thrombophlebitis

see also:

• Mx of lower limb DVT

• thrombophlebitis is thrombosis of a vein with associated inflammation and if infective, is called septic thrombophlebitis
• sterile thrombophlebitis of the peripheral veins is painful and causes local erythema and tenderness but generally settles without serious sequelae, although sometimes the thrombosis can extend into deeper veins resulting in a deep venous thrombosis (DVT)
• septic thrombophlebitis can be very serious as it tends to throw off septic emboli which can then form abscesses distant from the site, particularly in the lung.
  • less commonly, septic emboli may traverse a patent foramen ovale and cause distant metastatic infections such as septic arthritis, osteomyelitis, and hepatic abscesses

• may be:
  • sterile and due to chemical or mechanical irritation
    • risk factors include:
      • hypertonic fluid administration
      • acidic drug administration (eg. antibiotics)
      • failure to flush cannulae after administration ofpotentially irritant medications
      • iv extravasation of irritant substances
      • cannulae too big for the vein although catheter size has not been a proven cause
      • cannulae placed over joints or near venous valves
  • septic - usually caused from prolonged iv cannulation duration
    • risk factors include:
      • burns (heavy inoculum with weakened dermal immune defences)
      • local infections, abrasions or wounds
      • cannula in-situ duration
      • non-sterile cannula insertion (eg. emergency situations)
      • iv drug abuse
      • corticosteroids use
      • lower limb cannulation
      • colonisation of sterile phlebitis
    • most common infective organism is Staphylococcus aureus, but coagulase-negative staphylococci, enteric gram-negative bacilli, and enterococci are also frequently implicated
• Rx:
  • all patients with an intravenous access device should have the access site checked every shift for signs of phlebitis
  • remove any catheter at first sign of erythma - early phlebitis at an intravenous site usually resolves after a cannula is removed or resited
  • if suppurative, antibiotics will be needed
  • if abscess formation, then incision and drainage

• non-infective thrombophlebitis of superficial veins, usually the limb veins
• it is caused in a similar way to deep venous thrombosis (DVT):
  • venous stasis
  • abnormal coagulability, &/or
  • vessel wall injuries
• it is a clinical diagnosis based upon presence of tender and inflamed superficial veins
• may be confirmed on USS
• some may extend into the deep venous system to cause a deep venous thrombosis (DVT)
• Rx:
  • non-steroidal anti-inflammatory drugs (NSAIDs) have similar efficacy as low-molecular weight heparin (LMHW) in reducing the risk of extension of superficial thrombophlebitis into the deep venous system and are often more practical and more easily administered than LMHW
  • antibiotics are NOT routinely indicated
  • ambulation is important to limit venous stasis and reduce the progression of thrombosis
  • warm compresses may provide symptomatic relief
  • compression stockings are useful
  • consider 4-7wks of prophylactic dose of fondaparinux or enoxaparin anticoagulation if increased risk of embolism¹⁾²⁾³⁾:
    • affected venous segment ≥5 cm
    • in proximity (≤5 cm) to deep venous system (eg. at saphenofemoral junction)
    • positive medical risk factors
  • if indicated, 40mg s/c daily enoxaparin appears to be as effective in preventing PE and extension of thrombus as 1.5mg/kg ⁴⁾
  • consider referral to vascular surgery for extensive thrombosis extending to the sapheno-femoral junction as ligation of the saphenous vein may be considered if anticoagulation is C/I

• usually results from endometritis (eg. puerperal or following septic miscarriages or, rarely from PID)

• rare complication of diverticulitis, but may also occur with other intrabdominal infections which drain through the portal vein

• usually due to central catheter placement

• septic thrombophlebitis of the internal jugular vein
• usually results from extension of infection from tonsillitis, local dental or pharyngeal infections
• septic pulmonary emboli are nearly always present and lead to serious complications such as empyema and lung cavitation.
• aetiology:
  • Fusobacterium necrophorum (80% of cases)
  • other causes include Fusobacterium nucleatum, Bacteroides species, and streptococcal species
• clinical features:
  • sore throat and fever in 80%
  • swollen or tender neck in ~50%
  • pleuritic chest pain (due to septic emboli) in ~1/3rd

• a rare complication of facial infections involving the medial third of the face, or from ethmoid or sphenoid sinusitis, or rarely from oropharyngeal infections
• clinical features:
  • severe retro-orbital pain
  • facial or oropharyngeal infection
  • fever
  • possible visual disturbances if cranial nerves involved within the cavernous sinus
  • triad of ptosis, proptosis, and chemosis in 95% of patients
  • extraocular movement palsies in 88% of patients
  • abnormal fundi in 65% of patients
  • neck stiffness may be present

• a very rare condition with high mortality rate complicating meningitis