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IV Therapy Complications
Infiltration & Extravasation

Recognize, differentiate, and respond to fluid leaking into surrounding tissue, before serious tissue damage occurs.

NCLEX-RN

What Is Infiltration?

Infiltration occurs when a non-vesicant IV solution leaks out of the vein into the surrounding tissue. The IV catheter has dislodged or punctured the vein wall, so fluid no longer flows into the bloodstream.

Vein (blood vessel) IV catheter Fluid leaking into tissue

What Is Extravasation?

Extravasation is the same leaking process, but the escaped solution is a vesicant: a drug capable of causing blistering, severe tissue injury, and even necrosis (tissue death).

Vesicant Examples
Chemotherapy agents, dopamine, calcium chloride, potassium chloride, vasopressors.
Non-Vesicant Examples
Normal saline, dextrose solutions, many antibiotics, maintenance fluids.

Why It Matters

1
Patient safety: Unrecognized leakage can progress from mild swelling to compartment syndrome or necrosis.
2
Medication delivery: If fluid is in the tissue, the patient is NOT receiving the intended dose or hydration.
3
Frequent assessment: The nurse must routinely check the IV site, the earlier the catch, the better the outcome.

Signs at the IV Site

Swollen, cool, taut IV site Swelling (edema) Cool to touch Pale / blanched skin Pain / discomfort Slowed flow rate No blood return

The Golden Rule

1
Stop the IV infusion immediately.
2
Do NOT flush the catheter, this pushes more fluid into tissue.
3
Discontinue & remove the IV (unless aspirating vesicant first per protocol).
4
Elevate the limb and apply the appropriate compress.

Infiltration vs. Extravasation

InfiltrationExtravasation
Fluid typeNon-vesicantVesicant
Tissue damageMild, reversibleBlistering, necrosis
UrgencyPromptEmergency
AntidoteUsually noneMay be required

Warm or Cold?

Cold Compress
Used for infiltration and most vesicants. Cold causes vasoconstriction to limit spread and reduce swelling.
Warm Compress
Used for specific drugs (e.g., vinca alkaloids) to dilute and disperse. ALWAYS follow facility protocol or pharmacy.

Step-by-Step Response

1
Assess & confirm: Check for swelling, coolness, pallor, pain, slowed flow, no blood return.
2
Stop the infusion immediately, do not flush.
3
Disconnect & remove the catheter (for vesicants, aspirate residual drug first if protocol directs).
4
Elevate the extremity and apply the appropriate (usually cold) compress.
5
Notify provider, document, restart IV in a different site/limb.

Infiltration Grading

Infiltration is graded on a standardized scale. Grade increases with the size of swelling and severity of signs, where Grade \( 0 \) is no symptoms and Grade \( 4 \) is the most severe.

GradeFindings
\( 0 \)No symptoms
\( 1 \)Skin blanched, edema < 1 inch, cool
\( 2 \)Edema 1–6 inches, possible pain
\( 3 \)Gross edema > 6 inches, moderate pain, numbness
\( 4 \)Severe edema, blistering, blood product/vesicant leak

Example 1: Saline Drip

Scenario: A patient on normal saline reports the IV site feels "tight." You note swelling, the skin is cool and pale, and the flow rate has slowed. There is no blood return.

Example 2: Vesicant Drug

Scenario: A patient receiving a chemotherapy infusion complains of burning at the IV site. You observe swelling, redness, and an early blister forming.

Example 3: Don't Confuse It

Scenario: An IV site is warm, red, and the patient reports tenderness with a palpable cord along the vein, but no swelling away from the vein.

Common Mistakes

✕ Flushing the line
Never flush a suspected infiltration, it forces more fluid into the tissue.
✕ Removing too fast
For vesicants, aspirate residual drug before pulling the catheter, per protocol.
✕ Wrong compress
Applying warmth to plain infiltration can worsen swelling, cold is the safe default.
✕ Confusing with phlebitis
Warm + red = phlebitis. Cool + pale = infiltration. Don't mix them up.

Quick Summary

InfiltrationExtravasationPhlebitis
CauseNon-vesicant leakVesicant leakVein inflammation
TempCoolCool/burningWarm
ColorPalePale/redRed
First actionStop infusionStop infusionStop & remove

Question 1 of 5

A nurse suspects infiltration at a peripheral IV site. What is the FIRST nursing action?

Question 2 of 5

Which finding best distinguishes infiltration from phlebitis?

Question 3 of 5

A patient receiving a vesicant chemotherapy agent develops burning and blistering at the IV site. This complication is termed:

Question 4 of 5

For a standard infiltration of normal saline, which interventions are appropriate after stopping the infusion? Select the best option.

Question 5 of 5

Using the infiltration grading scale, a site with gross edema greater than \( 6 \) inches, moderate pain, and numbness is graded as: