IV Infiltrations and Extravasations: Causes, Signs, Side Effects, and Treatment

IV Infiltrations and Extravasations: Causes, Signs, Side Effects, and Treatment

Peripheral IVs are a common way of delivering IV fluids and medication. These IV’s are typically inserted into the hand or forearm. In small children they can also be seen in the foot or scalp. When receiving intravenous (IV) fluids or medications via a peripheral IV, it’s important to keep an eye out for common complications like IV infiltration or extravasation.

IV infiltrations and extravasations occur when fluid leaks out of the vein into surrounding soft tissue. Common signs include inflammation, tightness of the skin, and pain around the IV site.

IV infiltration is a common complication of intravenous (IV) therapy. According to current medical reports, about 50% of IVs fail, with over 20% of those failures due to infiltration or extravasation.1

Peripheral IVs are a common way of delivering IV fluids and medication. These IV’s are typically inserted into the hand or forearm. In small children they can also be seen in the foot or scalp. When receiving intravenous (IV) fluids or medications via a peripheral IV, it’s important to keep an eye out for common complications like IV infiltration or extravasation.

IV infiltrations and extravasations occur when fluid leaks out of the vein into surrounding soft tissue. Common signs include inflammation, tightness of the skin, and pain around the IV site.

IV infiltration is a common complication of intravenous (IV) therapy. According to current medical reports, about 50% of IVs fail, with over 20% of those failures due to infiltration or extravasation.1

Infiltration

Infiltration is the accidental leakage of non-vesicant solutions out of the vein into the surrounding tissue. This can occur with many antibiotics, dextrose solutions, or even normal saline.

When left unchecked and untreated, IV infiltration can result in pain, swelling, compartment syndrome, and even amputation of the affected limb.

Extravasation

When the leaked solution from an infiltration is a vesicant drug—one that causes tissue injury blisters or severe tissue damage—it is referred to as an extravasation.

Injuries from this type of IV failure can be severe and can lead to the loss of function in an extremity, and if the damage is severe enough, tissue death—known as necrosis.

According to the Infusion Nurses Society, the first step in reducing the risk of extravasation is to identify and recognize medications and solutions that are associated with tissue damage when the solution escapes from the vascular pathway.

Red List

Well-recognized vesicants with multiple citations and reports of tissue damage upon extravasation
Calcium chloride
Calcium gluconate
Contrast media – nonionic
Dextrose concentration ≥ 12.5%
Dobutamine
Dopamine
Epinephrine
Norepinephrine
Parenteral nutrition solutions exceeding 900 mOsm/L
Phenylephrine
Phenytoin
Promethazine
Sodium bicarbonate
Sodium chloride ≥ 3%
Vasopressin

Yellow List

Vesicants associated with fewer published reports of extravasation; published drug information and infusate characteristics indicate caution and potential for tissue damage
Acyclovir
Amiodarone
Arginine
Dextrose concentration ≥ 10% to 12.5%
Mannitol ≥ 20%
Nafcillin
Pentamidine
Pentobarbital sodium
Phenobarbital sodium
Potassium ≥ 60 mEq/L
Vancomycin hydrochloride

Causes

IV infiltrations and extravasations can be caused in a few different ways. The catheter can exit the vein by either backing out from the point of insertion or puncturing through the other side of the vein. Leakages are another cause of infiltration. Leakages can occur through the IV insertion site, through the opposing vein wall, or as a result of increased vein porosity.2 Each of these results in IV fluid leaking into the surrounding tissue and are not a result of a nurses “bad stick.”4

Catheter Punctures the Vein Wall

  • When the catheter pushes through the other side of the vein.
  • Can occur at time of insertion.
  • Result of patient movement or IV dislodgement.

Leakage from the Insertion Site

  • The medication or fluid escapes through the area where the catheter entered the vein.
  • Can occur when there is a clot or restriction to normal venous blood flow causing the fluid or medication to back up out of the insertion site.

Catheter Backs Out of Insertion Site

  • The catheter exits the vein completely.
  • Usually happens when the patient’s movements dislodge the IV catheter.

Vein Fragility

The structure of the vein can’t handle the infusion of the medication or fluid and “blows out.” This occurs most frequently in elderly patients.

Increased Vein Porosity

Usually due to inflammation, which widens the gaps between cells of the vein wall, allowing fluid to leak out.

Signs

Left untreated and unchecked, IV infiltration can lead to excessive fluid in one or more compartments of the arm, causing damage to nerves, arteries, and muscles. This typically requires surgery to prevent a permanent loss of function and possible amputation.

Some major signs of infiltration and extravasation include:

  • Swelling at or near the IV site. The skin will feel tight and cool to the touch.
  • Some patients experience intense pain or burning while others may just feel slight discomfort.
  • Skin discoloration
  • Numbness
  • Impaired blood circulation

The symptoms a patient experiences often depends on the severity and length of the infiltration.

