THROMBOPHLEBITIS
Definition
Superficial thrombophlebitis is a common disorder which occurs when a superficial vein, usually the long saphenous vein of the leg or its tributaries, becomes inflamed and the blood within it clots. It may be spontaneous or be associated with one or more risk factors, such as varicose veins or a prior history of superficial phlebitis or deep venous thrombosis (DVT).Venous thrombosis is clotting of blood within a vein.
Phlebitis is inflammation of a vein.
Diagnosis
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Diagnose superficial thrombophlebitis in a person with a superficial vein that is:Hard and painful to palpation. The vein feels like a hard cord if it is not varicosed, and like a hard knot if it is varicosed.
Inflamed, indicated by localized erythema, warmth, and swelling of the skin overlying the vein.
Diagnose infected superficial thrombophlebitis if there are features of cellulitis (acute onset of red, painful, hot, swollen, and tender skin), or an abscess associated with thrombophlebitis, especially if the person has a fever.
Consider an alternative diagnosis if there is generalized pain, swelling, erythema of the limb, or localized pain that is not clearly associated with a thrombosed superficial vein.
Management
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Treat pain with a simple analgesic.◦Prescribe an oral nonsteroidal anti-inflammatory drug (NSAID) and/or paracetamol.
Consider a topical NSAID for mild and limited superficial thrombophlebitis.
Continue treatment until pain settles (usually within 3–4 weeks, although the thrombosed vein may be palpable and tender for months).
Manage swelling and discomfort with compression stockings.Many people will find the use of class 2 compression stockings too painful. Class 1 stockings or travel socks are a practical alternative and are less likely to compromise arterial circulation.
Exclude arterial insufficiency before prescribing class 2 compression stockings.
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Advise the person that:A warm, moist towel or flannel applied to the affected limb may provide symptomatic relief.
Keeping the leg elevated when sitting may improve venous blood flow and reduce swelling.
They should continue using the affected limb and remain mobile in order to reduce the risk of deep vein thrombosis (DVT).
The pain and inflammation should begin to respond within a few days of starting treatment.
Risks, Infection & referral on
If there are signs of infection in a person with superficial thrombophlebitis:Consider arranging admission if there are signs of significant systemic illness especially if the person is at risk of serious harm because they are frail, elderly, immunocompromised, or have an indwelling intravenous catheter.
For all other people with infected superficial thrombophlebitis, prescribe flucloxacillin 500 mg four times a day for 7 days.For people who are allergic to penicillin, consider erythromycin (250 mg four times a day for 7 days) or clarithromycin (500 mg twice a day for 7 days).
CKS recommends admission for people with infected thrombophlebitis who are ill or are at risk of serious illness because they may require treatment with intravenous antibiotics.
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Identify people with risk factors that put them at increased risk of developing a deep vein thrombosis (DVT).A person's risk should be judged by considering the size and number of risk factors present. Particular importance should be given to people with:Thrombophlebitis that extends near where an affected superficial vein joins a deep vein, where the long saphenous vein joins the femoral vein at the groin.
Reduced mobility.
Thrombophlebitisnotassociated with varicose veins.
Past history of DVT or pulmonary embolism (PE).
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For people judged to be at increased risk of a DVT, consider consulting a haematologist to discuss the use of subcutaneous low molecular weight heparin or fondaparinux to prevent DVT.