Peripheral venous catheterization is a relatively safe procedure. Many of the complications listed below are more common with central venous catheters. However, knowledge of these complications is essential in order to recognize problems when they occur.

Early Complications

 

Late Complications
Early Complications

Infiltration | Arterial Placement | Air Embolism | Catheter Fracture & Embolism

 

Infiltration and Extravasation

Infiltration of the IV occurs when the tip becomes dislodged from the vessel lumen. This complication should be suspected when the intravenous fluid flows poorly, if the line is difficult to flush, if the automated pump sounds an alarm, or if the patient complains of pain. (Liu 2004, Weinstein 2001)

 

Infiltration can become a serious situation if toxic fluids are being administered through the line. These include hypertonic agents, cytotoxic agents, and vasopressors. Vasopressors, such as norepinephrine or dopamine extravasate into local tissues from an infiltrative line, severe tissue necrosis may result. This can be treated by injecting five cc phentolamine mixed with five cc of saline into the subcutaneous tissues with a small gauge needle. (Liu 2004)

 

It can be difficult at times to confirm that an intravenous catheter is actually within the lumen. Backflow of blood into the intravenous tubing upon the application of negative pressure (e.g. withdrawing on a syringe attached to the catheter) is not a reliable indicator, as the tip of the catheter may be partially in and partially out of the vessel lumen. Conversely, the absence of backflow does not necessarily indicate catheter malposition, as the tip of the needle may intraluminal but adjacent to a valve or vessel wall. The most reliable method to confirm intraluminal placement, and to exclude infiltration, is to apply tourniquet proximal to the catheter site tight enough to restrict venous flow. A catheter in the appropriate position will cease to flow in this situation, whereas an infiltrated line may continue to flow. (Weinstein 2001)

 

Arterial Placement

Peripheral catheters may accidentally be inserted into arteries instead of veins. This would occur most commonly in the antecubital fossa, with the catheter entering the brachial artery instead of the median cubital or basilic vein. Arterial cannulation is distinguished by arterial flow (pumping) of blood, which will also be a bright scarlet red if patient is not hypoxic. In this situation phlebotomy may still be performed but the catheter should subsequently be removed. Pressure should be placed over the site for one full minute, longer if patient is coagulopathic.

Air embolism

Air embolism is more commonly seen with central venous catheters, however may also occur with peripheral catheters. If air is introduced into the vascular system, it may accumulate and cause complications such as blockage of the right side of the vascular system (i.e. venous) leading to outflow obstruction of the right ventricle and pulmonary arteries. Possible symtpoms include impaired gas exchange, hypotension, and circulatory collapse. (Breen 2000, Feied 2002) Left-sided (arterial) obstruction may also occur, if an atrial or ventricular septal defect is present. Obstruction of the coronary or cerebral arteries by air can lead to myocardial infarction and acute stroke, respectively. (Breen 2000, Shockley 2002)

While it is classically taught that 5 ml / kg of air is needed to produce an "air lock" of the right ventricle and pulmonary artery, circulatory collapse has been reported with as little as 20cc of air. Should signicant air embolization occur, the patient should be placed in a left lateral recumbent position to trap the air in the right atrium. Available interventions include aspiration via a central venous catheter, hyperbaric treatment, and in severe cases, thoractomy. (Feied 2002)

To prevent air embolism, all tubing should be flushed prior to utilization. Additionally, all connections must be tight, and fluid bags should not be allowed to completely empty before replacement. If this occurs, the line should be removed from the catheter and re-flushed. (Weinstein 2001)

 

Catheter fracture and embolism

Catheter embolism is a rare complication of peripheral intravenous catheters. If the tip of the synthetic catheter is sheared off, it may potentially embolize and travel proximally in the circulation. This sequence of events occurs when the needle is withdrawn from the catheter and then reinserted. Therefore, once the needle is removed it should never be reinserted. (Weinstein 2001) Catheter embolism carries a high complication rate (up to 49%), and fluoroscopic catheterization and retrieval of the foreign body is usually recommended. (Roye 1996)

 

Late Complications

Infection | Thrombophlebitis | Phlebitis

 

Infection

Infection is a common complication of intravenous therapy. Intravenous catheters can lead to local infection as well as bacteremia from several mechanisms. The most common source of infection is skin flora, which migrates distally down the intravenous catheter. Coagulase negative staph and staphylococcus aureus, as well as yeasts (e.g. candida), are frequent isolates responsible for infection. (Garrison 1994) Other sources of infection include hematogenous spread from distant infections, as well as infected solutions or other equipment. Gram negative bacilli are often associated in these situations. (Sitges 1999) It should be noted that patients at the extremes of age (less than one year or greater than 60 years), those with infections at remote sites, and those with underlying immunodeficiency disorders are at greater risk for iatrogenic catheter related infections. (Garrison 1994)

The diagnosis of infection related to peripheral venous catheters is relatively straightforward. In most cases, localized inflammation, induration, and erythema will be present. Cultures of the catheter tip, which are often useful in regards to central venous catheter-related infections, are not routinely required for peripheral lines. More severe sequelae from line infections (such as septic shock, sustained bacteremia, metastatic infection, and endocarditis) are usually associated with the use of central venous catheters. (Garrison 1994, Sitges 1999)

The peripheral venous catheter should be removed at once if infection is suspected. the decision to begin antibiotics must be made on an individual basis. Antibiotics with activity against gram positive organisms (such as first-generation cephalosporins, penicillin, or vancomycin) should be initiated if there is evidence of systemic infection or spreading local infection.

Catheter related infections are best controlled by meticulous attention to sterility and preparation during insertion. Alcohol preps are adequate only if done appropriately (i.e. applied with a moderate amount of friction for one minute.) A quick swipe with an alcohol prep simply not effective. Iodine-based solutions are more effective than alcohol, and should be used if the patient is not allergic to iodine. These preps are most effective if allowed to dry on the skin for at least 30 seconds. (Weinstein 2001)

Thrombophlebitis

Peripheral venous thrombophlebitis, an extremely common complication, is heralded by pain, erythema, swelling, and a palpable cord along the course of the cannulated vein. Thrombophlebitis is caused by local damage to the venous wall, and resultant inflammation and thrombus formation. (Tagalakis 2002)

 

There are multiple risk factors for the development of thrombophlebitis. The length of duration of cannulation is proportional to the risk of thrombophlebitis. Catheters placed in the veins that overlay joints are more likely to cause thrombophlebitis, as motion of the joint can cause frictional trauma between the endothelium and the catheter. Stagnant blood flow in the lower extremities makes veins in this location more likely to develop thrombophlebitis. Numerous intravenous fluid solutions, such as potassium chloride, barbiturates, phenytoin, and chemotherapeutic agents, are known to cause endothelial damage and inflammation. Finally, poor technique and multiple attempts lead to vascular damage and thrombophlebitis. (Tagalakis 2002, Weinstein 2001)

 

Should thrombophlebitis developed, the intravenous catheter should be removed immediately. The most circumstances, no treatment is needed other than elevation of the extremity and the application of warm compresses. Antibiotics may be required if there is evidence of surrounding infection. (Weinstein 2001)

 

Thrombophlebitis can be prevented by following these recommendations (Tagalakis 2002):

 
  • Utilizing a septic technique
  • Using of alcohol or iodine prior to insertion
  • Securing catheter appropriately
  • Avoiding lower extremity insertion sites
  • Inspecting for thrombophlebitis daily
  • Replacing catheters every 72 hours
  • Avoiding unnecessary tubing changing
  • Replacing dressings as needed.
 

Back | Next