Phlebitis management. Was this handled correctly?

[elephantlover, BSN, RN]

Hello,
I am a senior nursing student. I am working to develop my clinical decision-making skills by observing the nurses I work with as a CNA. I have some questions regarding a situation I witnessed at work. I have read old discussion posts on related topics, but I still haven’t found my answer. Looking for your input.

A patient developed what appeared to be grade 3 or 4 phlebitis while receiving a vancomycin infusion through a peripheral line. I notified the RN and asked if she wanted me to remove IV catheter. After assessing the site, the RN decided she was going to leave the IV catheter in because it still flushed. This patient was in a lot of pain. I thought the proper course of action would be to remove the catheter, apply heat, and monitor frequently. This patient did not look like she would be a difficult IV start.

The policies and procedures manual stated that IV site removal may be warranted for treating phlebitis. This was not the definitive answer I was looking for. What would you do? Would contacting the provider to discuss a PICC line be warranted? How do you manage IV site complications like this one?

Thanks for letting me pick your brain.

[RNperdiem, RN]

I guess it depends on what else is going on. In my ICU, the policy is for a patient to have 2 peripheral IVs at all times unless there is a PICC or central line.

If this patient is on Vanco long term, a PICC is a good idea; vanco is tough on veins. The thing is, it takes time to find the provider, convince them a PICC is a good idea, have them place the order, contact the IV team(lucky if they work nights and weekends), and get better IV access. In the short term, the nurse might have to start a new peripheral IV.

The nurse might want to have a new IV placed first and delay removing the old one until a new IV is in, just in case.

[canoehead, BSN, RN]

Given what you've said, I would likely start another IV. If there was ten minutes left on the infusion, and it was an outpatient, I might ask the patient if ten more minutes was ok, then remove the IV.

When a patient complains of pain at an IV site I always take it seriously. Being uncomfortable with something stuck in your arm is normal, but pain is not. If its red, leaking or streaking I'll start a new one. If it looks ok, and flushes well, I let them know it looks ok, but if it bothers them I'll start a fresh one. When the patient says "yes!" to another stick, I bet the pain in the one they have is bad enough to take it out.

[elephantlover, BSN, RN]

This past week at work I was working with a different RN. We had a patient receiving a dobutamine infusion through a peripheral IV. The patient complained of pain at the infusion site a few hours in. There was no redness or swelling around the site, but this RN decided to remove the catheter immediately. Both dobutamine and vancomycin are vesicant medications. Our policy isn't clear. Trying to gauge what the most appropriate course of action is.

[elephantlover, BSN, RN]

4 hours ago, RNperdiem said:

I guess it depends on what else is going on. In my ICU, the policy is for a patient to have 2 peripheral IVs at all times unless there is a PICC or central line.

If this patient is on Vanco long term, a PICC is a good idea; vanco is tough on veins. The thing is, it takes time to find the provider, convince them a PICC is a good idea, have them place the order, contact the IV team(lucky if they work nights and weekends), and get better IV access. In the short term, the nurse might have to start a new peripheral IV.

The nurse might want to have a new IV placed first and delay removing the old one until a new IV is in, just in case.

I see what you're saying. This nurse did not intend to start a new IV. I work on a medical unit and our policy is that every patient needs IV access. I just don't understand why she wouldn't start a new IV for this patient who was not being discharged in the near future.

[Tenebrae, BSN, RN]

You said she didnt look like she'd be a difficult stick. Often you cant tell how easy a person is to get a line into until you have to try and get a line in.

That said, if the patient is complaining of pain, I would be seeking to get a new line in asap

[iluvivt, BSN, RN]

The PIV should have been taken out immediately.If the catheter is still in the vein, yes, it may flush but the vein was clearly inflamed and red and that will not improve until you get the mechanical irritant out (the cannula) and most importantly stop infusing the chemical irritant,in this case the antibiotic.Unfortunatly, this nurse used bad judgment.The PIV needs to be taken out...treated with heat and a new PIV placed.Then you need to look at the big picture=how long is the patient going to be on IV antibiotics=how irritating are those agents=what are the quality of the patient's veins=are they adequate enough to sustain the prescribed course of therapy.As a general guideline if a patient will be needing IV Therapy for more than 6 to 7 days a PICC or other type of CVAD is prudent. Although,with all the worry about Catheter Related Bloodstream Infection I have begun to see many more patients going much longer using peripheral veins than in the last 10 years or so and their peripheral veins are taking a beating. Our IV team is available for consult at any time and we will will evaluate the case,assess the quality of the peripheral veins (even assess with Ultrasound) then advocate for the best type of line for the patient. This is a very helpful service we provide and our nurse colleagues appreciate it.Many hospitals have algorithms that guide you in the type of line that is most appropriate but honestly you sometimes have to push the providers to order it.If we tell them we can no longer place any more PIVs or will not place anymore and they must come in to place a central line...we get our PICC order or tunneled CVAD...Yep they don't want to come and do it...

