I have had the opportunity to review quite a few cases that involved IV infiltration/extravasation and have been deposed in two of those cases.  But can one assume that all IV infiltrations suggest negligence on the part of the nursing staff caring for the patient?

IV sites infiltrate every day through no fault of the nursing staff.  Some of the causes of IV infiltration/extravasation that are not necessarily controlled by the nursing staff include high delivery rate of fluid, high pressure from the pump device, obstruction of blood flow through the catheter, and phlebitis.  The signs and symptoms of infiltration/extravasation include:  1) infusion of fluid slows or stops, 2) skin around the IV site is cool to the touch, 3) skin is tight, 4) swelling, 5) absence of diluted blood return, and 6) pain.  Complications from IV infiltration/extravasation include tissue damage, including necrosis, compartment syndrome, and reflex sympathetic dystrophy syndrome.iv-infiltration-jpg

The nurse’s responsibility lies in the close monitoring of peripheral IV sites and recognizing signs and symptoms of infiltration/extravasation in a timely manner, infusing only fluids that are acceptable for peripheral IV sites, and using the correct size catheter.  Detailed documentation of IV site assessments is imperative in the care of the patient.  IV sites should be numbered and have the fluids/medications infusing listed.  Check marks in a box saying the IV site was evaluated is not an acceptable or complete method to document assessments of IV sites.  IV’s that are closely monitored for signs of infiltration/extravasation should not result in severe complications in the event that an infiltration/extravasation does occur.  If an infiltration/extravasation does occur immediately stop the infusion of fluid/medication.  If the IV was infusing medication attempt to aspirate the medication prior to discontinuing the IV catheter.  Warm or cold compresses may then be applied to the site depending on the hospital policy.

Considerations for Picking the Correct Vascular Access Device

Extravasation of vasoactive substances (eg, dobutamine, dopamine, epinephrine, norepinephrine, and vasopressin) can result in ischemic necrosis because these substances reduce blood flow by causing severe constriction of smooth muscles around capillaries.  In addition, solutions with high electrolyte concentrations (eg, calcium chloride 5.5% or sodium chloride 3% or 5%) can prolong the depolarization and contraction of pre- and postcapillary smooth muscle sphincters, which, in turn, prolongs exposure to injurious substances and leads to ischemia and tissue necrosis (Darcy Doellman, et al., 2009).  Most institutions have policies regarding the need for central line access for the infusion of vasoactive medications except in an emergency situation.a3aa71367cbeeca56a74740a2df5a8e2 (1)

Drugs with a pH below 5, including Vancomycin, should not be infused through a peripheral vein, according to current Infusion Nurses Society standards of practice.  Occasionally, Vancomycin is prescribed until culture results are known.  In these cases a central venous catheter may not be inserted until the diagnosis is confirmed, and a peripheral catheter is the only choice.  To limit the potential for vein irritation and extravasation, the use of a small-gauge catheter, such as a 24-gauge, in the largest peripheral vein possible is necessary (Lynn Hadaway, 2004).



Works Cited

Darcy Doellman, B. R., Hadaway, Med, RN, BC, CRNI, L., Bowe-Geddes BS, RN, CRNI, L. A., Franklin, BSN, RN, MBA, CRNI, M., LeDonne, MD, J., Papke-O’Donnell, MSN, RN, CRNI, L., & Pettit, MSN, RNC, NNP, CNS, J. (2009, July/August). Infiltration and Extravasation: Update on Prevention and Management. Retrieved from Nursing

Lynn Hadaway, R. C. (2004). Giving Vancomycin Safely. Nursing , 17.









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  1. Jane K. German

    Thank you for sharing this article. I have worked on numerous cases regarding same for which many of these cases settled and might not have knowing this information.

  2. Lynn Hadaway

    Your post showed up on my Linkedin page today but I am not a member of your group so can’t put my comments there. Since I am one of the referenced authors on your post, I wanted to share several additional points. I have also been an expert on hundreds of legal cases involving infiltration and extravasation. Your post only mentioned monitoring the site, but nursing responsibility starts way before the monitoring stage. I was also disappointed to see that the Standards of Practice from the Infusion Nurses Society was not mentioned as this is the primary guidance document for prevention of this horrific complication. The problems I find in reviewing these cases are directly addressed by these standards. Site selection is probably the most important preventive step. Do not place a peripheral catheter in an area of joint flexion. Use an engineered catheter stabilization device and not tape. Catheter selection should be smaller not larger. Finally know the type of drug being given. Is it a vesicant or not? Assessment must include obtaining a blood return before each medication is given – again from INS standards. Treatment requires thermal manipulation depending upon the drug but too many nurses think that heat is always used. Finally, there is a recent updated literature review published in January issue of the Journal of Infusion Nursing about pH. This does not produce as much vein damage as originally thought, so watch for the next edition of the INS standards to have some changes on that issue. Small infiltration (nonvesicants) do occur but careful, frequent assessment will identify this early. Extravasation (vesicants) can be prevented when the nurse employs the standard of care for all the factors I mentioned plus monitors that infusion every 5 to 10 minutes, also a recommendation in a white paper from INS. And don’t forget that this complication is not limited to peripheral catheters as it is well documented to occur with all types of central venous catheters as well. Thanks for drawing attention to this serious complication. Lynn Hadaway

    • Carol

      Thank you Lynn for your excellent commentary. Rest assured I am aware of the INS standards and have utilized them when reviewing such cases as an expert. I find your comment regarding monitoring the infusion every 5-10 minutes interesting and wonder if you have any literature I could access with this type of time frame. I recently was an expert in a case (patient was intubated in an ICU under sedation) and the IV site was monitored every 4 hours. There were multiple issues with the case but the extravasation of Propofol (and probably leaving an IV site, with documented swelling, over 4 hours before discontinuing the IV) left the young woman with compartment syndrome and a hand that will never be functional (after multiple plastic surgeries). After my deposition the hospital did settle but the case went to trial for the physician’s care of the patient in the case. Thanks again for your input!

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