Reconnaître les complications Appliquer les bonnes pratiques

Définition Collection sanguine dans les tissus sous-cutanés autour du point de ponction.

Causes ■ Transfixion de la veine.■ Fuite depuis le point de ponction.

Prévention* ■ Utiliser en priorité les veines du membre supérieur et

commencer par la plus distale possible.■ Eviter les zones de flexion et les sites trop proches des

ponctions précédentes.■ Eviter la main, le poignet et la fosse antécubitale pour

perfuser les solutions irritantes. ■ Ne pas administrer en routine des solutions ayant une

osmolarité > 900 mosm/l.■ Bien fixer le cathéter à l’aide d’un pansement adapté.

Prévention* ■ Insérer toujours le cathéter, biseau orienté vers le haut.■ Attendre l’hémostase avant la repose du garrot si 2ème

tentative.■ Garder la peau tendue pendant toute la phase de pose du

cathéter.■ Relâcher le garrot dès que le reflux sanguin est visible.■ Retirer l’aiguille dès que la canule est cathétérisée dans la

veine.

Prévention* ■ Respecter les bonnes pratiques d’antisepsie : réaliser

une désinfection des mains, une phase de détersion, une antisepsie cutanée.

■ Connecter la ligne de perfusion selon les protocoles en vigueur.

■ Surveiller au moins 1 fois par jour le point de ponction et le pansement qui doit rester propre, sec et adhérent.

■ Limiter les manipulations de l’embase du cathéter et privilégier l’utilisation d’un prolongateur.

Veine céphalique

Veine basilique

Veine médiane

Arcade dorsale

Définition Contamination du site de ponction ou du sang par des agents pathogènes.

Causes 3 sources de contamination : ■ Peau du patient (depuis le point de ponction).■ Ligne de perfusion (depuis les connexions).■ Hématogène (foyer infectieux profond à distance du

point de ponction).

Prévention* ■ Respecter les bonnes pratiques d’antisepsie cutanée :

appliquer un antiseptique en solution alcoolique et attendre son séchage complet.

■ Choisir une gauge et une longueur adaptées au diamètre interne de la veine, à la solution et au volume à perfuser.

■ Choisir la veine la plus accessible et facile à palper.■ Bien fixer le cathéter à l’aide d’un pansement adapté.■ Ne pas administrer en routine des solutions ayant

une osmolarité > 900 mosm/l.■ Changer de point de ponction toutes les 72 h à 96 h. ■ Limiter les manipulations de l’embase du cathéter.

www.infusionsecurity.ch

DéfinitionInflammation de la veine ou d’un vaisseau lymphatique. Peut être associée à une thrombophlébite.

CausesL’inflammation peut être d’origine : ■ Mécanique : frottement de la canule sur l’endoveine.■ Septique : contamination bactérienne.■ Chimique : mauvaise hémodilution ou solution irritante

trop concentrée.

* D’après SFHH - HAS Prévention des infections liées aux cathéters veineux périphériques - Novembre 2005

Définitions L’infiltration est la diffusion accidentelle d’une solution hors de la veine, dans les tissus sous-cutanés. L’extravasation est l’infiltration d’une solution irritante causant une nécrose des tissus par agression chimique ou vasoconstriction sévère.

Causes ■ Défaut de fixation provoquant des mouvements du

cathéter dans l’endoveine.■ Solution trop concentrée ou au pH trop acide/basique.

Infiltration / Paravasation

Hématome

Infection du site de ponction

Phlébite

AV46

64_0

7.11

(HC1

087)

Les complications de la voie I.V. périphérique

IF YOUR PATIENT is receiving peripheralI.V. therapy, you’ll need to watch for signsand symptoms of complications, such as:n hypersensitivityn infiltrationn extravasationn phlebitisn infection.

We’ll fill you in on how to recognize thesecomplications and walk you through how totreat them, with an eye on prevention.

You’re so sensitiveBefore you adminis-ter an I.V. medica-tion, take steps tofind out if your pa-tient may be proneto hypersensitivity:n Ask him if he hasany allergies, in-cluding allergies tofood or pollen.n Ask if he has afamily history of al-lergies; if he does,he’s more likely todevelop a drug hy-persensitivity.n If your patient isan infant less thanage 3 months, askthe mother abouther allergy historybecause maternalantibodies may stillbe present.

