I have never seen any data on it use as a prophylactic measure. Many years ago, we reported our low rate of early stage mechanical phlebitis and decided that prophylactic treatment of every patient was not necessary. So we only treated therapeutically when it appeared. If I remember correctly, the had about 20 patients with ESMP and only 1 was removed. In that case the physician would not allow the 48-72 hours of treatment and ordered that it be pulled within a few hours. Lynn
As Lynn indicated, we too have stopped the routine use of warm compresses x 24 h post-insertion since moving up to the larger deeper upper arm veins (with ultrasound). I can't remember when we last saw a mechanical phlebitis since going upper arm. However, if it's been a particularly difficult insertion & the pt has several Virchow's Triad risk factors we then may suggest warm compresses. Sorry no hard data though to support this. Daphne
We don't see a mechanical phlebitis in the upper for the same reason we can't easily see an extravasation from a midline until it gets to the 'call the plastic surgeon' stage. It's just very difficult to assess in the upper arm.
Pay attention to the size of the catheter you are placing. This is one of the mantras of our practice, to place the smallest size catheter in the largest vein. Not to place the largest 'portion' of the catheter in the smallest vein.
I've heard nurses say the catheter taper is in the subcutaneous tract. When the taper is 10 cm long, that's 25% of the insertable length of many catheters placed on the right side. 5 fr should be 5 fr, 4 fr should be 4 fr. Catheter size should be labeled clearly and used appropriately. Who would argue that?
Hi Cindy: My question was about whether folks still use prophy heat application (not about whether to use heat after you're aware that there is a phlebitis).
We're very good about assessing vein size and catheter size - see my other posting just below this one about vein diameter/catheter diameter.
I actually created a very handy table that compares the relationship (in %) of the cross-sectional area of a vein with the cross-sectional area of 3, 4, 5, and 6 French catheters if anyone would like to use it - I'll see if I can get it posted on this website. It helps nurses with their initial PICC evaluation when they're not sure what size PICC to use.
We may do a QI audit soon, but our anecdotal experience is the same as Lynn and Daphne's - we've been using U/S and MST for years, and have seen very few cases of phlebitis.
Thanks all of you for your replies!
Mari Cordes, BS RN
Nurse Educator IV Therapy
Fletcher Allen Health Care
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
One clarification - my experience with very little early stage mechanical phlebitis was from the early 1990's, long before we were using US and MST. Lynn
Sorry Mari, that sounded really crabby as I reread it. I'm certain you're a great clinician and it sounds like you're very careful with your vein assessment. At one time we routinely ordered heat and elevation for the first 24 hours after insertion. Not really certain if it helped, but we did however, find that it didn't hurt!
Electronic communication can be so tricky! Thanks for following up with me; I really do appreciate everyone's input, including yours. See you online some more,
Mari
Mari Cordes, BS RN
Nurse Educator IV Therapy
Fletcher Allen Health Care
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
Currently we are having difficulty locating a vender for pre-warmed compresses for infiltration/phlebitis sites. Does anyone have any recommendations for this or devices to warm the compresses?
There are devices out there, such as a "k-pad" which is a moist heating pad that circulates warm water thru a pad that it is connected to. THe pad was disposable (for each patient) and the machine was capital equipment.
Our facility has used kpads for years, and sometimes they work fine but mostly - we (IV team) don't like them. Most of the time they're not warm enough (the facility locks them so that they don't get hot enough to burn someone), and recently one got so hot that they burned someone badly.
And...they are dry heat (the water stays inside the pad and doesn't come in contact with the patient, although you can put a warm washcloth under it, which has it's own problems.....
We've been using Thermacare (work great), but they're expensive. We'll probably keep these in stock on the floors, but only use them for confirmed cases of phlebitis.
Mari Cordes, BS RN
Nurse Educator IV Therapy
Fletcher Allen Health Care
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
To treat or not treat - no evidence based studies on phlebitis
Did it disappear and not be a problem with MST and US - visually it did and what we do not see we do not treat like asymotomatic thrombosis
We got deeper with upper arm and phlebitis may be an issue and it may not however to see it takes way more layers of tissue to visualize versus lower arm phlebitis so who knows if it occurs less. No one knows. Now it becomes visual with a thrombosis?
