Intra venous therapy complications

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”
“Reopen the Pipeline”, Hadaway C, Nursing.
2005, 35(8)
“Reopen the Pipeline”, Hadaway C, Nursing. 2005, 35(8)
Fibrin FlapIntaluminal thrombus
Total Occlusion
Probable cause: Intraluminal thrombus Symptom:
Unable to infuse or aspirate
Partial Occlusion
Probable cause: Fibrin flap
Symptom: Unable to aspirate

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