IV therapy is a common medical procedure used by nurses to deliver fluids, medications, and nutrients directly into a patient’s bloodstream, providing rapid absorption. While generally safe, maintaining an IV line requires constant monitoring due to potential complications. One common issue is infiltration, which occurs when IV fluid accidentally leaks into the soft tissue surrounding the vein. This involves the unintended delivery of a non-vesicant solution, meaning the fluid is not inherently irritating or damaging to the tissue.
Understanding Infiltration and Extravasation
Infiltration is defined as the accidental leakage of a non-irritating intravenous solution into the subcutaneous tissue around the insertion site. This occurs when the catheter tip either slips entirely out of the vein or punctures the vein wall, creating a pathway for the fluid to escape. Non-vesicant fluid, such as normal saline or certain antibiotics, then pools in the interstitial space. The body’s response to this excess fluid accumulation creates the physical signs observed at the site.
The distinction between infiltration and a related complication called extravasation is based entirely on the type of fluid involved. Extravasation occurs when the leaked fluid is a vesicant, a substance capable of causing blistering, severe tissue damage, or necrosis. Examples include certain chemotherapy drugs or high-concentration dextrose solutions. The root causes are often similar, stemming from an improperly secured catheter, patient movement, or a catheter size that is too large for the chosen vein.
Recognizing the Signs and Symptoms
Identifying infiltration early relies on a nurse’s visual assessment and physical examination of the IV site. The most noticeable sign is localized swelling, or edema, at or near the insertion point. When touched, the skin around the site often feels cool compared to the surrounding skin due to the temperature of the infused fluid. The skin may also appear pale or blanched because the pressure from the trapped fluid constricts the capillaries.
Patients may report discomfort, tightness, or pain at the IV site resulting from the pressure exerted by the fluid volume. Nurses also monitor for a noticeable decrease in the infusion rate or a complete stop of fluid flow, caused by the resistance of the surrounding tissue. Nurses often compare the affected extremity to the opposite limb to gauge the extent of swelling and temperature difference. The severity of infiltration is commonly graded using a standardized scale to guide the appropriate course of action.
Immediate Nursing Actions and Recovery
Once infiltration is confirmed, the immediate nursing action is to stop the IV fluid infusion completely to prevent further leakage. Following this, the IV catheter must be removed from the site. The nurse then elevates the affected extremity above the level of the heart, using gravity to promote the reabsorption of the pooled fluid.
Subsequent treatment often involves applying a compress, with the choice of heat or cold depending on the nature of the infiltrated solution. For most non-vesicant solutions like normal saline, a warm compress is used to increase blood flow and speed up fluid reabsorption. If the infiltrated solution is a blood product or certain medications, a cold compress may be indicated to reduce inflammation. The incident is thoroughly documented, and the site is continually monitored until resolution.