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ABSTRACT
How to cite this article:
Urbanetto JS, Muniz FOM, Silva RM,
Objective: to determine the incidence of phlebitis during and after the use of peripheral intravenous catheter (PIC), and analyse the
Freitas APC, Oliveira APR, Santos JCR. association of this complication with risk factors.
Incidence of phlebitis and post-infusion Methods: cohort study with 165 adult patients admitted to a university hospital in Porto Alegre, totalling 447 accesses, from De-
phlebitis in hospitalised adults. Rev cember 2014 to February 2015. Data were collected on a daily basis and analysed by means of descriptive and analytical statistics.
Gaúcha Enferm. 2017;38(2):e58793. Results: The incidence of phlebitis during PIC was 7.15% and the incidence of post-infusion phlebitis was 22.9%. Phlebitis during
doi: http://dx.doi.org/10.1590/1983- catheter use was associated with the use of Amoxicillin + Clavulanic Acid. The grade of post-infusion phlebitis was associated with
1447.2017.02.58793. age and use of Amoxicillin + Clavulanic Acid, Tramadol Hydrochloride, and Amphotericin.
Conclusion: The incidence of post-infusion phlebitis proved to be an important indicator to analyse the quality of the healthcare setting.
doi: http://dx.doi.org/10.1590/1983- Keywords: Phlebitis. Catheters. Patient safety. Nursing.
1447.2017.02.58793
RESUMO
Objetivo: Avaliar a incidência de flebite durante o uso de cateter intravenoso periférico (CIP) e pós-infusional e analisar a associação
com fatores de risco em pacientes hospitalizados.
Método: Estudo de coorte com 165 pacientes adultos internados em hospital universitário de Porto Alegre que totalizaram 447
acessos no período de dezembro 2014 a fevereiro 2015. A coleta dos dados foi diária, e a análise dos dados ocorreu pela estatística
descritiva e analítica.
Resultados: A incidência de flebite durante o uso do CIP foi de 7,15% e de flebite pós-infusional, 22,9%. A flebite durante o uso do
cateter associou-se com a Amoxicilina + Ácido Clavulânico. A flebite pós-infusional apresentou associação do grau de gravidade com
a idade e com o uso de Amoxacilina + Ácido Clavulânico, Cloridrato de Tramadol e Anfotericina.
Conclusão: A incidência de flebite pós-infusional mostrou-se um indicador importante para a análise do cenário da qualidade da
assistência em saúde.
Palavras-chave: Flebite. Cateteres. Segurança do paciente. Enfermagem.
RESUMEN
Objetivo: Evaluar la incidencia de flebitis en el uso de catéter periférico intravenoso (CIP) y posinfusional y analizar la asociación con
los factores de riesgo en pacientes hospitalizados.
Método: Estudio de cohorte con 165 pacientes adultos ingresados en un hospital universitario de Porto Alegre, que ascendió a
447 accesos de diciembre 2014 a febrero de 2015. La recolección de datos fue diaria y el análisis de datos fue mediante estadística
descriptiva y analítica.
Resultados: La incidencia de flebitis durante el uso de catéter periférico intravenoso fue del 7,15% y de la flebitis posinfusional fue del
22,9%. La flebitis durante el uso del catéter se asoció con el uso de Amoxicilina + Ácido clavulánico. La flebitis posinfusional presentó una
asociación del grado de gravedad con la edad, y con el uso de Amoxicilina + Ácido clavulánico, Clorhidrato de tramadol y Anfotericina.
a
Pontifícia Universidade Católica do Rio Grande do
Sul (PUCRS), Faculdade de Enfermagem, Nutrição e
Conclusión: La incidencia de flebitis posinfuncional mostró ser un indicador importante para el análisis del escenario de la calidad
Fisioterapia, Curso de Graduação em Enfermagem. de atención en salud.
Porto Alegre, Rio Grande do Sul, Brasil. Palabras clave: Flebitis. Catéteres. Seguridad del paciente. Enfermería.
lation, drugs that act on bone metabolism, and drugs committee of the PUCRS, with protocol number OF.
that affect gastrointestinal function(11). CEP–1082/07. The patients who met the inclusion cri-
Data were collected by a trained team that used a teria and accepted to participate in the research were
manual for support. Collection occurred in two specific informed of the objective of the study, the voluntary
occasions: on the day the PIC was inserted, and every nature of participation, and the approval of the ethics
day until the PIC was removed; and immediately after committee, after which they signed two copies of an in-
the PIC was removed, and every day for up to 96 hours. formed consent statement.
