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IV Infiltration
IV Infiltration
essentials
Inltration:
An ounce of prevention
KELLI ROSENTHAL, RN,BC, APRN,BC, CRNI, MS President and Chief Executive Ofcer ResourceNurse.Com Oceanside, N.Y.
THINK BACK over your last week of work. How many of your acute care patients didnt have a peripheral intravenous (I.V.) line? Probably not many, right? Peripheral access is a convenient way to deliver a lot of drugs. But its also fraught with possibilities for complications at or near the infusion site, most commonly infiltration, extravasation, and phlebitis. Lets face it: Even with excellent technique, you cant eliminate every one of these complications in every one of your patients. But you can take an active role in minimizing the risks by understanding how these complications occur, choosing the right veins and equipment, and closely monitoring the patient. In this rst part of a two-part series on the complications of I.V. therapy, Ill discuss inltration and extravasation. In part two, Ill cover phlebitis.
By the book
The textbook denition of inltration, courtesy of the Infusion Nurses Society (INS), is the inadvertent administration of nonvesicant medication or uid into the surrounding tissue instead of into the intended vascular pathway. Extravasation, the INS says, is the inadvertent administration of vesicant medication or uid into the surrounding tissue instead of into the intended vascular pathway. The INS denes a vesicant as an agent capable of causing injury when it escapes from the intended vascular pathway into the surrounding tissue.
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Whats all this mean to you? Simply put: Inltration and extravasation occur when the infusion cannula is no longer fully positioned in the vein. Why does it happen? There are several possibilities: improper insertion into the vein damage to the vein lining that causes it to swell and prevents forward ow of the infusate presence or formation of a clot within the vein or around the cannula cannula punctures (most likely to happen with metal scalp vein or buttery needles) or erosion through the veins opposite wall improper securement or patient movement, which simply causes catheter dislodgment.
time (not to mention increase supply costs). Serious tissue damage is unlikely, though. But you arent out of the woods yet: Major problems are lurking out there, in the form of large amounts of inltration or extravasation of solutions containing calcium, potassium, antibiotics, vasopressors, or chemotherapeutic agents, many of which are infamous for causing tissue damage. The extent of injury generally relates to how much uid or medication leaked into the tissue and when you initiated appropriate interventions. Your keen eye can make all the difference. Detecting inltration or extravasation early on may prevent nerve damage and tissue sloughing, which could require surgery. On the other hand, failing to promptly detect these complications can leave the patient with permanent disgurement and loss of function despite reconstructive surgery.
Grading inltrations
Grade 0 1 Clinical criteria No symptoms Skin blanched Edema <1 inch (2.5 cm) in any direction Cool to touch With or without pain Skin blanched Edema 1 to 6 inches (2.5 to 15 cm) in any direction Cool to touch With or without pain Skin blanched, translucent Gross edema >6 inches (15 cm) in any direction Cool to touch Mild to moderate pain Possible numbness Skin blanched, translucent Skin tight, leaking Skin discolored, bruised, swollen Gross edema >6 inches in any direction Deep pitting tissue edema Circulatory impairment Moderate to severe pain Inltration of any amount of blood product, irritant, or vesicant
Extravasation can cause tissue loss that may evolve into extensive wounds, as shown in this I.V. site 24 hours after inltration of calcium chloride.
smooth and resilient, not hard or cordlike. Avoid areas of exion; the catheter could too easily become dislodged. If a site near an area of exion is all thats available, though, you may need to use an armboard to keep it stable. Dont use hand veins if the patient needs to use his hands. The veins of the forearm above the wrist, especially on the inner aspect, usually provide better stability for anchoring the catheter. The bones of the forearm act as a
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i.v. essentials
natural splint to support the area. Avoid the antecubital fossa, though, because it contains the brachial artery and median nerve, among other important structures. Whats more, its tough to detect inltration in this area until the inltration becomes quite large. By then, the inltrated uid could compress these structures, resulting in nerve damage or tissue necrosis. With peripheral I.V. therapy, smaller is better. To maximize hemodilution of the medication, choose the smallest possible cannula that will safely deliver the infusion. That way, blood will return to the heart with minimal impedance from the catheter, diluting the infusate and carrying it away from the insertion site. Always insert the cannula bevel up to reduce the risk of puncturing the veins opposite wall. More clues to inltration: Age alert! a gravity infusion With kids and older slows or stops patients, assess you dont see a the I.V. site every blood return after hour, regardless of the type of uid lowering the infuinfusing. sion bag and applying pressure with your nger on the vein proximal to the cannula tip you notice uid leaking from under the dressing applying a tourniquet doesnt stop the infusion.