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The related factors of phlebitisamong low birth weight infantsin perinatology wardRisna Yuningsih1,2, Yeni Rustina1,Defi Efendi1,31Faculty of Nusing, UniversitasIndonesia; 2dr. Dradjat PrawiranegaraGeneral Hospital Serang-Banten;3Neonatal Intensive Care Unit,Universitas Indonesia Hospital,Indonesia

Abstract Peripheral intravenous line placement

might lead to some risks and complicationsin low birth weight (LBW) infants includ-ing phlebitis, which shows varying per-centages. This study aimed to analyze thecausative factors of phlebitis among LBWinfants in a perinatology ward. A total of106 LBW infants who selected using aconsecutive sampling technique were ana-lyzed with cross-sectional method. Datawere collected when LBW infants startedreceiving infusions until the infusion wasstopped under certain conditions, using theInfusion Nurses Society (INS) phlebitisscale and the Neonatal Infant Pain Scale(NIPS) as the instrument. The variablesrelated to phlebitis under bivariate analysisincluded the clinical experience of intra-venous insertion, infusion pumps, site ofinsertion, neonatal birth weight, and theadministration of total parenteral nutrition.The most significant risk factor ofphlebitis was the nurses’ clinical experi-ence of intravenous insertion (< 2 years).Therefore, the results of this study can beconsidered to improve the quality of nurs-ing care in perinatology ward.

IntroductionPeripheral intravenous line placement

is a common procedure performed onneonates that could pose some risks andserious complications because the fragileskin might be susceptible to infectiousorganisms. One of these risks is the condi-tion known as phlebitis.1,2 Peripheralintravenous line placement in prematureinfants has been proven to be an appropri-ate procedure during postnatal care.3Nurses are required to have sufficientknowledge and understanding related tothe type of access devices, the appropri-ateness of the selected devices for theadministered therapy, the maintenance ofthe devices, and the potential complica-

tion related to the devices and infusionfluids.2 Prolonged insertion of peripheralintravenous in neonates could be expen-sive, time-consuming, and significantlyrelated to neonatal morbidity andincreased incidences of phlebitis.4,5

The complications caused by intra-venous infusion are more common com-pared to those of central infusion-withvaried numbers of infiltration/extravasa-tion (2.9%-69.89%), phlebitis (16.7%-25.4%), and obstruction (12.27%) inci-dences.6-10 The causative factors ofphlebitis are the effects of total parenteralnutrition (TPN), antibiotics, infection,weight, blood transfusion, and the devicesused.7,8,11-13 Nurses play an important rolein performing intravenous insertion inneonates to prevent phlebitis. There is asignificant correlation between nurses’knowledge of intravenous therapy and theincidences of phlebitis, and there is also asignificant correlation between nurses’knowledge of intravenous therapy andpatient comfort.14 Therefore, paying atten-tion to the risk factors for phlebitis is cru-cial to prevent phlebitis incidence in LBWinfants.

Data from Hospital X in 2017 showedthat the number of births was 3720 and81.7% of them were high risks infants, forexample LBW, premature and asphyxia,needing postnatal treatment in the hospital.Such numbers were in line with the num-bers of intravenous therapy during hospital-ization. Therefore, the researcher was inter-ested in discovering the related factors ofphlebitis in LBW infants.

Materials and MethodsThis study employed a cross-sectional

analytical design. The total sample sizewas 106 LBW aged less than 37 weeks.They were hospitalized in Hospital X andreceived peripheral infusions. The sampleswere selected using a consecutive sam-pling technique from March 2019 to May2019 in the perinatology ward. The LBWinfants were included under the criteria: i)weight < 2500 grams; ii) gestational age

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Whitney U tests were used for the bivariatetest (based on data characteristics), whilelogistic regression was used for the multi-variate test.

ResultsThe results based on the respondent

characteristics and the correlation betweenindependent variables and phlebitis inci-dences can be seen in Table 1. Bivariateanalysis showed that the independent vari-ables indicating a significant correlationwith phlebitis were the clinical experienceof intravenous insertion (< 2 years), did notuse infusion pumps, site of insertion, neona-

tal birth weight, and the administration oftotal parenteral nutrition. The variables thatdid not indicate a significant correlationwith phlebitis were gestational age, the typeof infusion fluids, the type of medication,the use of infusion pumps, and the use ofsterile set in one pouch during insertion.The percentage of phlebitis incidenceobserved in this study was 27%.

The multivariate analysis was per-formed by entering the variable of P > 0.25in the model. The results are presented inTable 2.

