Letters to the EditorLetters to the EditorThrombophlebitis: A Common Complication of Amiodaroneto the editor: I read with interest the excellent article1 by Dr. Siddoway on the clinical use of the antiarrhythmic drug amiodarone (Cordarone) that appeared in the December 1, 2003, issue of American Family Physician. The author clearly presented the effectiveness and adverse effects related to this therapy that has been used intravenously or orally to convert and prevent recurrences of cardiac arrhythmias. However, there was no mention in the article1 of thrombophlebitis, a common complication associated with intravenous amiodarone.2Recent studies3 have reported rates of phlebitis as high as 16 percent with the intravenous administration of amiodarone. A meta-analysis4 of 18 randomized controlled trials studying intravenous amiodarone to convert atrial fibrillation reported an 8 percent rate of phlebitis among the 550 patients who received amiodarone. In this systematic review,4 phlebitis was the most common adverse effect of the drug, followed by bradycardia (4 percent of patients) and hypotension (2 percent of patients).Thrombophlebitis usually occurs when high doses of amiodarone are infused over a long period in peripheral veins. Thus, to avoid this side effect, the drug should be administered in a peripheral vein for a maximum of 24 hours. Afterwards, the drug must be used orally or a central vein access should be considered.5 By following these precautions, this minor but frequent complication can be avoided.HENRIQUE HORTA VELOSO, M.D. ANGELO AMATO VINCENZO DE PAOLA, M.D. VOTCOR-Hospital da Venervel Ordem Terceira da Penitncia Rua Conde de Bonfim 1033, Tijuca Rio de Janeiro, Brazil 20530-001REFERENCES1. Siddoway LA. Amiodarone: guidelines for use and monitoring. Am Fam Physician 2003;68:2189-96.2. Aravanis C. Acute thrombophlebitis due to IV use of amiodarone. Chest 1982;82:515-6.3. Vardas PE, Kochiadakis GE, Igoumenidis NE, Tsatsakis AM, Simantirakis EN, Chlouverakis GI. Amiodarone as a first-choice drug for restoring sinus rhythm in patients with atrial fibrillation: a randomized, controlled study. Chest 2000;117:1538-45.4. Hilleman DE, Spinler SA. Conversion of recent-onset atrial fibrillation with intravenous amiodarone: a meta-analysis of randomized controlled trials. Pharmacotherapy 2002;22:66-74.5. Faniel R, Schoenfeld P. Efficacy of i.v. amiodarone in converting rapid atrial fibrillation and flutter to sinus rhythm in intensive care patients. Eur Heart J 1983;4:180-5.Plebitis And Varicose VeinsThis is an inflammation of the veins. The signs are pain and tenderness in the course of the vessel, which soon becomes cord-like and knotted, by which it may be distinguished from arteritis. There are swelling and redness of the adjacent parts, the redness being in streaks. The limb below the part is swollen, from obstruction of the circulation and effusion of serum. Pus is a frequent production of phlebitis, in which case perfect occlusion of the vein above occurs, with the formation of an abscess, or the pus passes into the heart and produces excessive prostration. Varicose veins are the sequel generally to phlebitis.TREATMENT. -- The treatment consists in fomentations, leeching, and occasional purging. The alteratives should also be given. The topical application of tincture of lobelia and arnica are also useful. Rest is enjoined. The abscesses and consequent ulceration should be treated upon general principles. If the veins become varicosed, astringent applications, and careful bandaging, should be resorted to.The best method of curing varicose veins, however, is by elastic stockings. These give an equable pressure, which can be so regulated as to afford any compression desired, on every part of the leg where the varicose veins exist. If the veins are varicosed throughout the whole length of the limb, the full-length stocking should be worn. If confined only to the leg, the stocking represented on the right-hand side of the cut is alone necessary, and in some cases the knee-caps and anklets are only required, depending upon the situation of the varicose veins. These elastic contrivances are not only radical cures, but patients suffering from varicose veins have no idea what ease and comfort they afford. They give a very agreeable support to the limb, prevent varicose ulcers, besides quickly reducing the enlarged veins to natural size. They are made of the best silk, are very durable, and not so expensive as not to be afforded by the poorest sufferer. All those desiring these admirable contrivances are requested to correspond with the author; -- preliminary correspondence as to size, measurement, etc., is in all cases essential to secure that perfect adaptation which is indispensably necessary in order to afford relief and cure. Great harm is done if the elastic appliance is not eligible in every respect, and therefore patients should hesitate before purchasing those inferior, half cotton articles, which are purchasable everywhere; they do not fulfil the conditions required of them, and are capable of doing great injury, owing to the unequal compression they afford. Prices as above. If you would like to learn about the causes, symptoms and diagnosis ofPhlebitis, and Plebitis treatment, you will find the following information of help.Phlebitis Superficial thrombophlebitis is an inflammation of a vein just under the skin, usually in a leg. A small blood clot commonly forms in the vein, but is usually not serious. The condition usually settles and goes within 2-6 weeks. Treatments can ease pain or discomfort. Complications occur in a small number of cases. Superficial thrombophlebitis is different to, and much less serious than, deep vein thrombosis. What is thrombophlebitis?Phlebitis means inflammation of a vein. Thrombo(sis) means a blood clot in a vein.A vein is a blood vessel that takes blood towards the heart. If a vein becomes inflamed, a blood clot commonly forms inside the inflamed portion. So, the term thrombophlebitis is used to mean an inflamed