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Occurrence of phlebitis in patients on intravenous Ocorrência de flebite em pacientes sob utilização de amiodarona endovenosa Renata de Fátima Suardi Martinho1, Andrea Bezerra Rodrigues2 aBStract
ocorrência de flebite: idade superior a 65 anos (14,9%) e a condição Objective: To investigate the occurrence of phlebitis in patients
prejudicada da rede venosa dos pacientes (3,5%). Entre os fatores given amiodarone through a peripheral venous access, and to extrínsecos foram identificados: problemas quanto à administração describe nursing interventions in patients with phlebitis following the inadequada da medicação (13,9%) e intervenções de enfermagem use of this medication. Methods: A descriptive exploratory cross-
não compatíveis com o protocolo da Instituição para atendimento sectional quantitative study was undertaken. Data were gathered a esses casos (7,8%). conclusões: A maioria dos pacientes que
from the files of patients of a cardiology intensive care unit in a general recebeu amiodarona venosa na Instituição apresentou flebite. Foram hospital. results: Forty patients aged from 51 to 90 years, admitted
identificados fatores intrínsecos: idade e condição das veias, bem into a cardiology intensive therapy unit, were included. Fifty-five como fatores extrínsecos: problemas com diluição da droga e percent of these patients presented phlebitis. Intrinsic factors such atuações de enfermagem ausentes ou inadequadas.
as age over 65 years (14.9%) and poor condition of veins (3.5%) were noted. Intrinsic factors included drug administration issues (13.9%) Descritores: Cuidados de enfermagem; Educação em enfermagem;
and lack of compliance to institutional protocols by nurses (7.8%). Assistência ao paciente; Flebite; Amiodarona conclusions: most patients who were given intravenous amiodarone
at the Institution developed phlebitis. Intrinsic factors identified
were patient age and vein status, and the extrinsic factors were
intrODUctiOn
drug administration methods and lack of compliance to institutional Intravenous therapy (IVT) has become an indispensable tool for infusing large amounts of solutions, rapidly Keywords: Nursing care; Education, nursing; Patient care; Phlebitis;
attaining a pharmacological effect, giving hypertonic or extreme pH substances, and for giving drugs that may be poorly absorbed by the gastrointestinal tract(1).
The most common causes of infusion failure are phlebitis, leaking, obstruction, and accidental removal Objetivo: Identificar a ocorrência de flebite em pacientes que
receberam a medicação amiodarona por acesso venoso periférico e Phlebitis may be defined as venous cell inflammation descrever as intervenções de enfermagem em pacientes com flebite where endothelial cells become rough and facilitate que fizeram uso dessa medicação. Métodos: Estudo descritivo-
exploratório, transversal, quantitativo. Os dados foram coletados The pathophysiology of phlebitis consists of local a partir de informações contidas nos prontuários dos pacientes de vessel vasodilatation, increased capillary permeability, um centro de terapia intensiva adulto de uma unidade de cardiologia
de um hospital geral. resultados: A amostra foi composta por 40
which allows fluid leaking to the interstitial space, pacientes com idade entre 51 e 90 anos de idade que estiveram granulocyte and monocyte migration into tissues, hospitalizados em uma unidade de internação cardiológica e uma and edema. Numerous tissue products activate the unidade de terapia intensiva. Cinqüenta e cinco por cento desses macrophage system, and within hours these cells begin pacientes apresentaram flebite. Foram fatores intrínsecos para a to phagocytose destroyed tissues(1).
Study carried out at Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil.
1 Assisting nurse in Resource Planning and Optimization at Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil.
2 PhD; Lecturer of Nursing in Oncology at Faculdade de Enfermagem do Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil. Corresponding author: Renata de Fátima Suardi Martinho – Rua Mateus Grou, 79 – apto. 11 – Pinheiros – CEP 05415-040 – São Paulo (SP), Brasil – Tel.: 11 3088-7942 – e-mail: re_06@hotmail.com Received on Mar 19, 2008 – Accepted on Oct 30, 2008 Associated signs and symptoms are erythema, local Amiodarone, an antiarrhythmic agent, is one of the warmth and edema, a palpable fibrous cord along drugs that cause high rates of phlebitis. This drug was the vein, decreased infusion velocity, and increased developed in Europe in the early 1960s, and was used baseline temperature. As a result, there is discomfort initially as an anti-angina drug, and afterwards as an and pain, which may considerably increase during antiarrhythmic medication. It is a benzofuran derivative, with a molecular weight of 643.3 (free base) or 681.8 Some issues may affect the progression of phlebitis, in its saline form (hydrochloride). It is classified as an such as catheter size/material and device insertion at the amphiphilic drug, since it contains polar and apolar emergency room, which increases the risk compared to nuclei in its molecule; it is thus both hydrolytic and inpatient’s units. The length of hospital stay and routine lipophilic. About 37% of its weight is iodine(7-10).
peripheral vein catheter exchange procedures have also been associated with increased rates of phlebitis. amiodarone is used for the treatment of ventricular and Catheters should be replaced every 72 to 96 hours to supraventricular arrhythmias, atrial fibrillation, flutter, reduce such risk. Another factor is the type of infusion; and refractory ventricular tachycardia(9-10).
low or high pH solutions increase the risk. Among these At the hospital where the study was performed, solutions are potassium chloride, hypertonic glucose, amiodarone is available in 3-ml ampules containing 150 mg amino acids, lipids, antibiotics, especially betalactamic of the drug. Dilution must be done in 250 ml of 5% glucose drugs, vancomycin, and metronidazole. Infusion rates solution; there are conflicting data about the compatibility over 90ml/h also increase the risk of phlebitis. Moreover, between amiodarone and saline solution. Post-dilution intrinsic patient factors such as poor quality veins, stability is five days at room temperature – at 0.6 mg/ml – advanced age and individual biological vulnerability which is the maximum infusion concentration(11).
may also increase the risk of phlebitis(5).
The following measures should be applied when Phlebitis may be classified, according to its causes, as administering this medication to avoid phlebitis. Use mechanical phlebitis, bacterial phlebitis, post-infusion of correct venous puncture technique, which reduces microorganism transmission: water and antiseptic Mechanical phlebitis may be due to inappropriate soap hand washing or alcohol gel use; choice of vein sized catheters or poor puncture technique(1,4-5). An to be punctured; patient’s clinical status and veins; important factor in mechanical phlebitis is the type use of gloves for the procedure; skin antisepsis for of device used for puncture. These devices may be decreasing contamination by pathogens; and dressing conventional needle, over-the-needle, under-the-needle, mid-line, or double-lumen catheters(4-6).
Flushing with 10 ml of 0.9% saline solution should Bacterial phlebitis results from infection originating be done after the drug is given to keep the catheter from the procedure due to inadequate asepsis, failure patent when drugs are administered intermittently. The in detecting any intravenous device breakage and poor catheter should be removed immediately if there are infusion problems, signs or symptoms of phlebitis(12).
Post-infusion phlebitis is inflammatory, becoming Constant supervision of the puncture area is needed evident within 48 to 96 hours after the catheter is if the dermis and epidermis show any signs of change; removed; it is facilitated by the material of which the additionally, care should be taken to avoid infection and catheter is made and the time it remains within the vein. to identify possible risks, such as poor immunity. The Peripheral catheters remain patent up to 72 hours with insertion site should also be monitored routinely(13).
appropriate care. It should be noted that if there are any Frequent exposure to this drug has raised an signs or symptoms of complications, the nursing team is important issue for the work of nurses(14), since phlebitis responsible for making decisions, such as removing the may often occur, which increases the risk of infection device before the intended period(1,6).
and may prolong hospital stay, reducing patient’s Chemical phlebitis is usually related to irritating satisfaction and the quality of service.
drugs or solutions, inappropriately diluted or mixed medication, excessively rapid infusion, or the presence of small particles in the solution(4).
OBJectiVe
An important point is that drug and blood products The purpose of this study were to verify the occurrence should not be infused through the same route; the drug of phlebitis in patients given amiodarone through a may cause indeterminate effects. There are also related peripheral venous access route, to identify intrinsic and complications, such as transfusion reactions, circulatory extrinsic factors of phlebitis in patients given intravenous overload, potassium intoxication, hyponatremia or amiodarone, and to describe nursing interventions in Occurrence of phlebitis in patients on intravenous amiodarone MetHODS
We conducted a quantitative, descriptive, exploratory,
retrospective study. Data were obtained from the charts of patient of an adult cardiology intensive care unit at a major private general hospital in São Paulo. The sample consisted of patients admitted to Figure 1. Incidence of phlebitis related to administration of intravenous
hospital from January 2006 to January 2007 who were amiodarone by peripheral vein, São Paulo, 2007 given amiodarone by a peripheral venous catheter. A semi-structured script written by the authors was used for gathering data. It consisted of questions for characterizing the sample; questions about amiodarone, such as drug dosage, dilution, infusion velocity; questions about intrinsic and extrinsic factors that might increase the risk of phlebitis, such as the type and gauge of the vein puncture device, the duration of vein puncture; the use of other potentially phlebitis-causing solutions, such as hypertonic solutions, antibiotics and parenteral nutrition, and signs of phlebitis and prescribed nursing interventions. The Research Ethics Committee of the hospital in which data were gathered approved this study. There were 687 charts in which patients were given amiodarone intravenously within the study period. Of these patients, 60.8% received this drug by a central venous catheter. Forty of the sample patients were given the medication by a peripheral venous Most of the sample (n = 40) consisted of male Figure 2. Intrinsic and extrinsic factors identified in patients given amiodarone
patients (55%) aged from 51 to 90 years (87.5%), who who developed phlebitis, São Paulo, 2007 were admitted to the cardiology intensive care unit table 1. Nursing interventions related to phlebitis described in nursing
Figure 1 shows that most of the 40 patients who prescriptions and educational plan for patients, São Paulo, 2007 were given amiodarone by a peripheral vein developed nursing interventions
Figure 2 shows the incidence of phlebitis and its Do not contain interventions to treat phlebitis relation with extrinsic and intrinsic causal factors in Nursing interventions prescribed to avoid phlebitis associated patients who was given amiodarone. Intrinsic factors included age over 65 years (14.9%), and poor vein condition (3.5%). Extrinsic factors included errors in amiodarone dilution, the use of other potentially phlebitis-causing drugs together with amiodarone phlebitis, contrary to the institutional recommendation (13.9%), and inadequate nursing care in intravenous of applying warm compresses for 15 minutes every eight hours and keeping the affected limb elevated in relation Table 1 shows the nursing interventions related to phlebitis. Only 37.3% of the charts described nursing interventions that abided by the institutional protocol for treating phlebitis; in 35.3%, no nursing DiScUSSiOn
interventions were described for detected phlebitis.
Most patients who were given amiodarone by a Inadequate approaches in nursing care were found in peripheral venous access route within the study period 7.8% of cases, such as applying ice bags on patients with Predisposing factors for phlebitis in the sample were age over 65 years (considered in the literature as an interventions for the prevention of phlebitis (37.3%); intrinsic causing factor of phlebitis)(5), incorrect dilution in some cases (7.8%) non-recommended interventions of the drug (where dilution errors could be up to six times the recommended dilution), dilution using 0.9% saline solution, and the use of other drugs that could potentially cause phlebitis (such as amikacin, cefazolin, reFerenceS
1. Netto PS, Secoli SR. Flebite enquanto complicação local da terapia intravenosa: The recommended amiodarone dilution is 150 mg estudo de revisão. Rev Paul Enferm. 2004;23(3/4):254-9.
(one ampoule) for each 250 ml of 5% glucose solution. 2. Machado AF, Pedreira MLG, Chaud MN. Estudo prospectivo, randomizado e The manufacturer states that there are conflicting data controlado sobre o tempo de permanência de cateteres venosos periféricos em crianças, segundo três tipos de curativos. Rev Lat Am Enferm. about the compatibility between this drug and saline 3. Nascimento EMF, Souza MF. Infiltração em terapia intravenosa através de veia The pH of amikacin is 4.5; the pH of cefazolin periférica. Acta Paul Enferm. 1996;9(1):53-60.
ranges from 4.5 to 5.5; the pH of gentamicin ranges 4. Phillips LD. Complicações de terapia intravenosa. In: Phillips LD. Manual de from 3.0 to 5.5; and the pH of morphine ranges from terapia intravenosa. 2a ed. Porto Alegre: Artmed; 2001. p.236-76.
3.0 to 6.0. It is important to know these pH levels 5. Hospital Israelita Albert Einstein. Flebite [protocolo institucional]. criado em: to minimize the risk of phlebitis, and to dilute these 20021210; revisado em: 20060217. [Responsável: Lucia Marta Giunta da drugs as much as possible within clinically tolerable levels. Continuous evaluation, as recommended by 6. Pereira RCC, Zanetti ML, Ribeiro KP. Tempo de permanência do dispositivo venoso periférico, in situ, relacionado ao cuidado de enfermagem, em the Intravenous Nursing Society, should be done pacientes hospitalizados. Medicina (Ribeirão Preto). 2001;34:79-84.
when using these drugs, to minimize the risks of 7. Hospital Israelita Albert Einstein. Medicamentos que necessitam de dispositivos de controle de fluxo de infusão [protocolo institucional]. [criado Nursing interventions in these patients were not em: 20051129; atualizado em: 20051130.[Responsável: Cláudia Regina always adequate in this context, such as applying cold bags and Hirudoid® on the phlebitis area, and 8. Terra Filho M. Toxicidade pulmonar pela amiodarona. Rev Soc Cardiol Estado not following institutional guidelines (use of warm compresses during at least 15 minutes each time)(7,12,15).
9. Bronstein MD. Amiodarona e distúrbios da tireóide. Rev Soc Cardiol Estado de There were few nursing interventions for preventing 10. Goldenzwaig NRSC. Administração de medicamentos na enfermagem 2005/2006. or detecting phlebitis in this group of patients. 5a ed. rev. e atual. Rio de Janeiro: Guanabara Koogan; 2005. p. 56-8.
11. Ancoron: Cloridrato de Amiodarona [bula de remédio]. São Paulo: Libbis cOnclUSiOnS
12. Silva LMG. Cateteres venosos. In: Bork AMT. Enfermagem baseada em In this sample, 55% of patients given endovenous evidências. Rio de Janeiro: Guanabara Koogan; 2005. p. 190-211.
13. Johnson M, Bulechek G, Dochterman JM, Maas M, Moorhead S. Diagnósticos, The main intrinsic factor in these patients was age resultados e intervenções de enfermagem: ligações entre Nanda, Noc e Nic. Porto Alegre: Artmed; 2005. p. 143, 176, 246-7, 369-71. The main extrinsic factors in this group of patients 14. Pereira RCC, Zanetti ML. Complicações decorrentes da terapia intravenosa em pacientes cirúrgicos. Rev Lat Am Enferm. 2000;8(5):21-7. were inadequate drug dilution, the use of the same 15. Intravenous Nursing Society. Infusion Nursing Standards of Practice. J Intrav. venous route for other drugs that would potentially induce phlebitis, and inadequate nursing care in 16. Cristina I, Cruz F. Diagnósticos e prescrições de enfermagem: recriando os instrumentos de trabalho. Texto & Contexto Enferm. 1995;4(1):160-9.

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