Thrombophlebitis
An acute condition characterized by inflammation and thrombus formation, thrombophlebitis may occur in deep (intermuscular or intramuscular) or superficial (subcutaneous) veins. Deep vein thrombosis (DVT) or 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, causing venous insufficiency. (See Chronic venous insufficiency, page 1144.) This disorder is typically progressive, leading to pulmonary embolism, a potentially lethal complication. Superficial thrombophlebitis is usually self-limiting and seldom 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 and incidence
A thrombus occurs when an alteration in the epithelial lining causes platelet aggregation and consequent fibrin entrapment of red and white blood cells and additional platelets. Thrombus formation is more rapid in areas where blood flow is slower, due to greater contact between platelet and thrombin accumulation. The rapidly expanding thrombus initiates a chemical inflammatory process in the vessel epithelium, which 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.
DVT 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. It occurs in about 80 of every 100,000 people; 1 of every 20 persons is affected at some point during his lifetime. Males are at slightly greater risk than females. People older than age 40 are also at increased risk.
Causes of superficial thrombophlebitis include trauma, infection, I.V. drug abuse, and chemical irritation due to 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 DVT 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. Varicose veins may also be present. (See Varicose veins.) 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. Essential laboratory tests include:
❑ Duplex Doppler ultrasonography and impedance plethysmography make it possible to noninvasively examine the major veins (but not calf veins).
❑ Plethysmography shows decreased circulation distal to the affected area; this test is more sensitive than ultrasound in detecting DVT.
CONFIRMING DIAGNOSIS Phlebography, which shows filling defects and diverted blood flow, usually confirms the diagnosis.
Diagnosis must also rule out arterial occlusive disease, lymphangitis, cellulitis, and myositis.
Diagnosis of superficial thrombophlebitis is based on physical examination (redness and warmth over the 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. After the acute episode of DVT subsides, the patient may resume activity while wearing antiembolism stockings that were applied before he got out of bed.
Treatment also includes anticoagulants (initially, heparin; later, warfarin) to prolong clotting time. Low-molecular-weight (LMW) heparin has been shown to be effective in treating DVT. Although LMW heparin is more expensive, it doesn’t require monitoring for its anticoagulant effect. Full anticoagulant doses must be discontinued during any operative period because of the risk of hemorrhage. After some types of surgery, especially major abdominal or pelvic operations, prophylactic doses of anticoagulants may reduce the risk of DVT and pulmonary embolism. For lysis of acute, extensive DVT, treatment should include streptokinase. Rarely, DVT 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.
Therapy for severe superficial thrombophlebitis may include 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 DVT; close monitoring of anticoagulant therapy can prevent serious complications such as internal hemorrhage.
❑ Enforce bed rest as ordered, 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 extremity 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, as ordered.
❑ Measure and record the affected arm or leg’s circumference 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., as ordered, with an infusion monitor or pump to control the flow rate if necessary.
❑ Measure partial thromboplastin time regularly for the patient on heparin therapy; prothrombin time and international normalized ratio (INR) for the patient on warfarin (therapeutic anticoagulation values are 1½ to 2 times control values for prothrombin time and an INR of 2 to 3). Watch for signs and symptoms of bleeding, such as dark, tarry stools; coffee-ground vomitus; and ecchymoses. Encourage the patient to use an electric razor and to avoid medications that contain aspirin.
❑ Be alert for signs of pulmonary emboli (crackles, 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 subcutaneous injections. If he requires further assistance, arrange for a home health 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.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2008 Williams & Wilkins.
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