**7. Systemic complications**

*Nerve injury*: When tissue infiltration associated with a PIV catheter affects a nerve coursing the surrounding tissues, nerve injury can occur. It is also possible for the IV needle to lacerate, puncture, and potentially injure a nerve. Finally, localized bleeding/hematoma may irritate a nerve. *Diagnosis*: Patients may not experience any discomfort in the beginning, but it is possible for localized numbness or tingling, loss of sensation to pin prick to emerge later on [70, 71]. Nerve injury can range from neurapraxia with complete recovery (minor injury) to neurotmesis with Wallerian degeneration distal to the site of injury (severe injury) [70]. *Prevention and treatment*: The avoidance of nerve injury requires good procedural skills and knowledge of pertinent anatomy. The PIV placing provider should be conscious of venipuncture sites associated with the greatest risk, including the distal sensory branches of the radial and ulnar nerves for sites in the dorsal hand, the superficial radial nerve at the cephalic vein of the radial wrist, the median nerve on the volar aspects of the wrist, the median and anterior interosseous nerves at or above the antecubital fossa, and the lateral and medial antebrachial nerves for the antecubital fossa [36]. The needle insertion should be as shallow as possible, preferably at an angle of 5–15° relative to the skin and using the non-dominant arm [71]. Although nerve injury is rare, the patient should still be aware of this complication and encouraged to inform the nurse immediately if he or she experiences any strange sensation during PIV placement. Nerve damage tends to be self-limited, with typical recovery times of a few weeks or months. Surgical exploration may be required in patients with intractable pain, severe functional loss,

122 Vignettes in Patient Safety - Volume 4

or those without recovery signs within 3–6 months after the initial injury [72–74].

rate of occlusion was lower with heparin infusion compared to placebo infusion [59].

*Dislodgement*: Dislodgement can occur when IV catheter was incorrectly secured with standard medical tape or another adhesive securement device. More frequently, catheters that are correctly secured become dislocated when more forces are applied upon the catheter than the securement method was intended to endure. IV dislodgement can lead to an unscheduled IV restart or more invasive central line. Dislodgement rate has been reported in the range of 3.7–9.9% in a prospective randomized study with a mean of 6.9%. Even a greater rate of 17.5%

*Occlusion*: Occlusion is defined as the slowing or cessation of fluid infusion. It can occur due to the mechanical blockage within the cannula or fibrin deposition in/around the tip of the cannula. In addition, it may be due to swollen phlebitic veins, or insertion at a point of flexion, both of which may collapse the catheter and prevent flow [75]. There may be a higher incidence of occlusion associated with insertion in the hand, antecubital fossa, or upper arm, when compared to forearm placement [2, 37]. 25.6% had failed catheterization due to PIV occlusions in an analysis from a randomized controlled trial in Australia. The occlusion was associated with infusions of antibiotics, hydrocortisone, in the setting of concurrent infection, and the use of subsequent (rather than initial) catheters [37]. In a single-center prospective study done in Australia, catheter failure due to occlusion/infiltration was reported to be 14%. In the same study, flucloxacillin, female gender, and 22-gauge PIVs were significant predictors of occlusion [49]. *Diagnosis*: Occlusion can be diagnosed by the presence of discomfort, blood within the line, or PIV not running. *Prevention and treatment*: Actively checking for kinks and removing nonfunctioning cannulas will help reduce the overall duration of functional occlusion. Insertion of PIV by a trained specialist may also help reduce the risk of occlusion [37]. Various methods have been tried to prevent occlusion. In recent randomized trial, the

