If you are administering I.V. fluids or medications to a patient through a peripheral I.V. site, be alert for signs and symptoms of complications, institute preventive measures, and know how to intervene when complications do occur. 
 
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I.V. Fluids

Infiltration of I.V. Fluids

Infiltration occurs when I.V. fluid or medications leak into the surrounding tissue. Infiltration can be caused by improper placement or dislodgment of the catheter. Patient movement can cause the catheter to slip out or through the blood vessel lumen. 

Infiltration Signs and symptoms

• Swelling, discomfort, burning, and/or tightness 
• Leakage from the insertion site
• Cool skin, redness,and/or blanching
• Decreased or stopped flow rate, or high-pressure/distal-occlusion alarms

I.V. Infiltration Prevention

• Select an appropriate I.V. site, avoiding areas of flexion. 
• Use proper venipuncture technique.
• Follow your facility policy for securing the I.V. catheter.
• Establish catheter patency prior to any intravenous administration.
• Observe the I.V. site frequently.
• Advise the patient to report any swelling or tenderness at the I.V. site.

Management of I.V. Infiltration

• Stop the infusion and remove the device.
• Elevate the limb to increase patient comfort; a warm or cool compress may be applied, depending on the infiltrated solution.
• Check the patient's pulse and capillary refill time.
• Perform venipuncture in a different location and restart the infusion, as ordered.
• Check the site frequently.
• Document your findings and interventions performed.

Extravasation

Extravasation is the leaking of vesicant drugs into surrounding tissue. Extravasation can cause severe local tissue damage, possibly leading to delayed healing, infection, tissue necrosis, disfigurement, loss of function, and even amputation.

Signs and Symptoms

• Pruritis, tightness, burning, or discomfort at the I.V. site
• Cool skin, redness, and/or blanching at or above the I.V. site
• Blistering and/or skin sloughing
• Delayed manifestations of ulceration, eschar, and necrosis

Extravasation Prevention 

• Avoid veins that are small and/or fragile, veins in areas of flexion, veins in extremities with preexisting edema, or veins in areas with known neurologic impairment.
• Establish catheter patency prior to any intravenous administration.
• Be aware of vesicant medications, such as certain antineoplastic drugs. Examples include vancomycin, amiodarone, antineoplastic drugs (such as doxorubicin, vinblastine, and vincristine), hydroxyzine, promethazine, digoxin, and dopamine.
• Follow your facility policy regarding vesicant administration via a peripheral I.V.; some institutions require that vesicants are administered via a central venous access device only. 
• Give vesicants last when multiple drugs are ordered.
• Strictly adhere to proper administration techniques.

Management of Extravasation

• Stop the I.V. flow and remove the I.V. line, unless the catheter should remain in place to administer the antidote.
• Estimate the amount of extravasated solution and notify the prescriber.
• Administer the appropriate antidote according to your facility's protocol.
• Elevate the extremity.
• Perform frequent assessments of sensation, motor function, and circulation of the affected extremity. 
• Record the extravasation site, patient's symptoms, the estimated amount of extravasated solution, and the treatment.
• Follow the manufacturer's recommendations to apply either cold or warm compresses to the affected area.
• Perform venipuncture in a different location (proximal to the previous site, or in the contralateral arm) and restart the infusion as ordered, after changing IV tubing (per facility protocol).
• Continue to check the site frequently, then document findings and interventions.

Phlebitis 

Phlebitis is inflammation of a vein and may be caused by chemical, mechanical, or bacterial insults to the vein lining. Chemical phlebitis is often associated with the infusion of acidic, alkaline, or high-osmolarity solutions, or excessive infusion rate. Mechanical phlebitis can result from trauma to the vein during the insert of a PIV or using an inappropriately large PIV for the vein. Bacterial phlebitis may result from poor aseptic technique on insertion and may be related to emergent placement of PIVs.

