What to do about IV infiltration
Hint: Don't panic!
If you work with patients receiving infusions via peripheral IV, sooner or later you will experience an IV infiltrate, sometimes referred to as extravasation. This is when the intravenous catheter is no longer infusing fluid or medication into the vein, and the infusion is leaking into the surrounding tissue. Don't panic! Here is a quick guide to some first aid for IV infiltrates.
Stop the infusion! If you suspect an infusion, immediately stop the IV infusion while you assess the catheter insertion site. You might notice swelling, pain, or tenderness around the site. It might appear redder or paler than the surrounding skin. The area may also feel cooler to touch. Sometimes it can be difficult to tell. You can compare to the skin on the opposite extremity if that helps. The Infiltration Scale assigns a grade 0 through 4 based on the severity of symptoms. Assess the catheter for patency, see if you can aspirate blood return. I use a tourniquet if needed to check for blood return on a peripheral IV. When in doubt, don't use the site. If possible, transfer the infusion to an alternate working site, preferably on the other arm. If you have no choice but to use the same arm, make sure the site is above (proximal) to the site that infiltrated. Some references state that the nurse should initially leave the infiltrated site in place, I only leave it in long enough to attempt to aspirate. Always follow your institutional policy.
Report the infiltrate. Did you know that complications from IV therapy are a leading cause of lawsuits against nurses? You will want to protect yourself (and your patient of course!) by taking all the appropriate steps according to institutional policy. Report to your doctor or advanced provider the name of the medication or fluid that infiltrated, as well as the signs and symptoms your patient is experiencing. Orders to expect from your provider might include application of warm or cold compresses to the site, elevating the extremity, or even local injection of an antidote to prevent tissue damage. When my provider is uncertain about the correct steps to take for a particular infiltrate, I check with my hospital pharmacist regarding their recommendation.
Educate your patient and/or family. I explain to my patient what occurred and why. I also inform them that I notified the provider and what the next steps are for treating the infiltrate. I instruct them that I expect the pain and swelling (if any) to begin to improve over the next few hours but to let me or their next nurse know if they have increased pain or any other concerning symptom at the IV site. Experiencing a complication while you are in the hospital, even something that might seem minor to a nurse, can cause a lot of anxiety to a patient. Keeping them fully informed is the right thing to do, and helps maintain trust and transparency.
Perform ordered interventions. I apply the warm or cool compress as directed by my provider. Pharmay Joe provides the rationale for choosing one over the other for particular medications known to cause tissue damage. Johns Hopkins has a chart for management of IV infiltrates of a number of medications, including whether recommendation is for warm or cold compress, and what type of antidote may be given.
Document, document, document. You will want to document the type of fluid or medication that infiltrated, as well as the signs and symptoms experienced by your patient. Document the name of the provider who was notified, as well as the interventions ordered. And of course you will document your patient's response to the interventions. Generally, IV infiltrates are reportable events, meaning that an incident report should be filed according to your hospital policy.
Continue to monitor! When possible, I mark the area of infiltrate with a marker so that the site can be monitored. Be sure to report the IV infiltrate to the oncoming nurse so they can continue to assess. If your patient is being discharged, instruct them on any continuing care measures, signs or symptoms they should watch out for, and who to contact for further complications.
Most of the time, IV infiltrates resolve without lasting complications, but there is potential for serious tissue damage or even limb amputation, so always be vigilant. Early recognition that an IV is no longer working properly is the most effective measure in preventing nasty infiltrates. When in doubt.... take it out!