*Air embolism:* Air embolism is defined as an unintended venous administration of air through an intravenous access device or insertion site. It is usually associated with central venous catheters but can also occur with peripheral intravenous central catheters and less commonly with short peripheral catheters. The incidence of this complication may be low, but it is potentially fatal, with reported mortality as high as 30% [86]. Clinical signs and symptoms may vary depending on the patient, rate of infusion, volume of air, and anatomical location [87]. Physiologic injury can be due to associated ischemia, infarction, thrombotic, or inflammatory response. *Diagnosis:* Clinical signs and symptoms of air embolism may be nonspecific and not readily recognizable, yet immediate intervention is critical to adequately address the problem and prevent/minimize associated harm. Patient may present with sudden onset of dyspnea, cough, wheezing, chest or shoulder pain, tachypnea, tachycardia, hypotension, and/or neurological findings of cerebrovascular accidents [86, 88]. *Prevention and treatment*: For peripherally inserted catheters, prevention includes the avoidance of air, both primarily and by so-called "air traps" built into the IV circuit. When placing and removing central venous catheters, the patient should be placed in Trendelenburg (during catheter removal), followed by supine (subsequent 20–30 min) position. Prompt diagnosis and focused treatment are mandatory in cases of air embolism. After stabilizing the patient, immediate evaluation and management should be instituted [89]. Affected patients should be transferred to intensive care for close monitoring, with considerations given to hyperbaric oxygen therapy as an adjunct [88].

*Pulmonary edema*: Pulmonary edema or fluid overload is caused by excess fluid accumulation in the lungs, due to excessive fluid in the circulatory system [90]. Elderly, pregnant women, children, infants, and patients with cardiac, pulmonary, or renal disease are at risk of developing hypervolemia. In the context of IVT, fluid overload usually represents a combination of errors, from miscalculated IV rate, to inadvertently prolonged infusion, to lack of diagnostic recognition of early clinical symptoms. *Diagnosis:* Patients usually present with restlessness, breathlessness, tachycardia, dyspnea, cyanosis, and pink frothy sputum. Chest radiography can show typical findings of cephalization, interstitial edema, pulmonary vein enlargement, hilar fullness, Kerley lines, cardiomegaly, and pleural effusion [91]. Associated findings may include decreased oxygen saturation, increased respiratory rate, and pulmonary crackles on auscultation. Finally, increased body weight (e.g., "water weight") may be noted [92]. *Prevention and treatment*: The diagnosis of acute fluid overload requires immediate medical attention and treatment. This involves stopping the infusion, raising the head of the bed, applying oxygen, taking vital signs, complete cardiovascular assessment, diuresis when indicated, and appropriate education of the involved medical providers.

**Peripheral venous catheter adverse events**

Infusate solution leaks out into the surrounding tissue *Diagnosis*: detecting local tissue edema, cool skin, decreased flow rate, and comparison with contralateral

*Prevention:* avoiding PIV too close to the joint, securing

Bleeding from puncture site/localized collection of

*Prevention:* application of pressure after removal of cannula, usage of sterile transparent dressing

Due to tissue infiltration, IV needle laceration,

*Diagnosis:* localized numbness or tingling, loss of

*Prevention:* good knowledge of anatomy, shallow insertion at 5–15 degrees relative to the skin

*Diagnosis:* presence of discomfort, blood within the PV

*Prevention:* check the kinks; remove the nonfunctioning

Due to more forces applied upon the catheter than the securement method was intended to endure *Diagnosis:* checking the flow of IV fluids or IV flushes *Prevention:* effective securement; use of catheters with

Due to cold IV fluid infusion, drug-related irritation, or

*Diagnosis:* pain, blanching at the site, difficulty in

*Prevention:* apply warm compress; slow infusion rate

**Table 1.** Local and systemic complications of peripheral venous catheter.

Slowing or cessation of fluid infusion

wings, extension tubing for movement

**Tissue infiltration and extravasation**

the catheter, and monitoring site frequently

*Diagnosis*: swelling, tenderness, and reddish

**Hemorrhage/hematoma**

extravasated blood

discoloration

**Nerve injury**

**Occlusion**

cannula

**Dislodgement**

**Venous spasm**

palpating vein

trauma to the vein

hematoma irritation

sensation to pin prick

line, PIV not running

**Local complications Systemic complications**

**Air embolism**

Dangers of Peripheral Intravenous Catheterization: The Forgotten Tourniquet and Other Patient…

