Complications of Intravenous Therapy

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

2. 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

3. 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

4. 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.

6. 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

7. 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.

8. 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

9. HematomaPrevention • 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

10. HematomaTreatment • Apply direct, light pressure for 2-3 minutes after needle removed • Have patient elevate extremity • Apply Ice • Document

11. 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

12. ThrombosisTypes of Thrombus or occlusion • Persistent withdrawal occlusion • Partial occlusion • Complete occlusion • Fibrin tail • Fibrin sheath • Mural thrombosis

14. “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)

16. ThrombosisTypes 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

17. 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

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

19. 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

21. 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

22. 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

23. Chemical Phlebitis - Nafcillin

24. PhlebitisBacterial • 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

25. PhlebitisPostinfusion • 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

26. 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

27. 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

28. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

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

38. Infiltration • Complications fall into 3 catagories • Ulceration and possible tissue necrosis • Compartment syndrome • Reflex sympathetic dystrophy syndrome

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

40. Cellulitis from PIV

41. 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

42. 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

43. 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

44. 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

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

46. Extravasation

47. Phenergan – Intra-arterial

48. Phenergan Intra-arterial

49. Dilantin Extravasation