Treatment of Superficial Phlebitis Caused by Percutaneous Long Lines in Children with Cystic Fibrosis & other causes of Bronchiectasis

• Summary
• Background
• Clinical Assessment
• Medical Assessment
• Conservative Management
• Medical Management
• Assessment of Response
• Further Information

Summary

Key inclusion criteria:
Any patient with a percutaneous long line in situ showing signs of superficial inflammation but not showing any signs of infection

Assessment:
A thorough assessment by the attending nurse/doctor and if there is any suggestion of infection, as opposed to superficial inflammation from phlebitis, patients should be reviewed by the most senior member of the medical team available. (see details below)

Treatment:
Conservative management:

1. Slow down the rate of infusion
2. Dilute the intravenous medication
3. Elevate the affected limb
4. Apply a warm compress to the affected area

Medical management:

1. Topical non-steroidal anti-inflammatory medication – Ibuprofen 5% Gel TDS
2. Steroids (low dose) – Prednisolone 5mg OD (max 10mg)

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Background

Prolonged courses of intravenous antibiotics are common practice in children with cystic fibrosis (CF) and bronchiectasis. This is to eradicate certain bacteria and ensure reduction of colonisation. ¹ As a result of this, intravenous access can become a problematic issue in these patients.

There are a number of options in which intravenous antibiotics can be given. The most common is the simple short intravenous peripheral cannula, however these often do not last as long as desired and result in patients needing multiple cannulation attempts for a prolonged course of antibiotics. Mid-lines or peripherally inserted central catheters (PICC lines) are longer, more permanent methods of ensuring IV antibiotics can be given effectively.² They have the advantage that they can stay in-situ for longer, last longer and patients prefer them to short cannula, however they require more skill and technical ability to insert.^3,4 The final options are totally implantable venous access port devices (Port-a-caths; Pass-ports; etc), which are inserted under anaesthetic into a large central vein and stay in-situ even when the patient leaves hospital.⁵ The advantage of these is that they can stay in place for months or even years, however they require planning to insert and administration of a general anaesthetic. These devices need to be cared for and handled appropriately, including regular flushing and often avoidance of contact sports.

In hospital, most CF patients who require a course of antibiotics for more than seven days will have a long line inserted. One of the complications of having long lines is superficial phlebitis, which can be rather painful and uncomfortable, especially when the medication is infused through the vein. Phlebitis is the inflammation of the tunica intima of the vein; it can be caused by irritation from mechanical, chemical or infective means.⁶

When caring for long lines it is important to distinguish between irritation, caused by the infused medication, the mechanical irritation of the device within the vein and infection. Some signs that there is infection are evidence of tracking (spreading of erythema), excruciating pain when line is flushed, discharge from the line site, or systemic signs of infection (temperature, tachycardia, rising inflammatory markers). Infection is much more likely to be an issue if the long-line has been used for parenteral nutrition.

Once a diagnosis of superficial phlebitis has been made and the clinician has determined that there are no features to suggest line infection, then this clinical assessment must be carefully documented in the medical notes along with the clinician’s assessment of whether the line can thus continue to remain in situ.

Where there are no features to suggest line infection there are a number of methods which have been used to reduce the inflammation and the pain for the child, in order to prevent the need to remove the line and result in more attempts to re-site the intravenous line. One simple method which can be used is to dilute the medication. If the phlebitis is caused by chemical irritation then diluting the antibiotic may reduce the pain experienced. Infusing the medication slower may help to reduce the irritation experienced. It is important to ensure that the medication can be diluted and the time at which it is suggested to be infused over is appropriate. This information should be available from Medusa (available via Trust intranet), summary of product characteristics (available at http://www.medicines.org.uk/emc), medicines information or via your pharmacist.

Treatment of phlebitis is aimed at alleviating symptoms. This can be done by elevating the affected limb to reduce the swelling, compression with a warm or cool cloth, or administering topical non-steroidal anti-inflammatory drugs.⁷ The use of steroids for phlebitis caused by mechanical irritation to the vein has little published data, however there is good evidence for the use of steroids in patients who experience phlebitis as a complication of chemotherapy agents given intravenously.⁸

Below is a guideline for the benefit of nursing and medical staff if superficial phlebitis is suspected as a result of intravenous catheter access.

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Clinical Assessment

Any patient with a percutaneous long line in situ showing signs of superficial inflammation but not showing any signs of infection can be considered for treatment as detailed below.

The following characteristics help determine between inflammation from superficial phlebitis and infection;

Signs Consistent with Superficial Phlebitis:

• Mild erythema (redness)
• Minimal swelling around the insertion site
• Mild Pain (more so on flushing IV line)

Signs Consistent with Line Infection:

• Erythema (redness) – tracking/spreading of the erythema along the vein
• Pus discharging from line insertion
• Systemic features of infection – tachycardia, pyrexia, feeling unwell, rising inflammatory markers
• Excruciating pain even when the line is not being used
• Significant swelling of the affected limb

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Medical Assessment

If there is any suspicion that there may be infection rather than inflammation this needs to be discussed with the medical team.

• Seek advice from most senior member of the medical team available
• Ensure the assessment and outcome is documented in the medical notes
• Review this on a daily basis if there are ongoing concerns

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Conservative Management

Once the decision has been made that there is superficial phlebitis and not infection, treatment can be commenced.
Conservative management should be the first line.

• Slow down the rate of medication infusion (ensure this is appropriate, see earlier)
• Dilute the intravenous medication (check dilution recommendation if appropriate)
• Elevate the affected limb
• Apply a warm compress to the affected area – ensure that the insertion site of the long line does not get wet

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Medical Management

If the conservative management is not sufficient to reduce the pain on infusion then medical management should be considered.
This needs to be a decision made by the most senior member of the medical team with documented evidence as to the indication and treatment prescribed.

• Topical non-steroidal anti-inflammatory medication – Ibuprofen 5% Gel three times a day (Note that use in this indication must be on advice of a doctor)
• Steroids – low dose once daily – Prednisolone 5mg OD (from 1 year of age (or) up to max 10mg OD for children over 12 years of age)

It should be possible to continue to use the long line for infusion of antibiotics and other medication during the treatment as outline above. However if it is too painful for the line to be used or the medication will not infuse easily due to the swelling, an additional short term peripheral cannula may need to be used until the inflammation has improved.

Treatment should be no longer than 5 days in total unless agreed by the treating consultant.

Ibuprofen 5% gel is available to buy from a pharmacy. However, because of age restrictions and this indication not being covered by the ‘P’ licence a pharmacist will not be able to sell it for this purpose. It must therefore be prescribed by a hospital or primary care prescriber.

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Assessment of Response

• Once treatment has been started, the line should be reviewed prior to each drug administration by the nurse and, in addition, daily by the medical team.
• There should be documented evidence in the medical notes that this has been done and a clear plan put in place for further administration of the medication.
• Once there has been sufficient response to treatment this may be stopped. The desired response would include reduction of swelling and erythema, painless infusion of medication and easy flow of the medication in to the vein.
• If the treatment is ineffective (ie. no improvement in the symptoms after 48 hours) then the decision to remove the long line needs to be made by the medical team

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