Superficial thrombophlebitis Information | Mount Sinai

Thrombophlebitis – superficial

Thrombophlebitis is a swollen or inflamed vein due to a blood clot. Superficial refers to veins just below the skin’s surface.

Superficial thrombophlebitis is an inflammation of a vein just below the surface of the skin, which results from a blood clot. This condition may occur after recently using an IV line, or after trauma to the vein. Some symptoms can include pain and tenderness along the vein and hardening and feeling cord-like. Superficial thrombophlebitis is usually a benign and short-term condition. Symptoms generally subside in 1 to 2 weeks, but hardness of the vein may remain for much longer.

Shown here is erythema following the vascular pattern on a lower extremity. The superficial veins have become inflamed and dilated, causing the discoloration.

Causes

This condition may occur after injury to the vein. It may also occur after having medicines given into your veins. If you have a high risk for blood clots, you may develop them for no apparent reason.

Risks for thrombophlebitis include:

• Cancer or liver disease
• Deep vein thrombosis
• Disorders that involve increased blood clotting (may be inherited)
• Infection
• Pregnancy
• Sitting or staying still for a prolonged period
• Use of birth control pills
• Swollen, twisted, and enlarged veins (varicose veins)

Symptoms

Symptoms may include any of the following:

• Skin redness, inflammation, tenderness, or pain along a vein just below the skin
• Warmth of the area
• Limb pain
• Hardening of the vein

Exams and Tests

Your health care provider will diagnose this condition based mainly on the appearance of the affected area. Frequent checks of the pulse, blood pressure, temperature, skin condition, and blood flow may be needed.

Ultrasound of the blood vessels helps confirm the condition.

If there are signs of an infection, skin or blood cultures may be done.

Treatment

To reduce discomfort and swelling, your provider may recommend that you:

• Wear support stockings, if your leg is affected.
• Keep the affected leg or arm raised above heart level.
• Apply a warm compress to the area.

If you have a catheter or IV line, it will likely be removed if it is the cause of the thrombophlebitis.

Medicines called NSAIDs, such as ibuprofen, may be prescribed to reduce pain and swelling.

If clots in the deeper veins are also present, your provider may prescribe medicines to thin your blood. These medicines are called anticoagulants. Antibiotics are prescribed if you have an infection.

Surgical removal (phlebectomy), stripping, or sclerotherapy of the affected vein may be needed. These treat large varicose veins or to prevent thrombophlebitis in high-risk people.

Outlook (Prognosis)

This is usually a short-term condition that does not cause complications. Symptoms often go away in 1 to 2 weeks. Hardness of the vein may remain for much longer.

Possible Complications

Complications are rare. Possible problems may include the following:

• Infections (cellulitis)
• Deep vein thrombosis

When to Contact a Medical Professional

Contact your provider for an appointment if you develop symptoms of this condition.

Also contact your provider if you already have the condition and your symptoms worsen or do not get better with treatment.

Prevention

In the hospital, swollen or inflamed veins can be prevented by:

• The nurse regularly changing the location of your IV line and removing it if swelling, redness, or pain develop
• Walking and staying active as soon as possible after surgery or during a long-term illness

When possible, avoid keeping your legs and arms still for long periods. Move your legs often or take a stroll during long plane trips or car trips. Try to avoid sitting or lying down for long periods without getting up and moving about.

Cardella JA, Amankwah KS. Venous thromboembolism: prevention, diagnosis, and treatment. In: Cameron AM, Cameron JL, eds. Current Surgical Therapy. 13th ed. Philadelphia, PA: Elsevier; 2020:1072-1082.

Wasan S. Superficial thrombophlebitis and its management. In: Sidawy AN, Perler BA, eds. Rutherford’s Vascular Surgery and Endovascular Therapy. 9th ed. Philadelphia, PA: Elsevier; 2019:chap 150.

Last reviewed on: 5/10/2022

Reviewed by: Deepak Sudheendra, MD, MHCI, RPVI, FSIR, Founder and CEO, 360 Vascular Institute, with an expertise in Vascular Interventional Radiology & Surgical Critical Care, Columbus, OH. Review provided by VeriMed Healthcare Network. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

What are the stages of catheter-related phlebitis?

Phlebitis stages indicates the severity of inflammation in a vein due to an intravenous (IV) catheter. The score ranges from 0–4, according to how severe the symptoms are.

