Never Use An Intravenous Line Without Palpating and Inspecting It Visually

Ryan C. McHugh MD

Juraj Sprung MD, PhD

Intravenous (IV) infiltration is the unintentional extravascular leakage of IV fluid. Signs of infiltration include tissue edema, skin blanching or erythema, and skin temperature change. Patients may report pain and tightness around the IV site. Sites that are commonly infiltrated include the hand, forearm, and antecubital fossa, which are the most frequent sites of IV placement. Patient populations associated with higher rates of infiltration are critical care and oncology patients, owing primarily to the increased number of IV lines placed at a given time and the number of times that veins need to be accessed (e.g., repeated treatments with cytotoxic agents). Age groups at highest risk include the elderly and neonates. Neonates have small vessels and immature skin, whereas elderly persons have fragile vessels and skin. Placement of the IV outside the vessel in loose subcutaneous skin may mimic proper IV placement. Before use, every IV should be inspected visually for IV infiltration.

PERIOPERATIVE IV FLUID CONCERNS

Perioperative IV fluid therapies include crystalloids and colloids. Crystalloids are water-based solutions, usually with low-molecular-weight salts (vs. ions), whereas colloids contain high-molecular-weight proteins or glucose polymers. Another type of infusing material, called vesicants, has greater potential for substantial cellular injury. Vesicants include radiocontrast dyes, pressor agents, and chemotherapy solutions. In theory, colloid solutions may increase extravascular fluid content after infiltration by drawing fluid out of the cells, whereas any hypotonic solution may lead to cellular rupture after fluid absorption. Dyes act more like hypotonic solutions and include methylene blue and indocyanine green. Infiltration with these dyes may result in severe skin discoloration, but this effect is not permanent. The duration of discoloration is dependent on the rate of dye (fluid) reabsorption from the extracellular space, usually 12 to 24 hours. Hyaluronidase injected in multiple sites around the infiltration site has been used to treat mannitol infiltration.

INTRAOPERATIVE MONITORING

Before anesthetic induction, initial palpation of the IV site is recommended. If fluids (or medications) are administered by syringe extravascularly, they
may elicit high pressure on injection, causing pain in awake patients. Relying on a free-flowing IV may lead to false positives, particularly in the elderly, for whom loose skin may allow easy infiltration. For catheters that are not located in an extremity, such as central lines, be mindful of which vein the catheter is expected to enter because infiltration will depend on its position in the body; extravasated fluid may leak into the arm, chest wall, or neck. Positive aspiration of blood must be achieved, providing the IV was placed in the major central vein. Transducing the catheter should be done to confirm venous placement of a central line.

If the extremity is exposed during surgery, continuous monitoring of the IV site for edema or blanching are necessary. Jewelry such as rings should be removed before surgery, especially for arms that are tucked in (placed along the body and covered with drapes) and arms in which the IV catheter has been placed. However, the frequent practice of tucking in arms requires careful IV monitoring. Should the IV stop flowing intraoperatively, full inspection of the IV site must be made. Facilitation of a sluggish IV by using “pressure bags” should not be done until the site is properly inspected for signs of possible extravascular infiltration.

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