Key Takeaways
- Infiltration presents as coolness, pallor, and swelling at the IV site - stop infusion, remove catheter, elevate extremity
- Phlebitis presents as redness, warmth, and a palpable cord along the vein - discontinue IV, apply warm compress
- Extravasation involves vesicant medication leaking into tissue causing necrosis - stop immediately, aspirate if possible, follow antidote protocol
- Air embolism is prevented by priming tubing completely and using Luer-lock connections; position patient in Trendelenburg on left side if suspected
- Central line infections present with fever and redness at insertion site; use strict aseptic technique and change dressings per protocol
IV Therapy and Complications
Intravenous (IV) therapy is one of the most common invasive procedures in healthcare. Understanding proper technique, recognizing complications, and knowing appropriate interventions is essential for safe practice.
Types of IV Access
| Type | Description | Duration | Uses |
|---|---|---|---|
| Peripheral IV (PIV) | Catheter in peripheral vein | 72-96 hours | Short-term fluids, meds |
| Midline Catheter | Longer catheter in arm vein | 1-4 weeks | Extended therapy |
| PICC Line | Catheter threaded to SVC | Weeks to months | Long-term therapy, TPN |
| Central Venous Catheter | Direct access to central vein | Variable | Vasopressors, TPN, frequent access |
| Implanted Port | Surgically placed under skin | Years | Chemotherapy, intermittent access |
Peripheral IV Complications
Infiltration
Definition: Non-vesicant fluid leaks into surrounding tissue
| Assessment Finding | Description |
|---|---|
| Swelling/edema | Around insertion site |
| Coolness | Tissue feels cooler than surrounding area |
| Pallor | Skin appears pale |
| Pain | Discomfort at site |
| Decreased flow rate | Infusion slows or stops |
Interventions:
- Stop the infusion immediately
- Remove the IV catheter
- Elevate the extremity
- Apply warm or cool compress per facility policy
- Document the event
- Restart IV in different location (preferably opposite arm)
Phlebitis
Definition: Inflammation of the vein
Types:
- Chemical (irritating medications)
- Mechanical (catheter movement)
- Bacterial (infection)
| Assessment Finding | Description |
|---|---|
| Redness | Along the vein path |
| Warmth | At and around site |
| Tenderness | Pain with palpation |
| Palpable cord | Hardened vein |
| Streak | Red streak following vein |
Interventions:
- Discontinue the IV
- Apply warm, moist compress
- Document using phlebitis scale
- Restart in opposite extremity
- Notify provider if severe or infectious
Extravasation
Definition: Vesicant medication leaks into tissue, causing tissue damage or necrosis
Vesicant Medications:
- Chemotherapy agents (many)
- Dopamine, norepinephrine
- Calcium chloride
- Potassium chloride (concentrated)
- Vancomycin
- Diazepam
| Assessment Finding | Description |
|---|---|
| Pain/burning | Often severe |
| Swelling | At injection site |
| Redness progressing to blanching | Tissue damage occurring |
| Blistering | Indicates tissue necrosis |
Interventions:
- STOP the infusion immediately
- Leave catheter in place initially
- Aspirate residual drug if possible
- Apply cold or warm compress (drug-specific)
- Administer antidote if available (drug-specific)
- Notify provider immediately
- Document thoroughly with photos if possible
- May require surgical intervention
Systemic IV Complications
Air Embolism
Definition: Air enters the bloodstream through IV system
Risk Factors:
- Disconnected IV tubing
- Empty IV bag
- Central line removal
- Poor IV technique
Signs and Symptoms:
- Sudden chest pain
- Dyspnea, tachypnea
- Hypotension
- Confusion, altered LOC
- Churning "mill-wheel" heart murmur
Interventions:
- Clamp the IV line immediately
- Position patient on left side in Trendelenburg (traps air in right atrium)
- Administer 100% oxygen
- Notify provider immediately - emergency!
- Prepare for possible aspiration of air
Prevention:
- Prime tubing completely before use
- Use Luer-lock connections
- Ensure all connections are tight
- Use IV pumps with air detection
- Proper technique for central line care
Speed Shock
Definition: Systemic reaction to rapid IV medication infusion
Signs and Symptoms:
- Flushing of face and neck
- Headache
- Chest tightness
- Hypotension
- Cardiac arrest
Prevention:
- Use infusion pumps
- Verify correct rate before administration
- Know safe infusion rates for medications
Fluid Overload (Circulatory Overload)
Risk Factors:
- Elderly patients
- Heart failure
- Renal impairment
- Rapid infusion
Signs and Symptoms:
- Dyspnea, crackles in lungs
- Jugular vein distension (JVD)
- Peripheral edema
- Hypertension
- Bounding pulse
Interventions:
- Slow or stop the infusion
- Raise head of bed
- Administer diuretics as ordered
- Monitor I&O strictly
- Apply oxygen as needed
Central Line Complications
Catheter-Related Bloodstream Infection (CRBSI)
Signs and Symptoms:
- Fever, chills
- Redness, warmth, drainage at site
- Elevated WBC
- Positive blood cultures
Prevention (Central Line Bundle):
- Hand hygiene
- Full barrier precautions during insertion
- Chlorhexidine skin prep
- Optimal catheter site selection
- Daily assessment for line necessity
- Proper dressing changes
Interventions:
- Obtain blood cultures (from line AND peripheral)
- Notify provider
- Administer antibiotics as ordered
- Line may need to be removed
Pneumothorax
Associated with: Subclavian and internal jugular central line placement
Signs and Symptoms:
- Sudden dyspnea
- Chest pain
- Absent breath sounds on affected side
- Hypoxia
- Tracheal deviation (tension pneumothorax)
Post-Procedure: Obtain chest X-ray to confirm placement and rule out pneumothorax
IV Solution Types
| Solution | Type | Use |
|---|---|---|
| 0.9% NaCl (Normal Saline) | Isotonic | Volume replacement, blood administration |
| Lactated Ringer's | Isotonic | Fluid resuscitation, surgery |
| D5W | Isotonic in bag, hypotonic in body | Provides free water |
| 0.45% NaCl (Half Normal Saline) | Hypotonic | Cellular dehydration |
| D5NS | Hypertonic | Maintenance fluids |
| 3% NaCl | Hypertonic | Severe hyponatremia (ICU only) |
On the Exam
- Recognize infiltration vs. phlebitis vs. extravasation
- Know position for air embolism (left side, Trendelenburg)
- Understand prevention strategies
- IV solution characteristics
A patient's IV site shows swelling, coolness, and pallor around the insertion area. The IV rate has slowed significantly. The nurse recognizes this as:
A patient receiving IV therapy through a central line suddenly develops chest pain, dyspnea, and hypotension. The nurse suspects air embolism. The priority action is to:
Which IV solution is appropriate for blood transfusion?
A patient receiving IV vancomycin complains of severe burning pain at the IV site. The nurse notes the site is swollen and beginning to blister. The priority action is: