INFILTRATION AND EXTRAVASATION are all-too-common complications of intravenous (I.V.) infusion therapy, especially therapy involving peripheral I.V. sites. You can significantly reduce their likelihood by understanding what causes them, choosing the right veins and equipment for the prescribed therapy, and monitoring the I.V. site closely. In this article, I'll review guidelines for protecting your patients from these painful, costly, and potentially dangerous complications.
Getting down to definitions
According to the Infusion Nursing Standards of Practice, infiltration is “the inadvertent administration of nonvesicant medication or fluid into the surrounding tissue instead of into the intended vascular pathway.” This definition applies to most I.V. fluids and drugs, including irritants—fluids that can cause discomfort or pain at the venipuncture site or inside the vein or ones that can cause skin irritation such as contact dermatitis. Extravasation is infiltration with a vesicant medication or fluid. When these highly irritating fluids leak out of a vein, they cause blisters and can even damage or destroy surrounding tissue.
Because of these concerns, some infusates aren't appropriate for peripheral delivery. To prevent or reduce vascular complications, Infusion Nurses Society (INS, formerly Intravenous Nurses Society) standards recommend that you choose the type of vascular access according to the pH and osmolarity of the infusion. (See Special concerns with central venous access and implanted ports.)
Infiltration and extravasation occur when the I.V. catheter isn't fully in the vein or the vein has torn, letting the infusate leak. These complications occur when:
* the catheter isn't inserted correctly into the vein
* the lining of the vein has been damaged and swells, preventing the infusate from flowing forward; instead, the infusion stops or leaks out into the surrounding tissue
* a clot forms within the vein or around the cannula, causing infusate to seep into surrounding tissue or the vein to tear and infusate to leak out. Phlebitis or thrombophlebitis can also result.
* the cannula punctures or erodes through the opposite wall of the vein. This can also be accompanied by phlebitis or thrombophlebitis.
* the catheter is pulled out of the vein during patient movement or because it wasn't secured well.
Although infiltration and extravasation are more likely to occur with peripheral I.V. infusions, these complications can develop with central venous catheters and implanted infusion ports as well. The effects are sometimes devastating because of the volume involved and because these devices are more likely to be delivering vesicant medications. Be sure to closely monitor any infusion for signs of infiltration or extravasation, especially if the infusate is an irritant or vesicant.
Range of effects
Most I.V. infiltrations don't cause serious tissue damage, but they're uncomfortable for the patient. Also, infiltrations require you to remove the catheter and insert a new one elsewhere, reducing the number of I.V. sites available, taking up valuable time, and increasing the money spent on supplies.
The most serious consequences occur with extravasation of large amounts of highly irritating solutions, such as those containing calcium, potassium, some antibiotics, vasopressors, or chemotherapeutic agents. Tissue damage from vesicant solutions may be directly related to the drug's pH: Extremely acidic or caustic drugs and solutions can cause severe chemical burns. Extremely concentrated fluids or medications can cause tissue necrosis.
The extent of injury from infiltration or extravasation may depend on how quickly you intervene and how much fluid leaks into tissues, although even a moderate amount of fluid can cause damage due to compression. By detecting and treating infiltrations or extravasations early, you may prevent nerve damage and tissue sloughing requiring surgery. Failure to detect these complications promptly can lead to permanent disfigurement and loss of function, even if the patient undergoes reconstructive surgery. Patient injury related to infiltration and extravasation is a lawsuit waiting to happen.
Watch for these signs
To avoid problems, be alert for common signs and symptoms of I.V. infiltration, which include:
* skin that looks blanched, taut, or stretched or that the patient says feels “tight”
* edema at the insertion site
* cool skin temperature
* slowing or stopped gravity infusion
* I.V. fluid leaking out of the insertion site or from under the dressing
* a tourniquet applied above the I.V. insertion site that doesn't stop fluid from infusing
* no visible blood return when the infusion bag is lowered and you apply pressure on the vein proximal to the tip of the cannula. (Note: Blood return doesn't rule out infiltration.)
Discomfort or burning while an irritant or vesicant is being administered may indicate damage to the vessel. Consider a complaint of pain to be a warning sign that extravasation may occur if you continue to administer the medication. According to the INS, you should take these steps:
* turn off the infusion
* start an I.V. line in the other arm if not contraindicated
* follow your facility's policy for treating an infiltration or extravasation. For example, for an infiltration you may need to remove the line and apply warm or cool compresses; for an extravasation, you may need to administer an antidote before you remove the I.V. line.
Before administering a vesicant, vasoconstricting, or corrosive medication, be aware of your facility's policies for administering them and their antidotes. If an extravasation occurs, intervene appropriately before discontinuing the I.V. site.
To prevent infiltration, start by choosing a vein suitable for the therapy. Choose a vein that feels smooth and resilient, not one that's hard or cordlike. Avoid areas of flexion because movement can dislodge the catheter. If you must choose a site near an area of flexion, use an armboard per your facility policy. Arm boards are recommended by the INS in areas of flexion and directly adjacent to areas of flexion. If your patient will be using her hands for activities, avoid hand veins.
The veins of the forearm, especially on the inner aspect, are usually a good choice. Forearm bones act as a natural splint to support the site, providing stability.
Start as low on the forearm as possible (avoid any site below a recent venipuncture in the same vein), but don't use veins on the volar aspect of the wrist because they lie close to nerves. Also avoid using the inner aspect of the elbow (the antecubital fossa) to administer I.V. therapy. An infiltration in this area is difficult to detect until it becomes quite large. Fluid infiltrating the antecubital fossa could compress important structures in the area, such as the brachial artery and median nerve, causing nerve damage or tissue necrosis.
To maximize hemodilution of the medication, choose the smallest possible I.V. catheter that will safely deliver the infusion. This will allow blood flow to dilute the infusate and carry it away from the insertion site, and blood can return to the heart with minimal impedance from the catheter.
Always insert the I.V. device with its bevel facing up to reduce the risk of puncturing the vein's opposite wall. Consider using catheter securement or protection devices to reduce the risk of dislodgment, especially in pediatric or geriatric patients.
Assessing the site
After establishing a central venous access device or a peripheral I.V. access, assess the insertion site often—every 1 or 2 hours for a patient receiving a continuous infusion.
Make sure the site is easily visible by covering it with a clear, moisture-vapor transmissible dressing.
Palpate around the site for tenderness or coolness and swelling. Pick up the patient's arm to check for dependent edema. You can use a bright flashlight. A large, diffuse circle of light around the I.V. site indicates a collection of subcutaneous fluid. This can signal infiltration unless the patient has general edema.
Act fast when problems occur
If you discover that an I.V. line has infiltrated or extravasated, stop the infusion and thoroughly examine the site. If the patient has suffered a large infiltration or if an irritant or vesicant is involved, notify the patient's health care provider.
If the catheter remains lodged in tissue, you can attempt to aspirate any fluid remaining in the catheter to lessen the amount of drug pooled at the site. Some vesicant antidotes can be infused into the I.V. catheter before it's removed; check your facility policy, a drug reference, or the pharmacy to find out the recommended antidote, if any.
After removing the catheter, elevate the affected arm if it makes the patient more comfortable and apply cool compresses (or warm compresses, if vinca alkaloids or epipodophyllotoxins are involved). If the patient develops blistering, which may occur 48 to 96 hours after the injury, he may need to be examined by a plastic surgeon or the wound care service.
Documenting the problem
Follow your facility's guidelines for documenting infiltration or extravasation. Take exact measurements of arm circumference or the area of infiltration or extravasation. Following policy, take pictures of extravasations to help clinicians gauge progress and to document the scope of the injury.
Refer to the Infusion Nurses Society Standards of Practice Infiltration Scale to grade the infiltration, then incorporate the grade and criteria into your documentation. These standardize the description of an infiltration.
All infiltrations and extravasations, especially those that cause tissue damage, should be tracked for quality improvement purposes.
Improving practice in the future
If it hasn't already been done, partner with the pharmacy to develop a list of “alert” medications that have been involved in extravasation injuries so that patients needing these medications can be evaluated for central line placement. Also consider working with the pharmacy to develop grand rounds focused on these “alert” medications to enhance staff awareness of the risks of extravasation injury.
Routinely using commercially available securement devices can dramatically reduce the incidence of peripheral catheter dislodgment, a primary cause of infiltration. Educate patients about which signs and symptoms to report so the nursing staff can limit the severity of any infiltrations that occur.
By using the best and most appropriate practices for I.V. therapy, you'll lessen the chances of your patient having an infiltration or extravasation. If they occur despite your best efforts, you can limit the damage by recognizing the problem quickly and responding appropriately.
Special concerns with central venous access and implanted ports
According to the Infusion Nurses Society (INS) Standards, a medication or solution with a pH less than 5 or greater than 9 shouldn't be delivered through peripheral cannulas. Some examples of medications with extremely high or low pH are vancomycin (pH, ∼2.4) and phenytoin (pH, ∼12). Likewise, parenteral nutrition solutions containing more than 5% protein hydrosylate or 10% dextrose must be infused through a central venous access device.
Because an extravasation of a vesicant could be devastating, the INS standards call for all continuous vesicant infusions to be administered through a central venous catheter or port. If a bolus of a known vesicant or irritant medication must be infused peripherally, it should be administered through the side port of a running I.V. line, preferably one placed for this specific purpose.
When administering a vesicant or irritant through a central venous access device, always assess for a blood return before starting the infusion and recheck for blood return frequently. Loss of blood return may indicate that a fibrin sheath has formed on the outside of the catheter. If this sheath is patent over the catheter tip and some distance up the catheter, it could cause retrograde infusion, which could lead to leakage of fluid and medication into the surrounding tissue. Notify the health care provider to obtain orders for a thrombolytic medication to restore a free-flowing and aspirated blood return.
If blood return isn't restored with a thrombolytic, the health care provider will order a dye study through the catheter to assess for other possible causes of the occlusion, such as pinch-off syndrome. A possible complication of subclavian catheters, pinch-off syndrome occurs when the catheter is scissored between the first rib and the clavicle, usually from a too-medial placement. This can lead to catheter fracture.
If your patient has central access via an implanted port, a dislodged noncoring infusion needle can lead to extravasations. Always choose a needle that's long enough to hit the back of the port on access, but not so long that a portion of the needle sits above the septum. Using a needle that's too long can cause “rocking” within the port, damaging the septum and leading to extravasation of fluid from the septum.
When patients are connected to an infusion via their implanted ports, assess the port access site frequently (as you would a peripheral I.V. line), looking for any leaking under the dressing or subcutaneous swelling around the port. If the patient complains of any sensation while you flush or infuse fluid through the port, stop the infusion and notify the health care provider, who'll assess whether a port-catheter separation has occurred. Although rare, this complication can result from repeated friction, stress, or other causes.