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Int J Nurs Health Care Res, an open access journal
ISSN: 2688-9501
1Volume 6; Issue 06
Review Article
The Clinical and Economic Burdens of
Inltration and Extravasation with Peripheral
Intravenous Catheters: A Contemporary
Narrative Review
Amit Bahl1, Labib Haddad2, Klaus Hoerauf3,4, Alicia Mares3, Kimberly
Alsbrooks3*
1Emergency Medicine, Beaumont Hospital, Royal Oak, MI, USA
2West County Radiological Group, St. Louis, MO, USA
3Becton Dickinson and Company, Franklin Lakes, NJ, USA
4Department of Anesthesiology and Intensive Care, Medical University of Vienna, Wien, Austria
*Corresponding author: Kimberly Alsbrooks, Becton Dickinson and Company, 18-03 NJ-208, Franklin Lakes, NJ 07417, USA
Citation: Bahl A, Haddad L, Hoerauf K, Mares A, Alsbrooks K (2023) The Clinical and Economic Burdens of Inltration and
Extravasation with Peripheral Intravenous Catheters: A Contemporary Narrative Review. Int J Nurs Health Care Res 6:1436. DOI:
https://doi.org/10.29011/2688-9501.101436
Received Date: 21 June, 2023; Accepted Date: 28 June, 2023; Published Date: 03 July, 2023
International Journal of Nursing and Health Care Research
Bahl A, et al. Int J Nurs Health Care Res 6: 1436
www.doi.org/10.29011/2688-9501.101436
www.gavinpublishers.com
Abstract
Inltration and extravasation are complications of peripheral intravenous catheter (PIVC) use, and some of the most common
causes of catheter failure. The objective of this contemporary review is to characterize the incidence, risk factors, and clinical
and economic consequences of PIVC-related inltration and extravasation, as well as strategies for prevention. Recent evidence
demonstrates that inltration incidence ranges from 13% to 20%. Extravasation is less frequent, with a reported incidence of up to
4.5%. There are numerous patient and procedure-related factors that increase the risk of inltration and extravasation, which are
caused by the infusion of either a non-vesicant or vesicant, respectively. Inltration is often perceived as a minor complication,
but can result in skin damage (e.g., scars, blisters), infections, and nerve damage, amongst other injuries, while extravasation can
occasionally lead to severe consequences such as tissue necrosis and even limb loss. Both inltration and extravasation may require
additional venipunctures, resulting in treatment delays and patient discomfort. In addition to the clinical consequences, inltration
and extravasation are associated with high economic burden. This review also highlights how different considerations should
be taken based on the type of extravasations that may occur with PIVC administration of contrast media, radiopharmaceuticals,
vasopressors, and chemotherapy. Ultimately, use of PIVCs requires careful risk assessment and mitigation, effective monitoring and
diagnosis, and timely treatment to prevent or minimize the unnecessary burdens of inltration and extravasation for the patient and
healthcare system.
Citation: Bahl A, Haddad L, Hoerauf K, Mares A, Alsbrooks K (2023) The Clinical and Economic Burdens of Inltration and Extravasation with Peripheral Intravenous
Catheters: A Contemporary Narrative Review. Int J Nurs Health Care Res 6:1436. DOI: https://doi.org/10.29011/2688-9501.101436
2Volume 6; Issue 06
Int J Nurs Health Care Res, an open access journal
ISSN: 2688-9501
Keywords: Inltration; Extravasation; Peripheral intravenous
catheter; Economic burden; Clinical burden
Introduction
Peripheral intravenous catheters (PIVCs) are the most
frequently used invasive devices in hospitals [1]. Over a billion
PIVCs are inserted each year in hospitalized patients worldwide
[2], and in the United States (U.S.), more than 400 million short
PIVCs are inserted annually [3]. PIVCs are required for multiple
purposes, including blood sampling, medication, nutrient, uid,
and blood product administration, and injection of contrast media
for diagnostic imaging [4]. Even though PIVCs are an integral
part of patient care, they may be inappropriately used [5,6]. A
qualitative study revealed that while the rationale for inserting a
PIVC is based on multiple factors, in actual practice, clinicians
routinely insert PIVCs in most patients reexively [5]. Despite
attempts to standardize how and when PIVCs are used [4], the rate
of catheter failure remains unacceptably high, ranging from ~19-
54% across studies [7].
Some of the most common causes of PIVC failure are
inltration and extravasation (Figure 1 and Figure 2). These events
can be dened as the inadvertent administration of solutions or
medications into the surrounding tissue; inltration involves a
non-vesicant solution while extravasation involves a vesicant
[4]. A large volume of a non-vesicant solution or medication
can produce tissue damage through compartment syndrome
but would not result in tissue destruction [4]. Unlike vesicants,
where the damage is occurring in the surrounding tissue, irritants
are capable of producing discomfort (e.g., burning, stinging) or
pain because of irritation in the internal lumen of the vein with
or without immediate external signs of vein inammation [4].
Vesicants are capable of causing severe tissue injury or necrosis
[4]. Common vesicants include contrast media, vasopressors, and
radiopharmaceuticals [8]. Chemotherapy agents, however, can be
variably classied as non-vesicants, vesicants, or irritants [9].
Figure 1: A large inltration of intravenous uid into the hand and
arm of a patient who had a PIVC placed in the back of the hand.
PIVC: Peripheral Intravenous Catheter.
Figure 2: Extravasation of a vesicant (i.e., contrast media used
for medical imaging) into the patient’s hand from a PIVC that was
suboptimally placed in the wrist. PIVC: Peripheral Intravenous
Catheter.
Citation: Bahl A, Haddad L, Hoerauf K, Mares A, Alsbrooks K (2023) The Clinical and Economic Burdens of Inltration and Extravasation with Peripheral Intravenous
Catheters: A Contemporary Narrative Review. Int J Nurs Health Care Res 6:1436. DOI: https://doi.org/10.29011/2688-9501.101436
3Volume 6; Issue 06
Int J Nurs Health Care Res, an open access journal
ISSN: 2688-9501
In addition to the clinical consequences and harms to the patient,
inltration and extravasation can lead to signicant economic
burdens. A holistic review of the literature on healthcare burdens
of inltration and extravasation, as well as the epidemiology,
diagnosis, and management of these events, is not yet available.
Therefore, the objective of this contemporary review is to integrate
the published literature to cohesively characterize PIVC-related
inltration and extravasation to help inform optimal prevention
strategies.
Methods
A targeted literature review (TLR) for studies reporting on
the epidemiology and burdens associated with inltration and
extravasation from PIVC use, as well as treatment and prevention
strategies, was conducted using Ovid MEDLINE® (including
Epub Ahead of Print, In-Process & Other Non-Indexed Citations,
and Daily). As this was a TLR, only one database was searched.
The search strategy was developed in collaboration with an
experienced information specialist (Table 1). Predened study
eligibility criteria were used to screen all identied citations (Table
2). Example search terms included “inltration,” “extravasation,”
“non-vesicant,” “vesicant,” “irritant,” “leak,” “cost” and related
terms (Table 1). The search was restricted to full text, published
articles written in English from the last 5 years. Examples of
exclusion criteria included case studies, conference abstracts, and
studies focusing only on pediatrics, preclinical data, non-PIVC-
associated or non-catheter-related inltration and extravasation.
A non-systematic approach was preferred to ensure an in-depth
review of several targeted research questions, rather than an all-
encompassing systematic review of one topic. After applying
exclusion criteria and removing duplicates, the database search
identied 2097 abstracts for screening. After titles and abstracts
of all records identied were reviewed, ~100 full-text articles
were initially reviewed, and a nal 89 articles were included
here. Reference lists of published reviews were screened to help
supplement the list of studies included. Systematic Literature
Reviews (SLRs) and/or meta-analyses, as well as narrative
reviews and guidelines were selectively included based on recency
of publication and relevance. Screening and data extraction were
performed by one reviewer and validated by a second reviewer.