[elephantlover, BSN, RN]

20 hours ago, iluvivt said:

The PIV should have been taken out immediately.If the catheter is still in the vein, yes, it may flush but the vein was clearly inflamed and red and that will not improve until you get the mechanical irritant out (the cannula) and most importantly stop infusing the chemical irritant,in this case the antibiotic.Unfortunatly, this nurse used bad judgment.The PIV needs to be taken out...treated with heat and a new PIV placed.Then you need to look at the big picture=how long is the patient going to be on IV antibiotics=how irritating are those agents=what are the quality of the patient's veins=are they adequate enough to sustain the prescribed course of therapy.As a general guideline if a patient will be needing IV Therapy for more than 6 to 7 days a PICC or other type of CVAD is prudent. Although,with all the worry about Catheter Related Bloodstream Infection I have begun to see many more patients going much longer using peripheral veins than in the last 10 years or so and their peripheral veins are taking a beating. Our IV team is available for consult at any time and we will will evaluate the case,assess the quality of the peripheral veins (even assess with Ultrasound) then advocate for the best type of line for the patient. This is a very helpful service we provide and our nurse colleagues appreciate it.Many hospitals have algorithms that guide you in the type of line that is most appropriate but honestly you sometimes have to push the providers to order it.If we tell them we can no longer place any more PIVs or will not place anymore and they must come in to place a central line...we get our PICC order or tunneled CVAD...Yep they don't want to come and do it...

THANK YOU! This seems so straightforward in my mind. This patient's vein was being irritated by the catheter and the abx. Solution. STOP and remove. Further complications could develop. I just could not understand why my hospital's policy was so vague. We have resource nurses that will use ultrasound to start IVs as well. Takes the burden off the nurse. This seems black and white. Now I know what not to do. Thank you for walking me through the big picture.

[elephantlover, BSN, RN]

On 1/15/2019 at 11:01 PM, Tenebrae said:

You said she didnt look like she'd be a difficult stick. Often you cant tell how easy a person is to get a line into until you have to try and get a line in.

That said, if the patient is complaining of pain, I would be seeking to get a new line in asap

The patient was of normal weight. Middle-aged. Visible veins. We have IV resource nurses at the hospital I work at. I just was trying to understand why this particular nurse decided not to start a new IV.

But yes, thank you for your answer. If a patient complains of new pain at the IV site. Remove and start a new an IV.

[Tenebrae, BSN, RN]

1 minute ago, elephantlover said:

The patient was of normal weight. Middle-aged. Visible veins. We have IV resource nurses at the hospital I work at. I just was trying to understand why this particular nurse decided not to start a new IV.

But yes, thank you for your answer. If a patient complains of new pain at the IV site. Remove and start a new an IV.

I have a friend who appears to be a great person to put a line in, or take a blood test from. I went with her once to get a blood test and it took more than five attempts to get the test because her lovely looking veins just wouldnt give up the blood.

I usually have great IV access and no troubles with blood test. A few years ago when I had an infected axillary abscess that developed into sepsis, it took the IV tech seven attempts before he managed to get IV access and even then it was a fairly dodgy placement but it was literally the only vein that would hold a line

I'm not saying he wasnt an easy stick, just that sometimes the person who appears to have lovely veins may not be as easy as it appears.

[elephantlover, BSN, RN]

2 minutes ago, Tenebrae said:

I have a friend who appears to be a great person to put a line in, or take a blood test from. I went with her once to get a blood test and it took more than five attempts to get the test because her lovely looking veins just wouldnt give up the blood.

I usually have great IV access and no troubles with blood test. A few years ago when I had an infected axillary abscess that developed into sepsis, it took the IV tech seven attempts before he managed to get IV access and even then it was a fairly dodgy placement but it was literally the only vein that would hold a line

I'm not saying he wasnt an easy stick, just that sometimes the person who appears to have lovely veins may not be as easy as it appears.

Interesting. I hear what you're saying! I have more limited experience with venipuncture. I will keep this in mind. The RNs on my unit do not draw labs and they rarely start IVs.

I just don't think to claim someone is a difficult poke is a valid excuse to leave an IV catheter in a patient a red, rock hard vein just because it flushes.

[Tenebrae, BSN, RN]

11 minutes ago, elephantlover said:

Interesting. I hear what you're saying! I have more limited experience with venipuncture. I will keep this in mind. The RNs on my unit do not draw labs and they rarely start IVs.

I just don't think to claim someone is a difficult poke is a valid excuse to leave an IV catheter in a patient a red, rock hard vein just because it flushes.

I would agree.

Like I said, my only point was sometimes things appear to be a certain way, and its important to realise that there are sometimes other cirumstances or factors we are not aware of.

Hope that makes sense