Phlebitis predictors in cardiac patients undergoing peripheral intravenous therapy

Objective: To determine the incidence of phlebitis and its predictive factors in cardiac patients hospitalized in a coronary care unit. Method: this study is a prospective cohort, conducted with 60 adult cardiac patients using peripheral intravenous therapy, admitted to the hospital sector of the coronary unit from August to December 2012. The data were analyzed using BioEstat programs 5.0 and SPSS 20.0. Non-parametric data were analyzed using the chi-square test, Fisher exact test, and Mann-Whitney test. A p-value <0.05 was considered statistically significant. Results: The incidence of phlebitis was 12% about the proportionality of peripheral venous catheters (n=139). There were four variables identified as predictive factors for phlebitis, diabetes mellitus and dyslipidemia (p=0.02), hospitalization for three days and the number punches were over two (p<0.001). Conclusion: In this study, the phlebitis rate was twice greater than the established by the international standards. The cardiac patients with diabetes mellitus and dyslipidemia were 2.7 and 2.8 times the risk for phlebitis development than those who did not have these factors, respectively. Phlebitis predictors in cardiac patients undergoing peripheral intravenous therapy ORIGINALI Adriana Correia de Lima1, Rivaldo Venâncio da Cunha1, Marisa Dias Rolan Loureiro1, Maria Lúcia Ivo1, Albert Schiaveto de Souza1, Elenir Rose Jardim Curi Pontes1, Aston Marques da Silva Junior1, Isabelle Campos de Azevedo2, Marcos Antonio Ferreira Júnior2 1 Federal University of Mato Grosso do Sul, Campo Grande/MS, Brazil. 2 Federal University of Rio Grande do Norte, Natal/RN, Brazil. Contact information: Marcos Antonio Ferreira Júnior.  marcos_nurse@hotmail.com


Introduction
Cardiovascular diseases are circulatory system diseases with a broad spectrum of clinical syndromes and have an important impact on morbidity and mortality and hospitalization costs and outpatient monitoring [1].
According to the American Heart Association, more than 71 million Americans have one or more types of cardiovascular disease, frequently having coronary artery disease, heart failure, stroke and congenital cardiovascular defects [2].Thus, the number of patients hospitalized with heart disease is increasing worldwide.
Peripheral intravenous therapy has a set of knowledge and techniques that range from the administration of solutions and medications in the circulatory system to the catheters care (maintenance, salinization, cover exchange, and discard) [3].
Currently, the insertion of peripheral venous catheters (PVC) is one of the most commonly invasive procedures performed in hospitalized patients [4], and may result in adverse events or traumas located around the puncture site as hematomas, phlebitis, thrombophlebitis, infiltrations, extravasation and local infection [5,6].Adverse events are incidents that result in unintentional damage from the care and not related to the natural evolution of the patient´s disease [7].
Phlebitis is an adverse event that compromises the safety of the patient, defined as an inflammation of the vein which can be accompanied by pain, erythema, swelling and formation of palpable cord [8] and 2.5% to 70% among all patients who undergo this procedure have implications [9,10].
The potential danger for patients undergoing these procedures may result in a physical, social and financial burden to the health institutions, which requires constant prevention measures for patient safety.
Thus, this study was developed to verify the incidence of phlebitis and its predictive factors in cardiac patients hospitalized in a coronary care unit.