Table 1: Search Strategy
Database(s): Ovid MEDLINE(R) and Epub Ahead of Print, In Process, In-Data-Review & Other Non-Indexed Citations and Daily 1946
to September 27, 2022, Search Strategy.
# Searches Results
1
exp “Extravasation of Diagnostic and Therapeutic Materials”/ or (extravasat$ or postextravasat$ or post-extravasat$ or
((inltrate$ or escap$ or leak$) adj3 (vesicant$ or non-vesicants$ or nonvesicants$ or irritant? or agent? or material? or
media or medium or therapeutic? or drug? or uid? or solution? or medication?) adj5 (site? or tissue? or cavit$ or injection
or injur$ or damag$ or iatrogenic or vasoconstriction? or osmotic or cytotoxic))).ti,ab,kf,kw. [EXTRAVASATION TERMS -
BROAD]
22765
2 limit 1 to english language 21254
3(Adolescent/ or exp Child/ or exp Infant/) not (exp Adult/ and (Adolescent/ or exp Child/ or exp Infant/)) [CHILDREN <19
REMOVE] 2081142
4 exp Animals/ not (exp Animals/ and Humans/) [ANIMAL STUDIES ONLY - REMOVE - MEDLINE] 5050929
5
(address or autobiography or bibliography or biography or comment or dictionary or directory or editorial or “expression of
concern” or festschrift or historical article or interactive tutorial or lecture or legal case or legislation or news or newspaper
article or patient education handout or personal narrative or portrait or video-audio media or webcast or (letter not (letter and
randomized controlled trial))).pt. [Opinion publications - Remove -MEDLINE]
2748067
62 not (3 or 4 or 5) [EXTRAVASATION TERMS - BROAD - with limits] 13193
7
(ae or co or de).fs. or (safe or safety or side effect$ or undesirable effect$ or treatment emergent or tolerability or toxicity or
adrs or (adverse adj2 (effect or effects or reaction or reactions or event or events or outcome or outcomes))).ti,ab. [Adverse
Effects Filter -SENSITIVE- Golder, Su et al. 2006 - MEDLINE]
7832393
86 and 7 [EXTRAVASATION & AE] 5897
Citation: Bahl A, Haddad L, Hoerauf K, Mares A, Alsbrooks K (2023) The Clinical and Economic Burdens of Inltration and Extravasation with Peripheral Intravenous
Catheters: A Contemporary Narrative Review. Int J Nurs Health Care Res 6:1436. DOI: https://doi.org/10.29011/2688-9501.101436
4Volume 6; Issue 06
Int J Nurs Health Care Res, an open access journal
ISSN: 2688-9501
9
“Extravasation of Diagnostic and Therapeutic Materials”/ep or “Extravasation of Diagnostic and Therapeutic Materials”/
mo or exp Epidemiologic Factors/ or Epidemiological Monitoring/ or Data Collection/ or Incidence/ or Prevalence/
or Databases, Factual/ or Registries/ or exp Vital Statistics/ or exp Population Surveillance/ or exp “Surveys and
Questionnaires”/ or (epidemiolog$ or incidenc$ or prevalen$ or ((clinical or disease$ or factual) adj database$) or
(extravasat$ adj3 database$) or register or registers or registry or registries or population statistic$ or vital statistic$ or
vital registration$ or surveillance$ or ((clinical or disease$ or health) adj3 (survey$ or questionnaire$)) or (extravasat$
adj5 (survey or questionnaire$)) or (extravasat$ adj5 (comorbidit$ or co-morbidit$ or morbidit$ or multimorbid$ or multi-
morbidit$ or mortalit$)) or (extravasat$ adj5 (frequency or frequencies or number or numbers or rate or rates or statistic$))).
