INTRAVENOUS THERAPY

COMPLICATIONS
Gomer P. Ponso, RN
UC-CON Faculty
 IVT COMPLICATIONS
1. LOCAL COMPLICATIONS
2. SYSTEMIC COMPLICATIONS
 LOCAL COMPLICATIONS
of INTRAVENOUS THERAPY
1. Infiltration
2. Extravasation
3. Phlebitis
4. Thrombosis
5. Thrombophlebitis
6. Ecchymosis and Hematoma
7. Site infection
8. Venous spasm
9. Nerve damage
 INFILTRATION
• Leakage of a non-vesicant IV solution or
medication into the extravascular tissue
• The escape of fluid into the subcutaneous
tissue
 INFILTRATION
CAUSE:
• Peripheral catheter has puncture opposite vein wall
• Obstruction of blood flow causing backflow through
original entrance site
• Inflammatory process causing fluid leakage at the
capillary level
• Fibrin sheath fully encasing a venous catheter leading to
retrograde flow and leakage from venipuncture site
• Damage septum of implanted port
• Dislodge port access needle
 INFILTRATION
SIGNS and SYMPTOMS:
• Increasing edema around site
• Patient report of:
– skin tightness;
– blanching or coolness of skin;
– burning, tenderness, or general discomfort at the
insertion site;
– fluid leaking from puncture site;
– absence of a blood return (though this may not be
reliable with a short peripheral catheter)
 INFILTRATION
TREATMENT:
• Stop infusion and remove short peripheral catheter
immediately after identification of problem
• Apply sterile dressing if weeping from tissue occurs
• Elevate extremity
• Warm or cold compress may be used according to the
solution infiltrated and organizational policy. Warm
compress increase circulation to the area and speeding
healing. Cool compress may be used to relieve
discomfort and reduce swelling
 INFILTRATION
TREATMENT:
• Insert new catheter in the opposite extremity
• For all central venous catheters, obtain a study
to determine the cause of the problem
• For implanted port, remove and insert a new
port access needle
• Rate the infiltration using the INS infiltration
Scale and document
INFILTRATION
 INFILTRATION
PREVENTION:
• Catheter stabilization
– Use smallest catheter appropriate
– Avoid area of flexion or use arm board
• Avoid placing restraints at the IV site
• Make successive venipunctures proximal to the
previous site
• Monitor site frequently; educate patient about
activities and signs and symptoms
 INFILTRATION
PREVENTION:
• Central venous catheters
– Obtain a brisk blood return before using the
catheter for infusion
• Frequently assess proper positioning of port
access needle. Stabilize it well, and protect
from clothing
INFILTRATION
 EXTRAVASATION
• Leakage of a vesicant IV solution or
medication into the extravascular tissue
• This can occur with both peripheral and
central catheters
• The inadvertent administration of a vesicant
substance into the tissue surrounding the vein
• CAUSE:
– Same with infiltration
 EXTRAVASATION
SIGNS and SYMPTOMS:
• Same as for infiltration
• Blistering and tissue sloughing may not appear
for a few days and resolves over 1-4 weeks
with infiltration of some chemotherapeutic
agents such as anthracycline and alkylating
agents
 EXTRAVASATION
TREATMENT:
• Stop infusion, and disconnect administration set
• Aspirate drug from short peripheral catheter or port
access needle
• Leave short peripheral catheter or port access needle in
place to deliver antidote, if indicated by established
policy
• If possible, aspirate residual drug from the exit site of a
central venous catheter
• Administer antidote according to established policy
 EXTRAVASATION
TREATMENT:
• Apply cold compress for all drugs EXCEPT vinca
alkaloids and epipodophyllotoxins
• Photograph site
• Monitor at 24hr, 1 wk, 2 wk, and as needed
• Surgical interventions may be required
• Provide written instructions to patients and
family
 EXTRAVASATION
PREVENTION:
• Same as for infiltration
• Know the vesicant potential before giving any
IV medication
• Prevention is the key
EXTRAVASATION
 PHLEBITIS
• Inflammation of the vein
• Post-infusion phlebitis presents within 48-96hr
after the catheter has been removed
• Mechanical trauma from needle or catheter
• Chemical trauma from solution
• Septic (contamination)
 PHLEBITIS
CAUSE:
• Mechanical cause from insertion technique,
catheter size, and lack of catheter securement
• Chemical cause from extremes of pH and/or
osmolarity of the fluid or medication
• Bacterial cause from a break in aseptic
technique, poor securement, and extended
dwell time
 PHLEBITIS
SIGNS and SYMPTOMS:
• Patient may:
– Report pain at the IV site;
– Nurse may observe that vein appears red and
inflamed along the length
– Vein may become hard and cordlike
PHLEBITIS
 PHLEBITIS
TREATMENT:
• Remove short peripheral catheter at the first sign of phlebitis;
use warm compresses to relieve pain
• Monitor frequently
• Document using Phlebitis Scale
• Insert a new catheter using the opposite extremity
• Mechanical phlebitis occurring in the first week after PICC
insertion may be treated without catheter removal. Apply
continuous heat; rest and elevate the extremity. Significant
improvement is seen in 24hr, and complete resolution is seen
within 72hr. Remove catheter if treatment is unsuccessful.