catheter removal

**Pulmonary edema**

system

**Infection**

blood count, D-dimer

bronchospasm, wheezing

**Intra-arterial placement**

bleeding

**Hypersensitivity**

Rare unintended venous administration of air through IV site *Diagnosis:* nonspecific sudden onset of dyspnea, cough, wheezing, tachypnea, and/or neurological signs of CVAs *Prevention:* avoidance of air-traps in IV circuit; patient is in Trendelenburg position followed by supine position during

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Fluid overload caused by excess fluid accumulation in the lungs *Diagnosis:* breathlessness, tachycardia, dyspnea, cyanosis, pink frothy sputum, chest radiography, decreased oxygen saturation *Prevention:* avoidance of miscalculation IV rate and prolonged

Small part of the cannula breaks off and flows into the vascular

*Diagnosis:* symptomatology depends on the location,

*Prevention:* careful inspection of cannula; catheters should not be removed against unexpected resistance; repairs

*Diagnosis:* presence of purulent discharge, and/or temperature,

*Prevention:* ask about any previous history of allergies, stay with the patient for five to ten minutes to detect early signs

*Diagnosis:* detection of pulsatile blood, changes in capillary refill, appearance of ischemia, blood gas analysis, ultrasound *Prevention:* recollecting that veins are more superficial than arteries, immediate removal of PIV after detecting pulsatile

infusion, early recognition of symptoms

incidental finding on imaging, chest X-ray

Purulent discharge from the site after 2–3 days

*Prevention:* hand hygiene, aseptic technique

A severe hypersensitivity can be life- threatening *Diagnosis:* sudden fever, joint swelling, rash, urticarial,

Misplacement of PIV due to lack of vigilance

should only be done by manufacturer

**Catheter fragment embolism**

**(PVCAEs)**

limb

*Catheter fragment embolism*: Intravascular embolization of catheter fragment is a rare complication that occurs when a small part of the cannula breaks off and flows into the vascular system [93, 94]. *Diagnosis:* Symptomatology and diagnostic identification of intravascular embolization of catheter fragments are variable, largely depending on the location and size of the object. Most events are completely asymptomatic and only found incidentally on imaging performed for unrelated reasons [94]. Larger fragments, especially those that migrate into more central venous and pulmonary circulation, may result in palpitations, arrhythmias, chest pain, shortness of breath, cough, pain, and/or hypotension [86]. Chest X-rays may help assess the presence of any fragment. *Prevention and treatment*: Prevention starts with a careful inspection of the cannula and more specifically its distal end, to see if the PIV is structurally intact. Catheters should not be removed against unexpected resistance, which should prompt further investigation (e.g., ultrasound) before proceeding. PIV devices should be protected from twisting, bending, entanglement, etc. Repairs should only be done through official channels involving the manufacturer. Each event should be documented and disclosed to patients and their families, in accordance with existing guidelines [86].

*Infection*: Local infection is caused by lack of asepsis at insertion or regrowth of skin bacteria which then enter the PIV site. It can present as purulent drainage from the site; usually after 2–3 days it takes the body to mount a response after PIV placement. The majority of serious bloodstream infections are associated with central venous catheters, especially when catheters are placed emergently or used for prolonged periods of time [59]. For PIV catheters, the situation is different, since these are placed in less acutely unwell patients and typically require shorter periods of hospitalization and IVT. Although bacterial colonization of PIV catheters can increase with dwelling times of more than 72 h, there does not seem to be an elevated risk of associated phlebitis or infection regardless of whether the PIC catheter is replaced due to clinical indication or subject to routine replacement between 72 and 96 h [1, 2, 95, 96]. Thus, international guidelines now recommend removal of PIVCs when treatment is completed or sooner if any complication develops [97, 98]. Despite the


