Intravenous therapy complications can be local, occurring near the insertion site, or systemic. Local complications include hematoma, thrombosis, phlebitis, infiltration and infection. Proper venipuncture technique and ongoing assessment are key to preventing complications. Over 90% of hospitalized patients receive intravenous fluids and medications, making careful nursing care and monitoring important for patient safety.

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