Reference — IV Therapy

IV Therapy Complications Reference

Infiltration, extravasation, phlebitis, CLABSI, catheter occlusion, air embolism, and fluid overload — causes, clinical signs and symptoms, nursing interventions, grading, and prevention.

Educational use only. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.

Critical complications requiring emergency response: Extravasation (vesicant), CLABSI (sepsis), and Air Embolism. Recognize early — act immediately.

Quick Reference by Urgency

Complication	Type	Urgency	First Action
Air Embolism	Systemic	CRITICAL	Clamp line; left lateral Trendelenburg; O₂; call for help
CLABSI	Systemic	CRITICAL	Blood cultures × 2; notify provider; antibiotics as ordered
Extravasation	Local	CRITICAL	Stop infusion; aspirate; notify provider; antidote if ordered
Fluid Overload	Systemic	Moderate–Severe	Slow/stop IV; elevate HOB; oxygen if needed; notify provider
Phlebitis	Local	Moderate	Remove catheter; warm compress; resite; notify provider if grade ≥3
Infiltration	Local	Moderate	Stop infusion; aspirate; remove catheter; elevate; warm compress
Catheter Occlusion	Mechanical	Moderate	Assess for kinking; reposition; do not force flush; notify provider

Complication Details

Infiltration

Local

Non-vesicant fluid or medication leaks from the vein into surrounding interstitial tissue

Causes

Catheter displaced from vein
Vein wall punctured during insertion
Venous fragility (elderly, edematous patients)
IV site over a joint
Catheter poorly secured
Excessive infusion pressure

Signs & Symptoms

Swelling at or around IV site
Pallor and blanching of skin
Cool, tight skin at site
Slowed or absent infusion rate
No blood return
Mild discomfort or pressure at site

Nursing Interventions

Stop infusion immediately
Do NOT remove catheter until residual fluid aspirated
Remove catheter after aspirating
Elevate extremity above heart level
Apply warm compress (promotes reabsorption)
Outline swelling extent with marker and document
Notify provider if large volume or persistent swelling
Resite IV proximal to or in opposite arm

Prevention

Avoid inserting over joints
Use smallest appropriate gauge for infusion type
Assess site every 1–4 hours
Secure catheter and tubing well
Educate patient to report pain, swelling, or burning

Grading: Grade 1: Skin blanching, edema <1 inch. Grade 2: Edema 1–6 inches. Grade 3: Edema >6 inches, cool skin, decreased capillary refill. Grade 4: Tight/leathery skin, bruising, gross edema, circulatory impairment.

Urgency: Moderate

Extravasation

Local — HIGH PRIORITY

Vesicant (tissue-damaging) medication leaks from the vein into surrounding tissue — can cause progressive, permanent tissue damage

Causes

Vesicant infusion through peripheral IV site
Displaced catheter during infusion
Needle dislodgement in implanted port
Fragile or small veins
High-rate vesicant infusion
Undetected catheter tip migration

Signs & Symptoms

All infiltration signs PLUS:
Burning, stinging, or intense pain at site
Blisters forming around insertion site (early vesicant sign)
Progressive erythema or necrosis over hours to days
Induration (firm tissue around site)

Nursing Interventions

STOP infusion immediately — do not delay
Leave catheter in place — aspirate residual medication before removal
Outline extent of swelling and document time, size, appearance
Remove catheter after aspiration attempt
Elevate extremity
Apply compress: cold for most medications; warm for vinca alkaloids
Notify provider and pharmacy STAT
Administer antidote if ordered (phentolamine for vasopressors, dexrazoxane for anthracyclines, hyaluronidase for vinca alkaloids)
Surgical consultation for large-volume vesicant extravasation

Prevention

Use central access for all vesicant medications when possible
Assess site every 1–2 hours during vesicant infusions
Verify blood return before initiating vesicant infusion
Use only power-injectable PICC/port for contrast
Educate patient to report any burning or stinging immediately

Grading: Grade 1: Erythema <1 inch. Grade 2: Erythema 1–6 inches, blistering. Grade 3: Erythema >6 inches, blistering, ulceration, numbness. Grade 4: Necrosis, tissue loss, life-threatening consequences.

