• Background and Epidemiology
• Risk Factors for Infiltration and Extravasation
• Strategies for Prevention
• Early Recognition of Infiltration and Extravasation
• Grading Severity and Clinical Decision Making
• Managing Infiltrations and Extravasations
• Specific IV Therapies at Higher Risk
• Special Considerations for Vitamin Infusions

Intravenous (IV) therapy involves the infusion of medications, fluids or nutrition directly into a patient’s vein. It allows for the rapid and predictable delivery of therapies. Peripheral IV catheters, placed in the arms, hands or other extremities comprise the majority of IV access. With over 90% of hospitalizedpatients receiving IV therapy, peripheral IVs account for hundreds of millions of catheter placements per year in the United States alone.

However, peripheral IVtherapy does carry risks, with infiltration and extravasation among the most common complications. Infiltration refers to the unintended leakage of IV fluid into the surrounding interstitial tissue while the catheter remains in the vein. Extravasation is the leakage of IV fluid into the tissue after the catheter dislodges from the vein. While infiltration is more common, extravasation poses a greater risk of severe tissue injury, particularly when irritant, vesicant, or hyperosmolar fluids are being infused. Prevention and early detection of these events are paramount.

In this comprehensive article, I will review infiltration and extravasation in detail, including risk factors, prevention strategies, early detection, and management recommendations. I will also discuss special considerations that are important when administering specific IVtherapies like vitamin drips. By understanding best practices around IV infiltration and extravasation, healthcare providers can significantly reduce the risk of these complications. Excellent IVtherapy technique ultimately translates into improvedpatient safety and outcomes.

Background and Epidemiology

Infiltration and extravasation occur when IV fluid exits the vein lumen and leaks into the surrounding interstitial tissues. This can happen for a variety of reasons:

• Dislodgement or migration of the catheter out of the vein
• Rupture or blowout of the vein wall
• Backflow of fluid out of the catheter tip
• Excessive mobility or manipulation of the IV site

While infiltration suggests the catheter tip remains inside the vein, extravasation indicates it has become completely dislodged. Infiltration typically precedes extravasation, but both have similar consequences of fluid leaking into tissues where it does not belong.

The reported incidence of infiltration and extravasation varies widely based on definition, patient population, catheter site, and IV therapy. Overall, studies suggest:

• Up to 70% of peripheral IVs exhibit some degree of infiltration
• Extravasation occurs in 0.1-6% of peripheral IV starts
• Extravasation rates up to 25% in neonatal ICU patients
• 1% up to 55% of infiltrations progress to extravasations
• Half result in no visible skin damage; half cause detectable skin changes

Though infiltration happens more frequently, extravasation tends to result in greater tissue injury.Risk depends greatly on the typeof infusate. Vesicants like chemotherapy can cause severe necrosis. Irritants result in inflammatory changes, while hypertonic fluids draw fluid shifting chemically. Medications like IV contrast dye or calcium chloride carry high risks if they extravasate. Others like isotonic saline or lactated ringers are relatively innocuous.

Beyond the type of fluid, risks depend on flow rate, volume extravasated, site, duration, and patient factors. Infants and elderly demonstrate higher rates of complications compared to other groups. In summary, while most infiltrations and extravasations do not lead to major patient harm, clinicians must remain vigilant about IVtherapy risksgiven the potential for severe tissue necrosis and injury in some cases.

Risk Factors for Infiltration and Extravasation

Many factors relating to the patient, IV catheter, medication, and clinical technique can increase risk for IV infiltration or extravasation events. Identifying and mitigating modifiable risk factors are key prevention strategies.

