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IV Infiltration and other IV Catheter Complications: Identification and Management

Emergency (ER) New Nurse Nursing Assessment Procedures & Skills
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IV infiltration and other catheter complications are very common. If you work in the medical field, you know how vital these IV catheters are. But, as with any medical procedure, there are always potential complications that can occur. In this blog post, we’ll discuss IV Infiltration and other common IV catheter complications and how to manage them in your patients. With this information, you’ll be better prepared to handle any IV complications!

What is an IV Catheter?

IV catheters are small, thin tubes placed into a vein with a needle that is then retracted, leaving only the plastic catheter in place. This is used to administer medications and fluids directly into a person’s bloodstream.

IV catheters are invasive, which can lead to some level of risk for the patient. This is why assessment of the IV site is essential to ensure our patients’ safety and ensure there is no IV infiltration or any other complication occurring!

Assessment of the IV Site

Nursing assessment of the IV site is an essential part of managing IV catheter complications. As nurses, it’s important to monitor the IV site regularly and assess for any signs or symptoms of potential complications like IV infiltration.

When assessing the IV site, nurses must inspect and palpate not only the IV site, but also the IV dressing and any tubes or lines that the patient has attached.

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IV Insertion Site

  • IV site position
  • Skin erythema or pallor
  • Edema near insertion site
  • Temperature changes to skin
  • Pain at insertion site
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IV Dressing

  • Cleanliness
  • Dryness
  • Skin adhesive intact

Change IV Dressing per facility protocol

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Lines / Tubes

  • Ensure patency (Infusing without issues)
  • Ensure secured and not pulling
  • Check fluid bag levels and change as needed

IV Catheter Complications

Since IVs are so common within the hospital and ER, IV catheter complications like IV infiltration are also common.

Some of these IV catheter complications include IV infiltration, IV extravasation, IV site cellulitis, superficial thrombophlebitis, and IV catheter breakage. These complication rates are increased if improper technique is used while Inserting the IV.

1. IV Infiltration & Extravasation

This is an anterior forearm IV site that has IV infiltration indicated by edema and swelling with pallor around the IV siteIV Infiltration is when IV solution infuses or infiltrates surrounding tissue adjacent to the vein it is supposed to infuse into. This usually occurs when the IV catheter is malpositioned either during IV insertion or after being dislodged. This is why proper placement and securement of the IV, dressing, and tubing are important!

IV Infiltration generally refers to when this happens with normal fluid that is not damaging to the tissue. When the medication does cause damage to the tissue, these medications are called vesicants, and the infiltration is then referred to as extravasation

IV infiltration and other catheter complications are very common. If you work in the medical field, you know how vital these IV catheters are. But, as with any medical procedure, there are always potential complications that can occur. In this blog post, we’ll discuss IV Infiltration and other common IV catheter complications and how to manage them in your patients. With this information, you’ll be better prepared to handle any IV complications!

Signs & Symptoms of IV Infiltration

Signs and symptoms of IV infiltration will depend on what has infiltrated, and include:

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Pain

With IV infiltration, the patient may complain of pain at the IV site, especially with certain medications that are damaging to the tissue, known as vesicants, or medications that aren’t quite as bad but still known as irritants (see lists below).

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Swelling

Local swelling near their IV site the most common symptom of IV infiltration.

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Temperature change

There are often temperature skin changes with IV infiltration. This often is cold from the IV fluid being room temperature compared to their body temperature, but may also be warm in the setting of extravasation.

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Discoloration

IV infiltration will usually cause pallor, but may cause erythema or bruising as well.

Nursing Management of IV Infiltration

Interventions of IV infiltration and IV extravasation will depend on what has infiltrated, but will generally include the following steps:

Stop the fluids

Once you realize that the IV is infiltrated, stop the fluid to prevent further fluid/medicine from infiltrating.

Verify

Make sure the IV site is truly infiltrated. For a good assessment, you should try to to pull back blood return to see if it is still within the vein. Avoid applying pressure on the site.

Elevate the Extremity

Elevate the extremity above the level of the heart. This encourages drainage of the fluid into the vasculature where it should be, instead of in the extravascular space.

Keep the IV IN!

If a medication has infiltrated (aka extravasation), first notify the Provider / pharmacy BEFORE you remove the IV. This is because certain vesicants need to be irrigated or have the antidote administered into the IV before removal!

Notify the Provider

If the fluids had medication in it, it is a good idea to notify the provider and pharmacy to ensure no additional steps need to be taken.

Administer Treatment

After notifying the Provider and Pharmacy, you will have orders for treatment. For a simple IV infiltration with fluids, a compression wrap and time are usually sufficient.

For IV extravasation with a vesicant, sometimes certain antidotes are ordered and administered into the IV and locally infiltrated into the tissue surrounding the extravasated area.

Replace the IV

Remove the bad IV and insert a new IV in a different location. If using the same extremity, it is best to use a site proximal to the infiltration.

IV Vesicants

Below if a list of some commonly administered IV medications in the hospital which are vesicants and can cause tissue damage if extravasation occurs:

  • Acyclovir
  • Dextrose >10%
  • Mannitol
  • Nitroglycerin
  • Phenytoin
  • Sodium Bicarb
  • All Vasopressors (Dopamine, Dobutamine, epinephrine, etc)
  • Many chemotherapeutics (Cisplatin, vincristine, etc)

IV Irritants

Some medications cause irritation but not the same level of tissue damage as vesicants. These include:

  • Amiodarone
  • Esmolol
  • Gentamicin
  • Potassium chloride
  • Vancomycin

2. Thrombophlebitis

This is an anterior forearm IV site that has superficial thrombophlebitis indicated by a lighter erythema around the IV site and inflamed, red, and painful veinsSuperficial Thrombophlebitis is when there is inflammation of the veins (phlebitis) with some thrombus formation (blood clots) in a superficial vein. This occurs in superficial veins where the IVs are placed, and is different than Deep Vein Thrombosis (DVT) and is managed differently as well. 

There is always inflammation and an immune response whenever anything “doesn’t belong” in the body. In the case of IV catheters, this is usually not extreme, but sometimes the body reacts more significantly. This inflammation can lead to blood clot formation. 

Some causes or factors increasing the likelihood of thrombophlebitis to occur is:

  • Genetic conditions that increase the likelihood of blood clots (like Factor V Leiden)
  • Certain medications like estrogen or chemotherapies
  • Pregnancy
  • Smokers
  • Elderly patients 
  • Larger IV gauges

You’ll notice that these risk factors are similar for a patient developing DVTs and other blood clots. You can read all about Virchow’s triad here!

IV SIze

Remember that larger IV bores are associated with more endothelial vein wall damage and are more likely to cause issues like thrombophlebitis. Just another reason to only place the IV size that is appropriate, and bigger is not always better.

s/s of Superficial Thrombophlebitis

The signs and symptoms of thrombophlebitis are what you’d expect – redness, pain, and swelling, which is associated with most inflammatory states. Generally there won’t be as much swelling as with IV infiltration. 

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Pain

A patient with superficial thrombophlebitis from an IV will complain of pain at and surrounding the IV site

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Erythema

As with other inflammation, redness occurs and is visible on the skin and surrounding areas surrounding the IV site. You may notice this redness follow the vein specifically.

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Edema

You may notice some mild edema, but not as significant as with IV infiltration. This shouldn’t cause dramatic distal edema like DVTs.

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Temperature change

Like other cases of inflammation, you’ll notice the skin may feel warmer than the surrounding area.

Inflammatory Cascade

Remember that inflammation occurs when there is a suspected injury or foreign object. Your body activates your immune system and releases local chemicals (like histamine) and other inflammatory mediators, which cause capillaries to “leak”, increasing swelling and recruiting more white blood cells to fight the infection or foreign body. This leads to pain, redness, and swelling.

Nursing Interventions

When superficial thrombophlebitis is suspected, it will depend on the Provider on what kind of diagnostics are done. Generally, symptoms can mimic a DVT and a DVT should be ruled out. 

Stop Medications

Stop all meidcations or any infusions that are currently infusing into the vein.

Notify the Provider

Notify the Provider of suspected inflammation. If the pain or signs are significant, a DVT may need to be ruled out. This would be ruled out by a Venous Duplex of the upper extremity.

Remove the IV

Remove the IV from the patient.

Replace the IV

Insert a new IV in a different location. If using the same extremity, it is best to use a site proximal to the infiltration.

Administer Treatment

Most cases of superficial thrombophlebitis don’t require treatment with an antiocoagulant like a DVT would. Removing the IV, elevation, warm or cool compresses, and NSAIDs are part of symptomatic treatment.

