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An ounce of prevention
KELLI ROSENTHAL, RN,BC, APRN,BC, CRNI, MS President and Chief Executive Ofcer ResourceNurse.Com Oceanside, N.Y.

Beware of I.V. bags bearing vesicants.

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.

Problems big and small

In most cases, I.V. inltration will be a minor problem. Your patient will be in some discomfort, and stopping to reinsert the I.V. cannula elsewhere will eat up your

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

Youre the solution

So now that you know about the problem, lets talk about how you can be the solution. Preventing inltration starts with choosing the right vein for the job. Select veins that feel

Source: Infusion Nurses Society Inltration Scale

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.

I can see clearly nowwith a transparent dressing.

Take action, stat!

What should you do if you discover that, despite your best efforts, an I.V. solution has inltrated? Stop the infusion immediately and thoroughly examine the site. Does the catheter appear lodged in the tissue? If so, try to aspirate any uid remaining in the catheter to lessen the amount of drug at the site. In some cases, you can infuse an antidote for a vesicant or irritant medication into the I.V. catheter before removing it. Check your institutions policy and procedure on handling inltration and extravasation. After removing the cannula, elevate the affected arm, notify the patients health care provider, and apply cool compresses. (Use warm compresses if Vinca alkaloids are involved.) Finally, follow your hospitals policy for documentation, which should incorporate the INSs Inltration Scale (see Grading Inltrations).

Check and recheck

Keep an eye on the site throughout your shift. How often should you check on the patient? If hes receiving a continuous infusion of a vesicant or irritant solution, check the infusion site at least every hour. The same goes for pediatric or geriatric patients, regardless of the solution being infused. Assess the site a minimum of every four hours for patients receiving continuous infusions of nonirritating uids. Of course, you cant assess the site if you cant see it. So cover the I.V. cannula with a clear, moisturevapor transmissible dressing (also known as a transparent dressing). This way, you wont have to manipulate the site unnecessarily to see whats going on. Palpate for tenderness or coolness around the site. They indicate that uid is leaking into the surrounding tissue. If the catheter is correctly positioned, the patient wont feel pain and the skin will be warm. Pick up the patients arm to check for dependent edema. Using a transilluminator or penlight, inspect the skin. A large, diffuse circle of light around the I.V. site means that subcutaneous uid is present. If the patient isnt edematous for another reason, this probably means that the solution has inltrated.
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Learn more about it

Infusion Nurses Society: Infusion Nursing Standards of Practice, Journal of Intravenous Nursing. 23(6S):556-58, 583-85, November/December 2000. Khan, M., and Holmes, J.: Reducing the Morbidity from Extravasation Injuries, Annals of Plastic Surgery. 48(6): 628-632, June 2002. OGrady, N., et al.: Guidelines for the Prevention of Intravascular Catheter-Related Bloodstream Infections, Morbidity and Mortality Weekly Report. 51(RR-10):1-29, August 9, 2002. Reynolds, C.: Extravasation Management, available at http://www.musc.edu/pedres/Pharmacy/extravasation_ management_revised.htm, accessed May 23, 2003. Weinstein, S.: Plumers Principles and Practices of Intravenous Therapy, 7th edition. Philadelphia, Pa., Lippincott Williams & Wilkins, 2000.