Horrified: possible accidental arterial infusion - page 2
by Southgoing Zax 12,154 Views | 23 Comments
I had a patient yesterday who was hypoglycemic. Previously, I'd placed her IV in that diagonal vein in the AC that I've used 100x... Or so I thought. She had an episode of hypoglycemia and had to get D25%. I started slow pushing... Read More
- 1Jul 3, '12 by jadelpn GuideIf it were an existing SL, especially in the AC, it can and does infilltrate especially if the patient is bending arm. The moment that I saw that there was any irritation, discoloration, or met with any resistance,, would be when I would call a co-worker to attempt another IV in an alternate location, while I monitored the patient. Or your charge nurse for assistance. VERY important to make sure that you have no IV's needing rotating, or flushing with your assessments. The time to find out you have a bad IV is not when you are needing one stat. I understand that timing is of essence when someone is hypoglycemic and you need to get the dextrose in, but you need to err on the side of caution and what you are describing sounds to me like an infiltrate. Also be mindful of the IV gauge. If you are pushing dextrose through a 22, that is not easy, and can cause issue. IV's that are going to stay in are not ideal in the AC. If you have to get one in quickly for pushes and the like, that is one thing. If you have one that is staying in, then look for other sites than the AC.
- 1Jul 3, '12 by iluvivtAgree ,it's not uncommon to see the artery on top of the vein or to see an extra artery with US. Yes... you can use bedside US as one way to check your placement but you did a good assessment and had all the clues you needed to make the best decision and pull the line. I am not a great fan of US assisted PIVs though I do perform the procedure when needed. In a recent studies they have been found to have a high failure rate when compared to PIVs started in a traditional manner,with failure rates as high as 50% in 24 hrs. I have found this to be true. I have also found that the nurses have a much more difficult time assessing the sites and the infiltrations I see are much larger and caught later in the process of infiltrating. They do have a place in certain circumstances when specific and prudent guidelines are followed especially as a bridge line until a more suitable VAD can be placed if venous access still needed.
- 0Jul 3, '12 by Southgoing ZaxSo...just to clarify one more time. I understand that tissue damage from an extravasation or and infiltrate may not show up for weeks, but what about tissue damage related to an accidental arterial infusion? Given that this is not the same as an extravasation or infiltration, since infusions were entering the circulatory system and NOT the surrounding tissue (albeit in the wrong place) is there any reason to suspect that late-onset tissue damage will be a problem?
- 0Jul 3, '12 by Southgoing ZaxI'm glad to learn all of this as well, although at this point, the thought of getting back on the horse and taking care of patients makes me want to 1) puke and 2) run and hide. This is THE WORST thing that has ever happened to me, and I'm petrified for my patient!!!!! I want to DO something proactive, but what? It's all charted in descriptive detail, incident report filed, etc., and the patient's arm continues to be fine (now nearly 2 days out.) How awful! I'm just so worried that this period of being asymptomatic is a sort of false reassurance, and I'm really hoping someone can clarify whether a long period of being asymptomatic can still be followed by tissue damage.
- 0Jul 3, '12 by ~*Stargazer*~Tissue damage related to accidental arterial infusion is a result of the medication infusing into smaller and smaller vessels and into the capillaries, then the tissues. In this way, it would be similar to extravasation (in the case of D25, it would be considered extravasation rather than infiltration because D25 is a vesicant).
So, you would be looking for signs of tissue sloughing first in the distal tissues, i.e. the fingertips. Although I do not know the time frame from infusion to signs of tissue damage, I would think a delay would not be unusual since the damage is occurring under the skin and not visible to the naked eye.
On the other hand, since there are a lot of sensory nerve fibers in the fingertips, I would imagine that the patient would experience pain within a relatively brief time frame, were tissue damage occurring. So, that is what I would be assessing is for the presence of s/s of an inflammatory response in the fingers and hand of the affected extremity.
Wish I could help you on the time frame thing, but I think I'd take IVRUS and iluvivt's word for it. They seem to know what they're talking about.
- 0Jul 3, '12 by Asystole RNQuote from Been there,done thatThere is a reason why Dextrose >10% is run through a central line and not even through a peripheral. Dear God dextrose is not a pleasant drug to tissue.I remain confused. Why are you concerned about tissue damage, if the glucose entered the circulatory system via an artery?
BTW , having an MD in agreement with the plan "Don't impress me much"
- 1Jul 3, '12 by Asystole RNQuote from Southgoing ZaxYes it can happen.So...just to clarify one more time. I understand that tissue damage from an extravasation or and infiltrate may not show up for weeks, but what about tissue damage related to an accidental arterial infusion? Given that this is not the same as an extravasation or infiltration, since infusions were entering the circulatory system and NOT the surrounding tissue (albeit in the wrong place) is there any reason to suspect that late-onset tissue damage will be a problem?
Microthrombi can develop and take days to weeks to fully damage tissue. I just placed a PICC into a patient who developed microthombi in his right hand, cause unknown, and his fingers are slowly necrosing. Half of his 1st and 2nd digit are gone, his 3rd and forth tips are gone. It's been developing over the last 9-10 days or so.
When in doubt PULL IT OUT!