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].

Being one of the most commonly performed procedures on hospitalized patients, peripheral intravenous catheter (PIVC) insertions make them susceptible to infectious and noninfectious complications [3]. 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 [4]. Approximately 7000 patients are admitted in department of medicine at IGMC Shimla per year and nearly 70-80% of these patients require intravenous catheter insertion either for i.v. fluids or antibiotics. The exact incidence of superficial thrombophlebitis is not known and we do not know its effect on patient outcome.

The currently accepted model of the pathogenesis of peripheral vein infusion thrombophlebitis is that catheterization of the vein results in inflammation and thrombus formation. Irritation of the vein, whether due to the infusate, the catheter material, or bacterial colonization of the intravascular segment of the catheter, is thought to cause prostaglandin-mediated activation of the inflammatory cascade. At sites where the endothelium is severely inflamed, clotting intermediates are activated and accumulate; combined with stasis, this can initiate thrombosis. Histopathologic studies of veins following peripheral vein infusion thrombophlebitis demonstrate swelling of endothelial cells, leukocytic infiltration of the vein wall and other changes consistent with inflammation, along with fibrin deposition and thrombus formation. Duration of catheterization is the most important predictor of peripheral vein infusion thrombophlebitis [5], and the Centers for Disease Control and Prevention recommends rotation of catheter sites every 48 to 72 hours to minimize the risk of phlebitis [6].

There are four recognized routes for contamination of catheters:

• Migration of skin organisms at the insertion site into the cutaneous catheter tract and along the surface of the catheter with colonization of the catheter tip; this is the most common route of infection for short-term catheters [7]

  Table 1:      The Center for Disease Control and Prevention Recommendations for Preventing Peripheral Vein Infusion Thrombophlebitis

• Step 1	Select catheter based on the intended purpose and duration of use, and known complications (e.g., phlebitis); consider a polyurethane catheter
  Step 2	Aseptic technique for insertion
  Step 3	Disinfection of the site before insertion, with alcohol, povidone – iodine, or chlorhexidine
  Step 4	Secure catheter with sterile guaze or transparent dressing
  Step 5	Use an upper extremity site in preference to a lower extremity site
  Step 6	Observe catheter site and palpate for tenderness at least daily
  Step 7	Replace catheters and rotate peripheral venous sites every 48 to 72 hours
  Step 8	Remove catheters inserted in emergency rooms within 24 hours and insert a new catheter at a different site
  Step 9	Change tubing no more than every 72 hours unless clinically indicated; change tubing used to deliver blood, blood products, or lipid emulsions within 24 hours of initiating the infusion.
  Step 10	Replace dressing when the catheter is removed or replaced, or when dressing becomes damp, loosened, or soiled.

   

• Direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices [8]

• Less commonly, catheters might become hematogenously seeded from another focus of infection and 

• Rarely, infusate contamination might lead to (catheter related blood stream infections) CRBSI [9]

• Important pathogenic determinants of CRBSI are 

• The material of which the device is made

• The host factors consisting of protein adhesions, such as fibrin and fibronectin, that form a sheath around the catheter; and 

• The intrinsic virulence factors of the infecting organism, including the extracellular polymeric substance (EPS) produced by the adherent organisms

• Some catheter materials also have surface irregularities that enhance the microbial adherence of certain species (e.g., S. epidermidis and C. albicans). Catheters made of these materials are especially vulnerable to microbial colonization and subsequent infection. Due to the formation of the fibrin sheath, silastic catheters are associated with higher risk of catheter infections than polyurethane catheters. On the other hand, biofilm formation by C. albicans occurs more readily on silicone elastomer catheter surfaces than polyurethane catheters. Modification of the biomaterial surface properties has been shown to influence the ability of C. albicans to form biofilm.

• The adherence properties of a given microorganism in relationship to host factors are also important in the pathogenesis of CRBSI. For example, S. aureus can adhere to host proteins (e.g., fibrinogen, fibronectin) commonly present on catheters by expressing clumping factors (ClfA and ClfB) that bind to the protein adhesions.

• PIVC induced complications are one of the most important preventable problems in hospitalized patients which increase the morbidity and prolong the hospital stay. Predisposing factors for phlebitis are use of antibiotics and associated comorbidities like T2DM, obesity and hyperlipidemia. The incidence of PIVC related thrombophlebitis was found to be 53.09% which was comparable with other centers of the world. In this study mostly grade 1 and grade 2 thrombophlebitis were observed. All patients with peripheral venous catheter should be examined for signs of thrombophlebitis at least once daily. A suitable peripheral vein catheter chart should include date of catheterization, development of warmth, erythema, tenderness and a palpable venous cord.

•  Better insertion techniques may be sought to lower the incidence of PIVC related complications and to further delay their onset. Changing catheter is recommended when clinically indicated rather than 72 hours of insertion. We would like to recommend that all patients with peripheral vein catheter in situ be screened for complications of the peripheral venous catheter at least once daily recommended by the CDC guideline on prevention of intravascular catheter‑related infections. Patients with signs and symptoms of phlebitis should have their catheters replaced at a different site. Observation chart to document the development of signs of phlebitis may be developed in a hospital. This would help detect phlebitis much earlier and decrease patients’ discomfort and pain.

1. David, H. “Infections Due to Percutaneous Intravascular Devices.” Principles and Practice of Infectious Diseases, edited by G. Mandell, J. Bennett, and R. Dolin, 6th ed., Churchill Livingstone, 2005, pp. 3347–3352.

2. Sutariya, B., and W. Berk. “Vascular Access.” Emergency Medicine, edited by J. Tintinalli, G. Kelen, and S. Stapczynski, 5th ed., McGraw-Hill, 2000, pp. 103–104.

3. Todd, J. “Peripherally Inserted Central Catheters and Their Use in IV Therapy.” British Journal of Nursing, vol. 8, no. 3, 1999, pp. 140–148.

4. Johansson, M.E., Pilhammar, E., Khalaf, A., and A. Willman. “Registered Nurses’ Adherence to Clinical Guidelines Regarding Peripheral Venous Catheters: A Structured Observational Study.” Worldviews on Evidence-Based Nursing, vol. 5, no. 3, 2008, pp. 148–159.

5. Tagalakis, Vicky, et al. “The Epidemiology of Peripheral Vein Infusion Thrombophlebitis: A Critical Review.” The American Journal of Medicine, vol. 113, no. 2, 2002, pp. 146–151.

6. O'Grady, Naomi P., et al. “Summary of Recommendations: ‘Guidelines for the Prevention of Intravascular Catheter-Related Infections.’” Clinical Infectious Diseases, vol. 52, no. 9, 2011, pp. 1087–1099.

7. Safdar, N., and D.G. Maki. “The Pathogenesis of Catheter-Related Bloodstream Infection with Uncuffed Short-Term Central Venous Catheters.” Intensive Care Medicine, vol. 30, 2004, pp. 62–67.

8. Dobbins, B.M., Kite, P., Kindon, A., McMahon, M.J., and M.H. Wilcox. “DNA Fingerprinting Analysis of Coagulase Negative Staphylococci Implicated in Catheter-Related Bloodstream Infections.” Journal of Clinical Pathology, vol. 55, 2002, pp. 824–828.

9. Raad, I., Hanna, H.A., Awad, A., et al. “Optimal Frequency of Changing Intravenous Administration Sets: Is It Safe to Prolong Use Beyond 72 Hours?” Infection Control and Hospital Epidemiology, vol. 22, 2001, pp. 136–139.