Occurrence of phlebitis in patients on intravenous amiodarone

Original Article
Occurrence of phlebitis in patients on intravenous
amiodarone
Ocorrência de flebite em pacientes sob utilização de amiodarona endovenosa
Renata de Fátima Suardi Martinho1, Andrea Bezerra Rodrigues2
ABSTRACT
Objective: To investigate the occurrence of phlebitis in patients
given amiodarone through a peripheral venous access, and to
describe nursing interventions in patients with phlebitis following the
use of this medication. Methods: A descriptive exploratory crosssectional quantitative study was undertaken. Data were gathered
from the files of patients of a cardiology intensive care unit in a general
hospital. Results: Forty patients aged from 51 to 90 years, admitted
into a cardiology intensive therapy unit, were included. Fifty-five
percent of these patients presented phlebitis. Intrinsic factors such
as age over 65 years (14.9%) and poor condition of veins (3.5%) were
noted. Intrinsic factors included drug administration issues (13.9%)
and lack of compliance to institutional protocols by nurses (7.8%).
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
drug administration methods and lack of compliance to institutional
protocol by nurses.
Keywords: Nursing care; Education, nursing; Patient care; Phlebitis;
Amiodarone
RESUMO
Objetivo: Identificar a ocorrência de flebite em pacientes que
receberam a medicação amiodarona por acesso venoso periférico e
descrever as intervenções de enfermagem em pacientes com flebite
que fizeram uso dessa medicação. Métodos: Estudo descritivoexploratório, transversal, quantitativo. Os dados foram coletados
a partir de informações contidas nos prontuários dos pacientes de
um centro de terapia intensiva adulto de uma unidade de cardiologia
de um hospital geral. Resultados: A amostra foi composta por 40
pacientes com idade entre 51 e 90 anos de idade que estiveram
hospitalizados em uma unidade de internação cardiológica e uma
unidade de terapia intensiva. Cinqüenta e cinco por cento desses
pacientes apresentaram flebite. Foram fatores intrínsecos para a
ocorrência de flebite: idade superior a 65 anos (14,9%) e a condição
prejudicada da rede venosa dos pacientes (3,5%). Entre os fatores
extrínsecos foram identificados: problemas quanto à administração
inadequada da medicação (13,9%) e intervenções de enfermagem
não compatíveis com o protocolo da Instituição para atendimento
a esses casos (7,8%). Conclusões: A maioria dos pacientes que
recebeu amiodarona venosa na Instituição apresentou flebite. Foram
identificados fatores intrínsecos: idade e condição das veias, bem
como fatores extrínsecos: problemas com diluição da droga e
atuações de enfermagem ausentes ou inadequadas.
Descritores: Cuidados de enfermagem; Educação em enfermagem;
Assistência ao paciente; Flebite; Amiodarona
INTRODUCTION
Intravenous therapy (IVT) has become an indispensable
tool for infusing large amounts of solutions, rapidly
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
of the device(2-3).
Phlebitis may be defined as venous cell inflammation
where endothelial cells become rough and facilitate
platelet adhesion(1).
The pathophysiology of phlebitis consists of local
vessel vasodilatation, increased capillary permeability,
which allows fluid leaking to the interstitial space,
granulocyte and monocyte migration into tissues,
and edema. Numerous tissue products activate the
macrophage system, and within hours these cells begin
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: [email protected]
Received on Mar 19, 2008 – Accepted on Oct 30, 2008
einstein. 2008; 6(4):459-62
460
Martinho RFS, Rodrigues AB
Associated signs and symptoms are erythema, local
warmth and edema, a palpable fibrous cord along
the vein, decreased infusion velocity, and increased
baseline temperature. As a result, there is discomfort
and pain, which may considerably increase during
hospital stay(1,4).
Some issues may affect the progression of phlebitis,
such as catheter size/material and device insertion at the
emergency room, which increases the risk compared to
inpatient’s units. The length of hospital stay and routine
peripheral vein catheter exchange procedures have
also been associated with increased rates of phlebitis.
Catheters should be replaced every 72 to 96 hours to
reduce such risk. Another factor is the type of infusion;
low or high pH solutions increase the risk. Among these
solutions are potassium chloride, hypertonic glucose,
amino acids, lipids, antibiotics, especially betalactamic
drugs, vancomycin, and metronidazole. Infusion rates
over 90ml/h also increase the risk of phlebitis. Moreover,
intrinsic patient factors such as poor quality veins,
advanced age and individual biological vulnerability
may also increase the risk of phlebitis(5).
Phlebitis may be classified, according to its causes, as
mechanical phlebitis, bacterial phlebitis, post-infusion
phlebitis and chemical phlebitis. Mechanical phlebitis may be due to inappropriate
sized catheters or poor puncture technique(1,4-5). An
important factor in mechanical phlebitis is the type
of device used for puncture. These devices may be
conventional needle, over-the-needle, under-the-needle,
mid-line, or double-lumen catheters(4-6).
Bacterial phlebitis results from infection originating
from the procedure due to inadequate asepsis, failure
in detecting any intravenous device breakage and poor
catheter insertion technique(1).
Post-infusion phlebitis is inflammatory, becoming
evident within 48 to 96 hours after the catheter is
removed; it is facilitated by the material of which the
catheter is made and the time it remains within the vein.
Peripheral catheters remain patent up to 72 hours with
appropriate care. It should be noted that if there are any
signs or symptoms of complications, the nursing team is
responsible for making decisions, such as removing the
device before the intended period(1,6).
Chemical phlebitis is usually related to irritating
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
should not be infused through the same route; the drug
may cause indeterminate effects. There are also related
complications, such as transfusion reactions, circulatory
overload, potassium intoxication, hyponatremia or
hypocalcemia(4).
einstein. 2008; 6(4):459-62
Amiodarone, an antiarrhythmic agent, is one of the
drugs that cause high rates of phlebitis. This drug was
developed in Europe in the early 1960s, and was used
initially as an anti-angina drug, and afterwards as an
antiarrhythmic medication. It is a benzofuran derivative,
with a molecular weight of 643.3 (free base) or 681.8
in its saline form (hydrochloride). It is classified as an
amphiphilic drug, since it contains polar and apolar
nuclei in its molecule; it is thus both hydrolytic and
lipophilic. About 37% of its weight is iodine(7-10).
According to its main action mechanism,
amiodarone is used for the treatment of ventricular and
supraventricular arrhythmias, atrial fibrillation, flutter,
and refractory ventricular tachycardia(9-10).
At the hospital where the study was performed,
amiodarone is available in 3-ml ampules containing 150 mg
of the drug. Dilution must be done in 250 ml of 5% glucose
solution; there are conflicting data about the compatibility
between amiodarone and saline solution. Post-dilution
stability is five days at room temperature – at 0.6 mg/ml –
which is the maximum infusion concentration(11).
The following measures should be applied when
administering this medication to avoid phlebitis. Use
of correct venous puncture technique, which reduces
microorganism transmission: water and antiseptic
soap hand washing or alcohol gel use; choice of vein
to be punctured; patient’s clinical status and veins;
use of gloves for the procedure; skin antisepsis for
decreasing contamination by pathogens; and dressing
and catheter fixation(12).
Flushing with 10 ml of 0.9% saline solution should
be done after the drug is given to keep the catheter
patent when drugs are administered intermittently. The
catheter should be removed immediately if there are
infusion problems, signs or symptoms of phlebitis(12).
Constant supervision of the puncture area is needed
if the dermis and epidermis show any signs of change;
additionally, care should be taken to avoid infection and
to identify possible risks, such as poor immunity. The
insertion site should also be monitored routinely(13).
Frequent exposure to this drug has raised an
important issue for the work of nurses(14), since phlebitis
may often occur, which increases the risk of infection
and may prolong hospital stay, reducing patient’s
satisfaction and the quality of service.
OBJECTIVE
The purpose of this study were to verify the occurrence
of phlebitis in patients given amiodarone through a
peripheral venous access route, to identify intrinsic and
extrinsic factors of phlebitis in patients given intravenous
amiodarone, and to describe nursing interventions in
these patients.
