Risk factors for the development of phlebitis: an integrative review of literature

Abstract

OBJECTIVE

To describe the scientific evidence published in literature regarding the risk factors for the development of phlebitis.

METHOD

Integrative literature review with the inclusion of 14 original articles found in the LILACS, Scielo and Pubmed bases from January 2004 to April 2015, analyzed by levels of evidence and frequency, associated factors, degree and treatment of phlebitis.

RESULTS

The frequency / incidence / minimum rate of phlebitis was 3% and the maximum was 59.1%. Most articles (57.14%) reported an association of phlebitis with risk factors, including the dwell time, puncture site and / or anatomical region, hospitalization period, number of accesses, reason for removal, sex, antibiotics, intermittent maintenance and emergency insertion.

CONCLUSIONS

The need for standardizing the quantification of this event and a weak connection between the risk factors associated with phlebitis were identified. Further studies need to be developed in order to grant a real understanding of this disease in the daily routines of a hospital.

Keywords:
Phlebitis; Catheterization; peripheral; Nursing care; Infusions; intravenous; Review

Resumo

OBJETIVO

Descrever as evidências científicas publicadas na literatura acerca dos fatores de risco para o desenvolvimento das flebites.

MÉTODO

Revisão integrativa da literatura com inclusão de 14 artigos originais encontrados nas bases LILACS, Scielo e Pubmed de janeiro de 2004 a abril de 2015 e analisados quanto ao nível de evidência e frequência, fatores associados, grau e tratamento das flebites.

RESULTADOS

A frequência/incidência/taxa mínima de flebite foi 3% e a máxima foi 59,1%. A maioria dos artigos (57,14%) relataram associação da flebite com fatores de risco, dentre eles, o tempo de permanência, local de punção e/ou região anatômica, tempo de internação, quantidade de acessos, motivo de retirada, sexo, antibióticos, manutenção intermitente e inserção de emergência.

CONCLUSÕES

Identificou-se a necessidade uniformização da quantificação deste evento e uma baixa consonância entre os fatores de risco associados a flebites. Outros estudos necessitam ser desenvolvidos para o real entendimento deste agravo no cotidiano hospitalar.

Palavras-chave:
Flebite; Cateterismo periférico; Cuidados de enfermagem; Infusões intravenosas; Revisão

Resumen

OBJETIVO

Describir las evidencias científicas publicadas en la literatura sobre los factores de riesgo para el desenvolvimiento de las flebitis.

MÉTODO

Revisión integradora con la inclusión de 14 artículos originales se encuentran en el LILACS, SciELO y PubMed desde enero 2004 hasta abril 2015 y se analizaron para el nivel de evidencia y la frecuencia, factores asociados, el grado y el tratamiento de flebitis. RESULTADOSLa frecuencia/incidencia/ tasa mínima de flebitis fue del 3% y el máximo fue de 59,1%. La mayoría de los artículos (57,14%) reportaron asociación de la flebitis con los factores de riesgo, entre ellos la duración de la estancia, el sitio de punción y/o región anatómica, tiempo de internación, número de accesos, razón normal de retiro, el sexo, los antibióticos, mantenimiento intermitente y inserción de emergencia.

CONCLUSIONES

Se identificó la necesidad de estandarizar la cuantificación del evento y una línea baja entre los factores de riesgo asociados con la flebitis. Otros estudios necesitan ser desenvueltos para el real entendimiento de este agravio en la rutina hospitalario.

Palabras clave:
Flebitis; Cateterismo periférico; Atención de enfermería; Infusiones intravenosas; Revisión

INTRODUCTION

Intravenous therapy is a technical-scientific process eminently executed by the nursing staff in hospitals. The peripheral access is performed by inserting a catheter in a peripheral vein, mainly in the dorsal venous network of the hands and forearm.

Phlebitis is the inflammation of a vein, and is a common complication associated with the use of peripheral intravenous catheters^1-2. Some aspects are described as risk factors for the onset of phlebitis, such as: the catheter dwell time, puncture site, hospitalization period, use of antibiotics, emergency intervention, sex and number of punctures per patient^3-6.

