IV Complications

Infiltration and Extravasation:

Definitions and Misc. Info

Infiltration: the process in which a substance
enters or infuses into another substance or a
surrounding area. Infiltration may be an
intentional or unintentional process

Extravasation: the actual unintentional escape
or leakage of material from a vessel into the
surrounding tissue

Vesicant: an agent that is irritating and causes
blistering
 Infiltration and Extravasation:
Etiology
1 of 2

Puncture of distal vein wall during
venipuncture

Puncture of any portion of the vein wall by
mechanical friction from the catheter/needle
cannula

Dislodgement of the catheter/needle cannula
from the intima of the vein

Poorly secured IV device

Poor vein or site selection
 Infiltration and Extravasation:
Etiology
2 of 2

Improper cannula size

High delivery rate or pressure of the infusate

Over manipulation of the IV device, the site,
or both

Irritating infusate that inflames the intima of
the vein and causes it to weaken
 Infiltration and Extravasation:
Signs and Symptoms
1 of 2

Pain at or near the insertion site

Swelling proximal to or distal to the IV site

Puffiness of the dependent part of limb or
body

Taut, rigid skin around IV site

Blanching and coolness of skin around IV site

Damp or wet dressing

Slowed infusion rate
 Infiltration and Extravasation:
Signs and Symptoms
2 of 2

No back flow of blood into IV tubing when
clamp is full opened and solution container is
lowered below IV site

No back flow of blood into IV tubing when
tubing is pinched above cannula hub

Infusion stops running

The infusion continues to infuse when
pressure is applied to the vein above the tip of
the cannula
 Infiltration and Extravasation:
Interventions
The use of warm compresses to treat infiltration
has become controversial. It has been found that
cold compresses may be better for some
infiltrated infusates and warm compresses may
be more effective for others. It has also been
documented that elevation of the infiltrated
extremity may be painful for the patient. To act
in the best interest of the patient, following IV
infiltration, consult with the physician for order
regarding compresses and elevation.
 Infiltration and Extravasation:
Clinical Criteria
1 of 3
No symptoms
Skin blanched
Edema <1 inch in any direction
Cool to touch
With or without pain
Skin blanched
Edema 1-6 inches in any direction
Cool to touch
With or without pain
 Infiltration and Extravasation:
Clinical Criteria
2 of 3
Skin blanched, translucent
Gross edema >6 inches in any direction
Cool to touch
Mild-moderate pain
Possible numbness
Skin blanched, translucent
 Infiltration and Extravasation:
Clinical Criteria
3 of 3
(continued from previous slide)
Deep pitting tissue edema
Circulatory impairment
Moderate-severe pain
Infiltration or any amount of blood product,
irritant, or vesicant
 Catheter and Needle
Displacement:
Definitions and Misc. Info

Displacement: cannula has shifted from it's
intended placement site in the vein, or is
inadvertently removed from the vein.
 Catheter and Needle
Displacement
Etiology

1 of 1 secured after
Cannula was inadedaquatly
insertion

Tape around site becomes loose or detaches
from the skin

Insertion pulled out during transportation or
movement of the client
 Catheter and Needle
Displacement
Preventative Interventions

1 of
Explain to the patient 1 insertion their role
prior
in caring for the IV

Appropriate securing of IV line

Frequent assessment of site to ensure patency

IF THE SITE BECOMES DISLODGED,
THE SITE MUST BE MOVED!
 Occlusion and Loss of Patency:
Definitions and Misc. Info

Occlusion: occurs when there is some type of
blockage that interferes with the passage of
infusate into the vein. It can occur at any
point within the vein, the cannula, or the
tubing.
 Occlusion and Loss of Patency
Etiology

Tubing may be kinked or bent

Transition from electric pump to gravity flow

Not saline-locking the site when infusate runs
out

Fibrin sheath formation around and over the
tip of a cannula

Too large of a cannula
 Occlusion and Loss of Patency
Signs and Symptoms

Slowed rate of infusion even if clamp is
opened or height of infusate is raised

Infusion stops infusing

Infusion site pain (with normal appearance)

Blood backs up from the cannula into the IV
tubing
 Occlusion and Loss of Patency:
Interventions

For prevention, flush routinely, especially
with intermittent infusion devices

Pinch the IV tubing open and closed or gently
milk it

If the above doesn't work, attempt to irrigate
the line with normal saline
 Phlebitis:
Definitions and Misc. Info

Phlebitis: The inflammation of a vein

Inflammation: part of the body's normal
immune response to any type of injury or
invasion

Suppurative phlebitis: phlebitis in which pus
accumulates in the tissue
 Phlebitis:
Etiology

Bacterial: Pathogenic organisms can gain
access and stimulate inflammation.

