European Journal of Cardiovascular Medicine

Hyperlipidemia describes a condition in which there are elevated levels of serum lipids. Hyperlipidemia is a risk factor for the development of atherosclerosis because the excess lipids in the blood accumulate in the walls of arteries. Oxidation of low-density lipoprotein (LDL) results in the generation of oxidized (ox)LDL, which is a heterogeneous mixture of oxidized lipids and proteins. One bioactive oxidized lipid within ox LDL is oxidized 1-palmitoyl-2-arachidonoyl-sn-glycero-3-phosphoryl-choline (ox PAPC). Ox LDL binds a variety of cellular receptors on macrophages, monocytes, vascular smooth muscle cells (VSMCs) and endothelial cells (ECs). These receptors include the scavenger receptors SRAI/II, SRBI/II, CD36 and the immune receptor toll-like receptor 4 (TLR4).

According to studies conducted over the last two decades, 27 percent to 70 percent of patients receiving peripheral intravenous therapy develop phlebitis, which necessitates the removal of the cannula, the insertion of a new cannula in a different location, and, in many cases, local treatment and analgesic drugs. ^[1] Daily cannula site observation is advised in guidelines for intravenous treatment management, as is rotating cannula sites every 24 to 48 hours to limit the risk of phlebitis and infection. The expense of intravenous therapy is significantly increased as a result of this approach. ^[2]

Over the last two decades, studies about phlebitis have divided the risk factors into four main groups: patient characteristics, therapy administered, health professional practices and cannula characteristics. The condition may resolve easily or proceed to complications like DVT, pulmonary embolism, septicaemia, cellulitis, nodule formation or hyper pigmentation of skin. Moreover, it causes patient discomfort and insertion of a new catheter at a different site is required.

The complications associated with peripheral IV cannula and IV therapy can have a devastating effect on patient’s health and quality of life and also increase the costs of health care through prolonged hospital stay and treatment.[i] Given thrombophlebitis can put patient’s safety at risk, this study is aimed to identify its incidence and associated risk factors in our local community.

All adult patients admitted in Medicine wards and requiring intravenous cannulation over a period of one year were included in this observational study conducted in Department of Medicine of a Tertiary Care Teaching Hospital.

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. 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. Chi square test was applied to determine the association between the use of different drugs and the occurrence of thrombophlebitis. A p-value of less than 0.05 was considered to be statistically significant.

Catheters were inserted for reasons such as administration of fluids, intravenous drugs and blood products. Catheter gauge size was 20 in 249 (85.27%) patients and 18 in 43(14.73%) patients. 131(44.86%) catheters were inserted in the hand, 157(53.77%) in the forearm and 4 (1.37) were inserted at the other sites.  166 (56.85%)cannula were inserted by staff nurse and 126 (43.15%)cannula were inserted by Junior resident.

Cannula size and cannula site were also studied as a risk factors for thrombophlebitis. 28(65.12%) patients with 18 G cannula and 130 (52.21%) patients with 20 G cannula developed thrombophlebitis with p value of 0.058.

Cannula inserted on hand developed thrombophlebitis in 74(56.49%) patients compared to 83(51.60%) patients who have cannula inserted at other sites with P value of 0.400.Cannula were inserted either by staff nurses or Junior Resident and these were also studied as a risk factor for the development of thrombophlebitis. 91(54.82%) patients with cannula inserted by staff nurse and 65(51.59%) patients with cannula inserted by junior residents developed thrombophlebitis with P value of 0.532.

Hyperlipidemia was also studied as a risk factor. 37(71.16%) patients with hyperlipidemia developed thrombophlebitis with P value of  0.004. (Table 1)     

The most common infection encountered in the patients suffering from thrombophlebitis was Tropical Infections, followed by Pneumonia, and Urinary tract infection. Among patients with infectious diseases, 35(52.24%) patients developed thrombophlebitis with P value of 0.824. (Figure 1)

Figure 1: Description of Infections suffering from thrombophlebitis among the study participants.

Large bore catheters generally cause more phlebitis due to greater mechanical irritation. However, in contrast to most studies, our findings did not show catheter bore as a risk factor for phlebitis. One of the possible reasons may be that very large bore catheters (16G) were not used in our patients.

Based on our findings, we believe that if certain risk factors for phlebitis (such as diabetes, infectious diseases, and gender) are taken into account, the rate of phlebitis in high-risk groups can be reduced by: shortening catheter replacement intervals, better supervision during catheter insertion and maintenance, use of milder irritant intravenous drugs, especially antibiotics, and better control of underlying diseases

1. Lewis GB, Hecker JF. Infusion thrombophlebitis. Br J Anaesth. 1985;57:22-33.
2. [1]Hessov I. Prevention of infusion thrombophlebitis. Acta AnaesthesiolScand Supple. 1985;29:33-7.
3. [1]Mermel LA. Prevention of intravascular catheter -related infections. Ann Intern Med 2000; 132:391-402.
4. [1] Tan RH, Dart AJ, Dowling BA. Catheters: a review of the selection, utilisation and complications of catheters for peripheral venous access. Aust Vet J 2003; 81:136-9.
5. [1] Mandal A, Raghu K. Study on incidence of phlebitis following the use of pherpheral intravenous catheter. J Family Med Prim Care 2019;8:2827-31.
6. [1]Magerotel NP, Lima MHM, Silva JB, Lopes MD. Associação entre flebite e retirada de cateteresintravenososperiféricos. Enfermagem 2011;20:486-92
7. [1] Salma, U., Sarker, M., Zafrin, N. and Ahamed, K. (2019). Frequency of Peripheral Intravenous Catheter Related Phlebitis and Related Risk Factors: A Prospective Study. Journal of Medicine, 20(1), pp.29-33
8. [1] Maki DG, Ringer M. Risk factors for infusion -related phlebitis with small peripheral venous catheters. A randomized controlled trial. Ann Intern Med 1991; 114:845-54.
9. [1]Barbut F, Pistone T, Guiguet M, et al. [Complications due to peripheral venous catheterization: prospective study]. Presse Med 2003; 32:450-6. French
10. [1]Ena J, Cercenado E, Martinez D, Bouza E. Cross-sectional epidemiology of phlebitis and catheter -related infections. Infect Control Hosp Epidemiol 1992; 13:15-20
11.