Complications of Intravenous Therapy

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					  Complications of
Intravenous Therapy
   Principles of IV Therapy
           ADN136
          Fall Qr 09
     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
        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
             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.
                     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
                       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.
                     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
                   Hematoma
                   Prevention
   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
                   Hematoma
                   Treatment
   Apply direct, light pressure for 2-3 minutes
    after needle removed
   Have patient elevate extremity
   Apply Ice

   Document
                 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
               Thrombosis
     Types of Thrombus or occlusion
   Persistent withdrawal occlusion
   Partial occlusion
   Complete occlusion
   Fibrin tail
   Fibrin sheath
   Mural thrombosis
   “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
                                                                    “Reopen the Pipeline”, Hadaway C, Nursing. 2005,
Symptom: Unable to aspirate
                                                                                          35(8)
                  Thrombosis
        Types 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
                      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
                    Thrombosis
   Treatment
       Never flush a cannula to remove an occlusion
       Discontunue the cannula
       Notify the physician and assess the site for
        circulatory impairment


   Document
                      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
                          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
                        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
Chemical Phlebitis - Nafcillin
                          Phlebitis
                          Bacterial
   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
                        Phlebitis
                       Postinfusion
   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
                   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
                          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
                 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
               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
               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
                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
                 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
                  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
                     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
                     Infiltration
   Signs and Symptoms
       Coolness of the skin around site
       Taut skin
       Dependent edema
       Absence of blood return
       “Pinkish” blood return
       Infusion rate slows
                     Infiltration
   Complications fall into 3 catagories
       Ulceration and possible tissue necrosis
       Compartment syndrome
       Reflex sympathetic dystrophy syndrome
Infiltration – What else is wrong with
this picture?
Cellulitis from PIV
                   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
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
                  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
                     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
              Extravasations (cont)
   Prevention (cont)
       Site of venous access
       Condition of the patient
           Vomiting, coughing, retchin
           Sedated
           Unable to communicate


       Treatment
Extravasation
Phenergan – Intra-arterial
Phenergan Intra-arterial
Dilantin Extravasation
             Other Complications
   Local infection:
       Microbial contamination of the cannula or the
        infusate
       Thrombus becomes infected
   Venous Spasm: a sudden involuntary
    contraction of a vein or an artery resulting in
    temporary cessation of blood flow through a
    vessel
        Systemic Complications
   We will cover when we talk about Central
    Venous Access Devices