Nurses live a life of IVs. They deliver infusion IV therapy to many millions of patients in hospitals, homecare, long term care facilities, outpatient clinics, and physicians’ offices annually. RNs and LPNs perform many daily activities involving the safe delivery of IV therapy fluids and medications. IV therapy and vascular access devices have become so common in nursing care that it is easy to forget that serious, sometimes life-threatening complications can arise from improper fluid or drug delivery. Patient safety requires that nurses take precautions to avoid complications that are associated with infusion therapy.

Routine vigilance is a patient’s best protection

Much of what we do with IV lines may seem basic and routine, but specific guidelines ensure patients’ safety. For example, IV site maintenance infusion therapies can only be initiated when ordered by the physician or an approved provider, such as a nurse practitioner. The order should include the IV flow rate. Remember that “keep open” (KVO)1 or “wide open” are not appropriate orders because they do not specify a rate of flow. Primary and secondary continuous administration sets for peripheral and central venous catheters, including parenteral nutrition, need only be changed every 72 hours. However, primary intermittent administration sets often used for IV antibiotics need to be changed every 24 hours. All IV bags of solutions should be changed every 24 hours because solutions left hanging longer than 24 hours can be the source of bacterial growth. Infusing contaminated IV solutions can lead to sepsis and patient death. When extension tubing and needleless end caps are used on IV catheters, they should be changed at least weekly.¹ Although evidence-based practices have yet to evolve, Infusion Nurses Society has recently published new standards http://ins1.org/standards, while the Association for Vascular Access has weighed in with its own position papers www.avainfo.org/website/article.asp?id=1441.

The singular peripheral

Practitioners insert more than 5 million peripheral IV catheters into patients each year.² This device is by far the most commonly used venous access device. In choosing size, a 22-gauge IV catheter is appropriate for the infusion of peripheral IV fluids and medications in adult patients. On the other hand, a small 24-gauge catheter is appropriate for neonates, pediatrics, geriatric patients, and patients with small-lumen veins.

Even though a 20-gauge catheter is the most appropriate size catheter for adult blood transfusions, a 22-gauge catheter can safely infuse packed red blood cells into adults without damage to the red cells. A 24-gauge catheter is the most appropriate size for blood transfusions in neonates.

IV solutions or medications with a pH lower than 5 or higher than 9 and with a serum osmolality greater than 600 mOsm/L should be infused through a central venous catheter to prevent injury to the lining of the vein.¹ Commonly infused medications, such as vancomycin (Vancocin), promethazine (Phenergan), and concentrated potassium chloride infusion, all fall out of the safe range for peripheral infusions. Vancomycin, which has a pH of 2.4, the same as stomach acid, cannot be diluted to a safe pH level for peripheral administration.³ The optimal infusion site for this caustic medication is a central venous catheter. Promethazine must be diluted before infusing. It is recommended that or 25 mg (1 cc) of promethazine be diluted in a minimum of 9 cc of NSS and injected over one minute.⁴ Many hospitals have specific policies that 25 mg to 50 mg of promethazine be diluted in 50 cc of NSS and infused over 10 minutes. If the patient complains of pain or burning at the IV site during the infusion, the nurse should recognize that the drugs may be injuring the lining of the vein. The appropriate nursing intervention is to stop the infusion, dilute the medication when possible, or change the IV site to a larger vein or administer the medication through a central venous catheter.¹

Peripheral IV catheters that are capped for intermittent use should be flushed with 3 cc normal saline daily and/or after each use. Heparin is no longer the flush agent of choice for peripheral access devices.¹

The leaky IV

Infiltration, the leakage of nonvesicant fluid into tissues surrounding the vein, is not entirely avoidable.⁵ Catheters can puncture the vein wall or pull out of the vessel simply with patient movement. Obtaining a blood return does not guarantee correct placement of the catheter within the vein. For instance, IV catheters inserted into a small vein or into a dehydrated patient may prevent a return of blood by conventional methods, such as pulling back on a syringe, dropping the bag below heart level, or pinching the IV tubing.⁶ Also, poor circulating blood volume may not allow for a blood return if the blood pressure is too low, even when the catheter is in the vein.⁶ Routinely assessing for infiltration by noting skin temperature and observing for swelling around the IV site will prevent large infiltrations from occuring.^5,6 Procedures for securing catheters need to provide clear visibility of the access site and allow for monitoring skin integrity.¹