Chemical: caused by irritating or vesicant
solutions.

Mechanical: physical trauma from the skin
puncture and movement of the cannula into
the vein during insertion; any subsequent
manipulation and movement of the cannula;
clotting; or excessively large cannula.
 Phlebitis:
Signs and Symptoms

Erythema at the site

Pain or burning at the site and along the
length of the vein

Warmth over the site

Edema at the site

Vein hard, red, and cord like

Slowed infusion rate

Temperature elevation on degree or more
above the baseline
 Phlebitis:
Grading Criteria
1 of 2
Erythema at access site with or without pain
No symptoms
Pain at access site with erythema and/or
edema
Pain at access site with erythema and/or
edema
Streak formation
Palpable venous cord
 Phlebitis:
Grading Criteria
2 of 2
Pain at access site with erythema and/or
edema
 Phlebitis:
Preventative Interventions

Infusion container should be hung 36 inches
higher than the IV site

Clip body hair around the IV site, but DO
NOT SHAVE IT! Shaving may encourage
bacterial contamination.

Insertion should be performed with aseptic
technique
 Phlebitis:
Interventions

At the first sign of phlebitis, the IV must be
discontinued and the cannula removed. If the
site shows fever and drainage, contact the
physician.

Warm compresses may be used, according to
agency protocol
 Thrombosis and
Thrombophlebitis:
Definitions and Misc. Info

Thrombosis: the formation of a clot

Thrombophlebitis: the inflammation of a
vessel due to the development of a thrombus

Deep Vein Thrombosis (DVT): inflammation
of the larger deeper veins of the extremities

Venous Stasis: the condition wherein blood
flow is inhibited or stopped due to a clot
formation
 Thrombosis and
Thrombophlebitis:
Etiology

Usually the sequela1ofof 1
phlebitis, meaning it is
a consequence of it. A clot forms when the
blood vessel becomes traumatized.
 Thrombosis and
Thrombophlebitis
Signs and Symptoms

Slowed or stopped 1 of 2 rate
infusion

Aching or burning sensation at the infusion
site

Elevation in temperature on degree or more
above baseline

Skin warm and red around IV site

Cording of the infusion vein
 Thrombosis and
Thrombophlebitis
Signs and Symptoms

Malaise 2 of 2

Swelling and edema of the extremity

Diminished arterial pulses

Pallor
 Thrombosis and
Thrombophlebitis:
Interventions

1 ofand2 restarted elsewhere
IV must be discontinued
immediately

Physician should be consulted as to whether the
extremity should be elevated and warm, moist
compresses applied.

Physician may order antiembolic stockings
and/or the use of sequential compression devices
(SCDs)

Anticoagulants and anti-inflammatories and a
balanced routine of active and passive activity
and rest
 Hematoma:
Definitions and Misc. Info

Hematoma: the accumulation of clotted blood
in the tissue interstices

Ecchymosis: a black and blue skin
discoloration
 Hematoma:
Etiology

Faulty venipuncture technique, where the
cannula passes through the distal vein wall

Infiltration following cannulation of a vein

Flow control clamp for infusion is opened
before tourniquet is removed

Vessel rupture due to large cannula

Inadequate pressure applied following a
blood sampling stick or the discontinuation of
an infusion or heparin/saline lock.
 Hematoma:
Signs and Symptoms

Ecchymosis over and around insertion area

Pain at the site

Swelling and hardness at the insertion site

Inability to advance the cannula all the way
into the vein during insertion

Inability to flush the IV line
 Hematoma:
Interventions

IV line discontinued, and a 2X2 inch gauze
pressure dressing applied

Alcohol should not be used when removing
the cannula because it enhances bleeding and
may cause stinging

Once bleeding has stopped, the extremity
may be elevated and warm moist compresses
applied, depending on the severity
 Venous Spasm:
Definitions and Misc. Info

Venous spasm: a sudden involuntary
movement or contraction of a vessel wall as a
result of trauma or irritation; usually painful.

