1. PIVIE
Recognition, Management, and Prevention of Peripheral IV Infiltration and Extravasation Injury
Binita Patel, MD,
Jonathan Rangel, MSN, RN, CPN
Joyce Ramsey-Coleman, MBA, MSN, RN, NEA-BC

2. Learning Outcomes
At the end of this presentation, learners will be able to:
Define PIVIE
Differentiate infiltration vs. extravasation
Discuss risk factors for PIVIE
Identify drugs and solutions reported to cause extravasation injury
Explore appropriate management strategies to minimize complications
Describe methods to manage and prevent PIVIE

3. Definitions: What is PIVIE?
Is an acronym for Peripheral Intravenous Infiltration and Extravasation
is a Hospital Acquired Condition (HAC) as a potential complication from the use of peripheral intravenous catheters
is a metric used as a Nursing Sensitive Indicator (NSI)

4. What is a Hospital Acquired Condition?
A Hospital Acquired Condition (HAC) are complications or medical condition that were not present during admission to the hospital

5. More examples of HACs Central Line Associated Bloodstream Infection
Unplanned Extubations
Ventilator Associated Event
Pressure Ulcers/Injury
Adverse Drug Reactions
Falls and Trauma
Surgical Site Infections

6. What is a Nursing Sensitive Indicator?
Nursing-Sensitive Indicators (NSI’s) are measures and indicators that reflect the structure, processes and outcomes of nursing care (American Nurses Association, 2004).
These are typically correlated with the incidence and prevention of certain HAC’s.
Common metrics used as Nursing Sensitive Indicators:
Falls
Health-Associated Pressure Ulcers (HAPU)
Catheter-Associated Urinary Tract Infections (CAUTI)
Central Line-Associated Bloodstream Infection (CLABSI)
Ventilator-Associated Pneumonia (VAP)

7. Why are HACs important? These conditions cause harm Often preventable
There are tools and resources to reduce HACs
For discharges occurring on or after October 1, hospitals are not reimbursed for the cost of care
Why is this important? By using tools and resources to reduce HACs
Researchers concluded that:
- hospitals saved nearly $23 billion in costs
- avoided nearly 2.5 million hospital acquired conditions
- averted 95,000 deaths (This is what we are here for. The goal is to reduce harm to patients)

8. What is a Peripheral Intravenous Catheter(PIV)?
Common and universal medical practice to provide therapeutic IV fluids and medications.
Typically placed into a superficial vein within an upper extremity
Nearly every patient admitted for a hospital stay has an intravenous catheter placed
Most commonly placed in hand or the inside of the elbow joint (antecubital fossa)
Peripheral intravenous (IV) catheter insertion is a common and universal medical practice to provide therapeutic IV fluids and medications.
Nearly every patient admitted for a hospital stay has an intravenous catheter placed

9. Why Peripheral Intravenous Catheters?
Allows for the quick and easy delivery of intravenous medications
Mainstay of modern medicine
Delivery of drugs and other potentially live-saving agents in the case of rapid change in patient condition or patient decline
Many medications can only be given through the intravenous route
Mildly invasive procedure that can come with complications - as with all invasive procedures
Allows for the quick and easy delivery of intravenous medications
Quick and easy delivery of drugs and other potentially live-saving agents in the case of rapid change in patient condition or patient decline
Mainstay of modern medicine
Many medications can only be given through the intravenous route
Mildly invasive procedure that can come with complications - as with all invasive procedures

10. Statistics on PIV Therapy
Up to 90% of all inpatients have peripheral IV treatment
Higher incidence of infiltrations and extravasation within pediatric populations
Infiltration rates can vary between 23-78% of all peripheral IV’s
Extravasations occur in the pediatric population at an incidence of %
Extravasations occur at greater risk in children up to the age of 12 yrs.
Complications can vary greatly in severity
Some cases may not be immediately apparent
Severe cases may require surgical intervention or even amputation
Pettit (2003) noted that infiltrate rates vary from 23% to 78% and can have long-term sequelae.
Pettit, J. (2003). Assessment of the infant with a peripheral intravenous device. Advances in Neonatal Care, 3, doi: /S (03)
Paquette, V. (2011). Describing Intravenous Extravasation in Children. Can. Journal Hospital Pharmacy, 64)5)
From SPS: Intravenous catheter placement and management is commonly regarded as a routine clinical skill, (approximately 74% of hospitalized pediatric patients have vascular access catheters inserted either peripherally or centrally). However, potential complications from an IV infiltrate range from trivial irritation and discomfort to serious harm, such as permanent skin and soft tissue loss, impaired limb function, compartment syndrome, distal vascular compromise, and even loss of fingers or other parts of a limb.

