1. Complications of
Intravenous Therapy
Principles of IV Therapy
ADN136
Fall Qr 09

3. Complications of IV Therapy
 Nursing assumed the role of intravenous
therapy in the 1940’s
 Application of the nursing process is critical
in the prevention of complications
 90% of hospitalized patients receive IV fluids
and medications

4. Complications of IV Therapy
 Classified according to their location
 Local complication: at or near the insertions site
or as a result of mechanical failure
 Systemic complications: occur within the vascular
system, remote from the IV site. Can be serious
and life threatening

5. Local complications
 Occur as adverse reactions or trauma to the
surrounding venipuncture site
 Assessing and monitoring are the key components to
early intervention
 Good venipuncture technique is the main factor
related to the prevention of most local complications
associated with IV Therapy.
 Local complications include: hematoma, thrombosis,
phlebitis, postinfusion phlebitis, thrombophlebitis,
infiltration, extravasation, local infection, and veno
spasm.

7. Hematoma
 Hematoma and ecchymosis demote
formations resulting from the infiltration of
blood into the tissues at the venipuncture site
 Related to venipuncture technique
 Use of large bore cannula: Trauma to the vein
during insertion
 Patients receiving anticoagulant therapy and long
term steroids

8. Hematoma
 Subcutaneous hematoma is the most common
complication
 Can be a starting point for other complications:
thrombophlebitis and infection
 Related to:
 Nicking the vein
 Discontinuing the IV without apply adequate pressure
 Applying the tourniquet to tightly above a priviously
attempted venipuncture site.

9. Hematoma
 Signs and symptoms:
 Discoloration of the skin
 Site swelling and discomfort
 Inability to advance the cannula all the way into
the vein during insertion
 Resistance to positive pressure during the lock
flushing procedure

10. Hematoma
Prevention
 Use of an indirect method
 Apply tourniquet just before venipuncture
 Use a small need in the elderly and patients
on steriods, or patients with thin skin.
 Use blood pressure cuff to apply pressure
 Be gentle

11. Hematoma
Treatment
 Apply direct, light pressure for 2-3 minutes
after needle removed
 Have patient elevate extremity
 Apply Ice
 Document

12. Thrombosis
 Catheter-related obsturctions can be
mechanical or non-thrombotic
 Trauma to the endothelial cells of the venous
wall causes red blood cells to adhere to the
vein wall, forms a clot or Thrombosis
 Drip rate slows, line does not flush easily,
resistance is felt
 Never forcible flush a catheter

13. Thrombosis
Types of Thrombus or occlusion
 Persistent withdrawal occlusion
 Partial occlusion
 Complete occlusion
 Fibrin tail
 Fibrin sheath
 Mural thrombosis

15. “In Need of tPA Occlusions”
Intaluminal thrombus Fibrin Flap
“Reopen the Pipeline”, Hadaway C, Nursing. 2005, 35(8)
Total Occlusion
Probable cause: Intraluminal thrombus Symptom:
Unable to infuse or aspirate
Partial Occlusion
Probable cause: Fibrin flap
Symptom: Unable to aspirate “Reopen the Pipeline”, Hadaway C, Nursing.
2005, 35(8)

17. Thrombosis
Types of Thrombus or occlusion
 Thrombosis related to:
 Hypertensive pt; blood backing up
 Low flow rate
 Location of the IV cannula
 Compression of the IV line for an extended
period of time
 Trauma to the wall of the vein

18. Thrombosis
 Signs and Symptoms
 Fever and Malaise
 Slowed or stopped infusion rate
 Inability to flush
 Prevention
 Use pumps and controllers to manage flow rate
 Microdrip tubing for rate below50mL/hr
 Avoid areas of flexion
 Use filters
 Avoid lower extremeties

19. Thrombosis
 Treatment
 Never flush a cannula to remove an occlusion
 Discontunue the cannula
 Notify the physician and assess the site for
circulatory impairment
 Document

20. Phlebitis
 Inflammation of the vein in which the
endothelial cells of the venous wall become
irritated and cells roughen, allowing platelets
to adhere and predispose the vein to
inflamation-induced phlebitis
 Tender to touch and can be very painful

22. Phlebitis
 Mechanical:
 To large a catheter for the size of the vein
 Manipulation of the catheter: improper stabilization
 Chemical: vein becomes inflamed by irritating or
vessicant solutions or medication
 Irritation medication or solution
 Improperly mixed or diluted
 Too-rapid infusion
 Presence of particulate matter

23. Phlebitis
 Chemical (cont):
 The more acidic the IV solution the greater the
risk
 Additives: Potassium
 Type of material
 Length of dwell:
 30% by day 2, 39-40% by day 3 (Macki and Ringer)
 The slower the rate of infusion the less irritation

24. Chemical Phlebitis - Nafcillin

25. Phlebitis
Bacterial
 Also called Septic phlebitis: least common
 Inflammation of the intima of the vein
 Contributing factors
 Poor aseptic technique
 Failure to detect breaks in the integrity of the equipment
 Poor insertion technique
 Inadequate stabilization
 Failure to perform site assessment
 Aseptic preparation of solutions
 Hand washing and preparing the skin

