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IV Infiltration

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Definition

The IV infiltration can be defined as a complication of the intravenous therapy, with the administered medication infiltrating into the surrounding tissues. The leakage of the IV-administered fluids is clearly unintended, the condition being often presented as extravasation. The IV infiltration most commonly occurs when the IV catheter is dislodged from its normal place, leading to the fluids infiltrating in the nearby tissues.

The infiltration of non-vesicant drugs into the subcutaneous tissues can be the result of numerous actions, such as:

  • Puncturing the vein wall during the insertion of the IV catheter
  • Moving the arm in which the catheter was inserted, which ultimately leads to the erosion of the vein wall
  • The restriction of the blood flow in the area near the IV site (due to thrombosis or other factors)
  • An inflammatory process – this can lead to the widening of the gap between the cells of the vein wall, leading in the end to leakage.

Signs and Symptoms

These are the most common signs and symptoms of the IV infiltration:

  • Inflammation at or near the site of insertion
  • The skin is taut and swollen
  • Intense pain is experienced by the patient
  • The skin around the IV site is blanche and cool
  • The dressing applied over the IV site is either damp or wet
  • The infusion has reduced its speed or it has stopped altogether
  • If the solution container is lowered, there is no backflow of blood into the IV tubing

Grading

In the clinical practice, the IV infiltration can be graded into five different categories:

Zero

  • No symptoms

First grade

  • Skin appearance – blanche skin
  • Edema – under 1 inch (in any direction)
  • The skin is cool upon touch
  • The patient can be with or without pain

Second grade

  • Skin appearance – blanche skin
  • Edema – between 1 and 6 inches (in any direction)
  • The skin is cool upon touch
  • The patient can be with or without pain

Third grade

  • Skin appearance – blanche and translucent skin
  • Edema – over 6 inches (gross – in any direction)
  • The skin is cool upon touch
  • The pain can range from mild to moderate
  • Numbness can be present

Fourth grade

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  • Skin appearance – blanche and translucent skin
  • The skin can feel tight and leakage is present
  • The skin can be discolored or bruising is present
  • Inflammation is present at or the near the IV site
  • Edema – over 6 inches (gross – in any direction)
    • Deep pitting tissue edema can also be present in certain patients
  • The blood circulation in the area can be impaired
  • The pain can range from moderate to severe
  • Infiltration of: vesicant, irritant or blood product.

Treatment

The most common treatment measures in case of complications such as IV infiltration consist of:

Application of compresses (absorb the excess fluid, calm the pain, reduce the inflammation)

  • Cold compress
    • Recent infiltration
    • Hypertonic solution
    • Solution with increased pH
  • Warm compress
    • Infiltration occurring over time, reduced quantities of solutions that are not caustic
    • Isotonic solutions with normal pH

It is not recommended to elevate the affected limb of the patient, as this can lead to intense pain. On the other hand, one of the first measures that should be taken is represented by the discontinuance of the IV line.

Prevention

In order to prevent complications such as the IV infiltration, it is important that one follows the standard policy for the insertion of an intravenous catheter. If you are at the start of your nursing career, it is for the best that you practice the venipuncture skills on patients who do not suffer from chronic medical conditions and are well-hydrated. As you gain more experience, you can move on to the patients who have veins that are accessed a little bit more difficult. Keep in mind that there are certain medical conditions that change the integrity of the vein wall, such as diabetes or chronic hypertension. On the other hand, there are patients who receive intravenous therapy on a long-term basis – these are best handled by a nurse with experience.

The risk of IV infiltration can be seriously reduced by avoiding the insertion of the IV catheter in areas where there is a lot of movement, such as the hand, wrist or even the antecubital fossa. The most recommended point of access for the prevention of the IV infiltration is the forearm, where there are a lot of veins and the bones protect the catheter from the potential trauma generated by movement.

Management

If you suspect that the IV infiltration has occurred, the first and most important thing that you should do is discontinue the IV line. You might be reluctant to remove the IV catheter, especially if you have had difficulties in inserting it in the first place, due to the poor vein structure. However, you must not think about yourself but about the patient and how much discomfort and pain the IV infiltration generates. With patience and attention, you can place a new catheter, despite the poor vein structure, guaranteeing the comfort of the patient and the elimination of the systems caused by the IV infiltration.

As it was mentioned in the treatment section, you can apply either cold or warm compresses to the IV site. The warm compresses are recommended for non-vesicant drugs, increasing the blood flow in the area and the amount of interstitial tissue that comes in contact with the fluid. On the other hand, if the patient was administered fluids that are hypertonic or hyperosmolar, it is for the best to go with the cold compresses. These will reduce the contact with the interstitial tissues, reducing the damage done in the area. In case of fluids that are hypotonic or isotonic, you may choose the application of warm or cold compresses, according to the comfort of the patient.

If the fluids have infiltrated into the surrounding tissues, the administration on an antidote might be necessary. One of the most recommended antidotes to be administered is represented by hyaluronidase, which has fluid reabsorption as one of its main properties. In case of a gross IV infiltration, surgical intervention might be necessary to avoid the appearance of life-threatening symptoms. The surgical intervention generally consists of decompression in the area, along with the additional fasciotomy.


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