Patient-Related Risk Factors

• Pediatric or infant patients
• Geriatric patients, especially those with fragile veins
• Obese patients with difficult venous access
• Critically ill or injured patients with compromised circulation
• Patients requiring resuscitation with volume expanders
• Patients with chronic diseases causing edema or vascular insufficiency
• Agitated, confused, or combative patients
• Communication barriers limiting ability to report symptoms

Catheter-Related Risk Factors

• Small gauge catheters (higher risk of dislodgement)
• Catheters placed in joints, hands, feet (more mobility)
• Multiple punctures or traumatic insertion
• Poor catheter securement allowing dislodgement
• Prolonged catheter dwell time
• Using arm on same side as catheter (as with right-handed patients)

Medication-Related Risk Factors

• Vesicants such as chemotherapy drugs, inotropes, or calcium solutions
• Irritants and concentrated dextrose or electrolyte solutions
• Solutions with higher osmolality or extremes of pH
• Large volume infusions or high infusion rates
• IV push medicationsor infusions via small peripheral lines

Clinical Technique Risk Factors

• Difficult venous access or poor vein selection
• Inadequate stabilization of catheter
• Frequent manipulation or movement of arm
• High infusion pressures from poor catheter position
• Delayed recognition and treatment of complications
• Inadequate monitoring of IV site

By recognizing populations at higher risk and situations predisposing patients to IV complications, steps can be taken to reduce modifiable factors when possible. Risk mitigation strategies are integral to infiltration and extravasation prevention.

Strategies for Prevention

Meticulous IV insertion technique and ongoing catheter site monitoring represent the most effective ways to avoid infiltration and extravasation incidents. Key prevention strategies include:

– Careful Catheter Selection and Insertion

• Select appropriate catheter type and smallest size possible
• Choose visible, straight, distal vessels when possible
• Avoid joints, hand, feet, scarred or compromised sites
• Ensure proper catheter position with blood flashback

– Catheter Securement and Stabilization

• Use sterile tape, dressings or stabilization devices
• Consider arm boards for agitated or pediatric patients
• Minimize arm movement and manipulation

– Frequent IV Site Inspections

• Check hourly for swelling, leaking, pain
• Compare IV site to opposite extremity
• Educate patients on symptoms to report

– Optimal Catheter Maintenance

• Replace IV promptly at first signs of infiltration
• Avoid “saving” or extending use of compromised IVs
• Change dressings and tubing per protocol
• Flush lines only when needed to maintain patency

– Adjust Infusion Rates and Pressures

• Run at minimum rate needed for therapy
• Use controlled devices instead of free-flowing systems
• Monitor for resistance and maintain less than 25 psi

– Employ Multidisciplinary Strategies

• Education and competency training for staff
• Update policies and procedures periodically
• Emphasize culture of reporting near-miss events
• Standardize extravasation treatment protocols

Diligent nursing care with clinical vigilance represents the front line inpreventing IV therapycomplications. However, a systems-based approach across professions promotes consistent application of best practices. By making infiltration and extravasation prevention a priority through education and protocol standardization, IV therapy safety improves significantly.

Early Recognition of Infiltration and Extravasation

Prompt recognition of the early signs of IV infiltration or leakage provides the best opportunity to minimize patient harm. Subtle symptoms can precede obvious tissue effects by hours to days. All healthcare staff must remain vigilant in monitoring for the early manifestations:

Visible Signs

• Swelling around IV site
• Leakage of fluid under or around catheter
• Enlarged, cool, pale area around site
• Skin discoloration or redness
• “Tenting” or skin tightness when pinched
• Hardened tissue texture

Patient Symptoms

• New onset of pain or tenderness
• Tightness, pressure, throbbing, burning
• Changes in sensation or numbness
• Difficulty moving extremity

IV Flow Changes

• Slowed infusion rate
• Resistance flushing catheter
• Swelling of extremity distal to IV site

Comparative Signs

• Increased diameter of infused arm
• Skin color and temperature changes
• Greater firmness compared to opposite limb

The most common early signs are swelling and leakage of fluid around the catheter site. Pain, pallor, and firmness typically follow. IV flow changes manifest as the catheter becomes occluded with tissue edema. Subtle increases in limb diameter or firmness warrant extra vigilance and potential intervention before extensive tissue damage occurs.

Patient factors like communication barriers, distracting injuries, sedation, or neurological deficits can delay reporting of symptoms. Objective visual and tactile inspections by nursing staff take on greater importance for non-verbalizing patients.

No single symptom confirms infiltration or extravasation. Providers must synthesize multiple factors in deciding whether IV leakage has occurred. Early recognition depends on diligent checking technique, critical thinking, and prompt reporting by both patients and providers.