Urgency: CRITICAL — immediate action required

Phlebitis

Local

Inflammation of the vein wall at or near the IV site — may involve blood clot formation (thrombophlebitis)

Causes

Chemical: irritating or vesicant medications, pH extremes, hyperosmolar solutions
Mechanical: catheter movement, poor stabilization, catheter too large for vein
Bacterial: poor aseptic technique during insertion or access, prolonged dwell time
Post-infusion phlebitis: develops 24–96 hours after catheter removal

Signs & Symptoms

Redness, warmth, tenderness along vein tract
Induration (palpable hard cord)
Swelling at or above insertion site
Warmth and erythema extending proximal to site
Purulent drainage (if bacterial phlebitis)

Nursing Interventions

Remove peripheral catheter immediately
Apply warm compress to affected area
Elevate extremity
Document phlebitis grade
Notify provider for severe or spreading phlebitis
Culture site if purulent drainage present
Administer anti-inflammatory medication if ordered
Resite IV in opposite extremity when needed

Prevention

Use smallest gauge catheter compatible with therapy
Replace peripheral catheters based on clinical indication (signs of complication or no longer needed) with frequent site assessment, rather than on a routine 72–96 hour schedule (2024 INS Standards)
Dilute irritating medications; use piggyback rather than direct push when possible
Select stable site away from joints
Use proper aseptic technique during insertion and access
Assess site every 1–4 hours

Grading: Grade 1: Erythema +/- pain. Grade 2: Erythema + pain + induration. Grade 3: Erythema, pain, induration + palpable cord. Grade 4: Palpable cord >1 inch, purulent drainage.

Urgency: Moderate — remove catheter and resite

CLABSI (Central Line-Associated Bloodstream Infection)

Systemic

A primary bloodstream infection in a patient with a central venous catheter (CVC, PICC, or port) present when infection is identified and for ≥2 days before, with no other identifiable source

Causes

Skin organisms migrating along catheter tract (most common)
Intraluminal contamination during catheter hub access
Hematogenous seeding from another source
Contaminated infusate (rare)
Risk factors: femoral site, prolonged dwell, TPN, immunocompromised host, poor insertion technique

Signs & Symptoms

Fever >38°C (100.4°F) or hypothermia <36°C
Chills/rigors
Hypotension, tachycardia
Site redness, purulence, or tenderness
No other source of bacteremia identified

Nursing Interventions

Notify provider immediately
Draw blood cultures (×2 sets: one from catheter lumen and one peripheral)
Initiate broad-spectrum antibiotics as ordered
Assess for sepsis/septic shock — begin sepsis protocol if indicated
Remove catheter per provider order (may not be removed if no alternative access)
Antibiotic lock therapy for salvageable catheters (per policy)
Monitor vital signs and labs closely

Prevention

Use CLABSI prevention bundle: hand hygiene, maximum sterile barrier precautions, CHG skin antisepsis, optimal site selection, daily reassessment of need
Avoid femoral site when possible
Strict aseptic technique for all catheter access (scrub the hub)
Remove catheter as soon as no longer clinically indicated
Use CHG-impregnated dressings and catheter
Limit number of catheter lumens to those needed

Grading: CDC/NHSN definition — meets criteria or does not; no grading scale

Urgency: CRITICAL — sepsis risk; notify provider immediately

Catheter Occlusion

Local/Mechanical

Partial or complete blockage of catheter lumen preventing fluid infusion or blood aspiration

Causes

Fibrin sheath or clot formation
Drug precipitation (incompatible medications mixed in line)
Catheter kinking or positional occlusion
Lipid deposits (TPN)
Mechanical valve failure

Signs & Symptoms

Sluggish or absent infusion rate despite no infiltration
Unable to aspirate blood return
Resistance when flushing
Pump alarms for occlusion
Positional — flow improves or worsens with arm movement or position change

Nursing Interventions

Assess for kinking — straighten catheter
Reposition patient's arm or body
Attempt gentle aspiration with syringe
Notify provider if unable to clear
tPA (alteplase) instillation for thrombotic occlusion per order
Do NOT forcefully flush an occluded catheter — risk of catheter rupture or embolism
Catheter exchange over guidewire or replacement if unresolvable

Prevention

Flush with 10 mL NS using push-pause technique before and after each use
Flush between incompatible medications
Maintain positive pressure on catheter when disconnecting flush
Change TPN tubing per facility policy (lipid-containing solutions every 24 hours)
Use positive-displacement connectors per policy

Grading: Partial occlusion: can infuse but not aspirate. Complete occlusion: cannot infuse or aspirate.