Side Effects

When an IV fails or “goes bad”, there are a variety of complications and side effects that may set in depending on how the IV failed and how long it takes to discover and treat the issue. IV failures involving severe complications like extravasation, particularly from chemotherapy drugs, can leave permanent damage, including third-degree burns or necrosis.

Compartment Syndrome

Compartment syndrome is a painful and dangerous condition caused by pressure buildup from internal bleeding or swelling of tissues. Muscles in the patient’s hand, forearm, or lower leg are surrounded by tissue. These tissue bands create “compartments.” After infiltration, when too much fluid leaks into the tissue, a patient may experience compartment syndrome. Compartment syndrome may cause nerve, tissue or muscle damage. The condition often requires emergency surgery to decompress the affected area. Patients should expect more extensive rehabilitation and healing time.5

Skin Burns, Necrosis and Amputation

Serious burns may require a skin graft – a surgeon removes unburned skin on the patient and places it over the affected area. Wounds with necrotic, or dead, tissue cannot heal and must be removed to allow healthy tissue to grow in its place. While amputating the area may create a much larger wound, it is sometimes the only way to treat the complication.

Injuries and complications can usually be minimized or completely eliminated when patients and healthcare providers carefully monitor and care for the IV site. If you ever experience a complication as a result of IV therapy, be sure to notify a nurse or doctor immediately, so they can try to mitigate any lasting effects.

Permanent Nerve Damage

Nerve damage from IV insertion is relatively rare. It can be caused by puncturing the nerve with the needle when an IV is started, or from compartment syndrome. Another potential cause is infiltration – when the fluid leaks into the tissue around the vein. If an infiltration is severe enough, it can cause compartment syndrome and lead to nerve damage. While this is a less common complication, it can cause numbness, tingling, and even loss of function in the limb.

Medication dosing errors

Delivering drugs or fluids directly into the vein is a fast and effective way to administer medications to a patient. Infiltrations mean patients don’t receive the appropriate amount of medicine into their bloodstream making treatment less effective. For some patients, proper medication dosages are integral to optimal care, and improper dosages could worsen their condition.

Read Barby’s Anesthesia Awareness Story.

Treatment

If you think you are experiencing an infiltration or extravasation, tell the nurse or doctor immediately if you experience any pain, swelling, or tenderness.

Your clinician will likely do the following:

  • Stop the infusion
  • Remove the IV
  • Mark the outline affected area with a marker
  • Photograph the affected area
  • Apply a hot or cold compress based on the type of IV fluid infiltrated
  • Elevate the extremity
  • Inject medication into the subcutaneous tissue

Aftercare Management

  • Continue to use cold or hot compresses as directed by the clinician.
  • Rest and elevate the arm to reduce swelling and pain.
  • Protect the area from sunlight.
  • Check with the doctor about what hygiene products can be used on the area.
  • If you observe a fever and other signs of infection or if swelling or damage gets worse and pain increases, let the clinician know.

IV Infiltration Prevention

  • Be careful not to make any sudden movements during iv insertion and during iv therapy.
  • Stay hydrated before and throughout the duration of the IV therapy.
  • Make the doctor or nurse aware of any chronic conditions like diabetes or hypertension that may change the vein structure.
This article was reviewed by a team of clinicians for accuracy.
References

1Helm, R. E., Klausner, J.D., Klemperer, J.D., Flint, L.M., and Huang, E. (2015). “Accepted but Unacceptable: Peripheral IV Catheter Failure.” Journal of Infusion Nursing, 38(3), 189-203.
2An Ounce of Prevention – http://journals.lww.com/nursingmadeincrediblyeasy/Citation/2003/11000/Infiltration__An_ounce_of_prevention.10.aspx
3Gorski, L., Stranz, M., Cook, L., Joseph, J., Kokotis,K., Sabatino-Holmes,P. Van­Gosen, L. (2016) Development of an Evidence-Based List of Noncytotoxic Vesicant Medications and Solutions, Infusion Nurses Society.
4Does IV Infiltration/Extravasation Suggest Negligence? – http://alvinandassociateslnc.com/does-iv-infiltrationextravasation-suggest-negligence/
5National Institutes of Health. Compartment Syndrome. <http://www.nlm.nih.gov/medlineplus/ency/article/001224.htm>
IV Infiltration Aftercare Instructions – https://www.drugs.com/cg/iv-infiltration-aftercare-instructions.html
Complications of Peripheral IV Therapy – http://www.nursingcenter.com/ncblog/february-2015-(1)/complications-of-peripheral-i-v-therapy

Image Source: http://www.onlyanurse.com/nursingtopics/2015/12/5/looking-into-infiltration-and-extravasation