Chapter 8. Intravenous Therapy
8.2 Intravenous Therapy: Guidelines and Potential Complications
Intravenous therapy is treatment that infuses intravenous solutions, medications, blood, or blood products directly into a vein (Perry et al., 2018). Intravenous therapy is an effective and quick way to administer fluid or medication treatment in an emergency situation, and for patients who are unable to take medications orally. Approximately 80% of all patients in the hospital setting will receive intravenous therapy.
The most common reasons for IV therapy (Waitt, Waitt, & Pirmohamed, 2004) include:
- To replace fluids and electrolytes and maintain fluid and electrolyte balance: The body’s fluid balance is regulated through hormones and is affected by fluid volumes, distribution of fluids in the body, and the concentration of solutes in the fluid. If a patient is ill and has fluid loss related to decreased intake, surgery, vomiting, diarrhea, or diaphoresis, the patient may require IV therapy.
- To administer medications, including chemotherapy, anesthetics, and diagnostic reagants: About 40% of all antibiotics are given intravenously.
- To administer blood or blood products: The donated blood from another individual can be used in surgery, to treat medical conditions such as shock or trauma, and/or to treat a failure in the production of red blood cells. The infusion restores circulating volumes, improving the ability to carry oxygen and replace blood components that are deficient in the body.
- To deliver nutrients and nutritional supplements: IV therapy can deliver many of the nutritional requirements for patients unable to obtain adequate amounts orally or by other routes.
Guidelines Related to Intravenous Therapy
The following are general guidelines for peripheral IV therapy:
- IV fluid therapy is ordered by a physician or nurse practitioner. The order must include the type of solution or medication, rate of infusion, duration, date, and time. IV therapy may be for short or long duration, depending on the needs of the patient (Perry et al, 2018).
- IV therapy is an invasive procedure; therefore, significant complications can occur if the wrong amount of IV fluids or the incorrect medication is given.
- Principles of asepsis must be maintained throughout all IV therapy procedures, including initiation of IV therapy, preparing and maintaining equipment, and discontinuing an IV system. Always perform hand hygiene before handling IV equipment. If the connectors in the administration set and/or the solution become contaminated, they should be replaced with new ones to prevent introducing bacteria or other contaminants into the system and, thus, the patient (Centers for Disease Control [CDC], 2017).
- Understand the indications and duration for IV therapy for each patient. Practice guidelines recommend that patients receiving IV therapy for more than six days should be assessed for an intermediate or long-term venous access device (CDC, 2017).
- If a patient has an order to keep a vein open, or “TKVO,” the usual rate of infusion is 20 to 50 ml per hour (Fraser Health Authority, 2014).
- Complications may occur with IV therapy, including but not limited to localized infection, catheter-related bloodstream infection (CR-BSI), fluid overload, and complications related to the type and amount of solution or medication given (Perry et al., 2018).
- IV access devices are chosen based on need. A few of the reasons include if the solution or drugs have high or low pH or high osmolality. If so, a device where the tip of the catheter is in a large vessel that allows for high hemodilution is necessary. The anticipated length of treatment is another deciding factor because some devices have a longer dwell time than others—PVAD-short catheters have a shorter dwell time than CVADs (Perry et al., 2018). There are a variety of CVAD choices that allow treatment to better meet the needs of the situation.
- IV sites must be assessed regularly. Check your agency for specific guidelines. Some guidelines may suggest every 5 minutes, others hourly, others every 12 hours (Gorski et al., 2012; RCH, n.d.; RNAO, 2005). In the absence of guidelines, exercise some clinical judgement and consider that sites requiring more frequent assessment include those that have an infusion versus those that are locked; in an acute care environment versus a home environment; patient conditions where cognitive and sensory changes inhibit their ability to voice concerns; types of solutions—vesicants require more frequent site assessment than solutions with less potential for harm if infiltrated; location and type of catheter—areas of flexion have higher risk of infiltration; central venous access have higher risk of air emboli if equipment fails (Gorski et al., 2012).
Potential Complications of IV Therapy
Several potential complications may arise from intravenous therapy. It is the responsibility of the healthcare provider to monitor for signs and symptoms of complications and intervene appropriately. Complications can be categorized as local or systemic. Most complications are avoidable if simple hand hygiene and safe principles are adhered to for each patient at every point of contact (Fraser Health Authority, 2014; McCallum & Higgins, 2012). Table 8.1 lists the potential local and complications and treatment. It should be noted that local complications are more apparent with PVAD-short catheters but still apply to CVADs.