**Table 1.** Local and systemic complications of peripheral venous catheter.

*Pulmonary edema*: Pulmonary edema or fluid overload is caused by excess fluid accumulation in the lungs, due to excessive fluid in the circulatory system [90]. Elderly, pregnant women, children, infants, and patients with cardiac, pulmonary, or renal disease are at risk of developing hypervolemia. In the context of IVT, fluid overload usually represents a combination of errors, from miscalculated IV rate, to inadvertently prolonged infusion, to lack of diagnostic recognition of early clinical symptoms. *Diagnosis:* Patients usually present with restlessness, breathlessness, tachycardia, dyspnea, cyanosis, and pink frothy sputum. Chest radiography can show typical findings of cephalization, interstitial edema, pulmonary vein enlargement, hilar fullness, Kerley lines, cardiomegaly, and pleural effusion [91]. Associated findings may include decreased oxygen saturation, increased respiratory rate, and pulmonary crackles on auscultation. Finally, increased body weight (e.g., "water weight") may be noted [92]. *Prevention and treatment*: The diagnosis of acute fluid overload requires immediate medical attention and treatment. This involves stopping the infusion, raising the head of the bed, applying oxygen, taking vital signs, complete cardiovascular assessment, diuresis when indicated, and appropriate education of the involved

*Catheter fragment embolism*: Intravascular embolization of catheter fragment is a rare complication that occurs when a small part of the cannula breaks off and flows into the vascular system [93, 94]. *Diagnosis:* Symptomatology and diagnostic identification of intravascular embolization of catheter fragments are variable, largely depending on the location and size of the object. Most events are completely asymptomatic and only found incidentally on imaging performed for unrelated reasons [94]. Larger fragments, especially those that migrate into more central venous and pulmonary circulation, may result in palpitations, arrhythmias, chest pain, shortness of breath, cough, pain, and/or hypotension [86]. Chest X-rays may help assess the presence of any fragment. *Prevention and treatment*: Prevention starts with a careful inspection of the cannula and more specifically its distal end, to see if the PIV is structurally intact. Catheters should not be removed against unexpected resistance, which should prompt further investigation (e.g., ultrasound) before proceeding. PIV devices should be protected from twisting, bending, entanglement, etc. Repairs should only be done through official channels involving the manufacturer. Each event should be documented and disclosed to patients and their families, in accordance with existing

*Infection*: Local infection is caused by lack of asepsis at insertion or regrowth of skin bacteria which then enter the PIV site. It can present as purulent drainage from the site; usually after 2–3 days it takes the body to mount a response after PIV placement. The majority of serious bloodstream infections are associated with central venous catheters, especially when catheters are placed emergently or used for prolonged periods of time [59]. For PIV catheters, the situation is different, since these are placed in less acutely unwell patients and typically require shorter periods of hospitalization and IVT. Although bacterial colonization of PIV catheters can increase with dwelling times of more than 72 h, there does not seem to be an elevated risk of associated phlebitis or infection regardless of whether the PIC catheter is replaced due to clinical indication or subject to routine replacement between 72 and 96 h [1, 2, 95, 96]. Thus, international guidelines now recommend removal of PIVCs when treatment is completed or sooner if any complication develops [97, 98]. Despite the

medical providers.

124 Vignettes in Patient Safety - Volume 4

guidelines [86].