Grading Severity and Clinical Decision Making

Not all infiltrations progress to cause serious harm, but all warrant immediate attention and further evaluation. To determine appropriate next steps, clinicians categorize the suspected infiltration or extravasation based on severity:

Grade 1– IV fluid leaking into subcutaneous tissues but no skin changes

Grade 2– Skin swelling, blanching, redness in area around IV site

Grade 3– Skin blistering or palpable fluid pocket; site cool to touch

Grade 4– Skin necrosis or ulceration evident

Grades 1 and 2 represent early, mild to moderate tissue effects that may resolve spontaneously after discontinuing the infusion. Grades 3 and 4 are more severe with blistering, ulceration, and necrosis indicating the damaging effects are well underway.

Additional factors determine the treatment approach:

• Type and quantity of infusate – irritant vs vesicant solutions
• Location and size of infiltrate – distal sites more dangerous
• Duration of exposure – damage worsens over hours to days
• Characteristics of patient tissue – more fragile in infants, elderly

Clinical decision-making depends on synthesizing these characteristics along with the graded severity. Providers must decide promptly whether to:

Protocolized approaches guide decision making, but clinical judgment based on experience remains key. Underestimating or failing to recognize an evolving infiltration can result in preventable patient harm. Repeated assessments are warranted when any doubt exists.

Managing Infiltrations and Extravasations

Once an infiltration or extravasation is suspected, management entails:

Specific treatment measures aim to limit further infusion, mitigate damage, promote healing, and prevent complications.

Stop the Infusion Immediately

The very first step is to stop infusion of any IV solution, as this can worsen fluid trapping and tissue injury. Prolonged exposure to vesicants, irritants, or hypertonic fluids results in more extensive wounds. Clamp tubing if needed to prevent gravity flow while preserving IV access temporarily.

Leave the Catheter in Place

Remove tape and dressings to inspect the site, but do not yet remove the catheter. Removing it can seal off the source of leakage and cause fluid tracking along tissue planes. Observe for continued extravasation once the line is stopped. Consider injecting lidocaine through the IV to anesthetize the tract before removing.

Elevate the Extremity

Position the affected limb above heart level. Gravity discourages further fluid accumulation and swelling. Avoid excessive elevation that occludes venous return. Monitor distal pulses and for signs of limb ischemia. Keeping the extremity elevated complements other treatment measures.

Notify the Provider Immediately

Alert providers promptly of any suspected infiltration or extravasation, no matter how subtle the early signs. The provider performs a thorough assessment, classifies severity, and initiates the treatment protocol. Delaying notification or underestimating the severity risks progression to worse tissue damage.

Initiate Standardized Treatments

Protocolized treatment algorithms customized to the facility guide management onceseverity is classified. Measures aim to limit injury, reduce pain, and promote healing.

Mild Infiltration (Grade 1-2)

• Remove IV catheter
• Elevate extremity
• Cold compresses
• Analgesics
• Monitor for progression

Moderate Infiltration (Grade 2-3)

• Consider antidotes (hyaluronidase, phentolamine)
• Warm moist compresses to promote vasodilation
• Elevate and immobilize extremity
• Analgesics
• Avoid massage
• Consider topical dimethylsulfoxide (DMSO)
• Monitor closely

Severe Extravasation (Grade 3-4)

• Hyaluronidase infiltration as indicated
• Urgent surgery consult for possible debridement
• Warm compresses
• Elevation and immobilization
• Analgesics
• Slab or splint if extensive swelling expected
• Monitor for compartment syndrome

Additional agents like dimethylsulfoxide (DMSO) or topical nitrates may also be trialed under guidance of wound care specialists. However, the mainstays of treatment remain stopping exposure to the offending agent, supporting tissue perfusion, reducing swelling, and debriding devitalized tissue if needed urgently.

Reassess Frequently

Regardless of severity, monitoring the site for progression or improvement is essential. Perform extremity checks at least hourly, including measurements of swelling distance and palpation of firmness. Symptoms can worsen even after the infusion is stopped, as fluid continues diffusing into the interstitium. Repeated exams detect deterioration early.

Document the Event Thoroughly

Clear documentation of IV complications is imperative for continuity of care. Elements to document include:

• Time of onset of symptoms
• Appearance of site initially and over time
• Measures taken to treat and duration
• Changes in vital signs
• Medication and fluid types infusing
• Notifications made to provider and patient
• Response to therapy interventions
• Education on signs & symptoms to monitor

Thorough documentation facilitates quality review, debriefing, and future protocol updates aimed at improved practice. An accurate record also assists in liability defense if needed.

Specific IV Therapies at Higher Risk

While all IV medications and fluids can infiltrate or extravasate, certain types warrant additional precautions. Their damaging effects on tissue are more extensive and rapid if leakage occurs.

Chemotherapy Vesicants

Cytotoxic antineoplastic agents have direct toxic effects on cell membranes and proteins. Vesicants like anthracyclines, vinca alkaloids, and epipodophyllotoxins can cause severe necrosis. Effects worsen over hours to days as cell damage continues despite stopping the infusion. Irreversible neuromuscular damage occurs if allowed to diffuse into muscular compartments. Early signs include pain and erythema at the site – if noted, stop infusion immediately.

Vasoactive Medications

Catecholamine vasopressors constrict vessels and reduce perfusion. Extravasated vasoactives result in more severe tissue ischemia. Epinephrine and dopamine in particular are high-risk. Use central access when possible and monitor closely for infiltration. Phentolamine can reverse vasoconstriction if given early.

Hypertonic Saline and Dextrose

Solutions significantly hypertonic to plasma draw fluid by osmosis into the interstitium. Extravasation of hypertonic saline and dextrose over 50% can result in severe pain, compartment syndrome, and tissue sloughing. Effects worsen over 24 hours as fluid shifts increase edema. Early antidotes include hyaluronidase and topical DMSO.

Contrast Dyes

Radiocontrast media used in angiography and CT scans are hyperosmolar and chemically irritating. Even small volumes infiltrated cause significant inflammation. Compartment syndrome is a particular risk with these direct arterial injectates. Prompt surgery evaluation is warranted if more than 40-50 mL extravastes into an extremity.

Calcium Solutions

Calcium precipitates rapidly in tissue when extravasated due to its insolubility at physiologic pH. Resulting mineral deposits and necrosis can occur quickly, within hours. Prompt wide debridement is often required. Calcium increases injury when co-infiltrated with other vesicants.

Potassium Solutions

Hyperkalemia results when potassium salts directly contact cells, disrupting membrane potentials. Cardiac toxicity can occur along with tissue injury. The low volumes used limit severity but extravasation requires continuous cardiac monitoring and laboratory testing.

Special Considerations for Vitamin Infusions

With the growth in popularity of IVvitamin therapies, healthcare providers require awareness of infiltration precautions specific to these infusates. Vitamins pose lower risks than vesicants if extravasated, but still warrant care when administering.

Risk Factors

• Highly concentrated vitamin solutions with low pH or osmolality
• Concurrent irritant additives like glutathione, carnitine, or B-complex vitamins
• Peripheral IV catheters with difficulty obtaining or maintaining access
• Patients with fragile veins or difficulty communicating

Preventive Steps

• Use small gauge catheter only if vein easily accessed
• Confirm catheter patency before vitamin administration
• Consider proximal IV sites such as antecubital for high-dose vitamins
• Dilute vitamin C and B preparations if peripherally infused
• Start infusion slowly and increase rate gradually only if tolerated
• Do not exceed 25mL/hour for peripheral administration
• Frequently inspect IV site and patient tolerance

If Infiltration Occurs

• Promptly discontinue infusion if any swelling or leakage noted
• Remove catheter when able to maintain access in another site
• Apply warm compresses to promote vasodilation
• Hyaluronidase subcutaneously may facilitate absorption
• Elevate extremity and monitor for compartment syndrome
• Consider topical or oral steroids for inflammation
• Observe for signs of vascular occlusion from vitamin C precipitates

With proper precautions, vitamin infusions can be administered safely via peripheral IV access in most cases