Plebitis and Dobutamine

vamedic4, EMT-P · Apr 4, 2006

Had a patient with Dobutamine hanging IV
How long before phlebitis can develop. I flushed the line at 1130pm did not notice any redness. However at 7am the insertion site was red.......is it possible to get phlebitis in that time frame.
Or is that something that has to develop over 24hrs
Looking forward to your responses regarding development of phlebitis
See ya
Angela

Angela,

Phlebitis can develop at any time during, before or after the infusion. What's critical is your assessment of the IV site. Does it still flush?? Does it draw back? IF it flushes, is it painful? :madface: Is the site hard, red, hot or swollen?

I've made previous posts b4 about IVs and their patency...check one and see if anything is helpful to you.

And have a great day!!

vamedic4

Children's Medical Center Dallas

Emergency RN · May 28, 2006

First off, one must remember that every IV site, regardless of how textbook perfect the technique used to start it, is destined for failure over time. In other words, once an IV goes in, it is already starting to go bad. How soon it takes for any IV site to fail completely depends generally on two variables; the tolerance of the vein and the degree of irritation caused by the foreign substances being used.

Whether any IV site is patent or not depends wholly on what the site looks like at the time of the assessment. Indwelling time duration is probably not as important as most people would believe. Such that something that may have went in only a short while ago can easily fail, despite most believing that patentcy would (or should) last well beyond such a time frame... The most important thing is to check the site. If it's red, swollen, or tender where it was not before, then something had already happened. Usually, redness (erythema) is an indication of irritation.

As a sidebar worth mentioning: one of the time worn mistruths that we've all learned since nursing 101 is to test the patentcy of any IV site by noting the presence or absence of blood return. The premise had always been, that if one saw blood return, then the site was considered patent. Conversely, If one could not obtain a blood return, then the site was considered infiltrated and had to be discontinued. This is not true, and indeed is often meaningless at the bedside.

The entire rationale for this had always been based upon the idea that venous irritation, and it's attendent intimal swelling, would cause the inner walls of the vein itself to close in on and cover the tip of the catheter, thereby preventing blood return. This is correct ONLY if the size of the catheter closely approximates the vein lumen's caliber.

A much larger vein, though irritated, would not necessarily swell enough to block a catheter tip. This would allow continued blood return and foster a false sense of security in the caregiver to allow the site to continue. But since the intimal lining is already swollen, IV fluid would easily migrate from the vein into the surrounding tissue (extravasation) to the patient's detriment.

A much smaller vein, despite being non-irritated, may not produce any substantial blood flow into the catheter at all. This could be due to an absolute volume that such a vein can sustain, and the flow may thus be too small to be discernable. Or, it may be because the catheter itself is larger than the lumen of the vein, having been forced in on insertion. Such a vein-cath combination would not allow any blood flow at all. The catheter body blocks the distal end and a vein valve blocks the proximal end, thus creating a sealed vein chamber that surrounds the catheter tip. Similarly, a vein may be so small that the negative pressure created by the backflow attempt causes the lumen to collapse around the catheter tip. Such a site may be found "non patent" and discontinued despite it being clinically functional.

A much simpler test to determine if any IV site had begun to irritate the vein is to simply palpate the site. If one would close one's eyes and imagine the plastic catheter under the skin, and then palpate the site, the outline and shape of the catheter is distinct and is usually quite easily discernable. Now imagine if that same catheter, a day later, had grown a thick layer of outer skin; the outline and shape of the catheter had become indistinct, and would no longer be as easily discernable. In fact, when the intimal lining of a vein swells from irritation around the body of an IV catheter, this is exactly what it feels like. Even if no peri-site erythema or edema, or patient complaint of tenderness is found; and there is ample blood return, such a site has already failed and needs to be changed. As a matter of fact, this is the BEST time to catch it, that is, after the vein has been irritated but before any extravasation had occurred.

Ralph

Binkey, BSN · May 30, 2006

A couple of key things to remember here is that

1. Dobutamine and Dopamine are Vesicants. Therefore, these medications are very caustic to the inner lining of the vein (the tunica intima), and should ideally go via central catheter (one who's tip is in the SVC). According to the Infusion Nurses Society (INS), any medication who's pH is 9 should go via central catheter. This medication has a pH of 2.5-4.5.

Can it cause phlebitis in less than an 8 hr period? Yes, and if your pt was able to verbalize his/her feelings, a precurser to that redness is tenderness at the site or where the catheter tip terminates so he may have felt the beginnings of this process. Once this medication insults the inner lining of the vessel, the entire vessel starts to undergo changes which eventually culminate in the vessel wall becoming more permeable, and extravasation occurs.

Diane