Cramp: a strong, painful spasm
 Venous Spasm:
Etiology

Administration of an irritating infusate with a
high osmolarity or a high or low pH

Delivery of cold or viscous infusates

For some patients, entrance of IV cannula,
especially if cannula is too large

Too rapid infusion of infusate
 Venous spasm:
Signs and Symptoms

Slowed infusion rate

Stopped infusion rate

Severe pain from the IV site radiating up the
extremity

Blanching over the IV site

Redness over and around the IV site
 Venous Spasm:
Interventions

Prevention: use a large vein and a small-
gauge cannula so that blood flow is
unrestricted and allows for dilution of the
infusate; administer fluids at room
temperature

Once it occurs:
− Decrease infusion rate
− Apply warm compress if infusate is cold
− Pharmacist should be contacted about adding a
buffer if infusate is irritating
 Vessel Collapse:
Definitions and Misc. Info

Vessel collapse: the walls of a vein or artery
retract abnormally
 Vessel Collapse:
Etiology

Decreased circulation, as seen with excessive
blood or fluid loss and shock
 Vessel Collapse:
Signs and Symptoms

Inability to see a vein

Inability to feel a vein

Loss of vessel elasticity

Vessel feels flat or flaccid

Reduced or stopped infusion flow
 Vessel Collapse:
Interventions

Restart the IV elsewhere, preferably in a larger vein

If patient is in shock a physician may need to insert
a central line
− Stay with patient
− Provide reassurance
− Assist with central venous cannulation
− Keep the patient warm
− Lower head and elevate legs to promote venous
return
− Carefully monitor vital signs
 Cellulitis:
Definitions and Misc. Info

Cellulitis: the diffuse inflammation and
infection of cellular and subcutaneous tissue.
It is bacterial in nature.

Peau d'orange: site feels warm and the skin
has the roughened appearance of an orange
peel
 Cellulitis:
Etiology

Invasion and multiplication of bacteria into
the IV site
 Cellulitis:
Signs and Symptoms
1 of 2

Tenderness

Pain

Warmth

Edema

Induration

Red streaking on skin

Peau d'orange

Vesicles
 Cellulitis:
Signs and Symptoms
2 of 2

Abscess formation with pus

Ulceration

Fever

Chills

Malaise
 Cellulitis:
Interventions

Discontinue IV and start elsewhere

Physician may need to incise and drain an abscess

Limb may be elevated to reduce edema

Cool compresses to promote comfort often
alternated with war, moist compresses to promote
circulation

Sterile dressings should be used

Antibiotics, analgesics, and antipyretics are
generally administered
 Nerve, Tendon, Ligament and
Limb Damage:
Etiology

Incorrect insertion and placement of the IV
cannula, or improper securing and
stabilization of the cannula and IV line after
insertion
 Nerve, Tendon, Ligament and
Limb Damage:
Signs and Symptoms

Tingling

Numbness

Loss of sensation

Loss of movement

Cyanosis

Pallor

Deformity

Paralysis
 Nerve, Tendon, Ligament and
Limb Damage:
Interventions

Prevent damage by properly placing the IV
line

Frequently assess the extremity in which the
IV is placed
 Contamination and Infection:
Definitions and Misc. Info

Contamination: the introduction of
microorganisms or particulate matter into a
normally sterile environment
 Contamination and Infection:

Breaks in asepsis during the manufacture,
packaging, and storage of infusates,
medications, and delivery systems

Break in asepsis during setup and
administration of infusion therapy
 Contamination and Infection:
Signs and Symptoms

Chills

Malaise

Fever

Elevated leukocyte count

Normal appearance of IV site
 Contamination and Infection:
Interventions

IV must be discontinued and move to another
site with fresh equipment

Cannula, connection sites, tubing, and
infusate should be cultured
 Sepsis:
Definitions and Misc. Info

Sepsis: the (usually) febrile disease process
that results from the presence of
microorganisms or their toxic products in the
circulatory system.
 Sepsis:
Etiology

Most often attributed to Staphylococcus
aureus and S. epidermidis, the Candida
albicans yeast, and the coliform species
Escherichiea, Enterobacter, and Klebsiella.
 Sepsis:
Signs and Symptoms

Chills
1 of 2

Malaise

Altered mental status

Fever

Tachycardia

Tachypnea

Leukocytosis

Hypotension

Flushing
 Sepsis:
Signs and Symptoms
2 of 2

S/S of Toxic Shock Syndrome:
− Malaise with generalized myalgia and arthralgia
− Vertigo
− Nausea with vomiting
− Edema of hands and feet
− Desquamation of hands and feet
 Sepsis:
Interventions

