Infiltration and Extravasation in Intravenous Therapy: A Comprehensive Review of Mechanisms, Risk Management, and Medicolegal Implications

Infiltration and Extravasation in Intravenous Therapy: A Comprehensive Review of Mechanisms, Risk Management, and Medicolegal Implications

Abstract

Infiltration and extravasation are common complications of intravenous (IV) therapy, potentially leading to significant patient morbidity, increased healthcare costs, and medicolegal repercussions. This research report provides a comprehensive review of these adverse events, encompassing their definitions, classifications, etiological factors, risk assessment strategies, preventive measures, and management protocols. Furthermore, it delves into the legal landscape surrounding infiltration and extravasation injuries, addressing liability concerns and highlighting best practices for minimizing risk. This report aims to equip healthcare professionals with the knowledge and tools necessary to optimize patient safety and mitigate the potential adverse consequences associated with IV therapy.

1. Introduction

Intravenous (IV) therapy is a ubiquitous practice in modern healthcare, employed for the administration of fluids, medications, and blood products. While generally safe and effective, IV therapy is not without its risks. Infiltration and extravasation represent significant complications that can compromise patient well-being and lead to adverse outcomes. Infiltration refers to the inadvertent leakage of non-vesicant IV fluids or medications into the surrounding subcutaneous tissue. Extravasation, a more severe form of infiltration, involves the leakage of vesicant solutions, which are capable of causing tissue damage, necrosis, and functional impairment. These complications are not always easily distinguished clinically, and prompt and appropriate management is crucial to minimizing the extent of injury. This report will examine the underlying mechanisms, risk factors, prevention, and management of infiltration and extravasation, as well as explore the associated medicolegal considerations.

2. Definitions and Classification

• Infiltration: The unintentional leakage of non-vesicant IV fluids or medications into the surrounding subcutaneous tissue. The leaked fluid typically includes isotonic crystalloids or nutrients.
• Extravasation: The leakage of vesicant (irritating or blistering) medications or fluids into the surrounding tissue. This can cause tissue damage, necrosis, and even functional impairment.

Furthermore, infiltration and extravasation can be classified based on the following:

• Severity: Various grading scales exist to assess the severity of infiltration and extravasation injuries. Commonly used scales incorporate factors such as swelling, pain, skin discoloration, tissue damage, and functional impairment. The INS (Infusion Nurses Society) scale is widely recognized.
• Type of Fluid/Medication: The nature of the infused substance is a critical determinant of the potential for tissue damage. Vesicant medications, such as chemotherapy agents, vasopressors, and concentrated electrolytes, pose a higher risk of extravasation injuries.
• Mechanism of Injury: Infiltration and extravasation can occur due to various mechanisms, including catheter dislodgement, venous rupture, increased venous pressure, or improper catheter placement.

3. Etiology and Risk Factors

Several factors contribute to the occurrence of infiltration and extravasation, including:

• Patient-Related Factors:
  • Age: Infants, children, and elderly patients are at increased risk due to fragile veins and limited ability to communicate discomfort.
  • Comorbidities: Patients with pre-existing conditions such as diabetes, peripheral vascular disease, and compromised immune systems are more susceptible to tissue damage and delayed healing.
  • Cognitive Impairment: Patients with cognitive deficits may be unable to report early symptoms of infiltration or extravasation.
  • Obesity: The depth of the veins and subcutaneous fat in obese patients can make IV insertion and maintenance more challenging, increasing the risk of complications.
• IV Catheter-Related Factors:
  • Catheter Size: Larger-gauge catheters may increase the risk of venous trauma and extravasation.
  • Catheter Material: Certain catheter materials may be more prone to kinking or dislodgement.
  • Catheter Placement: Placement of the catheter near joints or in areas of flexion can increase the risk of mechanical irritation and vessel wall compromise.
• Medication-Related Factors:
  • Vesicant Properties: The inherent vesicant properties of certain medications are a primary determinant of extravasation severity.
  • Concentration: High concentrations of medications or electrolytes can exacerbate tissue damage.
  • Osmolarity: Hyperosmolar solutions can cause endothelial damage and increase the risk of infiltration.
• Administration Technique-Related Factors:
  • Multiple Venipuncture Attempts: Repeated attempts to insert an IV catheter can damage the vessel wall, predisposing it to leakage.
  • High Infusion Rates: Rapid infusion rates can increase venous pressure and the likelihood of infiltration or extravasation.
  • Lack of Monitoring: Inadequate monitoring of the IV site during infusion can delay the detection of complications.

4. Signs and Symptoms

The signs and symptoms of infiltration and extravasation can vary depending on the severity of the event and the type of fluid or medication involved. Common signs and symptoms include:

• Swelling: Localized swelling around the IV insertion site is a hallmark sign of infiltration or extravasation.
• Pain: Patients may report pain, burning, or tenderness at the IV site.
• Skin Discoloration: Erythema, pallor, or blanching of the skin around the IV site may indicate fluid accumulation or compromised circulation.
• Coolness to Touch: The skin around the IV site may feel cooler to the touch compared to surrounding areas due to fluid extravasation.
• Leakage: Visible leakage of fluid from the IV insertion site is a definitive sign of infiltration or extravasation.
• Decreased Infusion Rate: The flow rate of the IV fluid may slow down or stop altogether due to resistance from the surrounding tissue.
• Blistering: Blistering indicates significant tissue damage, typically associated with extravasation of vesicant medications.
• Ulceration: In severe cases, ulceration and tissue necrosis may develop, particularly with extravasation of potent vesicants.

It is essential for healthcare professionals to closely monitor IV sites for any signs or symptoms of infiltration or extravasation and to promptly investigate any patient complaints of discomfort.

5. Preventive Measures

Prevention is paramount in minimizing the risk of infiltration and extravasation. A multifaceted approach incorporating the following strategies is essential:

• Patient Assessment: Thoroughly assess patients for risk factors such as age, comorbidities, cognitive impairment, and history of previous IV complications.
• Site Selection: Choose an appropriate IV insertion site, avoiding areas of flexion, joints, and compromised skin integrity. Utilizing the non-dominant arm is preferred. Consider using the upper arm when administering vesicants because this provides space for the medication to dissipate compared with hand or wrist administration.
• Catheter Selection: Select the smallest-gauge catheter appropriate for the prescribed infusion, minimizing venous trauma.
• Dilution: Vesicant medications should be diluted according to manufacturer guidelines to minimize their potential for tissue damage. For example, the use of pre-mixed chemotherapy infusions is increasing and improving patient safety.
• Administration Technique: Employ meticulous venipuncture technique, avoiding multiple attempts and minimizing trauma to the vessel wall. Flushing the IV line before administering medication is an essential step.
• Infusion Rate Control: Administer IV fluids and medications at the prescribed infusion rate, avoiding rapid infusions that can increase venous pressure.
• IV Site Monitoring: Routinely monitor IV sites for signs and symptoms of infiltration or extravasation, including swelling, pain, skin discoloration, and leakage. Document findings regularly.
• Patient Education: Educate patients and their families about the potential risks of IV therapy and the importance of reporting any discomfort or changes at the IV site. Empower patients to report concerns proactively.
• Central Venous Catheters (CVCs): For long-term infusions or administration of highly vesicant medications, consider using a CVC, which reduces the risk of peripheral extravasation. PICC lines may be preferred as they cause less risk of pneumothorax and are easier to insert.
• Staff Training: Ensuring all healthcare providers administering IV medications have been fully trained in current best-practice guidelines.

6. Management of Infiltration and Extravasation Injuries

The management of infiltration and extravasation injuries depends on the severity of the event, the type of fluid or medication involved, and the patient’s overall condition. General principles of management include:

• Immediate Discontinuation of Infusion: Immediately stop the IV infusion if infiltration or extravasation is suspected.
• Aspiration: Attempt to aspirate any remaining fluid or medication from the IV site using a syringe. However, this is often ineffective in extracting a significant volume of the infiltrated fluid, particularly after some time has passed.
• Elevation: Elevate the affected extremity to promote venous return and reduce swelling.
• Cold or Warm Compresses: Apply cold or warm compresses to the affected area, depending on the type of fluid or medication extravasated. Cold compresses are generally recommended for most non-vesicant infiltrations and some vesicant extravasations to reduce inflammation and vasoconstriction. Warm compresses may be used to enhance absorption of certain medications.
• Hyaluronidase: Hyaluronidase is an enzyme that can be injected subcutaneously to break down hyaluronic acid, a component of connective tissue, thereby facilitating the absorption and dispersion of extravasated fluids. It is particularly useful for extravasation of non-protein-binding drugs such as vasopressors and contrast media.
• Phentolamine: Phentolamine is an alpha-adrenergic blocker that can be injected subcutaneously to counteract the vasoconstrictive effects of vasopressors such as norepinephrine and dopamine. This helps to restore blood flow to the affected area and prevent tissue necrosis.
• Dimethyl Sulfoxide (DMSO): DMSO is a solvent with anti-inflammatory and analgesic properties that can be applied topically to reduce pain and inflammation associated with extravasation. It is most effective when applied shortly after the injury.
• Topical Corticosteroids: Topical corticosteroids can be used to reduce inflammation and itching associated with extravasation. However, their use should be limited to mild cases and with caution, as they can impair wound healing.
• Surgical Consultation: In severe cases of extravasation, particularly those involving tissue necrosis or compartment syndrome, surgical consultation may be necessary. Surgical interventions may include debridement of necrotic tissue, fasciotomy to relieve pressure, or skin grafting.
• Pain Management: Provide adequate pain management to alleviate patient discomfort. Options include oral or intravenous analgesics, depending on the severity of pain.
• Documentation: Thoroughly document the infiltration or extravasation event, including the date and time of occurrence, type of fluid or medication involved, estimated volume infiltrated or extravasated, signs and symptoms, interventions performed, and patient response.
• Follow-Up: Schedule follow-up appointments to monitor the patient’s progress and assess for any long-term complications.