The factors related to phlebitis in LBWinfants were the nurses’ clinical experienceof intravenous insertion (< 2 years), the

administration of TPN for < 72 hours andbetween 72 hours and 120 hours, the inser-tion site on the distal lower extremity, birthweight of 1000–1500 grams, and the use ofinfusion pumps. Meanwhile, the most dom-inant factor related to the incidences ofphlebitis was the level of nurses’ clinicalexperience.

DiscussionPhlebitis incidences

The result showed that 27% of therespondents suffered from phlebitis.Infusion Nurses Society suggests that the

Article

Table 1. Distribution of respondents based on variables correlation with phlebitis incidences (n=106).

Gestational age Phlebitis incidences Total P-value Not phlebitis Phlebitis n % n % n %

Gestational age (1)< 28 weeks 3 42.9 4 57.1 7 10028-31 weeks 23 60.5 15 39.5 38 100 0.00132-36 weeks 47 77.0 14 23.0 61 100> 37 weeks 19 95.0 1 5.0 20 100Birth weight (2)1500-2499 grams 1 25 3 75 4 1001000-1500 grams 15 53.6 13 46.4 28 100 0.004< 1000 grams 57 77 17 23 74 100 Type of medication (3)No drug 0 0 2 100 2 100 0.004Line I 57 65.5 30 34.5 87 100Line II 11 100 0 0 11 100Line III 55 83.3 1 16.7 6 100Type of infusion fluids (4)Without infusion fluids 3 100 0 0 3 100 0.272Hypotonic 5 41.7 7 58.3 12 100Isotonic 1 100 0 0 1 100Hypertonic 64 71.1 26 28.9 90 100 The administration of TPN (5)Without TPNT 39 88.6 5 11.4 44 100 0.001PN 0-72 hours 29 58 21 425 50 100TPN 72-120 hours 4 44.4 5 5.6 9 100TPN > 120 hours 1 33.3 2 66.7 3 100 The use of infusion pumps (6)Using infusion pumps 44 62.9 26 37.1 70 100 0.078Not using infusion pumps 29 80.6 7 19.4 36 100 The use of sterile set in one pouch during insertion (7)With a specific set 14 93.3 1 6.7 159 100 0.034Without a specific set 59 64.8 32 35.2 1 100 Insertion site (8)Distal upper extremity 30 75 10 25 40 100 0.125Proximal upper extremity 35 70 15 30 50 100Distal lower extremity 7 46.7 8 53.3 15 100Proximal lower extremity 1 100 0 0 1 100 Clinical experience of intravenous insertion (9) > 10 years 13 86.7 2 13.3 15 100 0.0446-10 years 36 69.2 16 30.8 52 1003-5 years 23 69.7 10 30.3 33 100< 2 years 1 16.7 5 83.3 6 100 (1, 2, 3, 4, 5, 8, and 9) Mann-Whitney U Test; (6 and 7) Chi Square Test; TPN, total parental nutrition.

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rate of phlebitis should be equal to or lessthan 5%.14 Among the complications result-ing from infusion insertion, 17.84%-77.5%were phlebitis.7,15 Similar studies on pedi-atrics showed that phlebitis incidencesranged from 9%-71.25%.16,17 The differ-ence between these phlebitis incidencesneeds further analysis, especially thoserelated to the phlebitis scale used. Untilrecently, there was no adequate and specificphlebitis scale for neonates. Identificationof 71 phlebitis scales, three of which hadbeen analyzed psychometrically, yet noneof them has been strictly examined, andthese might explain the significant differ-ence among phlebitis scales and could bethe cause of the difference in the reportedphlebitis incidences.18 The hospital, wherethis study was conducted, might need to fur-ther explain the incidence discovery systemand reporting. This study provides newinsight related to the phlebitis incidencesnot only in neonates in general but also inmore specific areas such as the LBW andpreterm infants.

The correlation between the levelof clinical experience in intravenousinsertion and phlebitis incidences

The level of clinical experience of thenurses (< 2 years) was significantly associat-ed with the phlebitis incidences in LBW. Theclinical conclusion is that the probability ofphlebitis in LBW treated by < 2 year-experi-ence nurses was four times greater than thosewho were treated by > 10 year-experiencenurses. In a study done among nurses, intra-venous insertion training was found toincrease their knowledge and skill (31% and24%, respectively).19 In another study, theclinical experience of infusion insertion sig-nificantly affected the duration of peripheralintravenous cannulation therapy.20 Studieshave also demonstrated that there is a signif-icant correlation between nurses’ knowledgeabout infusion therapy and phlebitis inci-dences.14 In contrast, a study on neonates inNew Zealand stated that the discipline of the

inserter might not be the factor causing theperipheral intravenous complication.21 It isnecessary to consider the clinical experienceof the nurses in resolving the peripheral infu-sion cases in LBW.

The correlation between neonatalbirth weight and phlebitis incidences

This research shows that the probabilityof suffering from phlebitis among LBWweighing 1000-1500 grams were five timesgreater than among LBW weighing 1500-2499 grams. Studies have shown that neona-tal birth weight is associated with the infiltra-tion/complication of extravasation andincreases the risk of complication due to thesmall, fragile and less visible vein, and alsothe higher percentage of the adipose tissue.22Findings from a case study of 590 gramsneonates who suffered from phlebitis andexhibited malformation also support thisclaim.23 A study conducted in 2006 did notfind any significant causes of extravasationassociated with neonatal age and weight.24

The correlation between total par-enteral nutrition administration andphlebitis incidences

The duration for TPN was correlatedwith the incidences of phlebitis. The longerthe insertion, the higher the risk of phlebitis.TPN is the nutrient administered throughthe blood vessel and contained an aminoacid, glucose (10-20%), and lipid emulsions(10-20%). The fluid should preferably beadministered through the central blood ves-sels. However, it could also be administeredthrough the peripheral veins, if the osmolal-ity allows ranged from 800 to 1200mOsm/L.11,25 The small and fragile neona-tal veins make cannulation difficult, exhibitlow tolerance to pH change and osmolarity,which could trigger thrombophlebitis inneonates who received hypertonicsolution.4 Phlebitis has been reported as themost common complication during TPNthrough peripheral access in neonates (3%-31%).25 This emphasizes the fact that high

osmolarity fluids could increase the risk ofphlebitis incidences because of the size andfragility of the veins of LBW. The processof TPN liquid compounding was performedin the nursing room before it was adminis-tered to the respondents. Some studies haverevealed that the TPN compounding shouldbe conducted all in one by central pharmacyunder a closed system.26 The findings ofthis study suggest that the administration ofTPN should be given through centralvenous, and the nutrient fluid compoundingshould be conducted by pharmacy staff in aclosed system.

The correlation between infusionpumps and phlebitis incidences

The findings of this study showed aninverse relationship between the use ofinfusion pumps and phlebitis incidences,i.e., if the infusion pump is used, the risk ofphlebitis increases. Infusion pumps couldhelp to control the consistency of fluid vol-ume entering the patient’s body during theadministration of peripheral intravenous. Ingeneral, the infusion pump alarm will give asignal when the fluid is altered due to occlu-sion, but it cannot detect the early infiltra-tion. The pressure caused by the infiltrationcannot trigger the alarm because it is lowerthan the pressure caused by occlusion.27When the gravity method is applied toadminister the infusion or medication inpediatrics, the duration of peripheral infu-sion becomes longer (72.56 ± 35.85 hours)compared to when electronic pump or punc-ture is applied (60.03 ± 33.88 hours).28Research has demonstrated that 72% to99% of clinical alarms are false. The highnumber of false alarms has led to alarmfatigue, which can result in the desensitiza-tion of alarms and missed alarms.29 Thefindings of this study suggest that the inci-dences of phlebitis related to the use of infu-sion pumps is affected by other factors.

The correlation of insertion site andphlebitis incidences

The selection of peripheral intravenousinsertion site in the distal lower extremity wassignificantly associated with the incidencesof phlebitis in LBW infants (P = 0.019). Astudy found that the insertion site in the armarea affected the length of insertion withoutcomplication.20,30 Found a different resultreported that the insertion site of peripheralintravenous in neonates did not correlate withthe infusion complication. Further researchrelated to the site selection in neonates isrequired because the infusion insertion inLBW infants is quite risky, and the blood ves-sels of the babies are small, fragile, and canbe easily damaged by pressure.

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Table 2. Multivariate analysis with backward method between selected independent vari-ables and phlebitis incidences (n = 106).

Variable B Sig. Exp (B)

Clinical experience (< 2 years) 4.350 0.015 77.516TPN 72-120 hours 3.260 0.006 26.054TPN 0-72 hours 2.743 0.002 15.538Distal Lower Extremity 2.884 0.014 17.887Weight 1000-1500 grams 1.660 0.037 5.257Not using infusion pumps –2.051 0.032 0.112Constanta –3.920TPN, total parenteral nutrition.

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ConclusionsThe factors that have been proven to be

significantly correlated with the incidencesof phlebitis in LBW were the clinical expe-rience of intravenous insertion (< 2 years),did not use infusion pumps, site of inser-tion, neonatal birth weight, and the admin-istration of total parenteral nutrition.Gestational age, the type of infusion fluids,the type of medication, the use of infusionpumps, and the use of sterile set in onepouch during insertion did not correlatewith the incidences of phlebitis in LBW inperinatology ward. Multivariate analysisrevealed that the most significant factor isthe level of clinical experience of the nursesin charge.

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