Table 8.1 Potential Local Complications of IV Therapy |
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Complication |
Signs and Symptoms |
Prevention and Treatment |
Phlebitis, causes include:
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Localized redness, pain, heat, and swelling which can track up the vein leading to a palpable venous cord (feels like a small rope)
Note: Phlebitis may be more difficult to assess with a CVAD because the tip of the catheter (thus delivery of the meds or solutions) occurs in a larger vessel. |
Prevention: Assess sites frequently.
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| Infection: at insertion site or systemically | Insertion site may become red, tender, swollen, or have purulent drainage. Systemic signs and symptoms may include malaise, fever, hypotension, or tachycardia. | Strict hand-washing, aseptic technique for all procedures, close monitoring of vital signs, strict protocols for dressing, tubing and cap changes.
Report concerns to prescriber and agency Patient Safety & Learning System. Monitor blood work and vital signs. C&S of the site as per agency policy. PVAD-short and midline catheters showing S&S of local infection should be removed immediately. Monitor for signs and symptoms of systemic infection. |
Occlusions:
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Sluggish flow rate. Inability to flush or infuse IV solution or meds. Frequent downstream occlusion alarms on the IV controller / pump. | Prevention: Follow agency flushing protocols. Know what kind of needleless cap is in use and follow correct flushing procedure. Assess and resolve any mechanical occlusions.
Remove occluded PVAD-short catheters. Note: Specific information regarding CVAD occlusion will follow. |
Infiltration:
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Pain, swelling, redness, skin surrounding insertion site is cool to touch, change in quality or flow of IV, tight skin around IV site, IV fluid leaking from IV site, frequent occlusion alarms on IV pump. | Prevention: Confirm IV patency during IV therapy. Recheck IV patency before medication administration. Use IV securement devices to stabilize IV insertion sites. Avoid areas of flexion and always assess IV sites before, during, and after infusing IV fluids or medications.
Treatment: Stop infusion and remove cannula. Follow agency policy and guidelines related to infiltration. |
Extravasation:
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Same as infiltration but also includes burning, stinging redness, blistering, or necrosis of tissue. | Stop infusion. Remove PVAD-short or midline catheter. Follow agency policy for extravasation for specific medications. For example, toxic medications have a specific treatment plan. |
| Bleeding / hemorrhage | Bleeding at the insertion site.
If this is an arterial bleed, significant edema and pain may present itself. |
Bleeding (venous) at site sometimes controlled with manufactured hemostatic product (StatSeal).
Suspected arterial bleeds must be reported to an appropriate healthcare provider immediately |
| Data sources: Fraser Health Authority, 2014; Fulcher & Frazier, 2007; Interior Health Authority, 2012; McCallum & Higgins, 2012; Perry et al., 2018. |
Some agencies recommend using a phlebitis scale to objectively describe signs and symptoms of this IV site complication. IV sites should be assessed during IV therapy and for days following removal in the event site complications present themselves.
Table 8.2 Phlebitis Scale |
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Grade |
Clinical Indications |
| 0 | No symptoms. |
| 1 | Erythema at the access site. Pain may or may not be present. |
| 2 | Pain at access site with erythema or edema. |
| 3 | Pain at access site with erythema or edema. Streak formation. Palpable venous cord. |
| 4 | Pain at access site with erythema or edema. Streak formation. Palpable venous cord greater than 1.5 cm in length. Purulent drainage at insertion site |
| Data sources: Infusion Nurses Society, 2011; Interior Health, 2018 |
Systemic complications can occur apart from chemical or mechanical complications. To review the systemic complications of IV therapy, see Table 8.3.
Table 8.3 Potential Systemic Complications of IV TherapySafety considerations:
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Complication |
Signs and Symptoms |
Prevention and Treatment |
| Pulmonary edema: Also known as fluid or circulatory overload. A condition caused by excess fluid accumulation in the lungs due to excess fluid in the circulatory system and inability of the body to adapt. | ↓SpO2, ↑respiratory rate, dyspnea, coughing up pink frothy sputum, auscultation of dependent fine crackles | Prevention: Use IV controller / pump to prevent accidental bolus.
Treatment: Must be immediate. ↑HOB, vitals, administer oxygen, notify prescriber. Anticipate diuretics and slowed IV rates. |
| Catheter-related bloodstream infection (CRBSI): Caused by microorganisms that are introduced into the body during insertion if the device is contaminated, through skin organisms at the time of insertion, and afterward from the IV hub / connector and/or the solutions. | Confirmed by blood cultures.