The phlebitis is classified in four degrees, according to the clinical signs presented by the patient: Degree 1: Reddening (erythema) around the peripheral intravenous catheters (CIP), with or without local pain; Degree 2: Local pain with reddening (erythema) and / or swelling; Degree 3: Local pain with erythema, hardening and palpable venous cord formation; Degree 4: Local pain with erythema, hardening and palpable venous cord formation > 1 inch in length (2,54 cm) with purulent drainage⁷. Phlebitis can be classified, according to the causative factors in; mechanical phlebitis, bacterial phlebitis, post-infusion phlebitis and chemical phlebitis^2,7.

Based on the National Patient Safety Program guidelines⁸, health care should be carried out with a view to patient safety, reducing the risk of damage to the acceptable minimum. According to Infusion Nurses Society⁷, the acceptable phlebitis rate should be 5% or less for a given population. It is necessary, therefore, to hold a critical reflection on the role of nursing in patient care that uses peripheral intravenous devices, considering that phlebitis may be an initial route of complex diseases, such as thrombophlebitis and sepsis, e.g.

In the context described above, studies to seek evidence that will result in directing daily nursing practices to reduce the occurrence of this damage, which is currently described as an important indicator of the quality of care is necessary.

Therefore, this study was guided by the following question: what scientific evidence has been published in literature on the risk factors for the development of phlebitis? To answer this question, the objective was to describe the scientific evidence published in literature about the risk factors for the development of phlebitis.

METHOD

This paper is an integrative literature review, constructed from six predetermined steps⁹: (1) identification of the issue and guiding question of the study; (2) formulation of inclusion and exclusion criteria; (3) definition of the information that will be removed from the selected literature forming a categorization of studies; (4) evaluation of the articles already included in the integrative review; (5) interpretation and compilation of the identified results and (6) presentation of the synthesis of the acquired knowledge.

The defined theme was phlebitis, and the guiding question was "what scientific evidence has been published in literature on the risk factors for the development of phlebitis?" The search for articles was held in databases Scielo, Pubmed and LILACS, in English, Portuguese and Spanish. With support in the study's guiding question, keywords phlebitis, phlebite$, flebitis, peripheral catheterization, peripheral catheter$ and peripheral venous catheter. Inclusion criteria were: original articles available in full online, with a publication year between 2004 and April 2015, in Portuguese, English and Spanish, and performed with adult subjects with a peripheral intravenous catheter. Integrative or systematic review articles, monographs, dissertations or theses were excluded. Chart 1 presents the search results according to the descriptor and total of articles inserted in the study, after the application of the selection criteria for said articles. Some articles found in the LILACS database, were also found in the Scielo database, and were therefore only analyzed once.

Chart 1
List of search results on said data banks. Porto Alegre, April / 2015

To select the articles, the title and abstract of the article was first analyzed to ensure that it contemplated the purpose of the study and the criteria for inclusion and exclusion established. After identifying the relevant articles, a thorough exploratory reading of the articles in full, highlighting the important points found was carried out, building, in this way, a pre-analysis and synthesis of relevant data items based on a data collection instrument with pre-established questions: periodic, year of publication, authors, article title, outline, level of evidence, subjects involved, results and conclusions found.

For the classification of evidence level of the studies found, the classification proposed by Melnykand Fineout-Overholt¹⁰⁾ was used: Strong (level 1, the evidence are from systematic review or meta-analysis of all relevant randomized controlled clinical trials or arising out of clinical guidelines based on systematic reviews of randomized controlled clinical trials, level 2 evidence derived from at least one randomized well-outlined controlled trial); Moderate (level 3, evidence from well-designed clinical trials without randomization; level 4, evidence from cohort studies and well-designed case-control); non-randomized clinical trial case-control or cohort) and Poor (level 5 evidence originating from systematic review of descriptive and qualitative studies; level 6, evidence derived from a single descriptive or quantitative study; Level 7, evidence from authorities of opinion and / or expert committee reports).