Symptoms in the early stage involve redness and pain at the IV site. If the condition progresses to the advanced stage, additional symptoms include swelling and a palpable venous cord, which is firmness in the vein.

In the early stage, doctors recommend removing the IV device and inserting a new one in another site. If phlebitis reaches the medium stage, they advise considering treatment.

One treatment may entail topical anti-inflammatory medications for people to apply to the skin over the vein. Another treatment option is an oral medication to reduce the formation of blood clots.

Keep reading to learn more about phlebitis stages due to IV therapy, causes, diagnosis, treatment, and outlook.

Phlebitis is the inflammation of a vein, which results in redness, swelling, and pain. It can happen in an arm when a person receives IV therapy in a hospital.

The condition may also occur from a blood clot. When this happens, it is called thrombophlebitis. This may affect veins near the surface of the skin or deeper veins, but it usually occurs in the leg.

The staging system only applies to phlebitis due to IV therapy, a method of putting fluids into the bloodstream. It involves inserting a tube called a cannula into a vein. Approximately 25–35% of people who receive IV therapy in a hospital acquire phlebitis, notes an older 2002 study.

The chart below shows the phlebitis staging scale for IV therapy.

Stage	Description
Score of 0.	The IV site looks healthy.
Score of 1.	The IV site looks slightly red, and a person experiences slight pain near the site.
Score of 2, or early-stage phlebitis.	Redness and pain at the IV site are present.
Score of 3, or medium stage phlebitis.	Redness, swelling, and pain along the path of the IV cannula are present.
Score of 4, or advanced stage phlebitis.	Signs include redness, swelling, a palpable venous cord, and pain along the path of the IV cannula.

Causes of phlebitis include:

• infection
• injury
• irritation

The use and removal of an IV can lead to these causes. A 2016 study explains that IV-related phlebitis may stem from:

• Mechanical damage: This may happen when movement of the IV cannula inside a vein produces friction. It can also be due to irritation when a cannula is too wide for a vein.
• Chemical damage: This may occur when a drug or other component of fluid flowing through an IV has a characteristic that produces vein irritation.
• Infection: In response to IV insertion, bacteria may infiltrate a vein. This can create serious complications if the infection develops into sepsis. In sepsis, the infection leaves the IV site and becomes systemic, or circulates throughout the body.

Aside from IV therapy, thrombophlebitis can cause injury or trauma to a vein. If it affects a vein close to the skin surface, doctors call this superficial thrombophlebitis.

Risk factors for surface thrombophlebitis include:

• smoking
• taking oral contraceptives or hormone replacement therapy
• pregnancy
• underlying cancer

If phlebitis involves an IV site, a diagnosis may be evident by observing the symptoms.

In contrast, if symptoms suggest superficial thrombophlebitis, the following procedures are necessary for diagnosis:

• Physical examination: This entails noting any symptoms of redness, warmth, and tenderness over the track of a surface vein, along with a palpable cord.
• Medical history: This includes discovering whether a person has risk factors or conditions that may cause injury to a vein.
• Ultrasound: This imaging test can show the extent of superficial thrombophlebitis. It may also determine whether it has developed into the complication of deep vein thrombosis, a blood clot in a deep vein.
• D-dimer blood test: This test measures a protein fragment that results when a blood clot dissolves. As the level of D-dimer is not always higher than normal in superficial thrombophlebitis, its use is limited.

Treatment of IV-related phlebitis differs from the treatment of superficial thrombophlebitis.

Treatment for IV-related phlebitis

In the early stage, experts recommend removing the IV and inserting a new one in a different site. Once phlebitis reaches the medium stage, they also advise considering treatment.

A 2015 review evaluated the effectiveness of treatments for IV-related phlebitis. Due to limited, poor-quality data, the authors concluded that research is too preliminary to determine how well current treatments work. However, options include:

• Topical treatments. Examples include a nonsteroidal anti-inflammatory drug such as diclofenac gel (Voltaren) or a medication to reduce swelling of inflamed veins such as heparinoid (Hirudoid).

• Nonsteroidal anti-inflammatory drugs: These decrease inflammation and include medications, such as ibuprofen.

Treatment for superficial thrombophlebitis

Research from 2018 reports that most cases of superficial thrombophlebitis resolve on their own. Treatment may involve:

• elevating the leg above the heart to reduce swelling
• wearing elastic stockings
• applying warm compresses to the area
• using topical or oral anti-inflammatory medications

If superficial thrombophlebitis is more severe, treatment may include an anticoagulant, such as fondaparinux (Arixtra).

When the cause of the condition is an infection, in rare cases, treatment may necessitate surgical removal of the infected part of the vein.

Cases of phlebitis from an IV infusion can range from those involving mild discomfort to those with severe complications, such as sepsis. The outlook depends on the severity.

Phlebitis stages are a grading system that doctors use to diagnose and monitor the severity of inflammation of a vein associated with IV therapy.

Doctors do not use phlebitis stages to diagnose the severity of thrombophlebitis. Instead, the diagnostic process involves a physical exam, history, and ultrasound.

There are some differences in treatment between IV-related phlebitis and thrombophlebitis. Yet both conditions may entail treatment with nonsteroidal anti-inflammatory drugs or anticoagulants.

Accidental infusion past a vein – how to identify and what to do?

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The likelihood of infiltration and extravasation is significantly reduced if the nurse understands the causes of these phenomena, correctly selects the vein for puncture or catheterization and equipment, and carefully monitors the patient.

According to standard nursing practice, infiltration is the inadvertent introduction of a drug solution into the tissues surrounding a vein. Such drugs can cause irritation of surrounding tissues if they are in the subcutaneous tissue, but if they are poured onto the skin, contact dermatitis may develop. Extravasation is the introduction of a significant amount of a drug solution past a vein, and in some cases it is even accompanied by tissue necrosis.

In this regard, it must be remembered that some drug solutions are not intended for administration into peripheral veins. Infiltration and extravasation occur most often when the catheter is not completely in the lumen of the vein, or there is a gap in the vein wall that allows the solution to leak. Causes of this phenomenon:

• The catheter was inserted into the vein incorrectly;
• The vein is damaged, there is swelling of the tissue around, which prevents the proper flow of blood, the solution is retained and flows into the surrounding tissues;
• A thrombus forms inside the vein or around the catheter, which retains the solution, it goes out into the surrounding tissues. Also, phlebitis or thrombophlebitis develops at the same time;
• Catheter pierces or develops the opposite wall of the vein, which may also be accompanied by phlebitis or thrombophlebitis;
• The catheter is pulled out of the lumen of the vein due to movement of the patient or due to insecure fixation.

Although most often infiltrates and extravasations occur with infusion into a peripheral vein, these complications can also develop with the use of central venous catheters and implantable ports. In this case, the consequences can be catastrophic due to the large volume of solution used, and also because these devices are used to administer concentrated and viscous solutions.

In most cases, infiltrates do not lead to severe tissue damage, but they are very uncomfortable for the patient. You also have to remove the catheter from the vein and install a new one, which can reduce the number of potentially accessible veins, take time and increase costs.

The most serious consequences occur when irritating solutions, such as those containing calcium, potassium or chemotherapy drugs, are outside the lumen of the vessels. Tissue damage can be directly dependent on the pH of the solution: strongly alkaline or acidic solutions cause real chemical burns. Highly concentrated drugs can even cause tissue necrosis.

The degree of damage due to infiltration or extravasation may depend on how quickly all measures are taken, since even a small amount of fluid creates compression and damage. With early detection and treatment of infiltrates and extravasates, damage to nerves and tissues can be prevented, and surgical intervention can be prevented. Failure to recognize these complications in a timely manner can lead to permanent deformity and loss of function, even if the patient undergoes reconstructive surgery. Often such mistakes end up in litigation.

To avoid problems, be on the lookout for signs and symptoms of infiltration and extravasation, which include:

• “Puffed up” skin that looks shiny, tight and tight;
• Swelling at the insertion site of the needle or catheter;
• Skin cold to the touch;
• Discomfort;
• Slow down or stop infusion;
• Leakage of drug solution around injection site or under dressing;
• If a tourniquet is applied over the infusion site, the infusion does not stop;
• There is no blood flow through the catheter if the vein is clamped and the bag with the solution is lowered (the presence of blood does not exclude infiltration).

Discomfort and burning when infused with an irritant or viscous solution may indicate vessel damage. A complaint of pain at the site of a catheter or needle into a vein is the main sign that you need to intervene quickly. In this case, the following measures must be taken:

• Stop infusion;
• If there are no contraindications, insert a catheter into a vein in the other arm;
• For infiltration, apply a compress; if extravasation occurs, especially calcium chloride, seek immediate medical attention.

Before administering a viscous, vasoconstrictive or toxic drug solution, it is necessary to know which neutralizing agents (antidotes) are used for extravasation and infiltration.

To prevent infiltration, a suitable vein must be chosen. Choose a smooth and bouncy vein that doesn’t look like a knotted rope. Avoid flexion surfaces of the joints, as catheter displacement occurs most often here. If this is the only place where the catheter can be placed, use a splint. If the patient is conscious, the infusion is long, and he wants to move, and for example, read a book, then it is better to avoid using the veins of the hand.

Most often, it is optimal to catheterize the veins of the forearm, especially the inner part of it. The bones are a natural splint, the veins are fairly well fixed, so the likelihood of catheter displacement is greatly reduced.

Start picking a vein in the forearm as low as possible (don’t use a recent venipuncture), but don’t use veins on the outer surface of the forearm near the wrist, as the nerves run close there. It is better not to use the veins of the inner part below the elbow (antecubital fossa) – infiltration in this zone is very easy to see and it can be rather big. With significant infiltration in the antecubital fossa, the fluid compresses important anatomical structures and can lead to nerve damage and tissue necrosis.

To maximize the mixing of the drug solution with the blood, choose the smallest possible diameter catheter, this will allow the blood to mix with the infusate and ensure its adequate dilution.

Always guide the needle with the bevel upwards to reduce the risk of puncture through the vein, secure the catheter carefully so that it does not move, especially in children and the elderly.

After the doctor places the catheter in the central vein, or the nurse places the catheter in the peripheral vein, the puncture site is checked every hour or two, especially if a long infusion is carried out. Make sure that the site of the vein puncture is clearly visible (it is better to use transparent tapes, not gauze pads).

Check regularly for any tension or swelling at the insertion site. Ask the patient if there is pain, if he cannot speak, check the puncture site more often. If you notice infiltration or extravasation, stop the infusion immediately and check to see what has happened. If the infiltrate is large, or the solution was irritating, call a doctor immediately. If the catheter remains in place, you can try to aspirate part of the liquid that has entered the tissues with a syringe, and an antidote can also be injected through the catheter.

After removal of the catheter, the affected arm should be kept in an elevated position (for example, on a pillow), and a cold compress should be applied, if these are chemotherapy drugs, then a warm compress. If necrosis appears (usually after 2-3 days), it may be necessary to consult a surgeon.

How to document the complications of infusion therapy

First, the site of altered tissue must be measured so that the effectiveness of the treatment can then be assessed. It is imperative to monitor the condition of the skin and soft tissues in order to avoid serious complications, and it also helps to assess the quality of medical care.

The use of limb fixation devices, especially in pediatric and geriatric practice, can produce surprising results: the rate of catheter displacement can be reduced to zero without serious consequences. Compliance with the simple techniques described above can prevent complications. Well, if it did arise, then the consequences can be minimized if you quickly and adequately respond to what happened.

Separately about central venous catheters and implantable ports

In accordance with international standards, a drug solution having a pH of less than 5 and more than 9 should not be administered through peripheral veins. For example, these are vancomycin (pH, ∼2.4) and phenytoin (pH, ∼12). The same applies to solutions containing more than 5% protein hydrolysate, or 10% glucose.

Since extravasation of such a solution can have catastrophic consequences, they are all administered through a central venous catheter or implantable port. If you have to inject such a solution into a peripheral vein once, then it is injected through a thick catheter, through a side port during the infusion of saline, it is preferable to have a separate catheter for such purposes.

When infusing a viscous or irritating solution through a central venous catheter, the return flow of the catheter should always be checked and repeated frequently during infusion. If there is no reverse blood flow, then this can indicate the exit of the catheter from the lumen of the vein, and the leakage of the solution into the surrounding tissues. There may also be catheter thrombosis – in this case, immediately stop the infusion and call a doctor to avoid serious consequences.

Sometimes the doctor will do an X-ray-guided contrast study to make sure the catheter is open and can dissolve the clot.

