Infiltration, Extravasation

list the complications that can arise from IVs

• infiltration

• venous access device related infection

• phlebitis

• thrombus

• catheter embolus

• speed shock

• fluid overload

• air embolus

what should a normal iv site look like?

dry, clean, intact; no redness, swelling, or leakage

when should an iv site be assessed?

whenever fluids or meds are running and when flushing the IV

what is infiltration?

when an IV catheter becomes dislogued, penetrates a vessel wall, or a vein ruptures

non-vesicant IV fluid leaks into surrounding subcutaneous tissue due to dislodged catheter or vein rupture

what is non-vesicant IV fluid?

an infusion that doesn’t cause blistering or tissue death if it leaks into the tissue (infiltration)

• ex: 0.9% sodium chloride (normal saline), lactated ringer’s (LR), and usually D5W

signs of infiltration

• cool, pale, taut skin

• swelling at the site

• damp dressing

• slowed infusion rate

how does infiltrated skin look?

cool, pale, taut

what might be seen at the site of infiltration?

swelling due to fluid leaking into the subcutaneous tissue

how would an infiltrated IV site’s dressing feel?

damp

what rate would an infiltrated IV go at?

slow rate

how to prevent infiltration

use a site stabilization device to secure the catheter to avoid it from becoming dislodged

first action for suspected infiltration?

stop the infusion and remove the IV catheter immediately

after removing an infiltrated iv, what comfort and assessment steps follow?

• elevate the extremity

• apply warm or cold compress per solution/policy

• check pulse and capillary refill time

• restart proximal or in another extremity

• notify the primary doctor and document

what is extravasation?

vesicant medication infiltrates into surrounding tissue

what are vesicant fluids?

an IV medication/solution that can cause blistering, tissue necrosis, and severe damage if it leaks out of the vein

• usually given through a central line or midline to reduce risk

why are central lines or midlines preferred for vesicants?

they reduce the risk of severe tissue injury if leakage occurs (extravasation)

immediate actions for extravasation

• stop the infusion

• leave catheter in place if ordered to instill antidote

• notify provider

• instill antidote per protocol

• elevate and use warm or cold compress as directed

• document site, symptoms, estimated amount, and treatment