Protect patients from I.V. infiltration

Suppose you’re observing another nurse as she administers meperidine I.V., and you hear the patient complain of pain and burning at the catheter site. Your colleague assesses the site and doesn’t note edema, leakage, or changes in skin temperature or color. So she reassures the patient by explaining that many people complain of pain when receiving this drug.

What would you think of the care this nurse provided? Many nurses would say she performed appropriately. However, they would be wrong—and the patient could be headed for serious complications from infiltration.

A venipuncture may cause mild, transient pain, but I.V. fluid and drug administration shouldn’t hurt or burn. If the drugs are diluted and administered correctly, blood flow around the catheter is adequate to dilute them further, and if the catheter is properly immobilized, an infusion won’t cause pain. Discomfort or pain during an infusion indicates vein damage that will lead to infiltration.

Means of escape

Before reviewing how I.V. fluids and drugs escape the vein, let’s distinguish infiltration from extravasation, a related complication. The difference between the two is in the solution. According to the Infusion Nursing Standards of Practice written by the Infusion Nurses Society (INS):

  • Infiltration is the inadvertent administration of nonvesicant drugs or fluids into the subcutaneous tissue.
  • Extravasation is the inadvertent administration of vesicant drugs or fluids into the subcutaneous tissue.

Fluids and drugs can escape from the vein by several mechanisms:

  • a puncture of the posterior vein wall during peripheral I.V. catheter insertion.
  • catheter or arm movement causing the catheter tip to erode the vein wall
  • thrombosis or restrictions to normal venous blood flow proximal to the insertion site
  • inflammation, which widens the gaps between cells of the vein wall, allowing fluid to leak out.

Preventing infiltration

To prevent infiltration, follow the standards of the INS and the policies and procedures of your facility. Consider practicing your venipuncture skills on well-hydrated patients who don’t have chronic conditions. Then, move on to patients with veins that are more difficult to access. Aging and conditions such as diabetes and hypertension change the vein-wall structure. And patients receiving frequent or long-term infusion therapy may present challenges for nurses without extensive venipuncture experience.

Avoid the veins in the hand, wrist, and antecubital fossa as insertion sites because of the high risk of serious complications from catheter movement. Instead, use the veins of the forearm, where the bones provide a natural splint to prevent vein trauma from arm movement. (See Documenting I.V. catheter insertion by clicking on PDF icon above.)

You can find information on the proper infusion techniques for specific drugs in I.V. drug handbooks. Unlike drug handbooks that cover all administration routes, an I.V. drug handbook provides information on dilution, infusion rates, compatibility, monitoring, and precautions for the I.V. route.

Looking for signs of infiltration

Recognizing the early signs and symptoms of infiltration can limit the amount of fluid that escapes into the tissue. Such signs and symptoms include local edema, skin blanching, skin coolness, leakage at the puncture site, pain, and feelings of tightness. Compare the contralateral limb for differences in circumference. Look above and below the venipuncture site. Also, check the opposite side of the affected limb: it may be the only place where you can see that fluid is escaping from the posterior vein wall.

Consider the timing of signs and symptoms, too. Your patient may feel pain initially, but depending on the drug and the patient’s individual response, the pain may subside after a few minutes. Isotonic or hypotonic fluids and drugs may be quickly dispersed in the tissue and produce small amounts of swelling.
Hypertonic fluids will pull fluids from cells through osmotic fluid shifting, causing more interstitial fluid and compounding the problem.

To determine needle position, aspirate the cathe­ter for a blood return. Slowly and gently withdraw the syringe plunger and look for a brisk blood return. As an alternative, lower the fluid container below the venipuncture site and look for blood in the tubing.

Another alternative is the tourniquet test. Apply a tourniquet several inches above the venipuncture site and observe the gravity fluid flow. Compression from the tourniquet should stop or significantly slow the fluid flow. If you see little or no change, the fluid could be leaking into the subcutaneous tissue rather than flowing into the vein.

Don’t count on infusion-pump alarms to detect infiltration. Pumps don’t have mechanisms to detect infiltration, and they’ll continue to force fluid into the catheter, regardless of where it goes.

