IV Therapy: Infiltration vs Extravasation with Case Studies

What is Extravasation, Infiltration, and Phlebitis?

Infiltration vs Extravasation : Extravasation, Infiltration, and Phlebitis are most common local complications of the peripheral intravenous (IV) therapy. There are similarities and significant differences between each of those conditions.

According to the research evidence, 58.7% to 86.7% of patients have a peripheral venous catheter (PVC) inserted during their hospitalization. Generally, nurses are responsible for insertion, management, and care of PVCs of hospitalized patients.

Therefore, as nurses, we should be familiar with similarities and differences of extravasation, infiltration, and phlebitis. Because it will help us to take appropriate nursing interventions earlier in case of such complications.

Definition: IV fluid or medication leaks into surrounding tissue due to:

1. Catheter malfunction
2. Vein damage
3. Inadequate cannulation

Difficult Cannulation

Difficult intravenous access (DIVA), or difficult peripheral intravenous cannulation (DPIVC), describes a situation wherein a practitioner is having difficulty gaining peripheral vascular access, often because the patient’s veins cannot easily be seen or felt. It is generally defined as:

• Two or more failed cannulations, and/or
• Needing to use advanced or rescue techniques to gain peripheral vascular access.

Calculating a DIVA Score for Paediatrics

The difficult intravenous access (DIVA) score can be used to predict the likelihood of failing an initial cannulation in pediatric patients (Shaukat et al. 2019).

This is an important tool, as multiple attempts at cannulation may cause distress and pain to children (RCHM 2019).

If the patient scores four or more points in total, the initial cannulation has a greater than 50% chance of failing (RCHM 2019).

(Adapted from RCHM 2019)

Difficult Cannulation Guidelines

What Causes Infiltration and Extravasation?

When healthcare professionals administer a drug through IV therapy, there is a risk of the solution leaking out of the veins and into surrounding tissue.

IV Infiltration can be caused by the following factors:

• The IV pierces a vein.
• The IV catheter is the wrong size or is improperly secured.
• The IV catheter is improperly placed or becomes dislodged.

IV Extravasation can be caused by the following factors:

• The IV catheter is improperly placed or becomes dislodged.
• The IV catheter is the wrong size or is improperly secured.
• The drug is administered too quickly.
• The medication is very acidic or basic.
• There is an obstruction in the IV line.

Both infiltration and extravasation can interrupt treatment and impact patient health if excessive fluid pools around the tissue. The health complications associated with PIVIEs span a broad spectrum, from minor irritations to severe consequences, including:

• Minor Irritations: Patients may experience irritation and discomfort at the IV site. This is often dismissed but should not be overlooked as these irritations can escalate into more serious issues.
• Skin and Soft Tissue Damage: More severe complications can include permanent loss of skin and soft tissue, which prolongs recovery and may require surgical intervention.
• Impaired Limb Functionality: In some instances, the affected limb may suffer from functional impairment, affecting the patient’s mobility and quality of life.
• Compartment Syndrome: This is a severe and painful condition caused by pressure buildup from internal bleeding or swelling of tissues. It requires immediate medical attention.
• Distal Vascular Compromise: This involves obstructing blood flow to the extremities, which can lead to tissue necrosis if not promptly addressed.
• Loss of Extremities: In the most extreme cases, the complications can escalate to losing fingers or other parts of a limb, resulting in lifelong challenges for the patient.

Vascular Access Device Decision (VADD) Tool

Maintenance

1. Change IV tubing every 24-48 hours.
2. Change IV dressing every 7 days or PRN.
3. Monitor IV site for signs of infiltration or extravasation.
4. Document IV site assessment.
5. Rotate IV sites every 7-10 days.

Complication Prevention

1. Use pressure-reducing devices for high-pressure infusions.
2. Monitor electrolyte levels.
3. Avoid overlapping or concurrent infusions.
4. Use infusion pumps for precise flow control.
5. Regularly inspect IV equipment.

Extravasation and infiltrations staging

Nursing interventions and management of Extravasation

• Stop infusion immediately
• Aspirate for infused medication with a small syringe before removal
• Notify the prescriber and implement extravasation protocol as per advice
• Elevate the extremity
• Obtain new vascular access from the opposite side
• Perform frequent assessments of sensation, motor function, and circulation of the affected extremity
• Administer the appropriate antidote according to the facility’s protocol. For example:
  • Sodium thiosulfate for alkylating agents
  • Dexrazoxane for anthracyclines
  • Hyaluronidase for plant alkaloids
  • Phentolamine for vasopressors (e.g., dopamine, epinephrine, metaraminol)
• Apply thermal therapy – warm and cold compression for extraversion depends on the type of vesicant. For example:
  • Cold compression is recommended for alkylating agents, anthracyclines, antitumor antibodies, and taxanes.
  • Heat is recommended for plant alkaloids, vasoconstricting agents (e.g. dopamine, dobutamine, epinephrine)
• Observe site for signs and symptoms of compartment syndrome, nerve injury, blisters, skin sloughing, tissue necrosis, and functional and sensory loss
• Monitor the site at 24hr, 1 week, 2 week, and as needed. Also, INS suggests taking pictures of the site during these assessments.
• For all central venous catheters, obtain a study to identify the cause of the problem
• Rate the extravasation site using a standardized grading scale (eg: INS Infiltration Scale) and document the incident

Prevention of Extravasation

Preventive measures for extraversion include:

• Use smallest size catheter to give the infusion
• Consider and collaborate with doctor for CVAD to administer drugs and infusion with a pH less than 5 or greater than 9, or osmolarity greater than 600 mOsm/L, or final dextrose concentration greater than 10%
• Avoid inserting IV catheters near joint flexion and the lower extremities
• Avoid veins in the digits, hands, and wrist because of the close network of tendons and nerves
• Avoid re-cannulation close to previous sites
• Proper stabilize catheter to prevent movement at the insertion site
• Ensure adequate patency of VAD before starting the infusion
• Instruct patient to immediately report any pain, burning, or swelling with infusion administration
• Strictly adhere to proper administration techniques

Nursing intervention and management of Infiltration

• Stop the infusion immediately
• Aspirate fluid from catheter with a small syringe and remove catheter
• Apply sterile dressing if there is oozing from site
• Apply thermal therapy according to facility’s protocol
  • Warm compress helps to increase circulation to the area and speed up the healing process
  • Cold compress may be used reduce swelling and discomfort
• Elevate the extremity
• Obtain a new IV access in the opposite extremity
• Rate the infiltration using standardized grading scale (eg: INS Infiltration Scale) and document the incident

Prevention of Infiltration

• Select appropriate size catheter and vein.
• Avoid areas of flexion, veins in extremities with preexisting edema, or veins in areas with known neurologic impairment.
• Monitor the I.V. site frequently for any sign or symptoms.
• Ensure competency of venipuncture skill and techniques
• Strictly adhere to proper administration techniques.

IV Infiltration and Extravasation Case Studies:

Case Study 1: Infiltration

Patient: 45-year-old female with diabetes
IV Therapy: Peripheral IV with insulin and fluids
Symptoms: Swelling, redness, and pain at IV site
Assessment: Infiltration due to catheter malfunction
Treatment: Stopped infusion, elevated affected limb, applied warmth, administered pain relief
Outcome: Resolved with minimal tissue damage

Case Study 2: Extravasation

Patient: 30-year-old male with cancer
IV Therapy: Central line with chemotherapy
Symptoms: Severe pain, swelling, and blistering at IV site
Assessment: Extravasation of vesicant medication
Treatment: Stopped infusion, consulted oncologist, administered antidote, provided wound care
Outcome: Required surgical debridement and skin grafting

Case Study 3: Pediatric Infiltration

Patient: 6-year-old female with dehydration
IV Therapy: Peripheral IV with fluids and electrolytes
Symptoms: Swelling and pain at IV site
Assessment: Infiltration due to inadequate cannulation
Treatment: Stopped infusion, elevated affected limb, applied warmth, administered pain relief
Outcome: Resolved with minimal tissue damage

Case Study 4: Elderly Extravasation

Patient: 85-year-old male with pneumonia
IV Therapy: Peripheral IV with antibiotics
Symptoms: Severe pain, swelling, and blistering at IV site
Assessment: Extravasation of antibiotic
Treatment: Stopped infusion, consulted specialist, administered antidote, provided wound care
Outcome: Required hospitalization for wound management

Critical Care IV Therapy Considerations:

1. Fluid management:
   • Crystalloids vs. colloids
   • Fluid overload prevention
2. Vasopressor management:
   • Titration and weaning
   • Monitoring for complications
3. Antibiotic stewardship:
   • Appropriate selection and dosing
   • Monitoring for efficacy and toxicity
4. Electrolyte management:
   • Potassium, magnesium, and calcium supplementation
   • Monitoring for imbalances
5. Pain management:
   • Multimodal analgesia
   • Monitoring for efficacy and side effects

IV Therapy in Specific Critical Care Scenarios:

1. Sepsis:
   • Early goal-directed therapy
   • Fluid resuscitation and vasopressor support
2. Cardiac arrest:
   • Medication administration (e.g., epinephrine)
   • Fluid management
3. Trauma:
   • Fluid resuscitation
   • Blood transfusion management
4. Neurocritical care:
   • Osmotherapy (e.g., mannitol)
   • Medication management (e.g., sedatives)

REFERENCES:

1. Dougherty L. IV therapy: recognizing the differences between infiltration and extravasation. Br J Nurs. 2008 Jul 24-Aug 13;17(14):896, 898-901. doi: 10.12968/bjon.2008.17.14.30656. PMID: 18935841.
2. Alexander L Extravasation injuries: a trivial injury often overlooked with disastrous consequences. World J Plast Surg. 2020; 9:(3)326-330 https://doi.org/10.29252/wjps.9.3.326
3. Atay S, Üzen Cura Ş, Efil S Nurses’ knowledge and experience related to short peripheral venous catheter extravasation. J Vasc Access. 2023; 24:(4)848-853 https://doi.org/10.1177/11297298211045589
4. Bahl A, Johnson S, Alsbrooks K, Mares A, Gala S, Hoerauf K Defining difficult intravenous access (DIVA): A systematic review. J Vasc Access. 2021; 24:(5)
5. Cutuli SL, Dell’Anna AM, Carelli S, Annetta MG, Antonelli M Catheter-related thrombosis in critically ill patients: a clinical problem or just a matter of definition?. Intensive Care Med. 2023; 49:(7)878-879 https://doi.org/10.1007/s00134-023-07076-x
6. David V, Christou N, Etienne P, Almeida M, Roux A, Taibi A, Mathonnet M Extravasation of noncytotoxic drugs. Ann Pharmacother. 2020; 54:(8)804-814 https://doi.org/10.1177/1060028020903406
7. Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/

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