IV infiltration

[AllyRN, BSN]

So, I was discussing with this nurse about one of her patients. Her patient is a VERY hard stick. So difficult to the point where are IV team has put that patient on a “no more sticks” list because they have poked him about 11 times in 3 days, way past the hospital policy. Anyways, she said her patients IV site has no s/s of infiltration/phlebitis. But the patient said it was a slightly sore when she palpated it to check for and bubbling/infiltration. The IV flush perfectly, no signs or infiltration. We had the IV nurse come in to assess. She said because of the discomfort, it probably shouldn’t be used. We talked to other nurses who knew this patient better and they told her because there’s no s/s of infiltration/phlebitis, we should get a KVO (keep vein open) so we can at least have access just in case of an emergency due to the fact that it flushes well and with no s/s. Since it was night shift, the night float doctor agreed and said he would discuss with the NP in the morning for possibly a more permanent IV access. So the order was in place for 10 ml/hr to keep the vein open until they figured out what to do. The patient did not complain of any pain with IV fluid or flushing. Is this appropriate? Or should the IV been taken out immediately?

[iluvivt, BSN, RN]

While you may not feel a palpable cord or any erythema, inflammation or warmth along the vein pathway, pain and discomfort can be an early sign of phlebitis or even a very early infiltration. One thing you left out is how long had the line been in place and what had been infusing through it.Those pieces of information are useful in making the best decision for your patient.With only the information you provided me if I chose to leave the PIV in I would up my assessment frequency.If it is indeed "going bad" it will only get worse with time and that will soon be apparent. If ,however, it is a fairly new line,the medications and/or fluids are not irritating and the patient tends to be hypersensitive it may still be good.Keep in mind the average PIV has a dwell time of 44 hours before it becomes symptomatic...I said average now and have seen many PIVs last longer, but it's helpful to know that.The odds are it's on the way out.11 venipunctures in 3 days is not as bad as it may seem because it is all relative to the benefit the patient is going to receive by getting his IV antibiotics or other IV therapies. But you are correct in assessing the availability of the peripheral veins and then determining if they can sustain the currently prescribed IV therapies and if not some other type of access needs to be obtained...Midline,PICC or other type of CVAD...perhaps an EJ if there is a short term need

[MunoRN, RN]

Discomfort or soreness, particularly when the site is being palpated, is not by itself an indication that the catheter should be removed, and considering there is a retained impaled object in the arm, discomfort is not an unusual finding.

Assessment for infiltrations should instead be based on validated infiltration indicators. Using a KVO infusion hasn't been shown to improve identification of infiltration or to help maintain the patency of the line. Flush and assess for infiltration and phlebitis at appropriate intervals instead.

[MunoRN, RN]

9 hours ago, iluvivt said:

While you may not feel a palpable cord or any erythema, inflammation or warmth along the vein pathway, pain and discomfort can be an early sign of phlebitis or even a very early infiltration. One thing you left out is how long had the line been in place and what had been infusing through it.Those pieces of information are useful in making the best decision for your patient.With only the information you provided me if I chose to leave the PIV in I would up my assessment frequency.If it is indeed "going bad" it will only get worse with time and that will soon be apparent. If ,however, it is a fairly new line,the medications and/or fluids are not irritating and the patient tends to be hypersensitive it may still be good.Keep in mind the average PIV has a dwell time of 44 hours before it becomes symptomatic...I said average now and have seen many PIVs last longer, but it's helpful to know that.The odds are it's on the way out.11 venipunctures in 3 days is not as bad as it may seem because it is all relative to the benefit the patient is going to receive by getting his IV antibiotics or other IV therapies. But you are correct in assessing the availability of the peripheral veins and then determining if they can sustain the currently prescribed IV therapies and if not some other type of access needs to be obtained...Midline,PICC or other type of CVAD...perhaps an EJ if there is a short term need

I'm curious of source for "the average PIV has a dwell time of 44 hours before it becomes symptomatic." In the largest study of IV rotation practices, the median dwell time of catheters rotated when indicated was 99 hours, and most of those were removed because the IV therapy course had completed, not due to site complications.

Generally though, the evidence based practice has moved away from utilizing time as an indicator of risk for complications since it has shown to be an unreliable indicator.

[JKL33]

21 minutes ago, MunoRN said:

Discomfort or soreness, particularly when the site is being palpated, is not by itself an indication that the catheter should be removed, and considering there is a retained impaled object in the arm, discomfort is not an unusual finding.

This. Having an object stuck in your arm does not feel the same as not having an object stuck in your arm.

As I was reading the OP I was even wondering if the patient has been poked so many times partially because of a lack of objectivity about when an IV site is bad. I would never leave a catheter in place if a patient had complaints about it or wanted it removed or refused to have it remain in place. At the same time, there is room for assessing whether it is painful (becoming inflamed) vs. just feeling different (the difference being an ever-so-mild discomfort that one doesn't usually experience when an object is not stuck in the arm). These things can usually be successfully discussed with a patient.

[brownbook]

If it was infusing subcutaneously, giving IV fluids subcutaneously is an acceptable practice. So you weren't potentially harming the patient. BUT this route is only used for hydration. A subcutaneous site cannot be used for any "emergency" meds.

[MunoRN, RN]

2 hours ago, JKL33 said:

This. Having an object stuck in your arm does not feel the same as not having an object stuck in your arm.

As I was reading the OP I was even wondering if the patient has been poked so many times partially because of a lack of objectivity about when an IV site is bad. I would never leave a catheter in place if a patient had complaints about it or wanted it removed or refused to have it remain in place. At the same time, there is room for assessing whether it is painful (becoming inflamed) vs. just feeling different (the difference being an ever-so-mild discomfort that one doesn't usually experience when an object is not stuck in the arm). These things can usually be successfully discussed with a patient.

The "if in doubt take it out" way of thinking is still out there, even though it's no longer good practice. And isolated findings of soreness or discomfort at the site, which is not an abnormal finding, certainly does not justify the risks associated with repeated unnecessary insertions.

[iluvivt, BSN, RN]

5 hours ago, MunoRN said:

I'm curious of source for "the average PIV has a dwell time of 44 hours before it becomes symptomatic." In the largest study of IV rotation practices, the median dwell time of catheters rotated when indicated was 99 hours, and most of those were removed because the IV therapy course had completed, not due to site complications.

Generally though, the evidence based practice has moved away from utilizing time as an indicator of risk for complications since it has shown to be an unreliable indicator.

Yes! I am totally aware that time should not be used as an indicator of risk for peripheral IV Therapy related complications and site change should be based on assessment.That INS white paper came out awhile ago but the evidence was mounting long before it was was published as the importance of vein preservation was finally being recognized.My point is when you are assesing an IV site it is prudent to know its dwell time or in other words how long it has been in place.It is of course, is not the only parameter I look for but a site is more likely to become symptomatic the longer it dwells.I actually got the average dwell time of 44 hours from an article I read that summarized multiple studies I may be able to locate it..I do notice though our sites started by IV nurses and other highly skilled nurses do last longer owing to the skill of the insertor.

[lovingtheunloved, ASN, RN]

I’m sorry, how is a “no more sticks list” even a thing? So what, your IV goes bad and you’re on the list so you’re SOL and you just don’t get anymore IV meds? PICC ‘em!