Thrombophlebitis, Superficial Venous

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

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

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

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

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

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