After giving anI.V. medication, fol-low through withthese precautions:

n Stay with your patient for 5 to 10 min-utes to detect early signs and symptoms ofhypersensitivity, such as sudden fever, jointswelling, rash, urticaria (hives), broncho-spasm, and wheezing.n If he’s receiving the drug for the first orsecond time, check him every 5 to 10 min-utes or according to your facility’s policy.An immediate, severe reaction is life-threatening, so prompt recognition andtreatment are imperative.

At the first sign of hypersensitivity: n Discontinue the infusion and notify the

14 Nursing made Incredibly Easy! January/February 2008

Complications of peripheral I.V. therapy

Sometimes, Ican get a bitcomplicated...

Running down the infiltration scaleUse these classifications when documenting instances of infiltration.

Degree01+

2+

3+

4+

Source: Infusion Nurses Society, Infusion Nursing Standards of Practice, Journal of InfusionNursing, January/February 2006.

Description • No symptoms • Skin blanched• Edema less than 1 inch (2.5 cm) in any direction• Cool to touch• With or without pain • Skin blanched• Edema 1 to 6 inches (2.5 to 15 cm) in any direction• Cool to touch• With or without pain • Skin blanched, translucent• Gross edema more than 6 inches in any direction• Cool to touch• Mild to moderate pain• Possible numbness • Skin blanched, translucent, tight, leaking, discolored, bruised,

swollen• Gross edema more than 6 inches in any direction• Deep, pitted tissue edema• Circulatory impairment• Moderate to severe pain• Infiltration of any blood product, irritant, or vesicant

i.v. essentials

health care provider immediately. n Administer medications as ordered. n Monitor the patient’s vital signs and pro-vide emotional support.

Just say no to infiltrationInfiltration occurs when I.V. fluid leaks intosurrounding tissue. It’s commonly causedby improper placement or dislodgment ofthe catheter. When the tip of the catheter ispositioned near a flexion area, patientmovement may cause the catheter to slipout or through the lumen of the vessel. Therisk of infiltration increases in older patientsbecause their veins are thin and fragile.

Signs and symptoms of infiltrationinclude:n swellingn discomfortn burningn tightnessn cool skinn blanching.

If only a small amount of an isotonic solu-tion or nonirritating drug infiltrates, thepatient usually experiences only mild dis-comfort. Here’s what you need to do:n Stop the infusion and remove the device(unless the medication is a vesicant; consultthe health care provider and pharmacy).n Elevate the limb to increase patient com-fort. n Check the patient’s pulse and capillaryrefill time.n Counteract the effects of the drug as or-dered.n Perform venipuncture in a different loca-tion and restart the infusion.n Check the site frequently.n Document your findings using the infil-tration scale (see Running down the infiltra-tion scale).

Extra! Extra! Extravasationsuspected!Extravasation, the leaking of vesicant drugs(such as antineoplastics) into surroundingtissue, can cause severe local tissue damage,resulting in delayed healing, infection, tis-sue necrosis, disfigurement, loss of function,and even amputation.

To help prevent extravasation when giv-

ing vesicants:n Strictly adhere toproper administra-tion techniques.n Avoid using theback of the handwhere tendon andnerve damage ismore likely.n Avoid using thewrist and fingers be-cause they’re hardto immobilize andareas with previous

damage or poor circulation.n Give vesicants last when multiple drugsare ordered.

Signs and symptoms of extravasationinclude:n blanching, burning, or discomfort at theI.V. siten cool skin around the I.V. siten swelling at or above the I.V. site.

If you suspect extravasation, follow yourfacility’s protocol. Take these essential steps:n Stop the I.V. flow and remove the I.V.line, unless the catheter should remain inplace to administer the antidote.n Estimate the amount of extravasated so-lution and notify the health care provider.n Instill the appropriate antidote accordingto your facility’s protocol.n Elevate the extremity.n Record the extravasation site, your pa-tient’s symptoms, the estimated amount ofextravasated solution, and the treatment.

Follow the manufacturer’s recommenda-tions to apply either ice packs or warm com-presses to the affected areas.