low occurrence of both local and bloodstream infections involving PIV catheters, severe infections can still significantly contribute to patient morbidity simply because of the ubiquitous nature of peripheral catheters [59]. *Diagnosis:* Local infection can be diagnosed by signs and symptoms of tenderness, swelling, erythema, purulent drainage, temperature, and appropriate laboratory testing (e.g., comprehensive blood count or D-dimer in cases of phlebitis) [99]. Of note, lower extremity PIVs are associated with higher incidence of infections when compared to upper extremity PIVs [100]. *Prevention and treatment*: To reduce morbidity and financial burden of PIV-related infections, appropriate education and multidisciplinary efforts should be implemented. For all PIV catheters, a clean, dry, intact dressing is recommended because any soilage will facilitate microorganism growth. Any soilage covered by nontransparent dressings can increase the risk of not detecting infection [1]. The density of skin flora at the site plays an important role in infection. From purely procedural perspective, the first and essential parts of the process should involve removal of the infected PIV cannula and cleansing of the site using sterile technique. Hand hygiene, clipping of excess hair, skin preparation with alcoholic chlorhexidine solution, proper aseptic technique, and maximal sterile barriers including cap, mask, sterile gown, and gloves during insertion can reduce the incidence of infection [59]. During the PIV insertion process, the antiseptic scrubbing technique also modulates the risk of infection [76]. Post-insertion, infection prevention is still crucial and is achieved by meticulous attention to hand hygiene, aseptic preparation of injectates and infusates, needleless connector decontamination with effective antiseptic, and technique. The insertion site requires weekly redressing (or sooner if the dressing is compromised), including recleaning of the insertion site with alcoholic chlorhexidine. Under certain circumstances, such as neutropenic patients, filling and flushing the lumen of the catheter with an antibiotic solution may provide some prophylactic benefits [59]. A final and very simple way to prevent PIVCassociated infections is to ensure the PIVC is reviewed daily and documented, and there is consideration of removal, for example, with the patient moved to oral medication [101] and vigilance for "idle PIVCs" See **Table 1**.

*treatment*: Prevention is the most important measure in this setting. Providers must take great care that the PIV catheter is inserted into a vein, remembering that peripheral veins tend to be more superficial than arteries. Except for very few clinical circumstances (e.g., catastrophic hypotension), arterial cannulation will result in readily visible, pulsatile bleeding from the PIV catheter. In the case of inadvertent intra-arterial injection, it is primarily the intravenous drug that will be most likely to contribute to subsequent problems, as opposed to the ordinary intravenous electrolyte solution. Management consists of PIV catheter removal, assurance of hemostasis, prevention/management of vasospasm, and treatment of any distal complications

Dangers of Peripheral Intravenous Catheterization: The Forgotten Tourniquet and Other Patient…

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*Forgotten tourniquet*: Phlebotomy tourniquets are simple devices used to temporarily restrict venous blood flow, making veins more prominent and easier to see prior to PIV catheter placement. Some considerations regarding the use of tourniquets include the need for optimized location of placement (3–4 inches above intended PIV site), avoiding too much tension to prevent tourniquet from rolling up on itself/twisting and causing discomfort and releasing the tension within approximately 1 min of application [105]. Fortunately a rare occurrence, a phlebotomy tourniquet left in place for prolonged periods of time (e.g., hours) can result in the development of extremity compartment syndrome—a potentially limb-threatening condition [106, 107]. Compartment syndrome is a serious injury defined by an increase in pressure within a fascia-enclosed muscle compartment that results in compromised circulation leading to nerve damage and muscle necrosis [108]. This can lead to permanent disability, amputation, or even death from the release of toxic metabolites. Many of the above findings may not be present until late in the disease process. Thus, early diagnosis is imperative [109, 110]. A high degree of suspicion is crucial to allow an early diagnosis. Pain requiring analgesia in the extremity with the PIV should raise awareness and prompt a thorough examination of the entire extremity. Diagnosis can be especially challenging in children, intubated and sedated patients, and patients with neurological compromise or altered mental status. Increased vigilance must occur in these patients. If compartment syndrome is suspected once a "forgotten tourniquet" event occurs, an urgent surgical consult should be obtained. To prevent this serious omission and thus improve PS, appropriate education/training and procedural checklist implementation may be helpful [111]. Such occurrences, due to the potential for associated patient harm, should be viewed and treated as sentinel events [112]. In addition to compartment syndrome, this complication can also lead to the development of deep vein thrombosis in the affected limb [107]. This chapter's *Clinical Vignette* was based on a hypothetical scenario involving this rare but

Due to its ubiquitous nature, IVT is associated with significant number of complications, both in terms of absolute quantity and taxonomy. In a recent survey, approximately onethird of pediatric patients and one-fourth of adult patients reported experiences involving a potentially preventable IVT-related complication. As outlined throughout this book series,

See **Table 1**.

potentially severe occurrence.