Keep patient flat with legs elevated

Provide oral fluids

Keep warm

Medications as necessary to support blood
pressure, circulation, and promote comfort

Conserve strength

Administer oxygen

Analgesics and antipyretics may be given
 Hypersensitivity: Info

Hypersensitivity: the profound physiologic
response of the body to an antigen

Allergy: acquired abnormal immune response
to an allergen following sensitization
 Hypersensitivity:

Certain people are especially drug sensitive;
others are simply allergic to some specific
medications
 Hypersensitivity:
Signs and Symptoms
1 of 5

Facial edema

Generalized edema

Erythema along veins

Palpitations

Hypotension

Cardiac arrest

Dysphagia

Gastric cramping
 Hypersensitivity:
Signs and Symptoms
2 of 5

Intestinal cramping

Nausea

Vomiting

Flushing

Red flare

Rash

IV site edema

Pruritis
 Hypersensitivity:
Signs and Symptoms
3 of 5

Urticaria (hives)

Agitation

Anxiety

Confusion

Disorientation

Headache

Paresthesias

Vertigo
 Hypersensitivity:
Signs and Symptoms
4 of 5

Nasal congestion

Rhinorrhea (runny nose)

Cough

Sensation of tightness in throat

Mucous membrane edema

Wheezing

Bronshospasm

Respiratory obstruction
 Hypersensitivity:
Signs and Symptoms
5 of 5

Respiratory arrest

Watery eyes

Scratchy throat

Tinnitus

Buzzing sound in ears

Throbbing sensation in ears

Tingling/numbness in fingers and /or toes
 Hypersensitivity:
Interventions
At the first indication of a hypersensitivity
reaction, the nurse must either discontinue the
infusion and keep the vein open with normal
saline or, if the reaction is mild, slow th IV to a
KVO rate until further orders can be obtained.
NEVER REMOVE THE CANNULA! Vital
signs are to be taken and the physician notified.
The nurse must stay with the patient, reassure
him, and keep him warm. Emergency equipment
must be readily available. Emergency drugs are
administered according to agency policy and
physician orders.
 Embolism:
Definition and Misc. Info

Embolus: an aggregate of undissolved material
in the blood that is carried by circulatory flow.

Endogenous embolus: clotted blood, tissue
particles, tumor cell mass, or fat globules

Exogenous embolus: particulate matter, liquids,
gaseous material.

Ischemia: obstruction of a vessel due to
embolus.

Infarction: an area of necrosis following the
loss of blood supply.
 Embolism:
Etiology

Blood clot

Air embolism: through severed IV lines,
tubings that are not primed with infusate,
vented infusion containers that are allowed to
run dry, or disconnected and loose tubing
junctions

Catheter embolism: a portion of the catheter
breaks off

Any small, particulate matter that can enter
the bloodstream from the IV site
 Embolism:
Signs and Symptoms
1 of 2

Dyspnea

Tachypnea

Cardiac arrhythmia

Hypotension

Diaphoresis

Anxiety

Substernal pressure
 Embolism:
Signs and Symptoms
2 of 2

Chest pain with inhalation and exhalation

Localized decreased breath sounds

Pleural friction rub

Cough (often with hemoptysis)
 Embolism:
Interventions
1 of 2

Blood clot
− Low dose heparin or oral anti-coagulants
− Plan activity and movement
− Promote comfort and gas exchange by elevating
the head of the bed, assisting with coughing and
deep breathing, administering analgesics, and
maintaining a restful environment
 Embolism:
Interventions
2 of 2

Air embolism
− Mostly preventative and supportive

Catheter embolism
− Apply tourniquet above IV site
− Prepare for surgery
 Speed Shock:
Definitions and Misc. Info

Speed shock: the systemic reaction to the
rapid or excessive infusion of medication or
infusate into the circulation
 Speed shock:
Etiology

Flow control clamp is inadvertently left
completely open

EID (electronic infusion device) programmed
incorrectly
 Speed Shock:
Signs and Symptoms

Flushing of head and neck

Feeling of apprehension

Hypertension

Pounding headache

Dyspnea

Chest pain

Chills

Loss of consciousness

Cardiac arrest
 Speed Shock:
Interventions

Best intervention is prevention. Do not give a
medication without reading and following the
manufacturer's guidelines.

When it occurs:
− Slow or stop infusion
− Notify physician
− Observe for cardiac arrest