IV thereapy has very little evidence based study. Sad but true
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Daphne Broadhurst
Desjardins Pharmacy
Ottawa, Canada
Cindy Schrum RN CRNI
We don't see a mechanical phlebitis in the upper for the same reason we can't easily see an extravasation from a midline until it gets to the 'call the plastic surgeon' stage. It's just very difficult to assess in the upper arm.
Pay attention to the size of the catheter you are placing. This is one of the mantras of our practice, to place the smallest size catheter in the largest vein. Not to place the largest 'portion' of the catheter in the smallest vein.
I've heard nurses say the catheter taper is in the subcutaneous tract. When the taper is 10 cm long, that's 25% of the insertable length of many catheters placed on the right side. 5 fr should be 5 fr, 4 fr should be 4 fr. Catheter size should be labeled clearly and used appropriately. Who would argue that?
Cindy Schrum RN CRNI
Hi Cindy: My question was about whether folks still use prophy heat application (not about whether to use heat after you're aware that there is a phlebitis).
We're very good about assessing vein size and catheter size - see my other posting just below this one about vein diameter/catheter diameter.
I actually created a very handy table that compares the relationship (in %) of the cross-sectional area of a vein with the cross-sectional area of 3, 4, 5, and 6 French catheters if anyone would like to use it - I'll see if I can get it posted on this website. It helps nurses with their initial PICC evaluation when they're not sure what size PICC to use.
We may do a QI audit soon, but our anecdotal experience is the same as Lynn and Daphne's - we've been using U/S and MST for years, and have seen very few cases of phlebitis.
Thanks all of you for your replies!
Mari Cordes, BS RN
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
Mari,
One clarification - my experience with very little early stage mechanical phlebitis was from the early 1990's, long before we were using US and MST. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Thanks, Lynn - seems like there would be even lower incidence then with U/S and MST.
Mari Cordes, BS RN
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
Cindy Schrum RN CRNI
Sorry Mari, that sounded really crabby as I reread it. I'm certain you're a great clinician and it sounds like you're very careful with your vein assessment. At one time we routinely ordered heat and elevation for the first 24 hours after insertion. Not really certain if it helped, but we did however, find that it didn't hurt!
Cindy Schrum RN CRNI
Electronic communication can be so tricky! Thanks for following up with me; I really do appreciate everyone's input, including yours. See you online some more,
Mari
Mari Cordes, BS RN
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
Currently we are having difficulty locating a vender for pre-warmed compresses for infiltration/phlebitis sites. Does anyone have any recommendations for this or devices to warm the compresses?
Jan
Heat is not the treatment for most infiltrations - cold is!
Heat is used for phlebitis though. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
There are devices out there, such as a "k-pad" which is a moist heating pad that circulates warm water thru a pad that it is connected to. THe pad was disposable (for each patient) and the machine was capital equipment.
Not sure of theoother brands on the market
Cheryl Kelley RN BSN, VA-BC
Our facility has used kpads for years, and sometimes they work fine but mostly - we (IV team) don't like them. Most of the time they're not warm enough (the facility locks them so that they don't get hot enough to burn someone), and recently one got so hot that they burned someone badly.
And...they are dry heat (the water stays inside the pad and doesn't come in contact with the patient, although you can put a warm washcloth under it, which has it's own problems.....
We've been using Thermacare (work great), but they're expensive. We'll probably keep these in stock on the floors, but only use them for confirmed cases of phlebitis.
Mari Cordes, BS RN
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
Kathy Kokotis
Bard Access Systems
To treat or not treat - no evidence based studies on phlebitis
Did it disappear and not be a problem with MST and US - visually it did and what we do not see we do not treat like asymotomatic thrombosis
We got deeper with upper arm and phlebitis may be an issue and it may not however to see it takes way more layers of tissue to visualize versus lower arm phlebitis so who knows if it occurs less. No one knows. Now it becomes visual with a thrombosis?
IV thereapy has very little evidence based study. Sad but true
Kathy Kokotis
Bard Access Systems