Infiltrations & Extravasations
By Kelli Rosenthal, MS, RN, BC, CRNI, ANP, APRN, BC
Most patients admitted to acute care hospitals will receive some form of peripheral IV therapy during their stays. While peripheral veins are convenient conduits for many therapies, it is not at all uncommon for complications to develop at or near the site of infusion.
Among the most common complications associated with peripheral infusion therapy are infiltration and extravasation. Although it is impossible to eliminate all occurrences of these complications, risks of infiltration and extravasation can be reduced by understanding how they occur, choosing the right veins and equipment for the ordered therapy, and monitoring the IV site.
The Infusion Nursing Standards of Practice define infiltration as "the inadvertent administration of nonvesicant medication or fluid into the surrounding tissue instead of into the intended vascular pathway." The INS Standards define extravasation as "the inadvertent administration of vesicant medication or fluid into the surrounding tissue instead of into the intended vascular pathway." A vesicant is an "agent capable of causing injury when it escapes from the intended vascular pathway into the surrounding tissue."
Simply put, infiltration occurs when the infusion cannula is no longer fully in the vein. This can occur from improper insertion into the vein; damage to the lining of the vein which causes it to swell, preventing forward flow of the infusate; the presence or formation of a clot within the vein or around the cannula; or if the cannula punctures (most likely to happen with metal "scalp vein" or "butterfly" needles) or erodes through the opposite wall of the vein. The catheter may also simply come out with patient movement or improper securement.
Although IV infiltrations occur frequently, most do not cause serious tissue damage. At the minimum, though, IV infiltrations cause patient discomfort and require re-insertion of an IV elsewhere, which consumes nursing time and increases the cost of supplies. More serious outcomes occur with large infiltrations or extravasations of solutions containing calcium, potassium, antibiotics, vasopressors, or chemotherapy agents, which can cause marked tissue damage.
Often, the extent of injury from infiltration or extravasation is related to how much of the fluid or medication has leaked into the tissues, and when intervention was begun. Early detection of infiltrations or extravasations may prevent nerve damage and/or tissue sloughing, which could require surgery. Failure to detect them promptly can leave the patient with permanent disfigurement and loss of function despite reconstructive surgery and potentially result in litigation.
Common signs of infiltration are:
Edema at the insertion site
Taut or stretched skin
Blanching or coolness of the skin
Slowing or stopping of the infusion
Leaking of I.V. fluid out of the insertion site.
Prevention of infiltration starts right at the time of venipuncture with choosing a vein suitable for the therapy ordered. (Choose veins that feel smooth and resilient, not those that are hard or cord-like.) Avoid areas of flexion, since this can cause the catheter to become dislodged. (If you must choose a site near an area of flexion, it may be appropriate to use an arm board. Follow institutional policy.) If the patient will need to use their hands for other activities, avoid hand veins.
The veins of the forearm, especially on the inner aspect, usually provide greater stability when anchoring the catheter, since the bones of the forearm act as a natural "splint" to support the area. Start as low in the forearm as possible without choosing a site below a previous recent venipuncture in the same vein. Avoid the inner flexor aspect of the elbow, as this area, the antecubital fossa, contains important structures such as the brachial artery and median nerve. Another reason to avoid this area is that it is difficult to assess an infiltration there until it becomes quite large, by which time the infiltrated fluid could compress these structures, causing nerve damage or tissue necrosis.
In order to maximize hemodilution of the medication, choose the smallest possible cannula that will safely deliver the infusion. This will allow blood to return to the heart with minimal impedence from the catheter, diluting the infusate and carrying it away from the insertion site. Always insert the cannula bevel up to reduce the risk of puncturing the opposite wall of the vein.
Assess the infusion site often – at least every 1 – 2 hours for patients receiving continuous infusions of vesicant or irritant solutions (or pediatric or geriatric patients), and a minimum of every 4 hours for patients receiving continuous infusions of non-irritating fluids. Sites should be visible (use of a clear, moisture-vapor transmissible dressing aids this), and should be palpated for tenderness or coolness. Pick up the patient’s arm to check for dependent edema. You may use a transilluminator or penlight as well: if a large, diffuse circle of light is visible around the I.V. site, there is subcutaneous fluid present, which is often related to infiltration if the patient is not otherwise edematous. Consider using a catheter securement or protection device to reduce the risk of dislodgement, especially in pediatric or geriatric patients.
Suspect infiltration if:
A gravity infusion slows or stops
You cannot see a blood return after lowering the infusion bag and applying pressure with your finger on the vein proximal to the tip of the cannula
You notice leakage of fluid from under the dressing
Applying a tourniquet fails to stop the infusion of fluid.
The first steps after discovering an infiltrated IV are to stop the infusion and thoroughly examine the site. If the catheter appears to be lodged in the tissues, an attempt to aspirate any fluid remaining in the catheter can be made in order to lessen the amount of drug at the site. An antidote for a vesicant or irritant medication may be infused into the intravenous catheter prior to removal in some instances – check with a nursing drug handbook or the pharmacy to find out any recommended antidote. Be familiar with your hospital policy concerning administration of vesicant, vasoconstricting, or corrosive medications and their extravasation antidotes, and intervene accordingly before discontinuing the IV site. After removing the cannula, elevate the affected arm, notify the physician (for large infiltrations and extravasations), and apply cool compresses (warm, if vinca alkaloids are involved).
Also follow your hospital’s policy for documentation, which should incorporate the INS’ Infiltration Scale.
Infusion Nurses’ Society Standards of Practice – Infiltration Scale
No signs or symptoms
Edema <1 inch in any direction |
Cool to touch
With or without pain
Edema 1-6 inches in any direction |
Cool to touch
With or without pain
Skin blanched, translucent
Gross edema >6 inches in any direction |
Cool to touch
Skin blanched, translucent
Skin tight, leaking
Skin discolored, bruised, swollen
Gross edema >6 inches in any direction
Deep pitting tissue edema
Infiltration of any amount of blood product, irritant or vesicant
Khan MS, Holmes JD. Reducing the morbidity from extravasation injuries. Ann Plast Surg 2002 Jun;48(6):628-32; discussion 632.
Intravenous Nurses Society: "Infusion Nursing Standards of Practice," Journal of Intravenous Nursing. 23(6S), 2000.
Weinstein S. Plumer’s Principles and Practices of Intravenous Therapy. 7th ed. Philadelphia, PA: Lippincott, Willliams, Wilkins; 2000. Chapters 4, 9 ,10 and 19.
Millam DA, Masoorli S. Avoiding the Pitfalls of I.V. Therapy. Nursing Spectrum Online, (2003).
Masoorli S. Infusion therapy lawsuits: an occupational hazard. Journal of Intravenous Nursing. 18 (2), 1995 88-91.
Reynolds C. Extravasation Management. 2003.
Camp-Sorrell, D. (Ed.). Access device guidelines: Recommendations for nursing practice and education. Pittsburgh:
Oncology Nursing Press, Inc., a subsidiary of the Oncology Nursing
CDC. Guidelines for the prevention of intravascular catheter-related bloodstream infections. MMWR 2002;51:1-29.