Recognizing and Managing IV Infiltration

Scenario

While administering a broad-spectrum antibiotic via a peripheral IV, you notice the insertion site appears swollen, cool to the touch, and the patient reports pain at the site. The IV flow has slowed significantly.

Question: What are your immediate actions, and how do you manage this complication safely?

Best Practice Answer

1. Recognize the Complication Early:
   These findings — swelling, pallor, coolness, and discomfort — are classic signs of IV infiltration, meaning the IV fluid has leaked into surrounding tissue.
   Prompt recognition prevents further tissue damage and patient discomfort.

2. Stop the Infusion Immediately:

   • This is the first and most critical action.
   • Continuing infusion risks worsening tissue injury, especially if the medication is a vesicant (tissue-damaging).

3. Assess and Determine Severity:

   • Inspect for blanching, firmness, or extensive swelling.
   • Compare limb symmetry and check for capillary refill or pulses to rule out vascular compromise.
   • Note the type of solution or medication involved — vesicants (e.g., vancomycin, potassium chloride) require special handling.

4. Intervene According to Type of Solution:

   • Non-vesicant solutions: Remove the catheter, elevate the extremity, and apply a warm compress to promote absorption.
   • Vesicant medications:
     • Leave the catheter in place and notify the provider immediately.
     • Administer antidote through the same line if ordered (e.g., hyaluronidase).
     • Only remove the catheter after antidote administration.
   • Document the amount of infiltrated fluid if measurable.

5. Restart IV Access:

   • Insert a new IV in the opposite extremity or above the infiltration site (never below).
   • If repeated infiltration occurs, consider a midline or central line.

6. Documentation and Communication:

   • Record location, assessment findings, interventions, and patient response.
   • Notify provider and pharmacy as needed, particularly if a vesicant was involved.
   • Complete a safety event report if institutional policy requires it.

Real-World Application

This scenario is commonly asked in technical interviews and simulation labs to assess both clinical judgment and procedural safety.
A nurse’s first action and ability to differentiate vesicant from non-vesicant infiltrations are key indicators of competence in IV therapy management.

This is directly applicable in med-surg, oncology, and infusion therapy settings where continuous IV medications are used.

Tip: Interviewers consistently listen for the phrase —
“I would stop the infusion immediately, assess the site, and manage based on whether it’s vesicant or not.”
It shows critical thinking and adherence to infusion safety standards.