Elevated temperature, flushed, headache, malaise, tachycardia, ↓BP, and additional signs and symptoms of sepsis |
Prevention: Strict hand-washing, aseptic technique for all procedures, close monitoring of vital signs, strict protocols for dressing, tubing, and cap changes, prevent contamination of hub.
Treatment: Report concerns to prescriber; monitor bloodwork and vital signs; anticipate blood cultures; IV antibiotic therapy; consider catheter removal, if suspect. |
| Air embolism: The presence of air in the vascular system.
10 ml of air have been proven to have serious effects and is sometimes fatal. Tiny air bubbles are tolerated by most patients. |
Sudden shortness of breath, continued coughing, breathlessness, shoulder or neck pain, agitation, feeling of impending doom, light-headedness, hypotension, wheezing, tachycardia, altered mental status, jugular venous distension, ↓SpO2, cardiac arrest.
The effect of the air emboli depends on the rate and volume of air introduced. |
Prevention: Clamp extensions when not in use. IV equipment with Luer locks; fill drip chambers 1/2 to 1/3 full; use IV controller / pump; remove all air from tubing when priming; prime IV tubing prior to attaching to patient.
Treatment: Occlude source of air entry. Place patient in Trendelenburg position on left side (if not contraindicated), administer oxygen, vital signs, notify prescriber / RT. |
| Pulmonary embolism: A blood clot becomes free floating, enters venous circulation, and completely or partially blocks a pulmonary artery. The resulting hypoxic injury to lobe(s) of the lung result in circulatory issues. | Anxiety, chest pain, tachycardia, dyspnea, blood in sputum, ↓SpO2 | Prevention: Never irrigate clotted lines. Follow flushing protocols to prevent fibrin build up in lines. Prevent thrombophlebitis. Use filters when administering specific products (see agency policy). |
| Device embolism: Occurs when a small part of the cannula breaks off and flows into the vascular system.
Most likely to happen with repeated failed attempts of insertion of the same cannula, inferior quality of the IV cannula, or prolonged peripheral IV cannulation (Singh et al., 2015). |
Dependent on where the piece of IV cannula ends up, symptoms would depend on where the piece lodges itself.
If lodged in extremity: redness, pain, edema in the distal part of the extremity. |
Prevention: Do not reintroduce loosened stylets (needle) during insertion.
When removing any IV catheters, inspect tip to ensure end is intact. Report any concerns. |
| Data sources: Fraser Health Authority, 2014; Fulcher & Frazier, 2007; Interior Health, 2012; McCallum & Higgins, 2012; Perry et al., 2018; Singh, Kaur, Singh, & Kaur, 2015 |
Healthcare providers should assess a patient with a central line at the beginning and the end of every shift, and as needed. For example, if the central line has been compromised (pulled or kinked), ensure it is functioning correctly. Each assessment should include: CVCs have specific protocols for accessing, flushing, disconnecting, and assessment. All healthcare providers require specialized training to care for, manage complications related to, and maintain CVCs as per agency policy. Never access or use a central line for IV therapy unless trained as per agency policy. For more information on CVC care and maintenance, see the suggested online reference list at the end of this chapter.
- Type of CVC and insertion date: Reason for CVC?
- Dressing: Is it dry and intact?
- Lines: Secure with stat-lock, sutures, or Steri-Strips?
- Review: Patient still requires a CVC?
- Insertion site: Free from redness, pain, swelling?
- Positive pressure cap: Attached securely?
- IV fluids: Running through an IV pump?
- Lumens: Number of lumens and type of fluids running through each?
- Vital signs: Fever?
- Respiratory/cardiovascular assessment: Any signs and symptoms of fluid overload?
There are potential complications specific to central lines that the nurse should be aware of. Table 8.4 describes complications associated with CVADs specifically, along with signs and symptoms, interventions, and prevention. Assessment for persons with a CVAD also involves observing for the local and systemic complications discussed in Tables 7.9, 8.1 and 8.3.
Table 8.4 Potential Complications Associated Specifically with CVADs |
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Complication |
Signs and Symptoms |
Interventions |
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Mechanical related complications: Some of these may present at the time of insertion.
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Pneumothorax is characterized by ↓ / absent breath sounds in one lung, dyspnea, ↓SpO2, sharp pain in chest or shoulder. Subcutaneous emphysema may be present (palpate skin around insertion site…feels like bubbles popping under one’s fingers). | Elevate head of bed, respiratory assessment, administer oxygen, vitals, consult prescriber.
