ER Nurse Misses Vein During IV Placement Causing Infiltration Burns

This case involves a twenty-three-year-old female patient who was seen in the emergency room for lower back pain after being involved in a car accident. The patient was started on an IV drip of normal saline by an ER nurse while she waited for the ER physician to examine her. When the physician arrived forty-five minutes later, the patient complained of severe pain and tightness around the site of the IV. The patient’s arm displayed local edema, skin blanching, skin coolness, severe pain, and leakage at the puncture site. It was determined that the patient sustained IV infiltration burns and had to undergo surgical decompression of the forearm to relieve the rapid pressure buildup in the subcutaneous tissue.

Question(s) For Expert Witness

1. Could any therapeutic intervention have been initiated as soon as the infiltration was noticed to prevent the need for surgical decompression?

Expert Witness Response E-000253

If the signs and symptoms of infiltration are noticed, one should immediately stop the infusion and remove the catheter because continuing the infusion, despite the signs and symptoms of infiltration, will create the compartment syndrome scenario. A common intervention for infiltration is thermal management at the site. For certain nonvesicant drugs, applying heat to increase blood flow and the amount of interstitial tissue in contact with the fluid can dissipate the pressure. For hypertonic or hyperosmolar fluids, applying cold to restrict contact with additional tissue can be helpful as it limits the tissue affected by osmotic fluid shift. Another intervention is injecting an antidote. Hyaluronidase, a protein enzyme that breaks down the subcutaneous cellular components to allow fluid reabsorption, is probably the best choice, and several brands are available.