7. Legal Context and Liability

Infiltration and extravasation injuries can lead to legal claims of medical negligence if they result from a breach of the standard of care. To establish negligence, a plaintiff must demonstrate that:

• Duty of Care: The healthcare professional had a duty to provide reasonable care to the patient.
• Breach of Duty: The healthcare professional breached that duty of care by failing to meet the accepted standards of practice.
• Causation: The breach of duty directly caused the patient’s injury.
• Damages: The patient suffered damages as a result of the injury.

Potential areas of liability in infiltration and extravasation cases include:

• Improper IV Insertion Technique: Failure to use proper technique during IV insertion can lead to venous trauma and increased risk of infiltration or extravasation.
• Inadequate Monitoring: Failure to adequately monitor IV sites for signs of complications can result in delayed detection and more severe injuries.
• Failure to Respond Appropriately: Failure to promptly and appropriately manage infiltration or extravasation injuries can exacerbate tissue damage and lead to long-term complications.
• Lack of Informed Consent: Failure to adequately inform patients about the risks of IV therapy and obtain informed consent can give rise to legal claims.

To mitigate legal risks, healthcare professionals should adhere to the following best practices:

• Follow Established Protocols: Adhere to established institutional protocols and guidelines for IV therapy administration and management.
• Document Thoroughly: Maintain detailed and accurate documentation of all aspects of IV therapy, including insertion, monitoring, and management of complications.
• Communicate Effectively: Communicate clearly with patients and their families about the risks and benefits of IV therapy, as well as any potential complications.
• Seek Consultation: Seek consultation from experienced colleagues or specialists when dealing with complex or challenging cases.
• Maintain Competence: Participate in continuing education and training to maintain competence in IV therapy techniques and best practices.
• Adhere to Principles of Risk Management: By taking measures to prevent and mitigate the risk of IV infiltration and extravasation, healthcare professionals can significantly lower the likelihood of injury and subsequent legal action.

8. Conclusion

Infiltration and extravasation are significant complications of IV therapy that can lead to patient morbidity, increased healthcare costs, and medicolegal risks. A comprehensive understanding of the mechanisms, risk factors, prevention, and management of these adverse events is essential for all healthcare professionals involved in IV therapy. By implementing evidence-based strategies and adhering to best practices, healthcare providers can optimize patient safety and minimize the potential for adverse outcomes. Furthermore, robust documentation and effective communication are crucial for mitigating legal risks and ensuring the delivery of high-quality, patient-centered care. Future research is needed to further refine preventive measures and improve treatment strategies for infiltration and extravasation injuries.

References

1. Dougherty, L. (2008). Extravasation: Prevention and management. Nursing Standard (Royal College of Nursing (Great Britain): 1987), 23(11), 65.
2. Gault, D. T. (2005). Intravenous infusion extravasation injuries. British Journal of Plastic Surgery, 58(2), 143–151.
3. Hadaway, L. (2007). Infiltration and extravasation. American Journal of Nursing, 107(8), 64–72.
4. Infusion Nurses Society. (2021). Infusion therapy standards of practice. 8th ed. Wolters Kluwer.
5. Reynolds, P. M., MacLaren, R., Mueller, S. W., Fish, D. N., Kiser, T. H., & Allen, R. R. (2014). Management of extravasation of intravenous medications. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 34(11), 1169–1188.
6. Schrijvers, D. L., Bolderston, A., Heggie, J., Davidson, A., & Craft, A. (2008). Management of cytotoxic drug extravasation: guideline update. Journal of Clinical Oncology, 26(28), 4864–4868.
7. Wiklund, I., Stegmayr, B., & Asplund, K. (1991). Phlebitis and thrombosis associated with peripheral intravenous catheters. A prospective study. Acta Medica Scandinavica, 229(5), 473–479.