11. What Is An Infiltration?
Infiltration: inadvertent leakage of a non-vesicant solution from its intended vascular pathway (vein) into the surrounding tissue
When fluid infuses into the tissues surrounding the venipuncture site instead of the intended vein
Infiltration can be caused by improper placement or dislodgment of the catheter.
Patient movement can cause the catheter to slip out or through the blood vessel lumen. 
IV infiltration is one of the most common problems that can occur when fluid infuses into the tissues surrounding the venipuncture site
This happens when  the tip of the catheter slips out of the vein
The catheter passes through the wall of the vein
 The blood vessel wall allows part of the fluid to infuse into the surrounding tissue.
frequent assessment of the IV site can help to prevent many of the complications associated with IV infiltration
Comparison of the IV site with the same area on the opposite extremity can also be helpful in determining whether an infiltration has occurred
If the infiltration is severe, you may consider the application of a compress in addition to elevating the affected limb. Check your institution’s policy regarding which type of compress (warm or cold) should be applied.

12. Early Signs and Symptoms of Infiltration
Assessment around catheter:
Coolness or blanching at the catheter insertion site
Swelling 
Tenderness/Discomfort
Taut or stretched skin
Leakage of fluid at the insertion site
Inability to obtain any blood return
Change in quality and flow of the infusion or injection
Numbness, tingling, or 'pins and needles' 
Early signs and symptoms of extravasation are: 
burning, stinging pain, redness, followed by blistering 

13. Examples of Pediatric Infiltrations

14. What Is Extravasation?
Extravasation: The inadvertent leakage of a vesicant solution from its intended vascular pathway (vein) into the surrounding tissue
A vesicant refers to any medicine or fluid with the potential to cause blisters, severe tissue injury (skin/tendons/muscle) or necrosis if it escapes from the intended venous pathway
Vesicants can cause:
Pain and irritation to the vein
Phlebitis (Inflammation of a vein.)
Tissue destruction if solution exits vascular space
Vesicants can cause tissue destruction and / or blistering. Irritants can result in pain at the IV site and along the vein and may or may not cause inflammation. Extravasation can result in tissue sloughing, pain, loss of mobility in the extremity and infection. The treatment for extravasation will vary depending on the antidote for the infiltrated medication and your facility policy
Concentration of vesicant; the amount extravasated; and the type of vesicant are all factors which will influence the severity of the extravasation

15. Examples of Pediatric Infiltration and Subsequent Extravasation

16. Drugs and Solutions That Can Potentially Cause Extravasation Injury
Some Commonly
Used IV Medications
Vancomycin
Promethazine
Lorazepam
Diazepam
Digoxin
Propofol
Gentamicin
Phenytoin
Vasocompressive Agents
Dobutamine
Dopamine
Epinephrine
Norepinephrine Vasopressin
(Concentrated)
Electrolyte Solutions
Calcium chloride
Calcium gluconate Potassium chloride Sodium bicarbonate Sodium chloride
Almost All Chemotherapeutic Agents
Cytotoxic Agents
Hyperosmolar Agents
Radiographic Contrast Media
This is just a partial list. There is no definitive list.
This is partially due to the fact that concentrations of drugs and solutions can vary.
Certain drugs not typically considered to vesicants can sill be caustic to veins and surrounding tissues depending on the concentration

17. Categorizing Vesicants and Other High-Risk Infusion Solutions
Hyperosmolar Solutions
Non-Physiological pH
Acids
Alkaline Solutions
Vasopressors

