Infiltration and Extravasation

Key Points

• Infiltration occurs when the tip of an IV catheter slips out of the vein, allowing non-vesicant fluid to infuse into surrounding tissue; symptoms include coolness, swelling, and pain at the site.
• Extravasation is infiltration of a vesicant (tissue-damaging) medication — such as chemotherapy — into extravascular tissue, causing chemical injury, blistering, and potentially tissue necrosis.
• Both complications require immediate IV discontinuation and site removal; extravasation requires urgent intervention to prevent tissue death.
• Prevention requires frequent IV site assessment — never obscure the site with gauze or wrappings that prevent visual inspection.
• Phlebitis (vein inflammation) is a related IV complication distinct from infiltration; causes include chemical, mechanical, and infectious factors.

Pathophysiology

The integrity of an intravenous infusion depends on the catheter tip remaining within the vascular lumen. When this is disrupted, fluid enters the extravascular tissue:

• Infiltration: The catheter tip migrates out of the vein into the surrounding interstitial tissue. Non-vesicant solutions (IV fluids, most medications) accumulate in the tissue, causing local edema, cooler skin temperature, and discomfort. Tissue damage is usually minimal but can occur if large volumes accumulate.

• Extravasation: The same displacement occurs with a vesicant drug — a medication that is caustic to tissue. The chemical properties of the drug cause a direct injury to the surrounding cells, resulting in inflammation, blistering, ulceration, and in severe cases, irreversible tissue necrosis. Permanent scarring can occur, particularly in vulnerable populations such as neonates. Vesicants include chemotherapy agents (e.g., vincristine, doxorubicin), vasopressors (e.g., norepinephrine, dopamine), calcium chloride, and potassium chloride.

• Phlebitis: Inflammation of the vein wall from chemical irritation (irritating medications), mechanical trauma (catheter movement, excessive flexion), or infection. Presents with redness, warmth, streak formation, and tender cord along the vein.

Nursing Assessment

NCLEX Focus

Know the distinction: infiltration = non-vesicant fluid, usually reversible; extravasation = vesicant drug, risk of permanent necrosis. The nursing response differs — extravasation requires urgent assessment for antidote availability and provider notification.

Signs and symptoms to assess at every IV check:

Complication	Key Signs
Infiltration	Swelling, skin cool to touch, pain or discomfort, slowed or stopped infusion
Extravasation	Pain, stinging/burning, blistering, erythema, edema; warmth around site; may stop infusing
Phlebitis	Redness, warmth, tenderness, streak along vein; possible palpable cord

• Assess the IV site every 1–4 hours during active infusions, more frequently with vesicant infusions.
• Verify IV patency before each IV push medication administration.
• Never wrap or cover the IV site with gauze in a manner that prevents direct visual inspection — failure to assess the site allows complications to progress undetected.
• Measure and document extremity circumference when monitoring for significant infiltration.

Nursing Interventions

Both infiltration and extravasation:

1. Stop the infusion immediately and clamp the IV tubing.
2. Disconnect the IV tubing from the catheter; attempt to aspirate remaining fluid/drug from the catheter before removal.
3. Remove the IV catheter and assess it to confirm it is fully intact.
4. Notify the provider and document the event.
5. Avoid using the affected limb for further vascular access until the complication has resolved.

Infiltration (non-vesicant):

• Apply warm or cold compress per agency protocol and the specific fluid infused.
• Elevate the affected limb to reduce edema.
• Restart IV access in an alternate site proximal to the injury or in the contralateral extremity.
• During blood-product transfusion infiltration, stop infusion immediately, aspirate residual fluid from the catheter when possible, estimate infiltrated volume, start new access at a different site, and restart transfusion only after safety checks.
• Reinforce prevention with securement devices and avoidance of flexion sites when possible.

Extravasation (vesicant):

• Notify the provider urgently; some vesicants have specific antidotes (e.g., hyaluronidase for vinca alkaloids, dexrazoxane for anthracyclines).
• For vasopressor extravasation, follow protocol for early local antidote treatment (for example phentolamine infiltration around the affected site) to reduce dermal necrosis risk.
• Follow agency extravasation protocol — may include subcutaneous antidote injection, cold/warm application based on drug class, and wound care.
• For suspected central-line extravasation, stop infusion, aspirate residual drug from the catheter if possible, and anticipate catheter-integrity/placement imaging (for example chest X-ray) before restart.
• Document the drug name, estimated volume extravasated, site appearance, and interventions taken.
• Monitor the site closely over days for signs of progressive necrosis.

Vesicant Risk

Vesicant extravasation can cause permanent tissue damage within hours. Any patient receiving a known vesicant should have the IV site inspected at minimum every 1–2 hours. If a vesicant infusion stops unexpectedly or a patient reports new pain or burning at the site, treat as extravasation until proven otherwise.

Related Concepts

• cvad-indications-and-device-selection — Central venous access devices reduce peripheral extravasation risk for vesicant infusions.
• intravenous-fluid-categories-tonicity-and-infusion-regulation — IV fluid administration principles related to safe infusion practice.
• catheter-related-bloodstream-infection — Infectious complications from IV catheter use.
• blood-and-body-fluid-exposure-response — Occupational exposure precautions during IV management.
• medication-administration-safety-measures — System safeguards in medication administration applicable to IV drug delivery.

Self-Check

1. What is the critical difference between infiltration and extravasation, and why does the distinction matter clinically?
2. A nurse is caring for a postoperative patient receiving norepinephrine through a peripheral IV. The patient reports burning pain at the site. What should the nurse do first?
3. What nursing practice error contributed to the extravasation case described in clinical literature (neonatal ICU), and how could it have been prevented?