Phlebitis Signs and Symptoms

• Pain, tenderness, warmth, erythema
• Swelling, induration, purulent drainage
• Palpable venous cord

Phlebitis Prevention

• Use proper venipuncture technique.
• Choose the most appropriately sized catheter for the ordered infusion or medication, utilizing the smallest size appropriate to allow for hemodilution of the infusate.
• Use a trusted drug reference or consult with the pharmacist for instructions on drug dilution, when necessary.
• Monitor administration rates and inspect the I.V. site frequently.
• Change the infusion site according to your facility's policy.

Management of Phlebitis

• Stop the infusion at the first sign of redness or pain.
• Apply warm, moist compresses to the area and elevate the limb
• Assess and document the patient's condition and interventions.
• If indicated, insert a new catheter at a different site, preferably on the opposite arm, using a larger vein or a smaller device and restart the infusion.

Hypersensitivity Reaction

An immediate, severe hypersensitivity reaction can be life-threatening, so prompt recognition and treatment are imperative.

Signs and Symptoms

• Sudden fever

• Joint swelling
• Rash and urticaria
• Bronchospasm
• Wheezing 

Hypersenstivity Prevention

• Ask the patent about personal and family history of allergies.
• For infants younger than 3 months, ask the mother about their allergy history because maternal antibodies may still be present.
• Stay with the patient for five to 10 minutes to detect early signs and symptoms of hypersensitivity.
• If the patient is receiving the drug for the first or second time, check them every five to 10 minutes or according to your facility's policy. 

Management of Hypersensitivity

• Discontinue the infusion and notify the prescriber immediately.
• Administer medications as ordered.
• Monitor the patient's vital signs and provide emotional support.

Infection

Local or systemic infection is another potential complication of I.V. therapy. 

Signs and Symptoms

• Pain, tenderness, redness, or discharge at the I.V. site
• Fever

Infection Prevention

• Perform hand hygiene, don gloves, and use aseptic technique during I.V. insertion. 
• Clean the site with approved skin antiseptic before inserting I.V. catheter.
• Ensure careful hand hygiene before any contact with the infusion system or the patient. 
• Clean injection ports before each use.
• Follow your institution’s policy for dressing changes and changing of the solution and administration set. 

Management of Infection

• Stop the infusion and notify the prescriber.
• Remove the device.
•  If catheter-related bloodstream infection (CRBSI) is suspected, culture the catheter tip as ordered. Catheter tip culture from PIVs should not be done routinely (Zingg et al., 2023).
• Administer medications as prescribed.
• Monitor the patient's vital signs.

With careful attention and skill, you’ll be able to recognize, prevent, and manage these complications of peripheral I.V. therapy.

 
References: 

Buter, J., Steele K.T., Chung, K., Elzinga, K. (2023, September 27). Extravasation injury from chemotherapy and other non-antineoplastic vesicants. UpToDate. https://www.uptodate.com/contents/extravasation-injury-from-chemotherapy-and-other-non-antineoplastic-vesicants

Nickel, B., Gorski, L., Kleidon, T., Kyes, A., DeVries, M., Keogh, S., Meyer, B., Sarver, M. J., Crickman, R., Ong, J., Clare, S., & Hagle, M. E. (2024). Infusion Therapy Standards of Practice, 9th Edition. Journal of infusion nursing: the official publication of the Infusion Nurses Society, 47(1S Suppl 1), S1–S285. https://doi.org/10.1097/NAN.0000000000000532
 
Spencer, S., & Gilliam, P. (2015). Teaching patients about their short peripheral I.V. catheters. Nursing, 45(2), 64. https://doi.org/10.1097/01.NURSE.0000459801.33205.6a
 
Zingg, W., Barton, A., Bitmead, J., Eggimann, P., Pujol, M., Simon, A., & Tatzel, J. (2023). Best practice in the use of peripheral venous catheters: A scoping review and expert consensus. Infection prevention in practice, 5(2), 100271. https://doi.org/10.1016/j.infpip.2023.100271

 

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COLLECTION	POCKET CARD	POCKET CARD
Focus On: Fluids & Electrolytes	Complications of Peripheral Intravenous Therapy	Complications of Central Vascular Access Devices