18. Similarities and Differences
Medicine or IV (intravenous) solution leaves the vascular space and enter the tissue or skin around the IV insertion site.
The catheter punctures the vein wall, the catheter becomes occluded, or the vein itself leaks
Can be more serious. The medicine or solution leaked can cause damage to your skin or tissues. This damage can cause a painful ulcer or sore that will need treatment.
An infiltration does not usually cause harm, but the medicine or solution may cause redness, swelling, and discomfort around the site
INFILTRATION
EXTRAVASATION
Vesicants can cause tissue destruction and / or blistering. Irritants can result in pain at the IV site and along the vein and may or may not cause inflammation. Extravasation can result in tissue sloughing, pain, loss of mobility in the extremity and infection. The treatment for extravasation will vary depending on the antidote for the infiltrated medication and your facility policy
Concentration of vesicant; the amount extravasated; and the type of vesicant are all factors which will influence the severity of the extravasation

19. Risk Factors for IV Complications
Device-related
Large gauge cannula r/t vein size
Inadequately secured catheter
Inadequately secured line
Patient-related
Patients with small, fragile or thrombosed veins
Active patient
Patient’s inability to verbally communicate pain

20. Risk Factors for IV Complications
Drug-related
Chemotherapy and other known vesicants
Concentration of the drug/fluid
pH of drug/fluid (extremes of pH ie acid or alkaline - pH < 5 or >9)
Osmolality of fluid (osmolarity >375 can influence the degree of tissue damage eg hypertonic drugs/solutions eg 10% Dextrose and parenteral nutrition solutions)

21. Risk Factors for IV Complications
Clinician-related
Lack of intravenous therapy skills
Interruptions or distractions during drug administration
Lack of assessment, or infrequent assessments
Failure of early recognition

22. So How Do We Compare?

24. This is for a simple estimations for an IV infiltration without sequela.
If significant complications, the financial impact may be in the 10’s of thousands.
With significant injury, surgical intervention may be indicated. In certain cases there ay be risk of litigation.
Decreasing IV Infiltrates in the Pediatric Patient – System-Based Improvement Project
Tracie Wilt Major and Tricia K. Huey Pediatric Nursing January-February 2016/Vol. 42/No. 1
This is for an IV without sequela. If significant complications, the impact may be 10’s of thousands.

25. Management of Infiltrates and Extravasations

26. Immediate Bedside Actions
Stop infusion and disconnect drug/infusion
Communicate with patient/parent
Aspirate as much residual drug as possible.
DO NOT FLUSH.
Call Provider

27. Management: Mark and Measure
Remember to document:
Time and date of incident
Notification of provider
Infusing medication
Document:
Time and date of incident
Notification of provider
Infusing medication
Swelling measurement
Volume of fluid using formula

28. Severity Scoring System
>60%
30-60%
10-30%
<10%
Millam DA. Managing complications of i.v. therapy. Nursing 1988;18(3):34-43
% allows ability to gauge severity regardless of size of patient.

29. Nonpharmacological Interventions
Elevate extremity.
Remove any constricting bands or clothing.
Compresses: consider for lower severity infiltrate based on drug and recs
Check formulary to ensure appropriate warm vs cold compresses
Generally apply proximal to site, 20 minutes, 4 times/day x 1-2 d.
Less severe % (<10, 10-30%): Remove catheter
More severe % (>30%): Leave catheter in place for potential intervention

30. Management: Specific Agents
Vasopressors
Vasopressin, norepi, epi, dopamine, dobutamine
Cause vasoconstriction
RX: Phentolamine, most effective if within hours
RX: Topical nitroglycerine
Apply WARM compresses
Do not use hyaluronidase
Hyperosmolar Agents
TPN, D10 or more, complex fluids
Cause fluid shifts
RX: Hyaluronidase and saline washout
Apply COLD compresses
Contrast Media
Causes inflammation and fluid shifts
No consensus on management
Elevation and WARM compresses
Chemo Agents
Cytotoxic agents, cause tissue injury
RX: depends on agent
Options: hyaluronidase, dexrazoxane, DMSO, sodium thiosulfate, saline washout
Dexrazoxane