Subsequently, the relevant data were categorized and grouped into instruments named summary charts, built for the purpose of compiling relevant information such as authors, title, year and periodic where the article was published (Chart 2); outline; subjects involved and main findings (Chart 3). The purpose of these instruments was to aggregate the knowledge produced on the subject explored in this study. The authorship and reliability of the data contained in the articles included in this integrative review were guaranteed, and this article is linked to the research project approved by the institution's CEP under protocol Nº 1082/07.

RESULTS

In the research carried out in such databases, 429 articles were found, where only 14 (3%) articles were selected for the integrative review, in accordance with the inclusion criteria previously established.

In the LILACS database, 141 articles were located and only one (7%) was selected. In SCIELO database, 163 articles were found and only three (21%) were included. In PUBMED database, a total of 125 articles were found and only 10 (71%) articles were selected.

The countries of origin of the studies were Brazil, with five articles (36%), Australia with three articles (21%) and the United States, China, Spain, Nepal, the UK and Italy, with one article each. Magazines Acta Paulista de Enfermagem e Texto and Contexto Enfermagem presented two publications each. The others presented only one publication each. An increase of publications on the subject can be seen in recent years, especially in 2012, with five articles (36%), and 2014 with three articles (21%). Chart 2 presents the items included, according to the year, published periodical and main goal.

Chart 2
Synoptic chart with Articles included by authors, title, year and published journal. Porto Alegre, 2015. n =14 articles

For the presentation of the relevant findings from the 14 articles, Chart 3 shows the outline of the study, subjects involved and / or number of the CIP evaluated, level of evidence and main findings. In the main findings, a predetermined search in four categories was performed: (1) frequency / incidence / phlebitis rate, however, one of the articles presented terminology (percentage) to demonstrate its phlebitis results; (2) variables associated with phlebitis, (3) degree of phlebitis and (4) treatment interventions.

In regards to the first category, 21.4% of the articles had phlebitis often; 50% as incidence, 21.4% as a rate and 7.1% as percentage. As for the second category, variables associated with phlebitis, 57.1% reported some type of risk factors associated with phlebitis, with them being the dwell time (four articles); puncture site and or anatomical region (two articles); hospitalization period; number of accesses; normal use of the infusion apparatus; reason for removal; sex; antibiotics; intermittent maintenance; emergency medical insertion (one article each) and 42.9% do not describe variables associated with phlebitis. The third category, degree of phlebitis, was described in 35.7% of the articles, being grade 1 the most prevalent, with a maximum rate of 46.2%. The fourth category, interventions for the treatment of phlebitis was not described in 92.9% of the articles.

Regarding the level of evidence found in the articles included in this integrative review, 42.8% of the articles were classified as strong evidence - level 2; 28.6% as moderate evidence - level 4; and 28.6% as poor evidence - level 6 (Chart 3).

Chart 3
Synoptic chart - outline, subjects involved and main findings included in the articles. Porto Alegre, 2015. n =14 articles

DISCUSSION

Based on the analysis of 14 articles included in this integrative review on the theme phlebitis, it can be seen that the volume of publications on the subject is not sufficient to meet the needs, considering the importance of this indicator in the quality of care. The frequency / incidence / minimum rate of phlebitis was 3%¹⁷ and the maximum was 59.1%¹⁸. The results of this review showed an extremely comprehensive range between the findings and well beyond the up to 5% recommended by the Infusion Nurses Society⁷.

Another complicating aspect to understanding this event is that the data are often not ​explicit or are grouped with other events, such as phlebitis and infiltration of the CIP, with frequency of 43.5% ¹⁴⁾ or phlebitis and CIP occlusion, with a rate of 87.3%⁶.

