Part of the ICU Emergencies Hub — browse every related guide in one place.
Assess the peripheral IV site every 1–4 hours (frequency depends on infusion type, patient population, and facility policy): patency (flushes without resistance, blood return present); insertion site appearance (redness, swelling, warmth, pallor); patient symptoms (pain, burning, or pressure at the site); integrity of the dressing (occlusive, dry, dated); catheter stability (secured without tension on the catheter hub); infusion rate matching the ordered rate on the pump.
Both infiltration and extravasation involve fluid leaking outside the vein — the critical difference is whether the fluid is a vesicant (tissue-damaging) or non-vesicant.
| Infiltration | Extravasation | |
|---|---|---|
| Definition | Accidental infusion of a non-vesicant solution into surrounding tissue | Accidental infusion of a vesicant (tissue-damaging) solution into surrounding tissue |
| Solutions involved | Normal saline, D5W, dilute medications, non-vesicant antibiotics | Chemotherapy agents, vasopressors (norepinephrine, dopamine, vasopressin), calcium chloride, potassium chloride, hypertonic saline, phenytoin, amiodarone, contrast dye, some antibiotics (vancomycin, amphotericin) |
| Tissue damage potential | Typically resolves without permanent damage; discomfort and temporary swelling | Can cause severe necrosis, tissue sloughing, compartment syndrome, and permanent injury or loss of limb function |
| Signs and symptoms | Swelling at the site; coolness (infused fluid is at room temperature); slowed or absent infusion flow; loss of blood return; mild tenderness | All signs of infiltration PLUS: burning, stinging, or intense pain at the site; skin blanching or discoloration; blistering; skin breakdown |
Stop the infusion immediately. Disconnect the IV tubing. Attempt to aspirate fluid from the catheter before removing (may reduce the volume of infiltrated fluid). Remove the catheter. Elevate the extremity above heart level. Apply warm compresses for non-vesicant infiltrations (promotes reabsorption). Restart the IV in a different vein, preferably in the opposite extremity. Document the site assessment, estimated infiltration volume, interventions, and skin condition. Notify the provider if infiltration is large, if the extremity shows circulatory compromise, or if the patient has vascular disease that impairs absorption.
Stop the infusion immediately — leave the catheter in place (to aspirate the vesicant and potentially inject an antidote). Aspirate as much of the vesicant as possible through the catheter. Follow your facility's extravasation protocol — specific antidotes exist for some vesicants (hyaluronidase for vinca alkaloids, sodium thiosulfate for mechlorethamine, DMSO or hyaluronidase for anthracyclines). Remove the catheter. Mark the extravasation boundaries with a skin marker to track progression. Elevate the extremity. Apply ice or warm compresses as directed by the vesicant-specific protocol (NOT one-size-fits-all: some require cold, some require heat). Notify the provider immediately — extravasation with vesicants requires urgent physician assessment and may require surgical consultation for debridement.
Phlebitis is inflammation of the vein — characterized by redness, warmth, and tenderness along the vein proximal to the IV site. The Infusion Nurses Society (INS) phlebitis scale grades severity 0–4:
| Grade | Signs | Action |
|---|---|---|
| 0 | No symptoms | Continue monitoring |
| 1 | Erythema at IV site with or without pain | Observe the site; consider changing if trending worse |
| 2 | Pain at site with erythema and/or edema | Remove and restart; apply warm compress; document |
| 3 | Pain at site with erythema; streak formation; palpable cord | Remove and restart; warm compress; notify provider; possible thrombophlebitis |
| 4 | Pain at site with erythema; streak formation; palpable cord >2.5 cm; purulent drainage | Remove; warm compress; notify provider; IV antibiotics may be needed; possible infectious thrombophlebitis |
Phlebitis prevention: Use the smallest gauge catheter appropriate for the infusion (20–22 gauge for most adult uses; 18 gauge for rapid infusion or blood). Avoid antecubital and hand veins for long-term infusions. Change peripheral IV sites every 72–96 hours per policy (or when clinically indicated). Dilute irritating medications per pharmacy guidance. Use IV extension sets to move the catheter hub away from areas of flexion.
An occluded IV catheter fails to infuse (pump alarms "occlusion") or fails to flush. Before assuming occlusion: check that the roller clamp is open, check for kinked tubing, check that the pump is correctly loaded, ask the patient to relax their arm (muscle tension can compress a catheter in the antecubital). If these are not the cause: reposition the arm (change from flexed to extended); attempt a gentle flush with a 10 mL syringe (10 mL minimum — small syringes generate excessive pressure); try aspirating rather than pushing. If resistance persists after repositioning and aspiration attempt: do NOT force flush (risk of catheter damage or emboli); remove the catheter and restart. Never use excessive force to flush a peripheral IV — dislodge the thrombus into the patient's circulation, or rupture the catheter.
Related guides: Central line care | Medication safety | IV drip calculations
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