Method
A quantitative study of epidemiological approach with a prospective cohort, conducted with adult cardiac patients admitted to the coronary unit in a hospital in the Midwest region of Brazil from August to December 2012.
For data collection, an instrument specifically designed for this study was used, which contained the data of variables: a) demographic: age, gender, and color; B) Clinical: medical diagnosis, comorbidities, length of stay in days, percutaneous coronary intervention, use of antimicrobial drugs, corticosteroids, anticoagulant and antiplatelet agent; C) characterization of venipuncture: number of punctures, type and caliber of the catheter, anatomical location and the catheter dwell time; and D) therapy interruption reasons -outcome: hospital and/or sector discharge, recommended length of stay (up to 72 hours by the institution) and local complications.
The variables showing local complications, defined as any undesirable event that had prevented the continuity of therapy were classified as pain, heat, redness, palpable cord formation, infiltration, phlebitis (scales proposed by the Infusion Nurses Society [8], hematoma, ecchymosis, obstruction and accidental deletion.
Patients with heart disease, ≥ 18 years old, in early peripheral intravenous therapy, and those with central venous access were excluded and transferred to another sector.
The selected cardiac patients after admission in the sector were followed from the preview site inspection to the insertion and the time of the first peripheral venipuncture when the sites were observed every 24 hours until the removal of the catheter.The type of coverage and fixation was observed every day, performing the palpation at the insertion site and when necessary, a simple magnifying glass was used to help in the investigation of inflammatory signs.Such procedures have identified the presence of clinical manifestations and risk factors as well as the causes of local complications.Hospital records of all patients investigated for evaluation of additional data were consulted, such as the occurrence of adverse events, infection revealed by positive blood culture and intravenous drug prescription.
Each study subject was observed throughout the treatment when the presence of an event did not make impossible the occurrence of another of the same type or different.Thus, it was characterizing the study discontinuity.
Data were organized in tables with absolute and relative frequencies, and their variables were analyzed using BioEstat 5.0 and SPSS 20.0 programs.Non-parametric data were analyzed using the chisquare test, Fisher exact test, and Mann-Whitney test.A p-value <0.05 was considered statistically significant.
The research study protocol was approved in its ethical, and methodological aspects by the Ethics Committee of the Federal University of Mato Grosso do Sul (Protocol 2242 and CAAE 0342.0.049.001-11).Participants were informed about the objectives and procedures of the study and signed the Informed Consent Form before their inclusion in the study.
At the end of the follow-up, there were 17 patients analyzed who had phlebitis and 43 without it.
Table 1 shows that gender, age, ethnicity, and comorbidities of hypertension and smoking were not statistically significant for the development of phlebitis.However, there was a significant association between diabetes mellitus and dyslipidemia.
Twenty-three patients (38.3%) underwent Percutaneous Coronary Intervention; that is the method used for coronary reperfusion.Six patients (9.9%) used antimicrobial and one patient (1.7%) used corticosteroids.The combined platelet therapy and antiplatelet anticoagulant were used in 50 (83.3%)patients.
Other types of drugs or solutions used did not show relevance in the occurrence of phlebitis.In 60 patients, there were 139 peripheral punctures successfully performed, 55 of them (91.7%) were urgent, coming from the emergency unit of chest pain.The average of inserted catheter was 2.3 per patient, 14 of them (23.3%) were punctured once, 46 (76.7%) were subjected to two punches, 19 (31.7%) had three punches, 10 (16.7%) had four, three had five punctures, and one patient had six peripheral punctures.In all inserts, the intravenous device used was the type "off-the-needle", with polyurethane (Vialon®).Catheters caliber 20 were used in 105 punctures (75.5%) and caliber 22 in other 20 (14.4%).The sites chosen for the puncture were predominantly the forearm with 69 cases (49.7%), followed by the back of the hand with 39 (28.0%) and antecubital fossa with 31 (22.3%)cases.
As for the length of time, the use of a device exceeded to 72 hours.In 50 cases (35.9%) the device was maintained for up to 24 hours; in cases 42 (30.2%) it remained between 24 and 48 hours, and in 46 cases (33.0%) between 48 and 72 hours.
The main reasons for removal of the 139 peripheral venous catheters (PVC) were patient discharge in 55 (39.6%) cases, followed by removal of a length of stay in 30 cases (21.6%) due to the protocol used by the institution, changing them every 72 hours.
Regarding the 139 PVC entered, 54 of them (38.8%)developed complications, and 17 of them (12.2%) were phlebitis, ten (58.8%) in female and seven (41.2%) of the male.There was mainly grade 2 phlebitides in seven cases, grade 3 in seven patients and grade 1 in three patients.
The catheters permanence time in cases of phlebitis was 48 hours in 10 cases (58.8%), other 5 (29.4%) cases there was 24 hours and in two cases there were 72 hours of permanence.
Events such as heat, redness and pain were also analyzed individually as complications of peripheral intravenous therapy.Although alone they meant reasons for discontinuation of therapy, they were an important factor in the overall analysis.
In all cases of complications related to PVC, the average length of hospital stay was significantly higher than on patients who did not have complications.There was a higher incidence of complications such as pain, heat, redness, palpable cord formation and obstruction in patients with more than three days of hospitalization (Table 2).
It was observed that the number of hospitalization days for patients who developed complications related to phlebitis was higher (6.47±3.58)than in those without this occurrence (3.58±1.24)(Figure 1).The average number of punctures among patients with phlebitis (3.71±1.05)were significantly greater than those patients without phlebitis (1.77±0.61)(Figure 2).There were no isolated or associated complications among patients such as local infection, bloodstream infection, tremors, chills, secretion, and fever.

