Infusion-related phlebitis (IRP) refers to inflammation of the vascular endothelial wall that occurs secondary to physical and/or chemical damage from parenterally administered drugs. While the true extent of IRP is not fully known, a large study involving more than 20,000 catheter placements found an incidence rate of 30.7 per 100 catheters. Given how common IRP appears to be, pharmacists can play a major role in both preventing its occurrence and mitigating its effects should it occur.
A recently published paper reviewed the major etiologies of IRP and described potential pharmacologic and nonpharmacologic interventions to prevent and manage IRP and to improve vascular access health—especially when multiple drugs are being administered via IVl.
The pathophysiology of IRP is due to an injurious event to the vascular lining that can result in mechanical, chemical, or infectious IRP.
Mechanical IRP results from catheter-induced friction. Contributing factors for mechanical IRP include catheter location (placement in the lower extremities increases risk); catheter gauge (especially common with large gauge catheters that exceed 33%-45% of the vein’s inner diameter); catheter material (tetrafluoroethylene or Teflon increases the relative incidence 27%-46% compared with newer polyurethane derivatives); and duration of catheterization (catheter should not be changed more frequently than every 72-96 hours).
Chemical IRP occurs when the osmolarity (hyperosmolar fluids with >600 mOsm/L increase risk) or pH (IV drug pH <5 or >9) of the drug differ from that of blood plasma or, less frequently, by contamination from foreign microparticles in the parenteral solution. Parenteral medications that have been associated with chemical IRP due to pH and/or osmolarity excursions include vancomycin, amiodarone, phenytoin sodium, and etomidate. However, IV drugs with pH and tonicity in the physiologic range may also cause chemical IRP as in the case of amphotericin B, erythromycin, imipenem, meropenem, oxacillin, and many chemotherapeutic agents. Drugs that form precipitants such as diazepam, amiodarone, and phenytoin can also induce chemical IRP.
Use of colloidal lipid emulsions can reduce IRP and have been employed with the administration of clevidipine, dexamethasone palmitate, diazepam, etomidate, and propofol. Foreign microparticles that can occur with amoxicillin/clavulanate, vancomycin, dicloxacillin, erythromycin, benzylpenicillin, and cefuroxime increase risk of IRP.
Pharmacists can help reduce the risk of IRP by identifying drugs with high phlebitic potential and implementing strategies to mitigate this risk, such as recommending the use of an inline filter. The article contains an extremely useful table in which it identifies the causative agents and countermeasures for chemical IRP. It lists the potential mechanisms of chemical IRP, such as extremes in pH, high osmolarity, high concentrations, vesicants, drugs that form precipitants, microparticles, high doses, slow infusion rates of medications resulting in prolong drug contact, and countermeasures to reduce risk.
Infectious IRP is due to the migration or infiltration of bacteria into the catheter insertion site from a breach in aseptic technique or postplacement catheter contamination. Maintaining aseptic technique, ensuring adequate drying time for topical antiseptics before catheter insertion (i.e., up to 3 minutes), and avoiding touching the catheter tip to nonsterile surfaces may reduce the occurrence of infectious IRP. Antiseptics that are commonly used include chlorhexidine, iodine tincture, iodophor, and 70% isopropyl alcohol; however, the Infectious Diseases Society advises against the use of povidone iodine as it is associated with an increased risk of blood culture contamination. Additionally, the FDA has warned about rare but serious allergic reactions with topical chlorhexidine gluconate.
The paper also discusses pain-management strategies for patients who develop IRP. External application of topical anti-inflammatory creams or gels (e.g., diclofenac, nitroglycerin, dexamethasone, aloe vera, magnesium sulfate, or heparinoids) can reduce symptoms. Systemic anti-inflammatory agents may be needed. Other interventions include the topical application of a vapocoolant spray following catheterization. The use of generalized pretreatment regimens is controversial.
This article is an excellent resource for pharmacists as it offers ways to help minimize the negative impact of IRP on drug delivery and patient outcomes. Pharmacists can utilize the information presented in making policy and formulary decisions and treatment recommendations.
The content contained in this article is for informational purposes only. The content is not intended to be a substitute for professional advice. Reliance on any information provided in this article is solely at your own risk.