Anticipate chest x-ray, possible chest tube insertion. |
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Irregular heart rate. | Prevention post insertion: Use securement devices. Measure and record external length. Report discrepancies.
Treatment: Monitor vitals; notify prescriber; anticipate x-ray to confirm position. When confirmed, pull out catheter a prescribed distance. |
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Change in external length. | Prevention post insertion: Use securement devices. Measure and record external length. Report discrepancies. See Table 8.13 Principles of IV site dressing changes
Treatment: Assess vitals; consult prescriber; malposition may be confirmed by x-ray; may require central line to be pulled out some distance. The prescriber will advise. |
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Characterized by ↓SpO2, ↑respiratory rate, dyspnea, hypotension, ↓ / absent air entry to one lung | Elevate head of bed, respiratory assessment, administer oxygen, vitals, consult prescriber.
Anticipate chest x-ray, possible chest tube insertion. |
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Arterial bleed may be pulsating, ++ bruising and edema, blood bright red. Venous bleed slower, blood darker red. | Arterial bleed requires pressure. Monitoring vitals including pulse distal to the site.
Bleeding (venous) at site sometimes controlled with manufactured hemostatic product (StatSeal ®). |
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Catheter-related thrombosis (CRT) can be:
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Pain, tenderness, swelling, limb edema, warmth, erythema, and appearance of distended collateral vessels in surrounding area.
Extreme complications include pulmonary embolus, post-thrombotic syndrome, and vascular compromise Most catheter related thrombi are asymptomatic. |
Prevention through routine flushing following appropriate protocols. Prior catheter infections increase risk for developing a CRT.
Treatment: Vital signs; repositioning for comfort; notify prescriber; anticipate ultrasound, venogram, x-rays; may require anticoagulant therapy and possible removal of the CVC. |
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| Air embolism: the presence of air in the vascular system. Can occur during CVAD insertion or removal, during line changes, from cracked or disconnected equipment. 10 ml of air has been proven to have serious effects and is sometimes fatal. Tiny air bubbles are tolerated by most patients. | Sudden shortness of breath, continued coughing, breathlessness, shoulder or neck pain, agitation, feeling of impending doom, light-headedness, hypotension, wheezing, tachycardia, altered mental status, jugular venous distension, ↓SpO2, cardiac arrest. | Prevention: Clamp extensions when not in use. IV equipment with Luer locks; fill drip chambers 1/2 to 1/3 full; use IV controller / pump; remove all air from tubing when priming; prime IV tubing prior to attaching to patient; Valsalva maneuver prior to insertion and removal of CVAD.
Treatment: Occlude source of air entry. Place patient in Trendelenburg position on left side (if not contraindicated), administer oxygen, vital signs, notify prescriber / RT. |
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Occlusions can be:
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Sluggish flow rate. Inability to flush or infuse IV solution or meds. Frequent downstream occlusion alarms on the IV controller / pump.
++ resistance when flushing |
Prevention:
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| Damage to CVC line: Catheters can become broken or cracked. | Evidence of leaking | Prevention: Avoid sharp objects around CVADs, and only use needleless systems when accessing IV system. Do not use extreme force when flushing.
Assess for pinholes, cracks, tears, or leaks during routine care. Assess for leaks during routine care. Clamp immediately, and seal with sterile occlusive dressing to prevent air embolism, bleeding, or a catheter related blood stream infection (CRBSI). Notify prescriber / PICC team. Decisions to repair or replace the device to be made by someone who is specially trained. |
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Catheter-related bloodstream infection (CRBSI):
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Systemic: elevated temperature, flushed, headache, malaise, tachycardia, decreased BP, and additional signs and symptoms of sepsis |
CRBSI is confirmed with blood cultures. Prevention through strict hand-washing, aseptic technique for all procedures, close monitoring of vital signs, strict protocols for dressing, tubing and cap changes, blood cultures as required, IV antibiotic therapy, remove/replace catheter, prevent contamination of hub. |
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| Data sources: Baskin et al., 2009; BCIT, 2015a; Brunce, 2003; Fraser Health Authority, 2014; Interior Health Authority, 2012; Perry et al., 2018; Prabaharan & Thomas, 2014 |
Critical Thinking Exercises
- A patient is two days post op with nausea and vomiting. The prescriber orders to “saline lock the IV.” As the nurse describe your subsequent actions.
- During night shift rounds, the patient who was restless all night has pulled apart their IV tubing (the CVC remains in situ). As the nurse describe your subsequent actions.
- A first year student is shadowing you the nurse for the day and asks how you would know if someone is experiencing fluid overload from their IV therapy. How might you respond?