An 82-year-old female patient with a body mass index of 19 kg/m2 and a history of arterial hypertension treated with a combination of valsartan and lercanidipine, hypothyroidism treated with levothyroxine, and hypercholesterolemia treated with atorvastatin underwent an uncomplicated total hip replacement operation under spinal anesthesia with levobupivacaine. No previous history of an allergic reaction to medications was reported.
For postoperative pain management, as part of a multimodal regimen, an electronic patient-controlled analgesia pump containing morphine 0.4 mg/mL was connected to a dedicated peripheral venous catheter at the dorsum of the right wrist. Immediately after the patient initiated the first voluntary infusion of 2.5 mL, she reported localized itching followed by a burning sensation at the infusion site. Prominent ascending erythema outlining the infused vein and its proximal branches developed rapidly (Figure 1A), causing considerable distress to the patient.
Ascending erythema appeared immediately after the patient initiated the first infusion of morphine. (A) Patient’s wrist and forearm after acute phlebitis appeared and (B) 30 minutes later.
On palpation, the veins were soft but painful. The pump was removed and the veins were flushed with a saline infusion, revealing intact vein patency.
The patient’s symptoms were transient and resolved completely within 20 minutes (Figure 1B), with no systemic manifestations. Based on the acute onset, localization along the infused vein, lack of systemic manifestations, and rapid resolution, medication-induced phlebitis was considered the most likely diagnosis. Analgesia was managed thereafter with intravenous acetaminophen, dexketoprofen, and tramadol. None of these medications caused any symptoms.
ACUTE PHLEBITIS
Late-onset phlebitis, appearing 12 to 36 hours after intravenous cannulation and initiation of infusion therapy, is a common complication.1 Acute phlebitis after morphine infusion, however, is rare. We found only 1 case of morphine-induced phlebitis reported in the literature; it occurred in a cardiac emergency setting and involved a much more concentrated solution, and the patient had no symptoms except mild redness.2 Acute or transient phlebitis has also been reported after intravenous injection of diphenhydramine, meperidine, rocuronium, propofol, and ciprofloxacin.2
Potential mechanisms for acute medication-induced phlebitis include endothelial injury attributed to the injected solution’s pH, osmolality, or concentration, leading to mast cell degranulation and release of histamine and other mediators.3 Phlebitis is thought to occur more frequently when factors like old age, low body mass index, and atopic tendency are present.3
Although acute phlebitis is uncommon, it is essential to distinguish it from other conditions that may mimic its presentation and may represent more serious clinical entities, mostly appearing as late-onset phlebitis, hours or even up to 4 days after the triggering event.4 These include superficial thrombophlebitis and extravasation injury as well as more serious conditions like hypersensitivity reactions, cellulitis, lymphangitis, necrotizing fasciitis, and deep vein thrombosis.5
Management of acute medication-induced phlebitis should include immediately stopping the infusion, flushing the vein with saline to ensure patency, placing cold compresses to reduce localized symptoms, and observing for systemic involvement to rule out serious anaphylactic or thrombotic sequelae.3
In conclusion, a morphine infusion can rarely cause an acute, intense venous injury manifesting as a self-limiting superficial phlebitis without systemic involvement, which nonetheless can be quite distressing for the patient. Awareness of this reaction can prevent unnecessary concern and interventions while ensuring patient comfort.
DISCLOSURES
The authors report no relevant financial relationships which, in the context of their contributions, could be perceived as a potential conflict of interest.
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