Incidence of phlebitis associated with the use of peripheral IV catheter and following catheter removal

ABSTRACT Objective: to investigate the incidence of phlebitis and its association with risk factors when using peripheral IV catheters (PIC) and following their removal - (post-infusion phlebitis) in hospitalized adults. Method: a cohort study of 171 patients using PIC, totaling 361 punctures. Sociodemographic variables and variables associated with the catheter were collected. Descriptive and analytical statistical analyses were performed. Results: average patient age was 56.96 and 51.5% of the sample population was male. The incidence of phlebitis was 1.25% while using PIC, and 1.38% post-infusion. The incidence of phlebitis while using PIC was associated with the length of time the catheter remained in place, whereas post-infusion phlebitis was associated with puncture in the forearm. Ceftriaxone, Clarithromycin and Oxacillin are associated with post-infusion phlebitis. Conclusions: this study made it possible to investigate the association between risk factors and phlebitis during catheter use and following its removal. The frequency of post-infusion phlebitis was larger than the incidence of phlebitis with the catheter in place, with Phlebitis Grade III and II being the most frequently found in each of these situations, respectively. Aspects related to post-infusion phlebitis can be explained, given the limited number of studies addressing this theme from this perspective.


Introduction
Peripheral IV catheterization (PIC) is the most common invasive procedure performed on hospitalized patients (1) . It requires manual dexterity and tec hnical competence, knowledge of pharmaceutical therapy and familiarity with the anatomy and physiology of the vascular system. Because catheterization is done for different purposes and for different lengths of time, it represents a potential risk for a number of safety incidents, including microbial growth (2) . However, regardless of the generating factor, local complications take the form of bruises, infiltration, leakage, catheter obstruction and phlebitis (3) .
Phlebitis is an inflammation of the vein, which may bring with it pain, erythema, edema, hardening and/ or a palpable thread (4) . Numerous factors can influence the development of phlebitis, such as inadequate 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 (3,(5)(6) .
Phlebitis can be split into four types (7)(8) : mechanical, when movement of the cannula inside the vein causes friction and inflammation, or when the cannula is too wide for the vein; 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; 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 (7) . 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 (8) .
Phlebitis manifests in four grades: Grade 1erythema around the puncture site, with or without local pain; Grade 2 -pain at the puncture site with erythema and/or edema and hardening; Grade 3: pain at the puncture site with erythema, hardening and a palpable venous cord; Grade 4: pain at the puncture site with erythema, hardening and a palpable venous cord that is > 1 cm, with purulent discharge.
A search of the LILACS and SCIELO databases between 2003 and 2014 using "phlebitis" as the search criterion found 16 and 18 articles respectively, of which four and five respectively were relevant to this analysis, including repetitions. Only one of these had post-infusion phlebitis as a topic.
The incidence of phlebitis in the literature varies quite a bit, with reports ranging from 61.2% (9) to 1.3 %(10) .
The acceptable rate in any given population of patients is at most 5% (11) . Thus, this study is justified due to the need to monitor and track the incidence of phlebitis in this teaching institution.
By analyzing the aspects above, we found gaps in the knowledge of the incidence of phlebitis, especially post-infusion phlebitis. Given the need for research on this topic and its importance as an indicator of the quality of nursing care, the goal of this study is to investigate the incidence of phlebitis and the association between risk factors and the incidence of phlebitis while using and following the removal of PIC (post-infusion phlebitis) in hospitalized adults.

Method
This is a cohort study. respectively). Table 1 shows the descriptive data of age and gender, and those related to the use of PICs.   Table 3 shows the frequency of phlebitis while using PIC and following PIC removal, and the association of     Table 4 shows the results of the association of phlebitis during catheter use and following withdrawal and the use of drugs, by group. None of the groups of drugs studied showed any association with phlebitis.