Discussion
This cohort study observed 60 hospitalized cardiac patients in a coronary care unit, with the insertion of a total of 139 peripheral venous catheters, an incidence of 33% complications found, with the occurrence of phlebitis in 17 (12.2%)insertion sites.Another cohort study conducted in southeastern Brazil, with 60 neurosurgical patients (152 PVC) found a percentage of 10.5% of phlebitis [11], similar to this study.Two other cohort studies in hospitalized adults found phlebitis rates of 25.8% in 76 patients with cardiorespiratory and renal disease (155 PVC) [12] and 60% in 100 patients with pulmonary disease and cardiac patients (234 PVC), respectively [13].
In Germany, a prospective cohort study found in 1,582 patients (2,495 PVC), average rates of phlebitis of 27% [14].Another prospective observational study in Portugal with older adults (average age of 75.92 years old, SD=14.52)showed that in 1,244 catheters, the incidence of phlebitis was 11.09% [15].
The phlebitis incidence rates are different in the studies analyzed.It is noteworthy that when comparing these rates in national and international literature, it is necessary a careful analysis due to the uniqueness of the population, the method, and the sampling process, the materials used and the established protocols, including those relating to the standardization of terms.
The variable gender was not significant for the occurrence of phlebitis in the studied sample.However, studies have shown influence both in female [16][17] as male [18].
The skin color of the individuals as the studies carried out in other Brazilian studies showed no relationship with episodes of phlebitis found [9,19].
In this study, the average age was 64.44±12.57years old, and 63.33% were over 60 years old.Advanced age is considered an isolated risk factor for many diseases and for determining longer hospital stays and a higher incidence of adverse reactions to different drugs and procedures [20].
The age was not significant in the development of phlebitis in the patients with more or less than 60 years old.Different results with 100 elderly patients (72.0±7.7 years old) were found in Campinas, SP, demonstrating that they are susceptible to the occurrence of iatrogenic events such as infiltration, obstruction and phlebitis in peripheral venous access before 72 hours of puncture [21].
The predominant clinical variables in this study were acute coronary syndromes and among the most frequent comorbidities, diabetes mellitus and dyslipidemia were the significant factors for phlebitis.
Diabetes mellitus and dyslipidemia are firmly established risk factors for atherosclerosis, which is a complex chronic inflammatory process that affects elastic and muscular arteries.While the blood circulation has been extensively studied, there is little known about the pathophysiology of venous diseases related to these two diseases and also hypertension [22], present in 88.3% of patients.
A higher occurrence of inflammatory signs in patients with Diabetes and dyslipidemia was found.This fact may be related to the comorbidity presented by this group of patients and the various factors that lead to a predisposition to injury in the vascular endothelium.Diabetes mellitus has also been cited as a relevant factor for the development of phlebitis in another study [19].
The average of more than three days in hospitalization favored the development of phlebitis and other complications.These results are corroborated in a retrospective study of 100 patients' records when there was a statistically significant difference in length of stay between cases with reported iatrogenic (14.0±18.3days) compared to those without it (7.1±9.5 days).Infiltration, obstruction and phlebitis in peripheral venous access were among the most frequent iatrogenic [21].
Statistically significant association in patients who were hospitalized for more than eighteen days and higher frequency of phlebitis was also found in a study of 100 patients in the Brazilian Federal District [13].A cohort of 380 patients showed a strong correlation of the patient´s length of stay in intensive care units with the number of adverse events (p <0.0001), including phlebitis.In the adverse events associated with Nursing performance, phlebitis corresponded to 11.58% of these incidents [23].Although there are limited descriptions of the length of stay as a predisposing factor for phlebitis [13,21,23], this study could address this variable.
There were 23 patients (38.3%) of 60 in this study who underwent percutaneous coronary intervention and 50 (83.3%)used adjunctive pharmacological therapy using antiplatelet and oral, intravenous or subcutaneous anticoagulants.The administration of a dual antiplatelet therapy (aspirin + derived thienopyridine) is indicated for the reduction of thrombosis in patients with coronary artery disease with pharmacological stent implantation, and its maintenance is recommended for a minimum period of one year.[24] Some of the patients using this therapy had undergone stent implantation previously in other previous hospitalizations.In both cases, adjunctive therapy was used.
In nine cases, the patients had bruises during the observation period without interruption of therapy.In only one case, the presence of hematoma was interrupted.The increased number of patients with bruises may be due to oral antiplatelet therapy and/ or intravenous and oral anticoagulation therapy and/ or subcutaneous implemented as adjunctive therapy in cases of patients with stent implantation.
Patients using these drugs may have the potential for complications such as bleeding at the peripheral puncture site.In such cases, it is recommended the daily monitoring of the integumentary system for early detection of signals such as petechia, bruises, and hematomas.
There was a significant association between the higher number of punctures per patient with the occurrence of phlebitis, similar to other studies [9,13].In 17 patients who developed phlebitis, 15 of them (87%) underwent more than two punctures.
There are reports of complications for the length of stay, type, catheter caliber and device location.However, these variables did not show significant impact as predictors for the occurrence of phlebitis or complications in this study.It should be noted that the time of 72 hours stay was strictly fulfilled by the institution, the polyurethane (Vialon®) catheter was used in 100% of patients, having a lower incidence thrombogenic, more flexible, a lower risk of phlebitis [6,25] and more 20 and 22 caliver have been used as recommended in the literature, due to the fact of being less traumatic [6,17].