26. Phlebitis
Postinfusion
 Inflamation of the vein 48-96 hr after discontinued
 Factors that contribute:
 Insertion technique
 Condition of the vein used
 Type, compatibility, pH of solution used
 Gauge, size, length, and material
 Dwell time
 Infrequent dressing change
 Host factors: age, gender, age and presence of disease

27. Phlebitis
 Immune system causes leukocytes to gather at
the inflamed site
 Pyrogens stimulate the hypothalamus to raise
body temperature
 Pyrogens stimulate bone marrow to release
more leukocytes
 Redness and tenderness increase

28. Phlebitis
 Signs and Symptoms
 Redness at the site
 Site warm to touch
 Local swelling
 Palpable cord along the vein
 Sluggish infusion rate
 Increase in basal temperature of 1degree C or more
 Prevention
 Use larger veins for hypertonic solutions
 Central lines for Infusions lasting longer than 5 days

29. Phlebitis Scale
 0 – No clinical symptoms
 1- Erythema at access site with or without pain
 2- Pain at access site, with erythema and / or edema
 3- Pain at access site with erythema and / or edema,
streak formation, and palpable venous cord
 4- Pain at access site with erythema and / or edema,
streak formation, palpable venous cord > 1 inch,
purulent drainage

32. Thrombophlebitis
 Thrombophlebitis denotes a twofold injury:
thrombosis and inflammation
 Related to:
 Use of veins in the lower extremity
 Use of hypertonic or highly acidic infusion
solutions
 Causes similar to those leading to phlebitis

33. Thrombophlebitis
 Signs and Symptoms
 Sluggish flow rate
 Edema in the limbs
 Tender and cord like vein
 Site warm to the touch
 Visible red line above venipuncture site
 Diminished arterial pulses
 Mottling and cyanosis of the extremities

34. Thrombophlebitis
 Prevention
 Use veins in the forearm rather than the hands
 Do not use veins in a joint
 Assess site q 4 hr in adults, q 2 hr in children
 Catheter securment
 Infuse at rate prescribed
 Use the smallest size catheter to do the job
 Proper dilution

35. Thrombophlebitis
 Septic thrombophlebits can be prevented:
 Appropriate skin preparation
 Aseptic technique in the maintance of infusion
 Proper hand hygiene
 60% from patients skin
 35% from the line itself
 5% from hands

36. Infiltration
 The inadvertent administration of a non-
vesicant solution into surrounding tissue
 Dislodgment of the catheter from the vein
 Second to phlebitis as a cuase of IV therapy
morbidity

37. Infiltration
 Related to:
 Puncture of the distal vein wall during access
 Puncture of the vein wall by mechanical friction
 Dislodgement of the catheter from the intima of
the vien
 Poor securment
 High delivery rate
 Overmanipulation

38. Infiltration
 Signs and Symptoms
 Coolness of the skin around site
 Taut skin
 Dependent edema
 Absence of blood return
 “Pinkish” blood return
 Infusion rate slows

39. Infiltration
 Complications fall into 3 catagories
 Ulceration and possible tissue necrosis
 Compartment syndrome
 Reflex sympathetic dystrophy syndrome

40. Infiltration – What else is wrong with
this picture?

41. Cellulitis from PIV

42. Extravasation
 Inadvertent administration of a vesicant
solution into surrounding tissue
 Vesicant is a fluid or medication that causes the
formation of blisters, with subsequent sloughing
of tissues occurring from the tissue necrosis
 Extravasations related to:
 Puncture of the distal wall
 Mechanical friction
 Dislodgement of the catheter

43. Examples of Vesicants
 Phenergan pH is 4 to 5.5
 Dilantin pH is 12 (Drano has a pH of 14)
 High concentration KCL pH is 5 to 7.8
 Calcium gluconate pH is 6.2
 Amphotericin B pH is 5.7 to 8
 Dopamine pH is 2.5 to 5
 Nipride pH is 3.5 to 6
 10%, 20% or 50% dextrose pH is 3.5 to 6.5
 Sodium bicarbonate pH is 7 to 8.5

44. Extravasations
 Signs and Symptoms
 Complaints of pain or burning
 Swelling proximal to or distal to the IV site
 Puffiness of the dependent part of the limb
 Skin tightness at the veinpuncture site
 Blanching and coolness of the skin
 Slow or stopped infusion
 Damp or wet dressing

45. Extravasations
 Prevention:
 Use of skilled practitioners
 Knowledge of vesicants
 Condition of the patients veins
 Drug administration technique
 If continuous give in CVAD
 Only with brisk blood return of 3-5 cc
 Use of a free flow IV
 Do not use a pump on vesicants given peripherally
 Assess for blood return frequently

46. Extravasations (cont)
 Prevention (cont)
 Site of venous access
 Condition of the patient
 Vomiting, coughing, retchin
 Sedated
 Unable to communicate
 Treatment

47. Extravasation

48. Phenergan – Intra-arterial

49. Phenergan Intra-arterial

50. Dilantin Extravasation

61. Other Complications
 Local infection:
 Microbial contamination of the cannula or the
infusate
 Thrombus becomes infected
 Venous Spasm: a sudden involuntary
contraction of a vein or an artery resulting in
temporary cessation of blood flow through a
vessel

62. Systemic Complications
 We will cover when we talk about Central
Venous Access Devices