Thrombophlebitis
An acute condition characterized by inflammation and thrombus formation, thrombophlebitis may occur in deep (intermuscular or intramuscular) or superficial (subcutaneous [S.C.]) veins.
Deep vein thrombophlebitis affects small veins such as the soleal venous sinuses, or large veins, such as the vena cava, and the femoral, iliac, and subclavian veins. This disorder is frequently progressive, leading to pulmonary embolism, a potentially lethal complication.
Superficial thrombophlebitis is usually self-limiting and rarely leads to pulmonary embolism. Thrombophlebitis often begins with localized inflammation alone (phlebitis), but such inflammation rapidly provokes thrombus formation. Rarely, venous thrombosis develops without associated inflammation of the vein (phlebothrombosis).
Causes
A thrombus occurs when an alteration in the epithelial lining causes platelet aggregation and consequent fibrin entrapment of red blood cells, white blood cells, and additional platelets. Thrombus formation is more rapid in areas where blood flow is slower, due to greater contact between platelets and thrombin accumulation.
The rapidly expanding thrombus initiates a chemical inflammatory process in the vessel epithelium that leads to fibrosis. The enlarging clot may occlude the vessel lumen partially or totally, or it may detach and embolize, to lodge elsewhere in the systemic circulation.
Deep vein thrombophlebitis
This type of thrombophlebitis may be idiopathic, but it usually results from endothelial damage, accelerated blood clotting, and reduced blood flow. Predisposing factors are prolonged bed rest, trauma, surgery, childbirth, and use of hormonal contraceptives such as estrogens.
Superficial thrombophlebitis
Causes of superficial thrombophlebitis include trauma, infection, I.V. drug abuse, and chemical irritation due to the extensive use of the I.V. route for medications and diagnostic tests.
Signs and symptoms
In both types of thrombophlebitis, clinical features vary with the site and length of the affected vein. Although deep vein thrombophlebitis may occur asymptomatically, it may also produce severe pain, fever, chills, malaise and, possibly, swelling and cyanosis of the affected arm or leg.
Superficial thrombophlebitis produces visible and palpable signs, such as heat, pain, swelling, rubor, tenderness, and induration along the length of the affected vein. Extensive vein involvement may cause lymphadenitis.
Diagnosis
Some patients may display signs of inflammation and, possibly, a positive Homans’ sign (pain on dorsiflexion of the foot) during physical examination; others are asymptomatic. Consequently, essential laboratory tests include the following:
❑ Doppler ultrasonography is used to identify reduced blood flow to a specific area and any obstruction to venous flow, particularly in iliofemoral deep vein thrombophlebitis.
❑ Plethysmography shows decreased circulation distal to affected area; it’s more sensitive than ultrasound in detecting deep vein thrombophlebitis.
❑ Phlebography can show filling defects and diverted blood flow and usually confirms the diagnosis.
Diagnosis must rule out arterial occlusive disease, lymphangitis, cellulitis, and myositis.
Diagnosis of superficial thrombophlebitis is based on physical examination (redness and warmth over affected area, palpable vein, and pain during palpation or compression).
Treatment
The goals of treatment are to control thrombus development, prevent complications, relieve pain, and prevent recurrence of the disorder. Symptomatic measures include bed rest, with elevation of the affected arm or leg; warm, moist soaks to the affected area; and analgesics.
Deep vein thrombophlebitis
After the acute episode of deep vein thrombophlebitis subsides, the patient may resume activity while wearing antiembolism stockings that were applied before he got out of bed.
Treatment may also include anticoagulants (initially, heparin; later, warfarin) to prolong clotting time. Full anticoagulant dose must be discontinued during any operative period, due to the risk of hemorrhage.
After some types of surgery, especially major abdominal or pelvic operations, prophylactic doses of anticoagulants may reduce the risk of deep vein thrombophlebitis and pulmonary embolism. For lysis of acute, extensive deep vein thrombosis, treatment should include streptokinase.
Rarely, deep vein thrombophlebitis may cause complete venous occlusion, which necessitates venous interruption through simple ligation to vein plication, or clipping. Embolectomy and insertion of a vena caval umbrella or filter may also be done.
Superficial thrombophlebitis
Therapy for severe superficial thrombophlebitis includes an anti-inflammatory drug such as indomethacin, antiembolism stockings, warm soaks, and elevation of the leg.
Special considerations
❑ Patient teaching, identification of high-risk patients, and measures to prevent venostasis can prevent deep vein thrombophlebitis; close monitoring of anticoagulant therapy can prevent serious complications such as internal hemorrhage.
❑ Enforce bed rest, and elevate the patient’s affected arm or leg. If you plan to use pillows for elevating the leg, place them so they support the entire length of the affected leg to prevent possible compression of the popliteal space.
❑ Apply warm soaks to increase circulation to the affected area and to relieve pain and inflammation. Give analgesics to relieve pain.
❑ Measure and record the circumference of the affected arm or leg daily, and compare this measurement to the other arm or leg. To ensure accuracy and consistency of serial measurements, mark the skin over the area and measure at the same spot daily.
❑ Administer heparin I.V. with an infusion monitor or pump to control the flow rate if necessary.
CLINICAL TIP: Measure partial thromboplastin time regularly for the patient receiving heparin therapy, and prothrombin time (PT) and International Normalized Ratio (INR) for the patient receiving warfarin (therapeutic anticoagulation values for both are 11/2 to 2 times control values, and INR is 2 to 3 times control values).
❑ Watch for signs and symptoms of bleeding, such as coffee-ground vomitus, ecchymoses, and black, tarry stools. Encourage the patient to use an electric razor and to avoid medications that contain aspirin.
❑ Be alert for signs of pulmonary emboli (rales, dyspnea, hemoptysis, sudden changes in mental status, restlessness, and hypotension).
To prepare the patient with thrombophlebitis for discharge:
❑ Emphasize the importance of follow-up blood studies to monitor anticoagulant therapy.
❑ If the patient is being discharged on heparin therapy, teach him or his family how to give S.C. injections. If he requires further assistance, arrange for a visiting nurse.
❑ Tell the patient to avoid prolonged sitting or standing to help prevent recurrence.
❑ Teach the patient how to properly apply and use antiembolism stockings. Tell him to report any complications (such as cold, blue toes).
❑ To prevent thrombophlebitis in high-risk patients, perform range-of-motion exercises while the patient is on bed rest, use intermittent pneumatic calf massage during lengthy surgical or diagnostic procedures, apply antiembolism stockings postoperatively, and encourage early ambulation.
Book Source Details
- Book Title: Handbook of Diseases
- Author(s): Springhouse
- Year of Publication: 2003
- Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright Details: Handbook of Diseases, Copyright © 2008 Williams & Wilkins.
More About Causes of Vein symptoms
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More About This Book:
Title: Handbook of Diseases
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2003
ISBN: 1-58255-266-5
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