Fighting phlebitisPhlebitis, or inflammation of a vein, is acommon complication of peripheral I.V.therapy that’s associated with acidic or al-kaline solutions or those that have a highosmolarity. Other factors include:n vein trauma during insertionn using a vein that’s too smalln using a vascular access device that’s toolargen prolonged use of the same I.V. site.

Phlebitis can follow any infusion, but it’s

January/February 2008 Nursing made Incredibly Easy! 15

memoryjoggerAs soon as you spotinfiltration, think ofthe three C’s:Cut off (the infusion)Counteract (theeffects of the drug)Contain (the affect-ed area).

Get to knowthe signs andsymptoms towatch out for.

most common after continuous infusions,developing 2 to 3 days after the vein isexposed to the drug or solution. It developsmore rapidly in distal veins than in veinsclose to the heart. Phenytoin and diazepamcan produce phlebitis after one or moreinjections at the same I.V. site. Large dosesof potassium chloride, amino acids, dextrosesolutions, and multivitamins can causephlebitis as well. Certain irritating I.V. drugsare also likely to cause phlebitis when pig-gybacked, including:n erythromycinn tetracyclinen nafcillin n vancomycinn amphotericin B.

Take these steps to prevent phlebitis:n Use proper venipuncture technique.n If necessary, dilute drugs correctly.n Monitor administration rates.n Observe the I.V. site frequently.n Change the infusion site regularly ac-cording to your facility’s policy.

Signs and symptoms of phlebitis include:n redness or tenderness at the tip of thecathetern puffy area over the veinn elevated temperature.

To detect phlebitis, inspect the I.V. siteseveral times a day (see Classifying phlebitis).

Use a transparentsemipermeabledressing so you cansee the skin distal to the tip of thecatheter as well asthe insertion site.

If you suspectphlebitis, followthese steps:n At the first signof redness or ten-derness, stop theinfusion. n To ease your

patient’s discomfort, apply warm packs.n Document your patient’s condition andinterventions.n If indicated, insert a new catheter at adifferent site, preferably on the oppositearm, using a larger vein or a smaller deviceand restart the infusion.

Infection detectionA patient receiving I.V. therapy may de-velop a local or systemic infection. Monitoryour patient for signs and symptoms of in-fection, such as redness and discharge atthe I.V. site or an elevated temperature. Ifthe infection is systemic:n Stop the infusion.n Notify the health care provider.n Remove the device.n Culture the site and device as ordered.n Administer medications as prescribed.n Monitor the patient’s vital signs.

Let’s not get too complicatedComplications of peripheral I.V. therapycan be serious, but with your careful atten-tion and eye on prevention, you can helpyour patient avoid these pitfalls. n

Learn more about itInfusion Nurses Society. Infusion Nursing Standards ofPractice. Journal of Infusion Nursing. 29(1, Suppl.):S1-S92,January/February 2006.

I.V. Therapy: An Incredibly Easy Pocket Guide. Philadelphia,Pa., Lippincott Williams & Wilkins, 2006:174-177.

I.V. Therapy Made Incredibly Easy!, 3rd edition. Philadel-phia, Pa., Lippincott Williams & Wilkins, 2006:187-189.

Smeltzer SC, et al. Brunner and Suddarth’s Textbook ofMedical-Surgical Nursing, 11th edition. Philadelphia, Pa.,Lippincott Williams & Wilkins, 2007:350-351.

18 Nursing made Incredibly Easy! January/February 2008

Together, we can keep I.V. therapy

complicationfree!

memoryjoggerHere’s a handy tip:When administeringvesicants I.V., thinkhands off! Avoidthe back of the hand(where damage fromextravasation ismore likely) and thewrist and fingers(which are hard toimmobilize).

Classifying phlebitisUse these classifications when documenting phlebitis.

Degree01+2+

3+

4+

Source: Infusion Nurses Society, Infusion Nursing Standards of Practice, Journal of InfusionNursing, January/February 2006.

Description• No signs and symptoms• Erythema with or without pain• Erythema with pain• Edema may or may not be present.• Erythema with pain• Edema may or may not be present. • Streak formation• Palpable cord• Erythema with pain• Edema may or may not be present.• Streak formation• Palpable cord longer than 1 inch (2.5 cm) • Purulent drainage

i.v. essentials