Occurrence of phlebitis in patients on intravenous amiodarone
Yes
55%
Figure 1. Incidence of phlebitis related to administration of intravenous
amiodarone by peripheral vein, São Paulo, 2007
25
20
15
10
5
Infusion > 90 ml/hour
Multiple peripheral punctures
Inappropriate timing of infusion device
Use of drugs with pH < 6 > 8
Administration of loading dose
Inadequate nursing care
Extrinsic factors
Insertion of peripheral venous catheter during an emergence procedure
Intrinsic factors
Use of venous route for other drugs/solutions
Inadequate drug dilution
0
Poor vein condition/Capillary fragility
RESULTS
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
route.
Most of the sample (n = 40) consisted of male
patients (55%) aged from 51 to 90 years (87.5%), who
were admitted to the cardiology intensive care unit
(45%).
Figure 1 shows that most of the 40 patients who
were given amiodarone by a peripheral vein developed
phlebitis (55%).
Figure 2 shows the incidence of phlebitis and its
relation with extrinsic and intrinsic causal factors in
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
(13.9%), and inadequate nursing care in intravenous
therapy (7.8%).
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.
Inadequate approaches in nursing care were found in
7.8% of cases, such as applying ice bags on patients with
No
45%
Age > 65 years
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
hospital from January 2006 to January 2007 who were
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.
461
Figure 2. Intrinsic and extrinsic factors identified in patients given amiodarone
who developed phlebitis, São Paulo, 2007
Table 1. Nursing interventions related to phlebitis described in nursing
prescriptions and educational plan for patients, São Paulo, 2007
Nursing interventions
Nursing interventions to treat phlebitis
Do not contain interventions to treat phlebitis
Nursing interventions prescribed to avoid phlebitis associated
to amiodarone
Inadequate interventions
Total
n
19
18
%
37.3
35.3
10
19.6
04
51
7.8
100.0
phlebitis, contrary to the institutional recommendation
of applying warm compresses for 15 minutes every eight
hours and keeping the affected limb elevated in relation
to the body.
DISCUSSION
Most patients who were given amiodarone by a
peripheral venous access route within the study period
developed phlebitis.
einstein. 2008; 6(4):459-62
462
Martinho RFS, Rodrigues AB
Predisposing factors for phlebitis in the sample were
age over 65 years (considered in the literature as an
intrinsic causing factor of phlebitis)(5), incorrect dilution
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,
gentamicin and morphine.
The recommended amiodarone dilution is 150 mg
(one ampoule) for each 250 ml of 5% glucose solution.
The manufacturer states that there are conflicting data
about the compatibility between this drug and saline
solution(11).
The pH of amikacin is 4.5; the pH of cefazolin
ranges from 4.5 to 5.5; the pH of gentamicin ranges
from 3.0 to 5.5; and the pH of morphine ranges from
3.0 to 6.0. It is important to know these pH levels
to minimize the risk of phlebitis, and to dilute these
drugs as much as possible within clinically tolerable
levels. Continuous evaluation, as recommended by
the Intravenous Nursing Society, should be done
when using these drugs, to minimize the risks of
phlebitis(15-16).
Nursing interventions in these patients were not
always adequate in this context, such as applying
cold bags and Hirudoid® on the phlebitis area, and
not following institutional guidelines (use of warm
compresses during at least 15 minutes each time)(7,12,15).
There were few nursing interventions for preventing
or detecting phlebitis in this group of patients.
CONCLUSIONS
In this sample, 55% of patients given endovenous
amiodarone developed phlebitis.
The main intrinsic factor in these patients was age
over 65 years.
The main extrinsic factors in this group of patients
were inadequate drug dilution, the use of the same
venous route for other drugs that would potentially
induce phlebitis, and inadequate nursing care in
intravenous therapy.
einstein. 2008; 6(4):459-62
There was a small proportion of nursing
interventions for the prevention of phlebitis (37.3%);
in some cases (7.8%) non-recommended interventions
were taken.
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