IV Question

[CapricaNurse]

I had an older (60s) patient with a lot of generalized edema (from co-morbidities). He was getting 125 ml per hour IV fluid all my shift, into a Left midarm IV that had just hit the 70 - hour - since - insertion mark.

The IV cath was 20 gauge (1 inch long, I think). His right arm couldn't be used for IVs or anything (a medical condition was the reason for that).

So his ordered IV Fluid (normal saline, not a vesicant) goes in at 125 ml per hour all shift, no complaints, and the IV machine never alarms occlusion or anything else.

However, at just about shift change I noticed that his left arm (the one getting the IV fluids) is swollen - swollen in just about every place except for a 4-5 inch area around the IV cath insertion site itself. I put his left arm up on pillows, and again made sure that all around the IV site itself was soft, (which it was), although the rest of his left lower arm had taut skin. Weird. So I left the IV fluid running. Since report was in 45 minutes, I figured I'd ask the next shift nurse to call IV therapy to put in a new one. When the next shift nurse came in and saw the man's left arm swelling, she turned off the infusion (didn't check the area around the cath insertion itself) and she immediately pulled the IV cath out (the tip was intact, there was no bleeding after, we did apply a pressure dressing, there were no signs of infection).

Long question short: Should I have stopped the infusion immediately when I first saw the peripheral swelling? Second question (if so) should I have immediately removed the IV cath, while waiting for the new IV (even though it would have left the patient with no IV access)?

The patient has a condition where it was more than possible that he might have needed emergency meds pushed into an IV line between pulling the old one out, and IV therapy finding time for putting a new one in. The IV she (my next shift replacement) pulled out (in the left arm site, which as I mentioned had baby - soft surrounding skin for a hands-span area around it) was the only IV access the patient had at the time she pulled the IV out.

Brutal honesty is appreciated here. I promise I won't argue, I just want to learn, so if there is a next time, I do things 100% right.

If that area 4-5 inches or so around the 20 guage 1 inch IV cath insertion wasn't baby soft, I'd have turned off the infusion immediately myself. However, I wouldn't have pulled out his only line, even though it was not an ideal line, until IV therapy had gotten up there and placed a new one for him. I did recognize that the patient's arm swelling was not a good sign, and did place it up on 3 pillows. He denied any pain in the arm or at the IV site, and he was afebrile.

Thanks for any feedback.

[iluvivt, BSN, RN]

Let me answer your questions first and then I can explain why....YES.... you should have at least stopped the infusion and better yet discontinued it. next because you are describing and infiltration you should have elevated the patient's arm to their comfort level and applied a warm compress. Warmth in this case would be acceptable since you were infusing an isotonic IV fluids (warmth is OK for isotonic or near isotonic IV fluids,use cool for hypertonic or hypotonic).

Next IV pumps do NOT have an infiltration detector..remember it this way......YOU are the infiltration detector. The pump will alarm for the usual things such as air in the line,upstream or downstream occlusions,completion of secondaries or preset alarms such as VTBI infused complete.

The look of an infiltration or extravasation on a peripheral IV may vary depending upon a variety of reasons such as location of the cannula,length of the cannula, location on the vein where the cannula has exited the vein, size of the patient's arm,just to name a few. I once knew an IV nurse that threaded her catheters without ever pulling her needle back until she had the entire catheter in the vein. They always infiltrated about 12 hours later medial and lateral to the cannula. It was a very strange infiltration pattern until I saw how she started her IVs. What she did was scrape the vein on both sides while inserting..this so irritated the vein on both sides and that is exactly how her IV infiltrations looked.

Just because it was soft at the insertion site DOES not mean you did not have an infiltrate. Fluid being pumped into the tissue will have to go somewhere and it does always appear as a classic lump above the site. It will often appear as generalized edema of the arm and taut translucent skin. An old IV trick is to apply a tourniquet above the site..IF the IV stops..it is in the vein...if it keeps dripping..it is not. This only works as a gravity and of course, with some IVF you can safely run at a decent rate for a bit. I prefer to instruct nurses to ALWAYS compare to the other arm and compare them.

One other important thing that nurses get a bit confused about blood return and if they are getting a blood return from a PIV they think t is not infiltrating. This is NOT correct..you can still get a blood return and your IV can still be infiltrating. That is b/c your cannula can be partially out of the vein so you are still getting a blood return while the other part of the cannula is infusing into the tissue.

There is absolutely no point in keeping a IV in place that is NO good and especially one that is infiltrated as you described very well. If you are truly in doubt at the absolute minimum stop the IV fluids and lock if you need another to assess it for sure. It does not matter how ill or unstable someone is..if the IV is BAD it's bad. If the patient needs another right away someone needs to restart it. I hope this has helped some.

[iluvivt, BSN, RN]

You may not often have pain with an infiltration whereas a phlebitis hurts like h###.

[wooh, BSN, RN]

There is absolutely no point in keeping a IV in place that is NO good and especially one that is infiltrated as you described very well. If you are truly in doubt at the absolute minimum stop the IV fluids and lock if you need another to assess it for sure. It does not matter how ill or unstable someone is..if the IV is BAD it's bad. If the patient needs another right away someone needs to restart it. I hope this has helped some.

Re: The patient might need emergent drugs.

If the patient needs emergency drugs, where do they need to go? They need to go IV. Epi, atropine, whatever, aren't going to work subcutaneous. Which is where they'll go if the IV isn't good. If they need IV access, they need actual IV access into a vein. They don't need a catheter that's sending most to all of what's going into it into the tissue AROUND the vein.

[CrunchRN, ADN, RN]

Very educational thread. Thanks for sharing all the knowledge and experience.