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Quick Medical Diagnosis & Treatment 2020

Thrombophlebitis, Superficial Venous

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Citation

AMA Citation
Thrombophlebitis, Superficial Venous. In: Papadakis MA, McPhee SJ, Bernstein J. Papadakis M.A., McPhee S.J., Bernstein J Eds. Maxine A. Papadakis, et al.eds. Quick Medical Diagnosis & Treatment 2020 New York, NY: McGraw-Hill; . http://accessmedicine.mhmedical.com/content.aspx?bookid=2750&sectionid=231381964. Accessed April 06, 2020.

MLA Citation
. "Thrombophlebitis, Superficial Venous." Quick Medical Diagnosis & Treatment 2020 Papadakis MA, McPhee SJ, Bernstein J. Papadakis M.A., McPhee S.J., Bernstein J Eds. Maxine A. Papadakis, et al. New York, NY: McGraw-Hill, , http://accessmedicine.mhmedical.com/content.aspx?bookid=2750&sectionid=231381964.

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For further information, see CMDT Part 12-14: Superficial Venous Thrombophlebitis

Key Features

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

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

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

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 14–16.Initial anticoagulation for VTE.¹

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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

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

Di Nisio M et al. Treatment for superficial thrombophlebitis of the leg. Cochrane Database Syst Rev. 2018 Feb 25;2:CD004982.
[PubMed: 29478266]

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