Conclusion
In this study, adults with heart disease had a twice higher rate for development of phlebitis than the 5% established for patients by international standards in general of the Infusion Nursing Society.
The findings were about the cardiac patients with diabetes and dyslipidemia with a higher relative risk of 2.7 and 2.8 times, respectively for the development of phlebitis compared to those who did not have these factors.
Therefore, the cardiac patients using peripheral intravenous therapy showed three days in the hospital and more than two punctures as predictors of phlebitis.
Occurrences above the established standards interfere with the patient´s level of security, becoming susceptible to iatrogenic complications in the hospital.Even Although unintentional damaging effects, the relevance of this study is to encourage their reduction through the production of important information to the development planning activities for safer care to cardiac patients undergoing this therapy.
International Archives of Medicine is an open access journal publishing articles encompassing all aspects of medical science and clinical practice.IAM is considered a megajournal with independent sections on all areas of medicine.IAM is a really international journal with authors and board members from all around the world.The journal is widely indexed and classified Q1 in category Medicine.

Figure 1 :
Figure 1: Box plot chart with analysis of days in intravenous therapy and phlebitis outcome (n=60).Horizontal line: average, Box: interquartile interval, Bar: variation range, Symbol: outlier.

Figure 2 :
Figure 2: Box plot Chart with analysis of the number of punctures and phlebitis outcome (n=60).Horizontal line: Average, Box: interquartile interval, Bar: variation range, Symbol: outlier.* Statistically significant difference compared to patients without phlebitis (Mann-Whitney test, p <0.001).

Table 1 .
Clinical and demographic characteristics of cardiac patients using intravenous therapy in coronary care unit being monitored to verify phlebitis.Campo Grande, MS.Brazil 2012 (n=60).

Table 1 .
Average of hospitalization days in cardiac patients using peripheral intravenous therapy according to the occurrence of local complications.Campo Grande, MS, Brazil, in 2012 (n = 60).*Standard deviation; ** Averages Differences test; *** Mann-Whitney Test.