 PHLEBITIS
PREVENTION:
• Choose the smallest-gauge catheter for the required
therapy
• Avoid sites of joint flexion, or stabilize with an arm
board
• Avoid infusing fluids or medications with a pH below 5
or above 9 through a peripheral vein
• Avoid infusing fluids or medications with a final
osmolarity above 500mOsm/L through a peripheral
vein
 PHLEBITIS
PREVENTION:
• Rotate sites every 72-96hr according to
established policy
• Adequately secure the catheter
• Use aseptic technique
• For PICCs, teach patient to avoid excessive
physical activity with the extremity
PHLEBITIS
PHLEBITIS
PHLEBITIS
 THROMBOSIS
• Blood clot inside the vein
 THROMBOSIS
CAUSE:
• Anything that damage the endothelial lining of
the intima can initiate clot formation
• Traumatic venipuncture
• Multiple venipuncture attempts
• Use of catheters too large for the chosen vein
• Hyper-coagulable state and venous stasis
 THROMBOSIS
SIGNS and SYMPTOMS:
• Slowed or stopped infusion rate
• Swollen extremity
• Tenderness and redness
• Engorged peripheral veins of the ipsilateral
chest and extremity
 THROMBOSIS
TREATMENT:
• Stop infusion and remove short peripheral catheter
immediately
• Apply cold compresses to decrease blood flow and
stabilize the clot
• Elevate extremity
• Surgical interventions may be required
• For central venous catheter, notify the physician and
obtain request for a diagnostic study. Low dose
thrombolytic agents can be used to lyse the clot
 THROMBOSIS
PREVENTION:
• Use evidence-based venipuncture technique
• Make only two attempts to perform
venipuncture
• Choose the smallest-gauge catheter in the
largest vein possible
• Secure catheter adequately
 THROMBOSIS
PREVENTION:
• Use arm boards of short peripheral catheters
are placed in areas of joint flexion
• Ensure adequate hydration to avoid changes in
blood composition and flexion of the extremity
• Prophylactic low dose warfarin maybe
prescribed for patients with a central venous
catheter
THROMBOSIS
 THROMBOPHLEBITIS
• The presence of blood clot and vein
inflammation
CAUSE:
• Same as for phlebitis and thrombosis
SIGNS and SYMPTOMS:
• Same as for phlebitis and thrombosis
 THROMBOPHLEBITIS
TREATMENT:
• Same as for phlebitis and thrombosis
• Apply cold compress initially, followed by
warm
PREVENTION:
• Same as for phlebitis and thrombosis
THROMBOPHLEBITIS
 ECCHYMOSIS and
HEMATOMA
• Ecchymosis results from infiltration of blood
into the surrounding tissue.
• Hematoma results from uncontrolled bleeding
 ECCHYMOSIS and
HEMATOMA
CAUSE:
• Unskilled or multiple IV insertion attempts
• Patients with coagulopathy or fragile veins
(e.g. older adults and patients on steroids)
• Accidental laceration of a large vein or artery
 ECCHYMOSIS and
HEMATOMA
SIGNS and SYMPTOMS:
• Swelling
• Bruising
• Pain or tenderness
 ECCHYMOSIS and
HEMATOMA
TREATMENT:
• When removing device, apply light pressure;
excessive pressure could cause other fragile
veins in the area to rupture
• For hematoma:
– apply direct pressure until bleeding has stopped
– Elevate extremity
– Apply ice for first 24hrs and then warm compress
for comfort
 ECCHYMOSIS and
HEMATOMA
PREVENTION:
• Avoid veins that cannot be easily seen or
palpated
• Use extra caution in patients with
coagulopathies
• Use evidence-based venipuncture technique
HEMATOMA
ECCHYMOSIS
 SITE INFECTION
• Invasion of microorganisms at the insertion
site in the absence of simultaneous
bloodstream infection.
