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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
ocorrência de flebite: idade superior a 65 anos (14,9%) e a condição
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
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%)
Cuidados de enfermagem; Educação em enfermagem;
and lack of compliance to institutional protocols by nurses (7.8%).
Assistência ao paciente; Flebite; Amiodarona
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
drug administration methods and lack of compliance to institutional
Intravenous therapy (IVT) has become an indispensable
tool for infusing large amounts of solutions, rapidly
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
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:
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: firstname.lastname@example.org 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).
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
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
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
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
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
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
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,
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The manufacturer states that there are conflicting data
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ranges from 4.5 to 5.5; the pH of gentamicin ranges
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from 3.0 to 5.5; and the pH of morphine ranges from
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3.0 to 6.0. It is important to know these pH levels
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RESEARCH ARTICLE Dehydration Effects on the Risk of Severe Decompression Sickness in a Swine Model FAHLMAN A, DROMSKY DM. Dehydration effects on the risk of randomly may well contain physically or biologically severe decompression sickness in a swine model. Aviat Space Envi- definable variables that have not yet been identified as ron Med 2006; 77:102– 6. important factors,
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