The insertion site was inspected and palpated every day
to identify possible signs of phlebitis during the use and RESULTS
after removal of the PIC. When signs or symptoms of
phlebitis were identified, the nurse responsible for the The study sample consisted of 165 patients. Of these
unit was notified. patients, 73 (44.2%) were men and 92 (55.8%) were wom-
The incidence density of phlebitis was calculated by en. Their average age was 59.9 ± 19.7 years, with a medi-
applying the formula used in Brazil for this purpose(12), an of 61 (19 - 95) years. In terms of age per age group, 58
adapted for phlebitis during the use of PIC: (number of (35.2%) of the patients were 71 to 95 years old, 56 patients
cases of phlebitis during the use of PIC in the period/ (33.9%) were 49 to 70 years old, and 51 patients (30.9%)
number of patients per day with peripheral venous ac- were 18 to 48 years old. In terms of skin colour, 124 (75.2%)
cess in the period) x 100; and for post-infusion phlebitis: of the patients were white, 26 (15.8%) had brown skin, and
(number of cases of phlebitis after removal of the PIC in 15 (9.1%) had black skin.
the period/number of patients per day accompanied for
up to 96 hours after removal of the PIC in the period) x
100. The average number of patients with PIC per day was Table 1 – Frequency of phlebitis and grades of phlebitis
11.8, which totals 1016 patients in 86 days of monitoring. during use of PIC and after removal of PIC (post-infusion).
The average number of patients monitored after removal Porto Alegre, RS/Brazil
of the PIC per day was 10.7, totalling 888 patients during
Frequency %
83 days of monitoring.
The incidence of phlebitis during the use of the PIC Phlebitis during use of PIC
was calculated using the formula: (number of cases of (n = 447 PIC)
phlebitis during the use of PIC in the period/number of Yes 32 7.2
patients with peripheral venous access in the period) x No 415 92.8
100; and for the incidence of post-infusion phlebitis: Grade during use of PIC
(number of cases of phlebitis after removal of the PIC in (n = 32)
the period/number of patients monitored up to 96 hours I 26 81.2
after removal of the PIC in the period/number of patients
II 3 9.4
monitored up to 96 hours after removal of the PIC in the
III 3 9.4
period) x 100.
A specific code was attributed to each item of the IV - -
form. The data were subsequently transferred to an Excel® Post-infusion phlebitis
2010 Windows XP® spreadsheet by double entry, checked (n = 358 CIP)
for inconsistencies, and exported to Statistical Package Yes 82 23.0
for the Social Science (SPSS) software version 20.0 for No 276 77.0
statistical analysis. The data were analysed using descrip- Grade post-infusion phlebitis
tive statistics (absolute frequency, relative frequency, and (n = 82)
variability) and inferential statistics by means of the Chi-
I 39 47.0
Square test with Monte Carlo simulation at a significance
II 12 15.0
level of p < 0.05.
The study complied with the ethics precepts of Res- III 28 34.0
olution 196/96 (in force at the time of project approv- IV 3 4.0
al) and 466/2012, and approved by the research ethics Source: Research data, 2015.
The research participants were submitted to the in- During the use of the PIC, the frequency of phlebitis
sertion of 447 (100%) mandrel-type PICs. The puncture was 32 (7.2%) puncture sites, and 26 (81.2%) of these cas-
sites were forearm, with 164 (36.7%), back of hand, with es exhibited Grade 1 phlebitis. The frequency of post-infu-
106 (23.7%), cubital fossa, with 105 (23.5%), wrist, with 56 sion phlebitis was 82 (23%) of the cases, of which 39 cases
(12.5%), arm, with 12 (2.7%), foot, with three (0.7%), and (47.0%) exhibited Grade 1 phlebitis (Table 1).
jugular, with one (0.2%). The incidence density of phlebitis during the use of
Regarding the calibre, there was a higher frequency the PIC and post infusion was calculated separately to
of 22 gauge (G), with 229 (51.2%), followed by 24 G cali- ensure a clear and specific analysis for both occasions.
bre, with 94 (21%), 20 G with 16 (3.6%), and 18 G with 10 The data used to obtain the result of phlebitis during
(2.2%). The calibre could not be identified in 98 (21.9%) of PIC were the 32 cases of phlebitis found in the study di-
the punctures due to lack of records or use of a non-trans- vided by the number of patients/day (1016) submitted
parent dressing to fix the catheter. In terms of PIC mainte- to this risk (patients using PIC). The results of the divi-
nance, saline access was used in 362 (81%) of the punc- sion were multiplied by 100 and reached an incidence
tures, while continuous intravenous infusion was used in density of 3.14%. In the case of post-infusion phlebitis,
only 85 (19%) of the punctures. the 82 cases of phlebitis were divided by the number of
The average number of PICs per patient during admis- patients/day (888) submitted to the risk (up to 96 hours
sion was 2.3±1.3, and there was no concomitant use of of monitoring after removal of the PIC). The result was
PIC. Of this number, 165 (36.9%) used a PIC; 112 (25.1%) multiplied by 100, which produced an incidence densi-
used two PICs; 88 (19.7%) used three PICs; 50 (11.2%) used ty of 9.23%.