When a large amount of IV solution enters the tissues, nerve compression injuries can result. The weight of the solution in the tissues can compress nerve endings, causing patients to have symptoms of numbness and tingling within the swollen area. In this situation, the provider should be notified immediately. This is an emergency situation and a surgical fasciotomy may be needed to release the fluid pressure in the tissues. Warm or cold compresses and elevation of the infiltrated extremity are no longer the standard of nursing care for infiltration. Nurses should monitor the swollen area for any changes.⁵ Nursing documentation of an infiltration should include measurement of the swollen area.

A more serious leak

Extravasation is the inadvertent administration of a vesicant drug into the surrounding tissue that can cause tissue necrosis. Initially the extravasation presents as swelling at the IV site, but progresses over time from blisters, to blackened scabs, and finally to tissue sloughing. Nonchemotherapy vesicants include potassium chloride, calcium chloride, calcium gluconate, magnesium sulfate, phenytoin (Dilantin), and promethazine.^1,4

Many chemotherapy vesicants have their own recommended extravasation protocols, and institutional policy should dictate clearly what is to be done before the catheter is removed.⁶ If an extravasation is suspected, stop the infusion immediately, notify the physician, and consult with a pharmacist for treatment recommendations. Small extravasations do not result in serious injury to the patient. Large amounts of vesicant drugs in the tissue can result in severe damage requiring multiple debridements, partial- or full-thick skin grafts, and in some cases amputation.² Nursing documentation should include a measurement of the swollen area.

The inflamed vein

Phlebitis, inflammation of the vein, is a complication of IV therapy. However, clinicians can easily prevent this with close observation and timely IV device changes. IV sites should be changed on a regular basis, generally every 72 hours. However, an IV site may become tender in only a few hours, and the phlebitic process can continue for 48 hours after the catheter is removed.

The types of phlebitis include mechanical, due to vein injury from a large catheter in a small vein, or chemical, from solutions with a high or low pH and high osmolality (greater than 600 mOsm/L).¹ Bacteria at the catheter tip or at the insertion site may cause bacterial phlebitis. All peripheral IV catheters should be removed when the patient complains of pain or discomfort at the IV catheter site.¹ Phlebitis can advance to suppurative thrombophlebitis if the catheter is not removed at the first presenting symptoms of phlebitis. All IV sites are to be observed for 48 hours after the catheter is removed. If the patient is being discharged, he or she should receive written instructions about what to look for and who to call in the event of a complication.¹

Catheter-related sepsis

IV catheter-related sepsis can occur from poor catheter insertion technique or if phlebitis is allowed to progress. Bacteria from an IV site may migrate through the bloodstream causing fever, chills, malaise, and an elevated white blood cell count.² The IV line should be removed and two blood cultures obtained from two different venipuncture sites.² A positive blood culture with a possible IV catheter-related sepsis is indicated by the growth of more than 15 colonies of a specific bacteria. The most common organism, which can cause catheter related sepsis, is staph epidermidis.² Although this occurs primarily with central venous catheters, the risk exists with any indwelling catheter. Implications for proper skin disinfection, handwashing, and skillful venipuncture are obvious. Current evidence-based guidelines recommend cleansing peripheral sites with a chlorhexidine solution.¹ According to the CDC 2002 intravascular catheter guidelines www.cdc.gov/ncidod/dhqp/gl_intravascular.html, chlorhexidine is the gold standard for skin preparation prior to IV catheter insertion. When prepping the skin with chlorhexidine, cleanse the IV site from side to side, not in concentric circles.² Chlorhexidine has a residual effect on the skin for over 48 hours. The CDC also recommends the use of a catheter-stabilization device to minimize catheter movement in the vein. When the catheter moves, bacteria on the skin can be brought into the vein and the vascular system, resulting in a blood stream infection.

