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.
Short-term venous catheterization of superficial arm veins as well as the use of longer-term peripherally inserted central catheter (PICC) lines are the most common cause of superficial thrombophlebitis. Intravenous catheter sites should be observed daily for signs of local inflammation and should be removed if a local reaction develops in the vein. Serious thrombotic or septic complications can occur if this policy is not followed; S aureus is the most common pathogen. Other organisms, including fungi, may also be responsible.
Superficial thrombophlebitis may occur spontaneously, often in pregnant or postpartum women or in individuals with varicose veins, or it may be associated with trauma, as with a blow to the leg or following intravenous therapy with irritating solutions. It also may be a manifestation of systemic hypercoagulability secondary to abdominal cancer such as carcinoma of the pancreas and may be the earliest sign of these conditions. Superficial thrombophlebitis may be associated with occult DVT in about 20% of cases. Pulmonary emboli are exceedingly rare and occur from an associated DVT. (See Chapters 9 and 14 for discussion on deep venous thrombosis.)
In spontaneous superficial thrombophlebitis, the great saphenous vein is most often involved. The patient usually experiences a dull pain in the region of the involved vein. Local findings consist of induration, redness, and tenderness along the course of a vein. The process may be localized, or it may involve most of the great saphenous vein and its tributaries. The inflammatory reaction generally subsides in 1–2 weeks; a firm cord may remain for a much longer period. Edema of the extremity is uncommon.
Localized redness and induration at the site of a recent intravenous line requires urgent attention. Proximal extension of the induration and pain with chills and high fever suggest septic phlebitis and requires urgent treatment.
The linear rather than circular nature of the lesion and the distribution along the course of a superficial vein serve to differentiate superficial phlebitis from cellulitis, erythema nodosum, erythema induratum, panniculitis, and fibrositis. Lymphangitis and deep thrombophlebitis must also be considered.
For spontaneous thrombophlebitis if the process is well localized and not near the saphenofemoral junction, local heat and nonsteroidal anti-inflammatory medications are usually effective in limiting the process. If the induration is extensive or is progressing toward the saphenofemoral junction (leg) or cephalo-axillary junction (arm), ligation and division of the vein at the junction of the deep and superficial veins is indicated.
Anticoagulation therapy is usually not required for focal processes. Prophylactic dose low-molecular-weight heparin or fondaparinux is recommended for 5 cm or longer ...