As discussed in the September/October "Speaking of Standards [horizontal ellipsis]" column, it is not uncommon for many nurses to lack understanding about the difference between phlebitis and infiltration and/or underestimate the significance of these complications. Infiltration in particular is often not thought of as a noteworthy problem; in fact, some clinicians may consider it a "routine" and natural consequence of intravenous therapy.2

However, infiltration can result in significant injury. In a retrospective study in a single hospital, researchers reviewed 3 years of peripheral IV complications in patients who were administered IV medications in the emergency department or during hospitalization.3 The patients were identified based on diagnosis of the complication. In this study, the most frequent complication was symptomatic IV infiltration. The researchers found 26 incidents of minor, self-limited infiltration and 6 incidents of major complications secondary to infiltration. Major complications required surgery or therapy and included skin necrosis, finger stiffness, nerve irritation, neuropathy, and compartment syndrome. Three of the patients experienced scarring, skin depigmentation, and pain/weak hand grip as a result of the infiltration. Infusates included normal or half-strength saline,3 Decadron (dexamethasone), Phenergan (promethazine), and cisplatin/5-fluorouracil. Most infiltrations occurred in the hand or forearm.

Standard 54.1 defines infiltration as the inadvertent administration of a nonvesicant medication or solution into the surrounding tissue. Vesicant refers to any medication or fluid capable of causing injury, such as necrosis or tissue damage, when it escapes from the vein.1 If a vesicant inadvertently leaks into the tissue, the correct term is extravasation. In the study mentioned previously, infiltration of cisplatin or Phenergan would be considered extravasation, because both of these medications are vesicants.4 Note that extravasation is addressed separately in INS Standard 55 and that those standards include the prompt discontinuation of the infusion, physician notification, and immediate interventions to minimize the effects of the extravasation. An extravasation would be graded a "4" on the scale that follows.1

Infiltration or extravasation occurs as a result of mechanical, obstructive, and inflammatory causes.4 Examples include catheter dislodgment due to joint movement when the catheter is placed in an area of flexion, obstruction of fluid flow due to blood clots from a previously infiltrated venipuncture site distal from to the current IV site, and inflammation due to irritating fluids. Prevention of infiltration is essential. Additional standards provide guidance aimed at reducing the risk. Standard 37, Site Selection, addresses avoiding areas of flexion when placing a peripheral IV, avoiding subsequent cannulations proximal to previously cannulated sites, and avoiding peripheral infusion of irritating infusates (eg, parenteral nutrition, continuous vesicant drug infusions, infusates with a pH of <5 or >9, and infusates with osmolality of >600 mOsm/L).1 Standard 38 directs use of the smallest size and shortest length catheter to accommodate the therapy. Standard 43 speaks to catheter stabilization, shown to be important in the overall reduction of peripheral IV complications, as discussed in the January/February 2007 "Speaking of Standards" column.5

The infusion should be stopped immediately and the catheter removed at the first sign or symptom, which may include skin coolness, blanching, feelings of skin tightness, decreased mobility of the extremity, pain, or discomfort.2 As with phlebitis, the INS Standards of Practice recommends that infiltration be rated using a scale as follows:

* Grade 0 = No symptoms

* Grade 1 = Skin blanched, edema <1 inch, cool to touch, with or without pain

* Grade 2 = Skin blanched, edema 1-6 inches, cool to touch, with or without pain

* Grade 3 = Skin blanched/translucent, gross edema >6 inches, cold to touch, mild-moderate pain, possible numbness

* Grade 4 = Skin blanched/translucent, skin tight/leaking/discolored, bruised, swollen, gross edema >6 inches, deep pitting tissue edema, circulatory impairment, moderate-severe pain, infiltration of any amount of blood product, irritant, or vesicant

The Practice Criteria under the Infiltration Standard state that organizations should establish guidelines for interventions and treatments in policies and procedures. Guidelines should be based on the most recent scientific evidence. In a recent article, Hadaway provided a review of the literature on infiltration and extravasation treatment.4 It is essential that organizations recognize infiltration as an adverse outcome and monitor its incidence. This often-underestimated complication can have serious consequences.

ACKNOWLEDGMENTS

I would like to thank Lynn Hadaway, who also served on the Committee to revise the Infusion Nursing Standards of Practice, for her review of this month's column.

REFERENCES