Danger points — nerve injury

A common peripheral-IV insertion-related complication is nerve injury due to direct needle contact with a nerve. With each insertion of an IV device, nerve contact is a risk. The radial and median nerves are most often injured during the IV insertion procedure and the blood drawing procedure. When a needle point comes in direct contact with a nerve, the patient will immediately experience an electric-shock sensation that radiates down into the fingers. The appropriate nursing intervention is to immediately remove the IV catheter. The resulting injury may be a neuroma — scar tissue on the nerve at the point of needle contact, which may require extensive physical therapy and possible surgery. The lower inner aspect of the wrist and the three inch area just above the thumb are the two locations where nerve injury is likely to occur because the nerves are superficial in these locations. A possible sequelae to nerve injury is complex regional pain syndrome (formerly called reflex sympathetic dystrophy). This is a painful, progressive, permanent disability. Symptoms of this injury may include a painful, cold, mottled hand that sweats excessively. Injury to the median nerve, in the lower inner aspect of the wrist, can result in carpal tunnel syndrome. Nerve injury is easily diagnosed by means of nerve conduction studies which can pinpoint the specific area of injury, as well as, the severity of the nerve damage.

IV complications, such as phlebitis and infiltration, can be reduced if catheter tips are not located in areas of flexion, such as the antecubital fossa and wrist sites; small gauge catheters (22 g to 24 g) are used whenever possible; and nontraumatic cannulization techniques are employed.⁵ Vein trauma may result in pain, bruising, infiltration, phlebitis, and infection. Nurses who initiate venipuncture must receive adequate education and supervision of techniques until their competence is validated. A nurse should attempt no more than two cannulizations and, if vein assessment proves the veins are inaccessible, a peripherally inserted central catheter (PICC) may be an appropriate alternative device. Keep in mind, you should not perform a procedure if you feel you are not qualified to do so safely and competently.

Documentation that works

All IV therapy procedures, including catheter insertion and removal, and routine monitoring of IV sites, must be documented in the patients’ medical records to avoid legal pitfalls. The current standard of nursing care is to document IV insertion sites by using appropriate anatomical names of the accessed veins. It is no longer clinically or legally acceptable to document IV insertion sites by arm and hand geography, for example, “IV inserted into left forearm.” The appropriate documentation would be: “IV inserted into the left mid-cephalic vein.” Using this documentation format also validates the nurses’ knowledge of the venous anatomy of the upper extremity.

Documentation of an IV insertion should include date and time; anatomical name of the accessed vein; the gauge, length, and brand of the device; number of attempts; and identification of the person who inserted the device. Patient comments are an essential component of the documentation. Quote the patient’s response to the procedure to complete the documentation, instead of using common nursing clichés, such as “Patient tolerated the procedure well” and “IV infusing well.”¹ An example of proper documentation of a routine insertion might be: “12/1/06, 10 AM. #22 gauge, one-inch Introcan® inserted into right mid-cephalic vein on the first attempt. Capped and flushed with saline. Patient states, ‘My arm feels fine.’ Mary Nurse, RN.”⁶

When monitoring IV sites where no problems are observed, it’s best to document that fact, for example: “12/5/06, 2 PM. No signs of IV-related complications observed.” If a problem occurs that requires discontinuing and removing the IV device, documentation should include the reason why the catheter was removed and a description of the IV site. In the event of a complication, include a description of the severity of the injury, the nursing intervention, and the patient’s comments. An example of documentation of a complication might be: “12/10/06, 10 AM. IV in right mid forearm extravasated with calcium chloride. A two by three-inch area is swollen, hard, and cold. The IV device was removed and Dr. Smith was notified. Will continue to monitor the IV site. Patient states, ‘This spot feels cold, but it is not painful.’ Joe Nurse, RN.” Institutional policy may mandate that the nurse complete an incident or variance report. This documentation can aid in the internal peer review to identify any consistent problems.

The number of patients with peripheral IV catheters is increasing each year. Nurses are responsible for inserting peripheral IV devices and monitoring existing IV sites for early symptoms of IV-related complications. Patient safety is the main goal for nurses who are responsible for inserting peripheral IV catheters, monitoring IV sites, and administering intravenous fluids and medications. Frequent assessment of IV sites will prevent devastating patient injuries.