Urgency: Moderate — do not force; notify provider if unable to clear

Air Embolism

Systemic — LIFE-THREATENING

Air enters the venous system through an IV line, catheter hub, or needle tract — can cause cardiovascular obstruction and death if large volume

Causes

IV tubing disconnection or hub cap off
Catheter change or insertion without patient positioned correctly
Cracked or damaged IV tubing
Large central line catheter left open to air
Port needle removal before clamping line

Signs & Symptoms

Sudden onset of dyspnea, tachypnea
Chest pain or tightness
Mill-wheel murmur (churning heart sound on auscultation)
Hypotension, tachycardia
Altered LOC, cyanosis, or sudden deterioration
Patient reports 'air sucking' sensation during CVC change

Nursing Interventions

Clamp the IV line immediately
Position patient in left lateral Trendelenburg (Durant's maneuver) — keeps air in right ventricle, prevents air lock in pulmonary outflow
Call for emergency assistance
Administer 100% oxygen
Provider may aspirate air via catheter (emergent)
CPR if patient arrests
Document event and notify provider/risk management

Prevention

Prime IV tubing completely before connecting
Use Luer-lock connections — check all connections before infusion
Clamp catheter before disconnecting tubing
Position patient supine or Trendelenburg during CVC insertion/removal
Ask patient to hum or hold breath (Valsalva) during catheter changes when not on ventilator
Use occlusive dressing over insertion site after PICC/CVC removal

Grading: Volume-dependent: small volumes often asymptomatic; >50 mL may be fatal

Urgency: CRITICAL — emergency response required

Fluid Overload

Systemic

Excess intravascular volume exceeding cardiac and renal compensatory capacity — results in pulmonary and/or peripheral edema

Causes

IV fluid rate too high
Incorrect fluid type (hypotonic fluids in fluid-restricted patients)
Renal insufficiency or failure reducing fluid excretion
Heart failure — reduced cardiac output causes fluid accumulation
Rapid administration of colloids or blood products
SIADH — water retention without solute

Signs & Symptoms

Crackles/rales on auscultation (pulmonary edema)
Peripheral edema (pitting — bilateral)
Weight gain (1 kg = approximately 1 L fluid)
Elevated blood pressure, bounding pulse
Jugular venous distension (JVD)
Dyspnea, orthopnea, decreased SpO₂
Increased CVP if monitored
Foamy, pink-tinged sputum (severe pulmonary edema)

Nursing Interventions

Slow or stop IV infusion — notify provider
Elevate HOB 30–45°
Administer diuretics as ordered (furosemide most common)
Restrict IV and oral fluid intake as ordered
Monitor I&O, daily weights, serum electrolytes, BUN/creatinine
Apply oxygen if SpO₂ decreased
For severe pulmonary edema: position patient upright legs dangling, continuous monitoring, prepare for invasive interventions

Prevention

Accurate I&O documentation including all IV fluids
Daily weights — 1 kg gain in 24 hours warrants assessment
Use smart pumps for infusion rate control
Assess for fluid overload risk factors before and during infusion (CHF, CKD, elderly)
Reassess need for IV fluids at every shift and each assessment

Grading: Mild: weight gain, trace edema. Moderate: significant edema, crackles. Severe: frank pulmonary edema, hypoxia.

Urgency: Moderate to severe — escalate based on SpO₂ and respiratory status

Related Resources

IV Infiltration vs Extravasation GuideVesicant vs non-vesicant, antidotes, immediate interventions

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IV Complication Recognition ChartSigns, interventions, and prevention — all complications side-by-side

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Peripheral IV Insertion BasicsSite selection, insertion technique, and infection prevention

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Vascular Access DevicesWhen to use central access to reduce complication risk

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IV Therapy FundamentalsFluid types, fluid balance, and nursing monitoring

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Standards & sources

Fact-checked Jun 21, 2026

This page is written to align with Infusion Nurses Society (INS) Standards of Practice · CDC (CLABSI prevention) · Institute for Safe Medication Practices (ISMP). It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →