The progress of medical science and technology has been accompanied by the use of new diagnostic and therapeutic devices, each of which is associated with its own complications. One of the devices most used is the Peripheral Intravenous Catheter (PIVC) for drugs, fluid and blood product administration, or blood sampling [1]. One of the most common complications of PIVC is phlebitis. Phlebitis refers to the clinical finding of pain, tenderness, swelling, induration, erythema, warmth and palpable cordlike veins due to inflammation, infection and or thrombosis [2]. Many factors have been implicated in the pathogenesis of phlebitis, namely:

• Chemical factors such as irritant drugs and fluids

• Mechanical factors such as catheter material, size, site and duration of cannulation

• Infectious agents

   Patient factors that may affect the rate of phlebitis include age, gender and underlying conditions (i.e. diabetes mellitus, infections, burns) [3].

      Causes

Etiology of phlebitis can be split into four types: (i) Mechanical, when movement of the cannula inside the vein causes friction and inflammation, or when the cannula is too wide for the vein; (ii) Chemical     phlebitis, caused by the drug or fluid infused through the catheter, where factors such as pH and osmolality can significantly impact the incidence of phlebitis;(iii) Bacterial, when bacteria penetrates the vein, starting as an inflammatory response to catheter insertion and subsequent colonization of the site by bacteria. Bacterial phlebitis can create serious complications due to the potential for the development of systemic sepsis. (iv) Post-infusion phlebitis, normally appears 48 to 96 hours after the catheter is removed. Incidence is related especially to catheter material and the length of time the catheter remained in the patient’s vein [4]. Numerous factors can influence the development of phlebitis, such as improper technique when inserting the catheter, the patient’s clinical situation, the characteristics of the vein, drug incompatibility, tonus and pH of the medicine or solution, ineffective filtration, catheter diameter, size, length and material of manufacture; prolonged use [5]. 

     Types of Superficial Thrombophlebitis:

• Sterile superficial thrombophlebitis-It is the most common type of presentation among all the patients suffering from superficial thrombophlebitis.

• Traumatic superficial thrombophlebitis-Insertion of intravenous cannulation following a limb injury produces irritation due to irritation after ecchymosis of the surrounding tissue.

• Infective superficial thrombophlebitis- It occurs after insertion of intravenous cannula that leads to infection and eventually thrombosis. Use of appropriate antibiotics may prove to be useful.

• Migratory superficial thrombophlebitis - There has been no local cause identified as such but it is mostly found to be associated with an underlying malignancy. Sterile superficial thrombophlebitis- It is the most common type of presentation among all the patients suffering from superficial thrombophlebitis.

• Traumatic superficial thrombophlebitis- Insertion of intravenous cannulation following a limb injury produces irritation due to irritation after ecchymosis of the surrounding tissue.

• Infective superficial thrombophlebitis-It occurs after insertion of intravenous cannula that leads to infection and eventually thrombosis. Use of appropriate antibiotics may prove to be useful.

• Migratory superficial thrombophlebitis-There has been no local cause identified as such but it is mostly found to be associated with an underlying malignancy.

        Complications

• Being one of the most commonly performed procedures on hospitalized patients, Peripheral Intravenous Catheter (PIVC) insertions make them susceptible to infections and non-infectious complications [6]. PIVC complications are classified into minor and major categories based on the severity of symptoms. Minor complications include catheter occlusions, accidental removals, fear of sharp catheters (needle phobia) and pain. On the other hand, major complications tend to be more severe, such as phlebitis, infection, extravasation and even skin injuries [7]. Deep Venous Thrombosis (DVT) is the major complications of superficial thrombophlebitis. The occurrence of an episode of superficial thrombophlebitis is estimated to increase the odds of having deep venous thrombosis by 10 times over a period of 6 months [8]. DVT occurs due to the extension of thrombus through the perforating veins. It may, however, be possible even without such extension in case there is an available anatomical connection, hence strengthening the possibility of a hypercoagulable state after suffering from superficial thrombophlebitis. Studies reveal that the association is more frequent in patients having varicosities [9]. Varicose veins induce certain morphological changes that favor stasis as well as bidirectional blood flow in the perforating veins. However, some studies have shown that the odds of having DVT in the absence of superficial thrombophlebitis is almost 9 times than those having varicose veins [10]. Another complication of superficial thrombophlebitis is Pulmonary Embolism (PE). The frequency of association of PE with superficial thrombophlebitis is seen to be ranging from 3% to 33% [11].

       Grading of Superficial Thrombophlebitis

• Variations of the grading system for peripheral thrombophlebitis have evolved during the past 20 years, including the Maddox scale [12] and the Baxter scale [13] (Table 1).

       Table 1: Grading of Superficial Thrombophlebitis

• Grades	Clinical Criteria
  0	No symptoms
  1	Pain or erythema at intravenous site
  2	Pain at intravenous site with erythema or swelling
  3	Pain at intravenous site with erythema and swelling or a palpable venous cord
  4	Pain at intravenous site with erythema, swelling and a palpable venous cord
  5	Purulent discharge at intravenous site, along with all the signs of grade 4 thrombophlebitis

   

  Investigations

• The diagnosis of superficial thrombophlebitis is clinical. Hence, it remains pertinent to identify any possible cause and determine the extent to which thrombosis has occurred and that whether it has involved the superficial or deep venous systems. It is also important to understand if superficial thrombosis has also led to deep vein thrombosis. In lieu of it, certain investigations are available that indirectly support the evidence of presence of superficial thrombophlebitis, such as Venous duplex ultrasound scanning, hypercoagulability test and levels of D-dimer in blood. Duplex ultrasonography is an optimal venous imaging modality which has been recommended for confirmation of diagnosis. In the absence of any obvious etiology, the possibility of a relationship between superficial thrombophlebitis and hypercoagulability cannot be ruled out. Factor V Leiden mutation is main abnormality of coagulation that has been found to be associated with superficial thrombophlebitis [14]. D-dimer is a fibrin degradation product that is usually elevated in DVT and PE. Since superficial thrombophlebitis is linked to DVT and PE, the presence of increased levels of D-dimer in blood might contribute to the diagnosis for superficial thrombophlebitis and its complications.

   

  Treatment

• The treatment of superficial thrombophlebitis remains variable and controversial. However, therapeutic strategies must include symptomatic relief, limitation of thrombosis extension and, very importantly, reduction of the risk of pulmonary embolism. 

• Currently, there is no single, evidence-based therapy [15]. A recent Cochrane review examined a range of treatment modalities including hosiery, fondaparinux, various formulations of heparin, topical and oral non-steroidal anti-inflammatory drugs and surgery [16]. The review concluded that the available evidence on oral treatments, topical treatment and surgery was too limited to inform clinical practice about the effects of these treatments on venous thromboembolism or superficial thrombophlebitis extension. With respect to anticoagulants, the review concluded that a prophylactic dose of fondaparinux for 45 days seemed to be a valid therapeutic option.

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