If venous access is through an implantable port, it is important to choose a needle of adequate length so that it does not jump out of the port and the solution does not go into the surrounding tissue. If the needle turns out to be too long, then this can lead to damage to the port membrane, as a result of which extravasation will occur already through the membrane.

When medication is infused through an implantable port, the site of the port should be inspected frequently, as with a peripheral venous catheter, to promptly identify any leakage or swelling of the subcutaneous tissue near the port. If the patient complains of ANY discomfort, stop the infusion immediately and see what happens. If you suspect problems with the port, call a doctor immediately. Sometimes the port can become detached from the catheter, in which case the patient needs immediate surgery.

Infusion Site Infiltration Scale (Journal of Infusing Nursing, 2006)

0 no symptoms
1 point – tense skin, swelling up to 2.5 cm in diameter, cold skin, pain may or may not be
2 points – Skin is tight, swelling from 2 to 12 cm in any direction, skin is cold to the touch, pain may or may not be
3 points – the skin is tense and translucent, large swelling – more than 15 cm, in any direction, the skin is cold to the touch, the pain is moderate or moderate, there may be numbness
4 points – The skin is tense, translucent, dense, may even be damaged, discolored, there is a pronounced edema, more than 15 cm, in any direction, the edema is deep, there are blood flow disorders, pain is moderate to severe, there may be bruising

To the last, the most severe degree of infiltration also includes leakage of any blood product, irritant or very viscous solution.

References

1. Hadaway LC. Preventing extravasation from a central line. Nursing2004. 34(6):22-23, June 2004.
2. Hadaway LC. Reopen the pipeline for I.V. therapy. Nursing2005. 35(8):54-63, August 2005.
3. Infusion Nurses Society. Infusion nursing standards of practice. Journal of Infusion Nursing. 29(1S):S1-S92, January/February 2006.
4. Khan MS, Holmes JD. Reducing the morbidity from extravasation injuries. Annals of Plastic Surgery. 48(6):628-632, June 2002.
5. Luke E. Mitoxantrone-induced extravasation. Oncology Nursing Forum. 32(1), January 2005. http://www.ons.org/publications/journals/ONF/Volume32/Issue1/
6. Stranz M. Adjusting pH and osmolarity levels to fit standards and practices. JVAD. 7(3):12-17, Fall 2002.
7. Weinstein S. Plumer’s Principles and Practices of Intravenous Therapy, 8th edition. Philadelphia, Pa., Lippincott Williams & Wilkins, 2006.

Side effects of intravenous drips – ivtherapy

Side effects of intravenous drips – ivtherapy

Side effects of intravenous drips

Is intravenous vitamin C safe?

This is a concern for all our patients, as vitamin C is included in all of our cocktails.

A 2010 study evaluating the use of vitamin C among medical practitioners found that, after evaluating more than 9,000 patients, only minor side effects were noted, which included lethargy/fatigue, changes in mental status, and venous irritation. Clinically, if these effects occur, they are temporary and easily corrected.

Precautions to be observed when treating with drips:

Start with small doses of vitamin C.

We are also required to rule out kidney disease (ureter disease, kidney failure).

Rare hemolysis may occur in patients with erythrocyte glucose-6-phosphate dehydrogenase (G6PD) deficiency and therefore may be tested in some cases.
Localized pain at the infusion site may occur if the infusion rate is too high or the pH is too low. This is easily fixed by either slowing down the speed or changing the formula.

Vitamin C may decrease calcium, chloride and potassium levels and as a result some patients may experience trembling or pain. This is treated by further adjusting the formula with these ingredients.

Given the amount of fluid and sodium that are used as carriers of vitamin C, any condition that may be affected by an increased fluid load (eg, congestive heart failure, ascites, edema, pleural effusion, etc.) should be controlled more protocol carefully and specifically. Therefore, in our clinic, such diagnoses in the anamnesis are contraindications to the appointment of droppers.

As with any intravenous injection, infiltration or irritation of the veins is always a possibility.

What health benefits can be expected from intravenous vitamin drips?

Correction of any possible vitamin C deficiency (fatigue, bleeding).
Immunomodulation (strengthening of immunity).
Cytotoxic for cancer (has chemotherapeutic potential).
Supports white blood cells.
Stimulates the formation of collagen.
Inhibits hyaluronidase (prevention of cancer spread).