Thrombophlebitis is the most common complication of intravenous catheters and can lead to many problems and increased costs [1]. The peripheral vein is traumatised during the insertion of the peripheral venous catheter. This initial trauma and presence of foreign body in the vein stimulates an inflammatory response which predisposes to the development of thrombus and thus thromboembolism [2]. Infusion phlebitis, defined as the inflammation of the cannulated vein, is a frequent cause of pain and discomfort [3].

There are many factors that contribute to the aetiology of thrombophlebitis. These factors include cannula material, length, and bore size; operator skill in insertion; the anatomic site of cannulation; the duration of cannulation; the frequency of dressing changes; the character of the infusate; and host factors, such as patient age, Caucasian race, female gender, and the presence of underlying diseases [4].

Guidelines for the management of intravenous therapy have recommended daily surveillance of cannula sites and, to reduce the risk for phlebitis and infection, the rotation of cannula sites every 24 to 48 hours. This practice adds considerably to the costs of intravenous therapy. Most investigators have concluded that infusion phlebitis is primarily a physicochemical phenomenon [5]. Keeping this in mind, the objective of the study was to determine the procedures for cannulation and estimate the grades of thrombophlebitis thereafter. 

All adult patients admitted in Medicine wards and requiring intravenous cannulation during the period from Jul 2018 to Jun 2019 were included in this observational study conducted in Department of Medicine, Indira Gandhi Medical College (IGMC), Shimla, Himachal Pradesh. 

The patients were excluded if already suffering from thrombophlebitis at the time of admission, unconscious patients, patients with pre-existing septicaemia, patients who were hemodynamically unstable, patients who were cannulated in casualty, and/or patients who had already been cannulated at periphery. The study was initiated following approval from institute ethics committee at IGMC Shimla. All the study participants were included after they agreed to participate in the study. 

Data was entered in Microsoft Excel spreadsheet and analysed using Epi Info software version 7.2.2. Categorical data were presented as number of patients, their percentage and 95% Confidence Intervals. For quantitative variables, means and standard deviations was calculated.

Catheters were inserted for reasons such as administration of fluids, intravenous drugs and blood products. Most commonly, the catheter gauge size, used, was 20 in 236 (87.73%) patients and 18 in 33 (12.27%) patients. 119 (44.24%) catheters were inserted in the hand, 48 (55.02%) in the forearm and 2 were inserted at the other sites.153 (56.88%) cannula were inserted by staff nurse and 116 (43.12%) cannula were inserted by Junior resident. 

Standard Operating Procedures were followed in most of the patients, dressing of the cannula site was done daily and change of the cannula site was done every 72 hrs or earlier if indicated. In 13 patients (4.83%) SOP were not followed & in 15 (5.58%) out of 269 patients dressing of the cannula site was not done (Table 1).

At 24 hours, 16(5.95%) patients developed grade 1 thrombophlebitis. At 48 hours, 60 (22.39%) patients developed grade 1 thrombophlebitis, 14 (5.22%) developed grade 2 thrombophlebitis and 1 (0.37%) patient developed grade 3 thrombophlebitis. At 72 hours, 93 (36.90%) patients developed grade 1 thrombophlebitis and 34 (43.49%) developed grade 2 thrombophlebitis. 55 out of 269 patients were suffering from infectious diseases. Mostly patients were suffering from urinary tract infection, pneumonia, enteric fever, tropical infections like scrub typhus and other less common infections. Out of 269 patients, 253 (94.05%) were discharged, 12 (4.46%) patients died and 4 (1.49%) developed complications. Mean duration of hospital stay was 4.32 days with standard deviation of 1.48 days. 

Table 1: Description of the Cannulation procedure done among the study participants (N=269)

Large bore catheters generally cause more phlebitis due to greater mechanical irritation. The use of smaller calibre catheter is related to reducing the occurrence of phlebitis. Since they prevent mechanical irritation to the interior walls of small diameter veins [6]. Various studies have demonstrated that G20 and G22 were the main catheter sizes used (68.10% and 26.67% respectively), only 5.24% cannula was 18G, which is in discordance with our study as we had used 18G cannula in majority of the patients [7]. A study conducted by Abhijit Mandal & Raghu, showed that the incidence of phlebitis was higher when a larger calibre catheter was used and it was less in 20 G catheter. These findings coincide with the study conducted by Magerotel et al. [8].

Dressing regimens and methods of securing catheters may contribute to the occurrence of infection contributing to the complications including infiltration extravasation and catheter displacement. This finding was in agreement with the conclusion of a systematic review and meta-analysis that demonstrated the absence of any relationship between the type of dressing used in PIVC insertion sites and the recurrence of phlebitis, infiltration or skin dwelling bacteria in adult patients [9]. 

Table 2: Clinical profile and grading of Thrombophlebitis among the study participants (N=269)

In our study mostly Grade 0 followed by Grade 1 thrombophlebitis were observed. Grade 0 was more common. This might be because of the good nursing care provided to the patients. Most cases of thrombophlebitis were detected and preventive measures taken before severe forms or complications developed. In our hospital, the cannula was immediately replaced once the patient complains of pain or even slight erythema or swelling, so grade 2 and 3 were not observed. Some studies have shown that the rate of phlebitis increases with the time the cannula remains in situ [10]. So, scheduled replacement of IV cannula has been recommended. But recent studies showed that there is no increase in cannula related complications when the duration prolonged up to 96 hours [11]. But the cannula must be checked daily and if any evidence of phlebitis or infection is detected it must be removed immediately [12].

Most of the patients were suffering from UTI, Pneumonia, enteric fever, tropical infections like scrub typhus or leptospirosis and other non- specified infections. This is in contrast to the results of the studies conducted by Maki et al. [13], Tan et al. [14] and Ena et al. [15] in which no such findings were observed other than local erythematous reactions. 

Thrombophlebitis has a multifactorial etiology. It is also attributed due to the type of cannula used, the duration for which the cannula is used, the method of insertion of cannula, the personnel who use the cannula and the Standard Operating Procedures followed. We also discussed the various infections that were seen in patients with thrombophlebitis. However, further analytical studies are required to determine the association of the above-mentioned risk factors with thrombophlebitis.

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