If undetected, infiltration can become so severe that it affects the neurovascular status of the limb. Assess the patient for sensation, ability to move his fingers, and a palpable radial pulse. Continue this assessment during the infusion because these changes may not occur immediately. Excessive fluid in one or more compartments of an arm can cause damage to nerves, arteries, and muscles and requires immediate surgical intervention to prevent a permanent loss of function. (See Complications of infiltration by clicking on PDF icon above.)

Managing infiltration

If you identify signs and symptoms of infiltration, immediately stop the infusion and remove the catheter. If the I.V. site is the only one you have for a patient with poor veins, you may be reluctant to remove the catheter. But continuing the infusion despite the signs and symptoms of infiltration will create a much greater problem than establishing a new I.V. site, even in poor veins.

A common intervention for infiltration is thermal manipulation at the site. For certain nonvesicant drugs, you’ll apply heat to increase blood flow and the amount of interstitial tissue in contact with the fluid. For hypertonic or hyperosmolar fluids, apply cold to restrict contact with additional tissue, thus limiting the tissue affected by osmotic fluid shift. For isotonic or hypotonic fluid, choose heat or cold based on patient comfort.

Another intervention is injecting an antidote. Hyaluronidase, a protein enzyme that breaks down the subcutaneous cellular components to allow fluid reabsorption, is probably the best choice. Several brands are available: Amphadase, a bovine product; Vitrase, an ovine product; and Hylenex, a human recombinant product that avoids the problems associated with animal-derived products.

If large amounts of fluid have infiltrated, the patient may need surgical decompression with a fasciotomy—immediately.

Observe and protect

Your skilled assessment and intervention can protect your patients from the complications of infiltration. And your skills and quick action can also protect you and your facility from legal liability.

To help ensure these protections, be proactive. Review your facility’s policies and procedures for preventing, recognizing, and managing infiltration. If they aren’t correct, coherent, and current, initiate the process to improve them.

Selected references

Infusion Nurses Society. Infusion Nursing Standards of Practice. J
Infus Nurs
. 2006;29(1S).

Kagel E, Rayan G. Intravenous catheter complications in the hand and forearm. J Trauma. 2004;56:123-127.

Tiwari A, Haq A, Myint F, Hamilton G. Acute compartment syndromes. Br J Surg. 2002;89(4):397-412.

Willsey D, Peterfreund R. Compartment syndrome of the upper arm after pressurized infiltration of intravenous fluids. J Clin Anesth. 1997;9(5):428-430.

See also Follow standards of practice to prevent infiltration, a list of key points on how to prevent infiltration based on the Infusion Nursing Standards of Practice by the Infusion Nurses Society.

Lynn Hadaway is president of Lynn Hadaway Associates, Inc. in Milner, Georgia.

17 COMMENTS

  1. I’ve been trying to find info on my particular incident but I can’t find anything about blood transfusion infiltration.
    I had to go to the ER for for a blood transfusion because I was seriously anemic my hemoglobin was at 6.3.
    They gave me 2 units(bags) of blood. Shortly after they started the second bag, the IV started burning. I looked down and there was a golf ball size bump at the site.
    I pressed the button for the nurse. When the she got there she took it out and changed the IV site to hand. Bump eventually went away left a fairly big bruise. That was 6days ago. They never really said anything about it if there could be any serious complications. If anyone has any info regarding this type of situation I would appreciate it.

  2. I read this I’m wanting to make sure I’m reading this right that this is the right term that happened? Previous blood clotted left ankle on two occasions and the lungs broke from one of the ankles that round. Went in yesterday to doc had high bp, chest pains, short breath ekg all over the place so off to the Dr I’m sent. Nurse is a jimmy’n my port in my arm she can’t get it to stay up right for the iv to flow right so is twisting it angling it up every which way propping it in the air cotton balls tape. Told her elliquest bleeder. It’s already a mess by entry. Imaging guy is scared to use it. And I get back in there hooked back up my left arm it ain’t a movin’ right hand get drink of water husband looks up blood is filling my I’ve tubing. Hubby runs out call button is actually missing in our room. She walks in ok it’s no big deal. Least me grab this antibiotic pushes drip and blood back in me. Second time happened hand and arm is swelling up blood made it almost to antibiotics bag before I noticed it. Lab tech spotted it said wasn’t their when she walked in but just as fast as she said something it bout made the end of the lead. So nurse came in behind my bed no clue what she was doing but I thought I was going to have a heart attack. My husband said as she squeezed the whole bag of antibiotics in me my pulse jumped to 114 and up along with that bp cuff they had automatically going on me. Sorry for this being so long winded but if some one could lead me in the right direction I would sure be thankful