**9. Discussion**

#### **8. Special topics**

*Intra-arterial placement and injection*: An intra-arterial misplacement of PIV, including the initiation of intra-arterial infusion, occurs seldom but is considered a matter of serious concern. Although the precise number of inadvertent intra-arterial PIV cannulation and subsequent injection is unknown, the frequency has been estimated to be as low as 1 in 56,000 and as high as 1 in 3440 [102]. However, the potential consequences of missing the diagnosis can be devastating. If not promptly recognized, its consequences may include arterial spasm, distal ischemia, and eventual development of limb-threatening gangrene [103]. Risk factors associated with unintentional arterial PIV placement include morbid obesity, dark skin, lack of patient cooperation, significant hypotension, and lack of vigilance [103, 104]. *Diagnosis:* Diagnosis can be made by detecting red pulsatile blood, observing changes in capillary refill, the presence of intense pain, and/or the appearance of distal ischemia. Confirmation is done by blood gas analysis, pressure transducer placement, and ultrasound [104]. *Prevention and*  *treatment*: Prevention is the most important measure in this setting. Providers must take great care that the PIV catheter is inserted into a vein, remembering that peripheral veins tend to be more superficial than arteries. Except for very few clinical circumstances (e.g., catastrophic hypotension), arterial cannulation will result in readily visible, pulsatile bleeding from the PIV catheter. In the case of inadvertent intra-arterial injection, it is primarily the intravenous drug that will be most likely to contribute to subsequent problems, as opposed to the ordinary intravenous electrolyte solution. Management consists of PIV catheter removal, assurance of hemostasis, prevention/management of vasospasm, and treatment of any distal complications See **Table 1**.

*Forgotten tourniquet*: Phlebotomy tourniquets are simple devices used to temporarily restrict venous blood flow, making veins more prominent and easier to see prior to PIV catheter placement. Some considerations regarding the use of tourniquets include the need for optimized location of placement (3–4 inches above intended PIV site), avoiding too much tension to prevent tourniquet from rolling up on itself/twisting and causing discomfort and releasing the tension within approximately 1 min of application [105]. Fortunately a rare occurrence, a phlebotomy tourniquet left in place for prolonged periods of time (e.g., hours) can result in the development of extremity compartment syndrome—a potentially limb-threatening condition [106, 107]. Compartment syndrome is a serious injury defined by an increase in pressure within a fascia-enclosed muscle compartment that results in compromised circulation leading to nerve damage and muscle necrosis [108]. This can lead to permanent disability, amputation, or even death from the release of toxic metabolites. Many of the above findings may not be present until late in the disease process. Thus, early diagnosis is imperative [109, 110]. A high degree of suspicion is crucial to allow an early diagnosis. Pain requiring analgesia in the extremity with the PIV should raise awareness and prompt a thorough examination of the entire extremity. Diagnosis can be especially challenging in children, intubated and sedated patients, and patients with neurological compromise or altered mental status. Increased vigilance must occur in these patients. If compartment syndrome is suspected once a "forgotten tourniquet" event occurs, an urgent surgical consult should be obtained. To prevent this serious omission and thus improve PS, appropriate education/training and procedural checklist implementation may be helpful [111]. Such occurrences, due to the potential for associated patient harm, should be viewed and treated as sentinel events [112]. In addition to compartment syndrome, this complication can also lead to the development of deep vein thrombosis in the affected limb [107]. This chapter's *Clinical Vignette* was based on a hypothetical scenario involving this rare but potentially severe occurrence.
