Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 12-14: Superficial Venous Thrombophlebitis + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ Red, painful induration along a superficial vein, usually at the site of a recent intravenous line Marked swelling of the extremity may not occur +++ General Considerations ++ May occur spontaneously, often in pregnant or postpartum women or in individuals with varicose veins May be associated with Trauma Occult deep venous thrombosis (DVT) (in about 20% of cases) Short-term venous catheterization of superficial arm veins Longer term peripherally inserted central catheter lines May also be a manifestation of systemic hypercoagulability secondary to abdominal cancer Pulmonary emboli are exceedingly rare and occur from an associated DVT Observe intravenous catheter sites daily for signs of local inflammation + Clinical Findings Download Section PDF Listen +++ +++ Symptoms and Signs ++ Dull pain in the region of the involved vein Induration, redness, and tenderness along the course of a vein Process may be localized, or it may involve most of the great saphenous vein and its tributaries Inflammatory reaction generally subsides in 1–2 weeks; a firm cord may remain for much longer Edema of the extremity is uncommon Proximal extension of induration and pain with chills and high fever suggest septic phlebitis +++ Differential Diagnosis ++ Cellulitis Erythema nodosum Erythema induratum Panniculitis Fibrositis Lymphangitis Deep thrombophlebitis + Diagnosis Download Section PDF Listen +++ +++ Laboratory Tests ++ Blood culture: in septic thrombophlebitis, the causative organism is often Staphylococcus aureus; other organisms, including fungi, may also be responsible +++ Imaging Studies ++ Ultrasonography to assess extent of thrombosis + Treatment Download Section PDF Listen +++ +++ Medications ++ Nonsteroidal anti-inflammatory drugs For septic thrombophlebitis Antibiotics (eg, vancomycin, 15 mg/kg intravenously every 12 hours plus ceftriaxone, 1 g intravenously every 24 hours); if cultures are positive, continue for 7–10 days or for 4–6 weeks if complicating endocarditis cannot be excluded Systemic anticoagulation with heparin or fondaparinux Prophylactic dose low-molecular-weight heparin or fondaparinux is recommended for superficial thrombophlebitis of the lower limb veins measuring 5 cm or longer Full anticoagulation is reserved for disease that is rapidly progressing or there is concern for extension into the deep system Septic superficial thrombophlebitis requires Urgent treatment with heparin (Table 14–16) to limit additional thrombus formation and antibiotics (eg, vancomycin, 15 mg/kg intravenously every 12 hours plus ceftriaxone, 1 g intravenously every 24 hours) Removal of the offending catheter in catheter-related infections ++Table Graphic Jump LocationTable 14–16.Initial anticoagulation for VTE.1View Table||Download (.pdf)Table 14–16. Initial anticoagulation for VTE.1 Clinical Scenario Anticoagulant Dose/Frequency DVT, Lower Extremity DVT, Upper Extremity PE VTE, With Concomitant Severe Kidney Disease2 VTE, Cancer-Related Comment Unfractionated Heparin Unfractionated heparin 80 units/kg intravenous bolus, then continuous intravenous infusion of 18 units/kg/h × × × × Bolus may be omitted if risk of bleeding is perceived to be elevated. Maximum bolus, 10,000 units. Requires aPTT monitoring. Most patients: begin warfarin at time of initiation of heparin. 330 units/kg subcutaneously × 1, then 250 units/kg subcutaneously every 12 hours × Fixed-dose; no aPTT monitoring required LMWH and Fondaparinux Enoxaparin3 1 mg/kg subcutaneously every 12 hours × × × Most patients: begin warfarin at time of initiation of LMWH Dalteparin3 200 units/kg subcutaneously once daily for first month, then 150 units/kg/day × × × × Cancer: administer LMWH for ≥ 3–6 months; reduce dose to 150 units/kg after first month of treatment Fondaparinux 5–10 mg subcutaneously once daily; use 7.5 mg for body weight 50–100 kg; 10 mg for body weight > 100 kg × × × Direct-Acting Oral Anticoagulants (DOACs) Rivaroxaban 15 mg orally twice daily with food for 21 days then 20 mg orally daily with food × × × Contraindicated if CrCl < 30 mL/min Apixaban 10 mg orally twice daily for first 7 days then 5 mg twice daily × × × Contraindicated if CrCl < 25 mL/min Monotherapy without need for initial parenteral therapy Dabigatran 5–10 days of parenteral anticoagulation, then 150 mg orally twice daily × × × Contraindicated if CrCl < 15 mL/min Initial need for parenteral therapy Edoxaban 5–10 days of parenteral anticoagulation, then 60 mg orally once daily; 30 mg once daily recommended if CrCl is between 15 and 50 mL/min, if weight ≤ 60 kg, or if certain P-gp inhibitors are present × × × Contraindicated if CrCl < 15 mL/min or > 95 mL/min Initial need for parenteral therapy 1Obtain baseline hemoglobin, platelet count, aPTT, PT/INR, and creatinine prior to initiation of anticoagulation.Anticoagulation is contraindicated in the setting of active bleeding.2Defined as creatinine clearance < 30 mL/min.3If body weight < 50 kg, reduce dose and monitor anti-Xa levels.CrCl, creatinine clearance; DVT, deep venous thrombosis; PE, pulmonary embolism; P-gp, P-glycoprotein; VTE, venous thromboembolic disease (includes DVT and PE).Note: An “×” denotes appropriate use of the anticoagulant. +++ Surgery ++ Ligation and division of vein at junction of deep and superficial veins indicated when process is extensive or progressing toward the saphenofemoral or cephalo-axillary junction +++ Therapeutic Procedures ++ Local heat Bed rest with leg elevation + Outcome Download Section PDF Listen +++ +++ Complications ++ Serious thrombotic or septic complications can occur if intravenous catheters are not removed once local reaction develops in the vein +++ Prognosis ++ Course is generally benign and brief Prognosis depends on the underlying pathologic process In patients with phlebitis secondary to varicose veins, recurrent episodes are likely unless correction of the underlying venous reflux and excision of varicosities is done Mortality from septic thrombophlebitis Low and prognosis is excellent with early treatment ≥ 20% without aggressive treatment + Reference Download Section PDF Listen +++ + +Di Nisio M et al. Treatment for superficial thrombophlebitis of the leg. Cochrane Database Syst Rev. 2018 Feb 25;2:CD004982. [PubMed: 29478266]