3. Cellulitis

This is an anterior forearm IV site that has cellulitis indicated by erythema around the IV siteCellulitis is when there is a local skin and soft tissue bacterial infection. This can occur anywhere on the skin, and is usually caused by a “break” in the skin barrier.  Since an IV (and anything invasive like that) breaks the skin integrity, this offers a pathway for bacteria to enter the skin and lead to infection.

This is why it’s so important to follow an aseptic (aka sterile) technique when placing an IV catheter. Just like improper technique can lead to IV infiltration, it can also lead to IV site cellulitis if you aren’t careful!

Certain patients more prone to developing cellulitis are those with immunocompromised conditions and states, which commonly include uncontrolled diabetes.

Signs & Symptoms of cellulitis

Cellulitis from a peripheral IV has the same signs and symptoms as cellulitis in any other area. These changes to the skin are associated with inflammation and infection, and include:

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Pain

A patient with cellulitis will often complain of pain around the IV site.

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Fevers

Patient’s with infections like cellulitis often present with fevers, which may indicate early sepsis. 

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Discharge

Discharge around the IV insertion site can occur with cellulitis.

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Erythema

Redness to the area is pretty prominent with cellulitis.

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Edema

There may also be some mild edema at the site, but generally not as much as IV infiltration.

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Temperature change

The surrounding area is usually warm or hot compared tot he surrounding skin temperature.

Nursing Interventions

When you suspect IV site cellulitis, you should do the following:

Stop medications

Stop all medications or any infusions that are currently going through the vein (remember they can also have IV infiltration, thrombophlebitis, or something else going on too).

Check Vitals

Do a full set of vitals including a temperature to make sure the vitals are stable and see if there are any fevers.

Notify the Provider

Notify the Provider of suspected infection. They will determine if antibiotics are necessary.

Remove the IV

Remove the IV from the patient. 

Replace the IV

Insert a new IV in a different location. If using the same extremity, it is best to use a site proximal to the infiltration

Administer Treatment

Most cases will require antibiotics – either IV or PO. IV antibiotics that commonly are ordered include:

  • Keflex
  • Bactrim
  • Clindamycin
  • Ceftriaxone
  • Vancomycin (if MRSA risk)

4. IV Breakage

This is the tip of an 20 gauge (20g) IV catheter where the tip is broken, indicating IV catheter breakageIV breakage is a rare but serious complication of IV therapy. The breakage can occur due to several reasons, such as catheter damage, improper insertion technique, or excessive catheter manipulation.

It is important to prevent this, as the broken catheter tip can embolize to the heart or the lungs.

Signs & Symptoms of IV breakage

The signs and symptoms of IV catheter breakage can vary depending on the location and size of the broken catheter piece. If the broken piece is small, the patient may not experience any symptoms. However, if a larger piece breaks off, the patient may experience pain, swelling, redness, or tenderness at the site of the breakage. In severe cases, the broken piece can embolize through the bloodstream and lodge in other into the cardiac or pulmonary vasculature, which can obviously be bad news. 

The main sign will occur when you take the IV out and notice that the entire catheter is not intact!

Nursing interventions

When you notice that the IV catheter not fully intact, you must act quickly and notify appropriate personnel.

Prevent It

The first step is to never pull out the IV if you are getting resistance. Cover the area with a sterile bandage and apply a warm compress to the area to relax the vein. After 5 minutes you can try to remove the line again very gently. If there is still resistance, contact the Provider / Vascular surgery or interventional radiology immediately!

Immobilize the Arm

Keep the arm still and below the level of the heart. We are trying to prevent the catheter piece from traveling up the veins to the heart or lungs.

Apply Tourniquet

Apply a tourniquet near the armpit. This is to close off the veins and prevent the catheter piece from passing by. Make sure to check a radial pulse to make sure the tourniquet is not too tight.

Notify Provider(s)

Notify the patient’s Hospitalist/Attending and/or Vascular surgery or interventional radiology.

Monitor

Imaging such as X-rays or ultrasounds may be performed, and removal will occur by the specialists. Monitor the patient for acute chest pain, SOB, or vital sign changes which may indicate embolization of the catheter.

Early recognition and quick nursing intervention of IV catheter complications like IV infiltration can go a long way in saving your patient. Nurses play a critical role in identifying and taking prompt action to manage these complications. Proper monitoring, assessment, and management of IV catheter complications and IV infiltration can help prevent further harm to patients and improve their overall outcomes. By recognizing the signs and symptoms of IV catheter complications and following best practices for IV therapy, nurses can ensure that patients receive safe and effective care.

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