pharmacologically and chemically compatible;
• intramuscular and subcutaneous administration of drugs should not be abrupt, so that the drug can be gradually distributed in the tissues.

Do not self-medicate! Injections should be carried out under aseptic conditions, with strict adherence to all rules of disinfection and hygiene.

90,000 Signs and methods of infection and hacking of sites

Every second, your site receives many requests. Some of them are real visitors and customers who want to purchase a product or service on it, read the news or share something. The other part is queries from robots that index content for display in search engines. And among all this variety, there are requests, the purpose of which is to find a vulnerability of your site for hacking or infection.And, if the site is not well protected from such requests, it can be compromised in a matter of minutes.

Treatment of viruses on websites: checklist

So that you can quickly determine the fact of infection of a website by external signs, we have compiled for you a general list of symptoms and causes of malware.

Signs of site infection

Signs can be either explicit or implicit – it depends on the specifics of your site and how the attackers decided to use it after being compromised.

You can quickly check whether a site is infected through a special service in a search engine or using online scanners:

However, it is important to remember that these tools only detect and show malicious inclusions in the site code. And infection can have more serious consequences – for example, when a cryptocurrency miner or a password bruteforcer is installed on the server through hacking a website. In such cases, it is required not only to cure the site, but also to analyze the processes running on the server and search for their roots.

Methods of infection

The list of methods of compromising websites is very extensive. And most often it is specific to each individual resource. Nevertheless, there are well-known approaches:

Infection through CMS vulnerabilities

Standard scenario: researchers discover a vulnerability, inform the CMS developers, they prepare a patch and release an update. After that, information about the discovered vulnerability, usually in the form of an exploit – instructions on how to use the vulnerability – is released to the world.And since updates are often installed out of time by users (56% of sites hacked in 2019 used outdated versions of CMS), a fertile environment for malware appears.

Infection through vulnerabilities of CMS plugins and extensions

The situation is similar, but, alas, much more deplorable. Plugin developers pay very little attention to security – some popular plugins with a huge number of downloads have actual vulnerabilities. Therefore, before installing the next extension, check the reviews about it on the forums or its mentions on information security resources.What can we say about free and unlicensed solutions that can contain vulnerabilities or malware in a ready-made form on purpose.

Infection through vulnerabilities in scripts

No matter how rich the capabilities of the CMS and the lists of plugins are, you always have to independently implement something to solve your specific tasks or connect ready-made libraries. It happens that vulnerabilities appear in certain functions and methods of the language used for this – which makes your site an easy target for hacking or infection.

Infection through password guessing for FTP users

The FTP protocol is used to work with site files. It is not hard to imagine what a leak of access to one of the FTP users could result in: an attacker can either cleanly delete all the contents of the home directory, or freely place malicious software – by uploading a script or editing the site files. And if you remember that in the configuration files of the site, access to the database is also spelled out, ooh…

Infection through vulnerabilities or server hacking

This is one of the worst scenarios. When attackers gain access to a server (usually root), they gain access to all data located on it. Compromise of sites in such cases becomes a secondary matter, but it can take place.

Infection via SQL Injection

SQL Injection is a rather complex mechanism for infecting or hacking, but nevertheless it is popular.By manipulating queries to the database, an attacker can gain access to the data of site visitors or make changes to them – up to adding new users to the admin panel or the database itself.

Infection after data leaks

For example, it is standard practice to hack mailboxes and check messages in them for different authorization data. If in the process a letter is found with access to the server or to the admin panel of the site, write lost.