Discussion
The results of following 171 hospitalized patients using PIC enabled important analyses that can contribute to elucidating a number of aspects related to the incidence of phlebitis during intravenous therapy.
Regarding incidence, our study showed that total incidence (2.63%) and the incidence of phlebitis during PIC use (1.25%) and following catheter removal (1.38%) were within the international guidelines of the Intravenous Nurse Society (4) , or less than 5%. Compared to other studies (10,14 ), we found a wide variation in incidence, from 1.3% to 25.8%. This may be due to the different methods used and the specific limitations of each study.
We found a higher incidence of phlebitis after catheter removal (1.38%) than when the PIC was in place. Literature searches found no data comparing the incidence of phlebitis during PIC use and after removal, which demonstrates the need for further studies on this topic, and the importance of monitoring the insertion site following catheter removal, a procedure that is not well disseminated and that makes a major difference in early identification of post-infusion phlebitis. This etiology is likely due to an inflammatory reaction starting close to the moment when the catheter was removed, with still with no visible symptoms. This should be considered in protocols so as not to underestimate the incidence or prevalence of phlebitis in the institution.
Regarding Grade, the most frequent grade of phlebitis found during catheter use was Grade II, while Grade III was the most common in post-infusion phlebitis. Other studies corroborate these findings, with Grade I and II phlebitis being more common with PICs in place (3,6) . We found no studies elucidating the Grade of phlebitis in post-infusion phlebitis, once again showing the need to investigate this topic and train nursing teams in the specificities of post-infusion phlebitis.
Of the 361 PIC punctures analyzed, the average permanence of the catheters was 3.37 ± 1.11 days, and the median 3 days, as recommended by ANVISA and the Royal College of Nursing , (15)(16) . Of the 167 catheters remaining for more than 72 hours, 24 patients (14.4%) showed the signs and symptoms of phlebitis. There was a significant (p=0.016) incidence of phlebitis compared to those who did not develop phlebitis. We found that the length of time the catheter remains in place influences the appearance of phlebitis, as found in another study, where the incidence of phlebitis was 62.5% when PICs remained in place longer than 72 hours.
Regarding gender and age, we found no statistical association with the incidence of phlebitis, unlike another study (8) , claiming that one of the risk factors is being older than 65. However, in terms of gender it agrees with the study (9) that states there is no association between gender and phlebitis.
Although the forearm is the preferred location for puncture due to its thick veins (6) , only 1.9% of the punctures in this study were in the forearm. On the other hand, this location was of limiting significance (p=0.054) in terms of developing phlebitis, when compared to other locations. Another study found no significant association between part of the body and phlebitis (3) , however the forearm was the location of puncture most often used by the nursing team.
When we analyzed the incidence of phlebitis against the gauge of the IV catheter, we found the most frequently used gauges were 22G and 24G (94.5%). We found limiting significance (p=0.057) in the incidence of post-infusion phlebitis when larger caliber catheters were used (18G and 20G). These findings coincide with those of another study (3) , where 65% of the phlebitis cases were in patients in which 18G and 20G catheters had been used, unlike a previous study (17) that found a higher incidence of phlebitis (80.7%) when using 22G and 24G catheters.
When we looked at the therapeutic class of the drugs we monitored, 51.0% of the patients used antibiotics while the PIC was in place, however we found no significant association with the incidence of phlebitis. Yet when looking at each drug individually, Ceftriaxone (p=0.033), Clarithromycin (p=0.014) and Oxacillin (p≤ 0.001) showed an association with postinfusion phlebitis. Looking at the package leaflets for these drugs (18) , we found that phlebitis was listed as a possible adverse reaction only for Ceftriaxone and Oxacillin, which is in agreement with the findings of the present study.
Other medicines, while not showing any significant association, did have relevant results, such as amiodarone and ferric hydroxide, where we found a higher percentage of the signs of phlebitis in patients using these medicines (20.0% and 23.8% respectively) than in those who did not. We also found a higher percentage of post-infusion phlebitis among patients who used vancomycin (33.3%) than among not making use of this medication. In terms of the pH of the medicines, the more acidic the higher the risk of chemical phlebitis (19) , which is in agreement with the findings regarding oxacillin (pH of 4.5 -7.5) (20) ,

Conclusion
This study allowed us to look at the association between risk factors and the incidence of phlebitis This study helped elucidate aspects related to the incidence of post-infusion phlebitis. It is important to intensify education and training in early identification of phlebitis, and to monitor the insertion site after the catheter is removed, as few studies have addressed this topic from this perspective.