One aspect that deserves special attention is the study of the dwell time variable of the CIP. Of the 14 articles included, eight^{3,4,6,11,16-19} were developed in order to study the association of this variable with the presence of phlebitis and / or compare the scheduled removal of up to 72 hours (three days) or the removal according to a medical evaluation of the CIP insertion point were related to phlebitis.

Among these studies, only three described an association between phlebitis and variable dwell time ≥ 72 hours, resulting in higher risks for the development of phlebitis^4,18-19; one found an association of phlebitis with the catheter dwell time <48 hours³ and, the four^6,11,16-17 that compared the routine removal with the medically recommended removal found no association of these variables with the occurrence of phlebitis.

Although there is a recommendation to replace peripheral catheters every 72-96 hours to reduce the risk of infection and phlebitis in adults^19-20, the replacement of peripheral catheters in adults only when medically recommended needs further study²⁰. In children, the appointment of the CIP exchange is consolidated in cases where it is medically recommended and not routine^21-22. In Brazil, in situations where the peripheral access is limited, the decision to keep the catheter beyond 72-96 hours depends on skin integrity, duration and type of prescribed therapy and should be documented in the patient records²¹.

Thus, a reflection on the real benefits in routine exchange is needed, as are studies to prove the effectiveness of CIP exchange, considering the risks and losses of intravenous therapy. It is known that this can cause discomfort, acute pain, anxiety caused by the need for new peripheral venous punctures that compromise the well-being of patients during hospitalization.

Although the concept of phlebitis not be new, its assessment is still in consolidation. The research of the degrees of phlebitis was seen in only 42.86% of the articles. Three studies used phlebitis analysis according to the Infusion Nurses Society and showed degree 1 as prevalent in two articles (41.6%)¹¹ and (46.2%)⁴ and third degree in 2 (40%)⁵.

Another article classifies the degree as the Visual Infusion Phlebitis Assessment Scale (VIPAS)³ and yet another form of phlebitis rating was through points: when presenting two points of a scale of 10, it is considered phlebitis. Symptoms of pain are considered 1 point; redness less than 1 cm, 1 point, and above 2 cm, 2 points; edema, redness and exudate drainage, 1 point; and serosanguinous exudate that needs dressing change, 2 points⁶.

As a limitation found in this review, is the lack of information / data on the treatment of phlebitis, since only one article¹² mentions intervention for the treatment of phlebitis, despite the importance of the subject. Another critical point was the lack of a follow-up accounts of post-infusion phlebitis, a factor that also contributes to the uniqueness of some important results, especially for the incidence or frequency of phlebitis.

CONCLUSIONS

This integrative review reached the objective of describing the scientific evidences published in the literature about the development of phlebitis. However, it was found that the phlebitis arising from the CIP insertion still requires studies with strong evidence level (level 1 or 2) to deepen the investigations into the etiology and associated factors. It is necessary to carry out studies that make comparisons between safe and effective interventions when phlebitis is detected in patients, to guide the assistance provided by the professionals, because the lack of the adoption of scales to identify the degrees and treatments of phlebitis makes it difficult for the teams to make decisions regarding the best practices.

The publications that addressed phlebitis show a worrying result, given the disparity of research in this regard. There is a diversity in the way the occurrence of phlebitis is measured which signals the need for an alignment of researchers in this area, as well as follow-up surveys after catheter removal seeking to identify post-infusion phlebitis.

The results about the risk factors associated with phlebitis are still controversial in the literature, which complicates decision making for the teams regarding best practices for the prevention of this disease. However, most studies have pointed to the need for further research about the catheter dwell time, since this variable differs among the analyzed items.

The nursing staff has a key role in prevention, early identification, classification and treatment of this disease. As a result, it is suggested that further research with outlines of randomized controlled clinical trials can be conducted in Brazil that subsequently promote meta-analysis type studies, which provide maximum evidence about phlebitis related to CIP for subsidize clinical guidelines and quality indicators of health care

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Publication Dates

• Publication in this collection
  2017

History

• Received
  02 Aug 2015
• Accepted
  12 Jan 2016