32. Other Management and Consultations
Consults
Wound care/ostomy team
Plastic surgery
Consult early
Dressings: Promote moist, clean, warm environment
Surgical interventions rare
Debridement +/- reconstruction: Continuous pain, persistent ulceration, full- thickness skin necrosis
Fasciotomy: compartment syndrome
In the event of tissue necrosis, the wound should be
dressed in a manner to promote a moist, clean, and warm
environment, while removing excess exudate.
Debridement (with or without reconstruction) is indicated
if extravasation results in continuous pain (persisting
for 1–2 weeks), persistent ulceration, or full-thickness
skin necrosis.9,11,14,15,46,57 Fasciotomy is the treatment of
choice if compartment syndrome develops.6,41

33. What Can You Do?

34. Nursing Responsibilities
The nurse plays a vital role in preventing complications
Intravenous therapy is now an integral part of the majority of nurses' professional practice
Must be competent to undertake the procedure and maintain knowledge and skills 
The nurse has a duty to monitor the patient and their response throughout the duration of intravenous medication administration

35. Prevention: 4 P’s Proper Size
Use the smallest gauge plastic cannula feasible.
Placement
Avoid joints (eg wrist, antecubital) and limbs with impaired arterial, venous or lymphatic circulation or any neurological impairment (Wengstrom et al, 2008).
Protection
Stabilize and secure the cannula in place using dressing that does not obscure the site (ie transparent dressing).
Patency
Confirm blood return prior to vesicant administration.
Hourly site assessment during any infusions 

36. Safe Administration of High-Risk Drugs
The patency must be assessed prior to infusion
The line should be flushed to determine if any resistance is felt
Slow or lack of blood return could indicate a problem
Must be administered in concentrations recommended by the manufacturers. 
Vesicants should be administered first in a sequence of medications as vascular integrity decreases over time and also the vein is less irritated initially 
The patency of the vein and catheter must be assessed prior to administering vesicant drugs/fluids. The line should be flushed to determine if any resistance is felt and there should be a brisk, free flowing blood return into an empty syringe; slow or inadequate blood return could indicate a problem
A flashback of blood into a saline syringe is not an adequate assessment of any venous access device when administering vesicant drugs
Vesicant drugs/fluids must be administered in concentrations recommended by the manufacturers. 
Vesicants should be administered first in a sequence of medications as vascular integrity decreases over time and also the vein is less irritated initially 

37. Further Prevention of Infiltration and Extravasation
Patient-related 
Instruct the patient and family:
About the risks of vesicant administration.
Do not disturb or dislodge the cannula or port needle; take care when mobilizing patient.
Instruct the family to immediately call nurse if there is any sign of pain, swelling or concern about IV. 

38. Summary
More than 90% of hospitalized patients require peripheral intravenous (IV) access for the delivery of fluids, nutrition, or medication.
Peripheral IV site complications, such as infiltration, extravasations, and phlebitis, account for the greatest risk to most patients receiving infusion therapy.
Complications may result in substantial acute or chronic injury, which may be further exacerbated if the affected individual is a child.
Evidence suggests that the implementation of bedside-nurse training and more frequent assessment will reduce the risk for peripheral IV site complications.

39. References
Bonsall, L. (2015, February 9). Complications of Peripheral I.V. Therapy [Web log post]. Retrieved July 5, 2018, from
Coyle, C., Griffie, J., Czaplewski, L. (2014) Eliminating Extravasation Events: A Multidisciplinary Approach. Infusion Nurses Society 37 (3)
Infusion Nurses Society (2011) Infusion nursing standards of practice Journal of Infusion Nursing 29 (1): S1-S92. 
Jeong, I., Park, S., Park, K. (2016). Effect of Observation Window at Peripheral Intravenous Catheter Site on Early Recognition of Infiltration among Hospitalized Children.   Journal of Korean Academy of Nurses. 46(4),  
Park, S., Jeong, I., Jun, S. (2016) Identification of Risk Factors for Intravenous Infiltration among Hospitalized Children: A Retrospective Study. PLoS ONE 11(6): e
Pettit, J. (2003). Assessment of the infant with a peripheral intravenous device. Advances in Neonatal Care, 3, doi: /S (03)
Taylor, J. (2016). Implementing an Evidence-Based Practice Project in the Prevention of Peripheral Intravenous Site Infiltrations in Children. Journal of Infusion Nursing 38(6) doi: /NAN

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