[John]

I would like recomendations for the treatment of an infiltrated IV consisting of D5 1/3ns with 40 MEQ KCL that was running at 125cc/hr. The patient was 85 years old, non-responsive in an emaciated condition. The affected arm was swollen from wrist to shoulder about 4 to 5 times the size of the unaffected arm. Weeping was present on much of the arm and decreased circulation was noted in the hand.
Other data:
Patient Weight = 100lbs
K+ = 2.8 on admit
IV has been running for 14 hours
Patient is on NG tube feeding at 40 cc/hr

I was asked for my opinion.

My thoughts include:

Warm towel and elevate arm to enhance circulation and reabsorbtion of infiltrated fluid.
Restart iv in unaffected arm.
Contact MD for further treatment orders.
Questions for MD would include:
Is IV rate too high
Need for pain medication
Document above
Complete Incident Report


My supervisor made the decision to over ride my suggestions.
Treatment used was an ice pack
The MD was not notified.
No incident report was made.
Documentation in the chart indicates a routine infiltration and restarted IV.

Patient outcome is still pending.

I would like comments on was my plan correct? What should I do now?

Replies can be sent to kc4zgq@hotmail.com

[Ron Miser]

I agree with your response to the situation the use of ice packs is not appropriate as you want to promote reabsorption of the fluid. Notifying the physician is a judgement call but if there was any circulatory comprimise they probably should have at least been notified at an appropriate time. The incident report is an institutional policy and is there only to protect the institution and help with any data collection for CQI. But I would have filed one just in case.. Hope it helps I think you were on the right track. My only other question is was the IV infiltrated or is the patients oncotic pressure so low it couldn't hold that much fluid in the vascular tree. Also the type of solution and rate in my opinion was a poor choice. The lack of sodium would only lend the fluids to go to third space and not affect the circulating volume. I would be concerned too with the patients sodium level and LOC. Hope this helps. Keep up the good work. Sometimes you have to keep pushing to facilitate change..
RON

[Ron Miser]

I agree with your response to the situation the use of ice packs is not appropriate as you want to promote reabsorption of the fluid. Notifying the physician is a judgement call but if there was any circulatory comprimise they probably should have at least been notified at an appropriate time. The incident report is an institutional policy and is there only to protect the institution and help with any data collection for CQI. But I would have filed one just in case.. Hope it helps I think you were on the right track. My only other question is was the IV infiltrated or is the patients oncotic pressure so low it couldn't hold that much fluid in the vascular tree. Also the type of solution and rate in my opinion was a poor choice. The lack of sodium would only lend the fluids to go to third space and not affect the circulating volume. I would be concerned too with the patients sodium level and LOC. Hope this helps. Keep up the good work. Sometimes you have to keep pushing to facilitate change..
RON

[Ladena]

Treatment for infiltration/extravasation is very controversial and you can find any number of people who would agree with your recommendations. I have read recommendations to use cool or cold compresses if IVF contains more than 20 meq/KCl in a litre due to KCL being a vesicant and not wanting the drug to be further distributed in the tissues, as it would be with warm compresses. And there are some sources now that disagree that you should even elevate the involved extremity due to possibility of further copromising circulation. Whatever the treatment recommended by hospital policy, drug literature or doctor's order, I think evaluation of that tx. is of utmost importance. I agree wholeheartedly that an occurence report (our current jargon)
should have been filled out for an infiltration of that size and the MD should have been notified, especially since there was some decrease in pulse noted.
The issue of appropriate IV solution is very valid. Hopefully, your concerns were addressed by the physician at some time.

[CHRIS TAYLOR]

The first thing that comes to my mind is... They have the wrong person in the Supervisor position.
Your recommendations were right on the money. I would have also measured the circumference of both the lower and upper arm and done this on a daily basis until resolved.
Our current practice includes the use of an "Infiltration Scale" that grades from 1 to 5, much like the Phlebitis Scale. This can be found in "Intravenous Therapy, Clinical Principles and Practice." It is put out by the INS. This book is wonderful!!!!!
We also check peripheral sites every 2 hours that have continuous infusions running through them (this comes from CDC recommendations). This may have avoided alot of problems with your patient.

[shastacicuRN]

With an infiltration, I have used a warm moist compress around the affected limb. Wrap a plastic bag around the moist compress to keep it warm longer and elevate the limb only slightly. Change the compress as needed, until the edema has gone down. Usually charting about the infiltration is sufficient. No need to call the M.D. I agree with frequent checks of the IV sites as a preventive measure.... but you can't always do that if other emergencies come up unexpected.

[Binkey]

Originally Posted by John

I would like recomendations for the treatment of an infiltrated IV consisting of D5 1/3ns with 40 MEQ KCL that was running at 125cc/hr. The patient was 85 years old, non-responsive in an emaciated condition. The affected arm was swollen from wrist to shoulder about 4 to 5 times the size of the unaffected arm. Weeping was present on much of the arm and decreased circulation was noted in the hand.
Other data:
Patient Weight = 100lbs
K+ = 2.8 on admit
IV has been running for 14 hours
Patient is on NG tube feeding at 40 cc/hr

I was asked for my opinion.

My thoughts include:

Warm towel and elevate arm to enhance circulation and reabsorbtion of infiltrated fluid.
Restart iv in unaffected arm.
Contact MD for further treatment orders.
Questions for MD would include:
Is IV rate too high
Need for pain medication
Document above
Complete Incident Report


My supervisor made the decision to over ride my suggestions.
Treatment used was an ice pack
The MD was not notified.
No incident report was made.
Documentation in the chart indicates a routine infiltration and restarted IV.

Patient outcome is still pending.

I would like comments on was my plan correct? What should I do now?

Replies can be sent to kc4zgq@hotmail.com

As an educator for infusion therapy, I encourage the use of warmth for an infiltrated IV site, but only if you have an isotonic solution or you have had an extravasation of a vinca-alkaloid. Everything else should have ice as you want to decrease the uptake of these damaging fluids by the tissue. As for as elevation of the extremity, I leave that up to the patient... If the patient feels better with it elevated, I do so. Studies have not proven a benefit one way or the other with elevation.
If the arm was swollen 4-5X from baseline, You definetly should have contacted the MD. Your worries include arterial compression from all the accumulated IV fluid. Was the IV fluid going to fast? Not necessarily... But certaintly it appears to be neglect from nursing as they should have "caught" it way before you had this gross infiltrate.
An incident report, I believe also should have been filed as they are an internal tool to monitor quality of care.. which in this case was lacking.
Hope this helps..
DD