vein, with or without a small blood clot inside the vein. (However, thrombophlebitis is commonly just called phlebitis.) What is superficial thrombophlebitis?The superficial veins are the ones that you can often see or feel just under the skin. Most bouts of thrombophlebitis occur in a leg vein, but any superficial vein can be affected. A typical site is in a varicose vein in a leg. Varicose veins are common, particularly in pregnant women. Superficial thrombophlebitis is not usually serious, but complications sometimes occur (see below).Note: this page does not deal with inflammation or thrombosis of deep veins. The deep veins are larger, pass through the muscles in your arms and legs, and you cannot see or feel them. Some people get confused between superficial thrombophlebitis and deep vein thrombosis. They are quite different. A deep vein thrombosis (DVT) is more serious, and is dealt with in another page.What causes superficial thrombophlebitis?Most casesMany cases occur for no apparent reason. A slight injury to the vein may trigger the inflammation in some cases. Many cases occur in people who already have varicose veins of the legs. Varicose veins are probably more prone to minor injuries which can lead to inflammation.Risk factorsThere are a number of 'risk factors' that make it more likely for inflammation or a blood clot to develop in a vein which may lead to superficial thrombophlebitis.Abnormality, damage or injury to a vein. Varicose veins are the most common abnormality. A common cause of injury is by injecting drugs into a vein. This is common in people who inject 'street drugs'. Sometimes it occurs after having intravenous injections or intravenous infusions ('drips') in hospital. There are other rare disorders that can damage veins such as Behcet's disease, Buerger's disease, and Mondor's disease. Abnormalities of blood clotting factors. Various conditions can alter certain chemicals ('clotting factors') in the bloodstream which make the blood more easy to clot. These include: using the oral contraceptive pill, cancer, smoking, and pregnancy. One study found that an episode of thrombophlebitis in the leg occurred in about 1 in 200 pregnant women, with most occurring in the first 48 hours after giving birth. There are also some rare hereditary blood disorders where blood clots develop more readily than usual. Stasis of blood (blood flowing more slowly than normal). For example, this occurs in varicose veins, during long flights, in people who are immobile, and following major surgery. What are the symptoms of superficial thrombophlebitis?Swelling, redness, and tenderness along a part of the vein are the usual symptoms. You may develop a fever (high temperature). If a blood clot develops inside the inflamed part of the vein, the vein may then feel hard or 'knobbly'. The blood clot is usually of little concern as it is small. There are many other veins which carry the blood, and bypass the blocked vein. When the inflammation settles, a persistent darker area of skin (hyperpigmentation) may remain over the affected vein. A persistent firm nodule (small lump) may also remain below the skin at the site of the affected vein. What is the treatment for superficial thrombophlebitis?Most bouts of superficial thrombophlebitis settle within 2-6 weeks. No treatment may be needed if the symptoms are mild. Treatment aims to ease symptoms.Keep on with normal activities as much as possible. A hot flannel (cloth) placed over the vein may ease the pain. Anti-inflammatory painkillers such as ibuprofen may ease the pain (but are not advised if you are pregnant). Paracetamol is an alternative. When you rest (when watching TV, or reading a book, etc), if you raise an affected leg so that your foot is higher than your hip, it helps to reduce swelling and discomfort. You can do this by lying on a sofa and putting the leg up on some cushions. When sleeping in bed, you can keep your leg raised by putting it on a pillow. Compression (support) stockings may be advised by your doctor if a vein in your leg is affected. This may ease discomfort whilst the inflammation settles. If varicose veins are the source of the problem, once the inflammation has settled, you may wish to consider treatment to remove the varicose veins. See your doctor for advice.Are there any complications from superficial thrombophlebitis?The inflammation and pain usually settle within a few weeks. Most people make a full recovery. The possible complications listed below are uncommon, but are listed to give a guide as to 'what to look out for'. See a doctor as soon as possible if you suspect a complication is developing. Infection. Sometimes the affected vein becomes infected. The pain may then become worse, and the redness spreads. You are likely to feel generally unwell. You may need antibiotics if the vein becomes infected. Rarely, infection in a vein becomes severe and may spread to other areas of the body. Blood clot extending. In some cases, the blood clot extends further up the vein. It may join with a deep, large vein, and the clot may extend to cause a 'deep vein thrombosis' (DVT). This is more likely if the superficial thrombophlebitis is in the upper thigh, near to where the superficial veins and the deep veins of the leg meet. It is also more likely to occur if the superficial thrombophlebitis develops in a previously normal vein (not a varicose vein). Another page deals with DVT. Very briefly, see a doctor urgently if: inflammation, redness, or hardness spread up the inner thigh towards the groin. your whole leg swells. pain becomes suddenly worse. you develop any new breathing problems, or get chest pains. (Sometimes a clot from a DVT breaks off and travels to the lung.)Rare conditions. If you have recurring bouts of superficial thrombophlebitis, it may be the first indication of a more serious condition (listed above in 'risk factors'). Tests may be advised if there is no explanation for recurring bouts of superficial thrombophlebitis. EMIS and PIP 2005Updated: September 2005PRODIGY Validated