  3. I went to ER on July 15. A nurse practitioner was my provider at ER and he told me I am dehydrated. The nurse injected a needle in my right arm to do a procedure called Intravenous therapy where they inject I.V fluid inside a vein in the arm. She put remote control type of thing on my bed and said, “If you need help, press this button and I will be here.” She left and closed the door.
    10-15 minutes later, I noticed my arm started swelling. I thought it might be normal. Later, my nails got blue and my right hand got colder than my right arm as if my right arm was dying. I noticed my arm where the nurse did that procedure is swollen and is getting big. So I pressed the button hoping the nurse will come. Nobody showed up. I pressed it again and again, but no one came. I cried for help many many times, “Help! please someone help me!” No one could hear me. Why? Because I could hear them in the lobby talking loud and laughing as if they have a party. I first thought to hit the closed door with my shoe so hard to make a loud noise. Then, I said to myself. It is useless because I had one pair of shoe and it would make only 2 knocks. Then, what? I heard my heart starting beating abnormal. Now, I got really panicked! I turned that plastic thing to the right and to the left not sure how to remove it. I finally removed the needle and the water started coming from the plastic. With my finger I kept the water hole tight to stop it from leaking. I went out and saw a nurse and asked him to stop the I.V fluid from leaking.
    I saved my life that day from ER room and came home.

  4. This happened to me too much too fast of a IV fluid causing my heart to fell and fluid to get in my lungs… I went in the ER for pain in my toes from my RA and ended up with this reaction from the IV I had several test ran throughout the day for 4 days not finding any issues with my heart to cause the leakage from the IV now I’ve been on several heart related medications since to make sure my heart is good crazy huh

  5. I was poked in wrong vein site I even felt weird feeling in neck spine, told nurse trying to put an I.V. on me and she stated it was fine after a few other poking and searching of vein in same site she was able to find a vein which made everything very painful and lots of burning on site with changes in skin color and temperature she said everything was fine. Went home all bruised up with a big bump feeling my whole vein shifting from side to side while in a lot of pain. Put ice and still in pain. Thanks for the information, I knew something was not right and the information published proves that what that nurse did is not right. Thank you.

  6. Yes please make sure you know exactly what you are doing when inserting an IV . Last October 2016, living in small town with just one hospital, I was given a bad IV ,they tried numerous sites leaving me very bruised , then put IV in crook of left arm, MISSING THE VEIN , I did not realize at the time! I went in for chronic pancreatitis, after being admitted and in my room, I drifted off , sometime later remember feeling weird heard distant voice saying 76 , still dropping, CRITICAL!!!! Actually think I died, eventually when back on this earth noticed I was on oxygen. Apparently I respiratory failure!!!! Never got treated for chronic pancreatitis , no ice chips or sponge pop to moisten mouth, they FED ME ORDINARY FOOD!!!!!! No one will admit to this deadly mistake, I am now on oxygen 24/7 out of pocket $2,550.00 dollars for a light weight g4 Inogen! STILL FURIOUS !!! HI CINDY

  7. I just had two infiltrations in 3 days. Drug was vancomycin. The symptom was severe itching at the IV site and pain on flushing the IV. I was very glad my nurses listened and stopped the IV immediately before I had any severe side-effects.

  8. Recently I was hospitalized for IV antibiotics for an infection.
    Several nurses attempted the IV insertion and I was poked at least 12 times and infiltrated at least 10 times. This was for a 4 day stay. The pain I was put through was tremendous; the pokes painful and after the infiltration was so painful I wanted to die. The article was helpful. Thanks.

  9. This article was great. This happened to me, and the burning sensation was a 10, the worst pain I ever felt. I had told the nurse it was burning on and off, but she said it was due to nerves being close to the site. When I was taken to be put asleep, I didn’t go to sleep, but instead experienced the worst pain ever. The anethesiologist (?) had to remove the IV and he placed it in my other arm with no problem – and off ot sleep I went! From now on only he will be allowed to put in the IV.

  10. Would like some clinical advise based on evidence. Are there nurses with professional degrees who have a research background out there who could add some evidence?

LEAVE A REPLY

Please enter your comment!
Please enter your name here