four PICs; 20 (4.5%) used five PICs; nine (2%) used six PICs; A comparison of these findings with those of other na-
and three (0.7%) used seven PICs. In relation to PIC perma- tional and international studies showed that the incidence
nence, the average time was 58.9 ± 26.9 hours, with a me- of phlebitis during PIC use ((32 phlebitis/447 PIC) x 100)
dian of 72 (24 - 168) hours. Most of the PICs remained in the was 7.15%, which the incidence of post-infusion phlebitis
patients for ≤ 72 hours (n = 386; 86.3%), and the other PICs ((82 phlebitis/358 CIP) x 100) was de 22.9%.
remained for > 72 hours (n = 61; 13.7%). Table 2 shows the results of the association analysis
Table 1 shows the frequency of phlebitis during use of of the socio-demographic characteristics with the occur-
the PIC and after removal (post-infusion) of the PIC. rence of phlebitis and its grades during PIC.
Table 2 – Socio-demographic data and their association with phlebitis and grades of phlebitis during PIC. Porto Alegre,
RS/Brazil. n = 447 PICs
Table 3 – Data of the association of phlebitis and grades of phlebitis during PIC with risk factors related to PIC and medi-
cation. Porto Alegre, RS/Brazil. n = 447 CIPs
With regard the occurrence of phlebitis, a similar dis- with the occurrence of phlebitis and its grades after re-
tribution was observed among the patient with phlebitis moval of the PIC.
in terms of age, sex, and skin colour, with no statistical The occurrence of phlebitis revealed a similar distribu-
significance. In relation to grade, the previous analysis tion between the patients who had phlebitis in relation
was repeated with age and sex. In this case, a statistical to age, sex and skin colour, with no statistical significance.
significance was observed for skin colour, showing the In relation to grades, the same analysis was repeated with
white and brown skin were associated with Grade I phle- sex and skin colour. However, there was a statistical signifi-
bitis and black skin was associated with Grade III phlebitis cance for age, where the patients in the 19 to 48 age group
(Table 2). and the patients in the 71 to 95 age group associated with
Table 3 shows the results of the non-statistical associa- Grade I phlebitis, while the patients in the 49 to 70 age
tion of the risk factors with phlebitis and grade of phlebitis group associated with Grade III (Table 4).
during PIC. Table 5 presents the results of the statistical association
The data were similarly distributed between the pa- of the risk factors with phlebitis and grade of phlebitis after
tients regarding total number of PIC, PIC permanence, removal of the PIC.
PIC site, and calibre of PIC, maintenance of PIC, number Post-infusion phlebitis was not associated with any of the
of medication classes, and number of medication per risk factors related to the catheter or number of drugs used.
PIC. In terms of phlebitis grade, there was also a similar The same occurred with the grades of phlebitis (Table 5).
distribution between the patient with phlebitis, with a However, in the individual analysis of the use of med-
limit value (p = 0.059) in the PIC maintenance variable ication, Tramadol Hydrochloride, Amoxicillin + Clavulanic
(Table 3). Acid, and Amphotericin showed a statistical significance
The individual analysis of the medication revealed a (p = 0.049) for the occurrence of post-infusion phlebitis. In
statistical significance (p = 0.009) for Amoxicillin + Clavu- the association analysis of the classes of medication with
lanic Acid with the occurrence of phlebitis during the PIC. post-infusion phlebitis, there was a positive association
In terms of the grade of phlebitis during PIC, none of the (p = 0.0032) to the antifungal drugs, the anti-inflammatory
medication showed a significant association. drugs, and the drugs that act on the blood. With regard the
Table 4 shows the results of the association analysis grade of post-infusion phlebitis, none of the medication or
of the socio-demographic characteristics of the patients medication classes showed a significant association.
Table 4 – Socio-demographic data and their association with phlebitis and its grades after removal of the PIC (post-infu-
sion phlebitis). Porto Alegre, RS/Brazil. n = 358 CIPs
Table 5 – Data of the association of phlebitis and grade of phlebitis after removal of the PIC (post-infusion phlebitis) with
the risk factors for phlebitis. Porto Alegre, RS/Brazil. n = 358 CIPs
lin + Clavulanic Acid, and Amphotericin were also associat- would allow nurses at the front line of intravenous ther-
ed with this type of phlebitis. apy and the multi-professional team to understand and
In relation to the pH of the medication, the more acid the minimise this event that compromises the safety of pa-
drug, the greater the risk of chemical phlebitis(17). This infor- tients during hospitalisation.
mation is supported by the pH of the Tramadol Hydrochlo-
ride (pH 5.5 to 6.3) and Amphotericin (pH 6.0 to 7.5), but not REFERENCES
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