Suppose you’re observing another nurse as she administers meperidine I.V., and you hear the patient complain of pain and burning at the catheter site. Your colleague assesses the site and doesn’t note edema, leakage, or changes in skin temperature or color. So she reassures the patient by explaining that many people complain of pain when receiving this drug.
What would you think of the care this nurse provided? Many nurses would say she performed appropriately. However, they would be wrong—and the patient could be headed for serious complications from infiltration.
A venipuncture may cause mild, transient pain, but I.V. fluid and drug administration shouldn’t hurt or burn. If the drugs are diluted and administered correctly, blood flow around the catheter is adequate to dilute them further, and if the catheter is properly immobilized, an infusion won’t cause pain. Discomfort or pain during an infusion indicates vein damage that will lead to infiltration.
Means of escape
Before reviewing how I.V. fluids and drugs escape the vein, let’s distinguish infiltration from extravasation, a related complication. The difference between the two is in the solution. According to the Infusion Nursing Standards of Practice written by the Infusion Nurses Society (INS):
- Infiltration is the inadvertent administration of nonvesicant drugs or fluids into the subcutaneous tissue.
- Extravasation is the inadvertent administration of vesicant drugs or fluids into the subcutaneous tissue.
Fluids and drugs can escape from the vein by several mechanisms:
- a puncture of the posterior vein wall during peripheral I.V. catheter insertion.
- catheter or arm movement causing the catheter tip to erode the vein wall
- thrombosis or restrictions to normal venous blood flow proximal to the insertion site
- inflammation, which widens the gaps between cells of the vein wall, allowing fluid to leak out.
To prevent infiltration, follow the standards of the INS and the policies and procedures of your facility. Consider practicing your venipuncture skills on well-hydrated patients who don’t have chronic conditions. Then, move on to patients with veins that are more difficult to access. Aging and conditions such as diabetes and hypertension change the vein-wall structure. And patients receiving frequent or long-term infusion therapy may present challenges for nurses without extensive venipuncture experience.
Avoid the veins in the hand, wrist, and antecubital fossa as insertion sites because of the high risk of serious complications from catheter movement. Instead, use the veins of the forearm, where the bones provide a natural splint to prevent vein trauma from arm movement. (See Documenting I.V. catheter insertion.)
You can find information on the proper infusion techniques for specific drugs in I.V. drug handbooks. Unlike drug handbooks that cover all administration routes, an I.V. drug handbook provides information on dilution, infusion rates, compatibility, monitoring, and precautions for the I.V. route.
Looking for signs of infiltration
Recognizing the early signs and symptoms of infiltration can limit the amount of fluid that escapes into the tissue. Such signs and symptoms include local edema, skin blanching, skin coolness, leakage at the puncture site, pain, and feelings of tightness. Compare the contralateral limb for differences in circumference. Look above and below the venipuncture site. Also, check the opposite side of the affected limb: it may be the only place where you can see that fluid is escaping from the posterior vein wall.
Consider the timing of signs and symptoms, too. Your patient may feel pain initially, but depending on the drug and the patient’s individual response, the pain may subside after a few minutes. Isotonic or hypotonic fluids and drugs may be quickly dispersed in the tissue and produce small amounts of swelling.
Hypertonic fluids will pull fluids from cells through osmotic fluid shifting, causing more interstitial fluid and compounding the problem.
To determine needle position, aspirate the catheter for a blood return. Slowly and gently withdraw the syringe plunger and look for a brisk blood return. As an alternative, lower the fluid container below the venipuncture site and look for blood in the tubing.
Another alternative is the tourniquet test. Apply a tourniquet several inches above the venipuncture site and observe the gravity fluid flow. Compression from the tourniquet should stop or significantly slow the fluid flow. If you see little or no change, the fluid could be leaking into the subcutaneous tissue rather than flowing into the vein.
Don’t count on infusion-pump alarms to detect infiltration. Pumps don’t have mechanisms to detect infiltration, and they’ll continue to force fluid into the catheter, regardless of where it goes.
If undetected, infiltration can become so severe that it affects the neurovascular status of the limb. Assess the patient for sensation, ability to move his fingers, and a palpable radial pulse. Continue this assessment during the infusion because these changes may not occur immediately. Excessive fluid in one or more compartments of an arm can cause damage to nerves, arteries, and muscles and requires immediate surgical intervention to prevent a permanent loss of function. (See Complications of infiltration.)
If you identify signs and symptoms of infiltration, immediately stop the infusion and remove the catheter. If the I.V. site is the only one you have for a patient with poor veins, you may be reluctant to remove the catheter. But continuing the infusion despite the signs and symptoms of infiltration will create a much greater problem than establishing a new I.V. site, even in poor veins.
A common intervention for infiltration is thermal manipulation at the site. For certain nonvesicant drugs, you’ll apply heat to increase blood flow and the amount of interstitial tissue in contact with the fluid. For hypertonic or hyperosmolar fluids, apply cold to restrict contact with additional tissue, thus limiting the tissue affected by osmotic fluid shift. For isotonic or hypotonic fluid, choose heat or cold based on patient comfort.
Another intervention is injecting an antidote. Hyaluronidase, a protein enzyme that breaks down the subcutaneous cellular components to allow fluid reabsorption, is probably the best choice. Several brands are available: Amphadase, a bovine product; Vitrase, an ovine product; and Hylenex, a human recombinant product that avoids the problems associated with animal-derived products.
If large amounts of fluid have infiltrated, the patient may need surgical decompression with a fasciotomy—immediately.
Observe and protect
Your skilled assessment and intervention can protect your patients from the complications of infiltration. And your skills and quick action can also protect you and your facility from legal liability.
To help ensure these protections, be proactive. Review your facility’s policies and procedures for preventing, recognizing, and managing infiltration. If they aren’t correct, coherent, and current, initiate the process to improve them.
Infusion Nurses Society. Infusion Nursing Standards of Practice. J
Infus Nurs. 2006;29(1S).
Kagel E, Rayan G. Intravenous catheter complications in the hand and forearm. J Trauma. 2004;56:123-127.
Tiwari A, Haq A, Myint F, Hamilton G. Acute compartment syndromes. Br J Surg. 2002;89(4):397-412.
Willsey D, Peterfreund R. Compartment syndrome of the upper arm after pressurized infiltration of intravenous fluids. J Clin Anesth. 1997;9(5):428-430.
See also Follow standards of practice to prevent infiltration, a list of key points on how to prevent infiltration based on the Infusion Nursing Standards of Practice by the Infusion Nurses Society.
Lynn Hadaway is president of Lynn Hadaway Associates, Inc. in Milner, Georgia.