Transcript Complications of Intravenous Therapy

Complications of
Intravenous Therapy
Principles of IV Therapy
ADN136
Fall Qr 09
Complications of IV Therapy
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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
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Classified according to their location
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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
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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
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Hematoma and ecchymosis demote
formations resulting from the infiltration of
blood into the tissues at the venipuncture site
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Related to venipuncture technique
Use of large bore cannula: Trauma to the vein
during insertion
Patients receiving anticoagulant therapy and long
term steroids
Hematoma
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Subcutaneous hematoma is the most common
complication
Can be a starting point for other complications:
thrombophlebitis and infection
Related to:
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Nicking the vein
Discontinuing the IV without apply adequate pressure
Applying the tourniquet to tightly above a priviously
attempted venipuncture site.
Hematoma
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Signs and symptoms:
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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
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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
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Apply direct, light pressure for 2-3 minutes
after needle removed
Have patient elevate extremity
Apply Ice
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Document
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Thrombosis
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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
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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
Symptom: Unable to aspirate
“Reopen the Pipeline”, Hadaway C, Nursing. 2005,
35(8)
Thrombosis
Types of Thrombus or occlusion
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Thrombosis related to:
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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
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Signs and Symptoms
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Fever and Malaise
Slowed or stopped infusion rate
Inability to flush
Prevention
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Use pumps and controllers to manage flow rate
Microdrip tubing for rate below50mL/hr
Avoid areas of flexion
Use filters
Avoid lower extremeties
Thrombosis
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Treatment
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Never flush a cannula to remove an occlusion
Discontunue the cannula
Notify the physician and assess the site for
circulatory impairment
Document
Phlebitis
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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
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Tender to touch and can be very painful
Phlebitis
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Mechanical:
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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
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Irritation medication or solution
Improperly mixed or diluted
Too-rapid infusion
Presence of particulate matter
Phlebitis
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Chemical (cont):
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The more acidic the IV solution the greater the
risk
Additives: Potassium
Type of material
Length of dwell:
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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
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Also called Septic phlebitis: least common
Inflammation of the intima of the vein
Contributing factors
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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
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Inflamation of the vein 48-96 hr after discontinued
Factors that contribute:
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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
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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
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Signs and Symptoms
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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
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Use larger veins for hypertonic solutions
Central lines for Infusions lasting longer than 5 days
Phlebitis Scale
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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
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Thrombophlebitis denotes a twofold injury:
thrombosis and inflammation
Related to:
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Use of veins in the lower extremity
Use of hypertonic or highly acidic infusion
solutions
Causes similar to those leading to phlebitis
Thrombophlebitis
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Signs and Symptoms
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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
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Prevention
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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
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Septic thrombophlebits can be prevented:
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Appropriate skin preparation
Aseptic technique in the maintance of infusion
Proper hand hygiene
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60% from patients skin
35% from the line itself
5% from hands
Infiltration
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The inadvertent administration of a nonvesicant solution into surrounding tissue
Dislodgment of the catheter from the vein
Second to phlebitis as a cuase of IV therapy
morbidity
Infiltration
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Related to:
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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
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Signs and Symptoms
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Coolness of the skin around site
Taut skin
Dependent edema
Absence of blood return
“Pinkish” blood return
Infusion rate slows
Infiltration
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Complications fall into 3 catagories
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Ulceration and possible tissue necrosis
Compartment syndrome
Reflex sympathetic dystrophy syndrome
Infiltration – What else is wrong with
this picture?
Cellulitis from PIV
Extravasation
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Inadvertent administration of a vesicant
solution into surrounding tissue
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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:
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Puncture of the distal wall
Mechanical friction
Dislodgement of the catheter
Examples of Vesicants
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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
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Signs and Symptoms
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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
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Prevention:
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Use of skilled practitioners
Knowledge of vesicants
Condition of the patients veins
Drug administration technique
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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)
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Prevention (cont)
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Site of venous access
Condition of the patient
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Vomiting, coughing, retchin
Sedated
Unable to communicate
Treatment
Extravasation
Phenergan – Intra-arterial
Phenergan Intra-arterial
Dilantin Extravasation
Other Complications
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Local infection:
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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
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We will cover when we talk about Central
Venous Access Devices