• Infection localized at the insertion site, the
port pocket, or subcutaneous tunnel
 SITE INFECTION
CAUSE:
• Break in aseptic technique during insertion or
handling of sterile equipment
• Lack of proper hand hygiene and skin
antisepsis
 SITE INFECTION
SIGNS and SYMPTOMS:
• Site appears red, swollen, and warm
• Patient may report tenderness at the site
• May observe purulent or malodorous
exudates
 SITE INFECTION
TREATMENT:
• Clean exit site with alcohol, expressing
drainage if present
• For short peripheral catheter, midline catheter,
or PICC, remove using sterile technique and
avoid contact between skin and catheter
 SITE INFECTION
TREATMENT:
• Send catheter tip for culture, if requested
• Clean site with alcohol, and cover with dry
sterile dressing; physician to evaluate for
septic phlebitis and need for antimicrobial
therapy or surgical intervention
 SITE INFECTION
PREVENTION:
• Use strict aseptic technique when inserting,
maintaining, or removing catheters
• Practice evidence-based hand hygiene
• Ensure dressing remains clean, dry, and
adherent to skin at all times
SITE INFECTION
 VENOUS SPASM
• A sudden contraction of vein
 VENOUS SPASM
CAUSE:
• A normal response to irritation or injury of the
vein wall
SIGNS and SYMPTOMS:
• Cramping or pain at or above the insertion site
• Numbness in the area
• Slowing of the infusion rate
• Inability to withdraw midline catheter or PICC
 VENOUS SPASM
TREATMENT:
• Temporarily slow infusion rate
• Apply warm compress
• Do not immediately remove short peripheral catheter
• If occurring during midline catheter or PICC removal, do
not apply tension or attempt forceful removal
• Reapply a dressing, apply heat, encourage patient to
drink warm liquids, and keep extremity covered and dry
12-24hr may required before catheter can be removed
 NERVE DAMAGE
• Inadvertent piercing or complete transection
of a nerve
 NERVE DAMAGE
CAUSE:
• Venipuncture near known nerve locations
• Unanticipated nerve locations
SIGNS and SYMPTOMS:
• Reports of tingling or feeling “pins and
needles” at or below the insertion site
• Numbness at or near the insertion site
 NERVE DAMAGE
TREATMENT:
• Immediately stop the insertion procedure if
the patient reports extreme pain
• Remove the catheter if reports of discomfort
do not improve when the catheter is secured
 NERVE DAMAGE
PREVENTION:
• Avoid using the cephalic vein near the wrist
• Avoid using veins on the palm side of the wrist
• Adequately secure the catheter, but avoid
tape that is too tight
• Support areas of joint flexion with an arm
board
 SYSTEMIC COMPLICATIONS
of INTRAVENOUS THERAPY
1. Circulatory Overload
2. Speed Shock
3. Catheter Embolism
4. Air Embolism
 CIRCULATORY OVERLOAD
• Disruption of fluid homeostasis with excess
fluid in the circulatory system
 CIRCULATORY OVERLOAD
CAUSE:
• Infusion of fluids at a rate greater than the
patient’s system can accommodate
SIGNS and SYMPTOMS:
• Patient may report shortness of breath and cough
• Patients BP is elevated and there is puffiness
around the eyes and edema in dependent areas
• Patients neck veins may engorged, and nurse may
hear moist breath sounds
 CIRCULATORY OVERLOAD
TREATMENT:
• Slow the IV rate, and notify physician
• Raise patient to an upright position
• Monitor v/s and administer oxygen as
prescribed
• Administer diuretics as prescribed
 CIRCULATORY OVERLOAD
PREVENTION:
• Monitor I&O carefully, and notify physician as
soon as an imbalance is noticed between the
patient’s I&O
 SPEED SHOCK
• Systemic reaction to the rapid infusion of a
substance unfamiliar to the patient’s
circulatory system
 SPEED SHOCK
CAUSE:
• Rapid infusion of drugs or bolus infusion, which causes
the drug to reach toxic level quickly
SIGNS and SYMPTOMS:
• Patient may report lightheadedness or dizziness and
chest tightness
• Nurse may note that patient has a flushed face and an
irregular pulse
• Without intervention, patient may lose consciousness
and go into shock and cardiac arrest
 SPEED SHOCK
TREATMENT:
• Immediately discontinue the drug infusion and
hang isotonic solution to keep the veins open
• Monitor v/s carefully, and notify physician for
further treatments
 SPEED SHOCK
PREVENTION:
• Be aware of the appropriate infusion rate of
medications and adhere to them
• Use of infusion control devices assists in
prevention of speed shock
 CATHETER EMBOLISM
• A shaving or piece of catheter breaks off and
floats freely in the vessel
 CATHETER EMBOLISM
CAUSE:
• Anything that damage the catheter:
– During insertion
– Drainage change
– Excessive force with flushing or medication
administration
 CATHETER EMBOLISM
SIGNS and SYMPTOMS:
• Depending on where the catheter embolizes,
this could be life threatening
• Cardiopulmonary arrest could occur
 CATHETER EMBOLISM
TREATMENT:
• Emergently notify the physician.
• Remove the catheter, and apply a tourniquet high
on the limb of the catheter site
• Inspect catheter to determine how may have
embolized
• An x-ray is taken to determine the presence of any
catheter piece
• Surgical intervention may be necessary
 CATHETER EMBOLISM
PREVENTION:
• When inserting over-the-needle catheters,
never reinsert the needle into the catheter
• Avoid pulling a through-the-needle catheter
back through the needle during insertion
• Avoid scissors near the catheter with dressing
changes
 AIR EMBOLISM
• Air in the circulatory system break in the IV
system allowing air in the circulatory system as
a bolus
 AIR EMBOLISM
SIGNS and SYMPTOMS:
• Respiratory distress
• Increase HR
• Chest pain
• Cyanosis
• Decreased BP
• Change in LOC
• Shock
 AIR EMBOLISM
TREATMENT:
• Pinch off catheter or secure system to prevent
entry of air
• Place client on left side in Trendelenburg
position to rap air in right atrium
• Inform physician
• Monitor v/s and pulse oximetry
• Administer oxygen
THANK YOU ALL FOR LISTENING!

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