ti,kf. [EPIDEMIOLOGY TERMS - MEDLINE]
3714404
10 6 and 9 [EXTRAVASATION & EPIDEMIOLOGY] 957
11 exp “costs and cost analysis”/ or costs.tw. or cost effective$.tw. [McM Cost balanced] 521496
12 (cost$ or cost benet analys$ or health care costs).mp. [McM Econ balanced] 835638
13
Economics/ or exp “Costs and Cost Analysis”/ or Economics, Nursing/ or Economics, Medical/ or Economics,
Pharmaceutical/ or exp Economics, Hospital/ or Economics, Dental/ or exp “Fees and Charges”/ or exp Budgets/ or exp
models, economic/ or markov chains/ or monte carlo method/ or exp Decision Theory/ or (economic$ or cost or costs or
costly or costing or price or prices or pricing or pharmacoeconomic$ or pharmaco-economic$ or expenditure or expenditures
or expense or expenses or nancial or nance or nances or nanced).ti,kf. or ((cost$ adj2 (effective$ or utilit$ or benet$
or minimi$ or analy$ or outcome or outcomes)) or economic model$).ab,kf. or ((value adj2 (money or monetary)) or
markov or monte carlo or budget$ or (decision$ adj2 (tree$ or analy$ or model$))).ti,ab,kf.
714808
14 (economic$ or cost or costs or costly or costing or price or prices or pricing or pharmacoeconomic$ or pharmaco-economic$
or expenditure or expenditures or expense or expenses or nancial or nance or nances or nanced).ab. /freq=2 356345
15 13 or 14 [CADTH Econ lter - non-validated] 852708
16
(economics/ or exp “costs and cost analysis”/ or economics, dental/ or exp “economics, hospital”/ or economics, medical/
or economics, nursing/ or economics, pharmaceutical/ or (economic$ or cost or costs or costly or costing or price or prices
or pricing or pharmacoeconomic$ or (expenditure$ not energy) or (value adj1 money) or budget$).ti,ab.) not (((energy or
oxygen) adj cost) or (metabolic adj cost) or ((energy or oxygen) adj expenditure)).ti,ab. [NHS EED Econ lter - tested for
performance]
1130567
17
exp Delivery of health Care/ec or exp Hospitalization/ or exp Health Resources/ or “Facilities and Services Utilization”/ or
exp Utilization Review/ or Absenteeism/ec or Presenteeism/ec or Sick Leave/ec or (((healthcare or health care or resource?
or review?) adj3 (utili#ation? or utilise? or utilize? or utili#ing)) or ((length$ or duration) adj2 stay) or (number adj2 (night?
or day?) adj2 stay$) or (time adj2 discharge) or ((hospital$ or primary care or surger$) adj (visit$ or contact$ or attendance$
or admission$ or episode$)) or (hospital adj2 cost$) or hospital day$ or ((patient$ or inpatient$ or in-patient$) adj (cost$
or stay)) or ((clinic? or surger$ or hospital?) adj2 (work-ow or work ow)) or (consultation$ adj2 (time or length)) or
hospitalization$ or hospitalisation$ or rehospitalization$ or rehospitalisation$ or re-hospitalization$ or re-hospitalisation$ or
((patient? or inpatient$ or in-patient$) adj3 (management or care continuity or navigat$ or transfer$ or handoff or hand-off
or discharge$ or transition$ or triage)) or ((absentee$ or presentee$ or productivit$ or ((work$ or employ$) adj5 (absenc$ or
absent$ or presenc$ or present$)) or ((work$ or employ$) adj5 abilit$) or (time adj1 away) or ((sick or medical) adj leave))
adj8 cost?)).ti,ab,kf,kw. [HCRU TERMS]
820245
18 11 or 12 or 15 or 16 or 17 [COSTS/ECONOMICS/HCRU TERMS - combined lters - MEDLINE] 2010081
19 6 and 18 [EXTRAVASATION & COSTS/ECONOMICS/HCRU] 769
20
exp epidemiologic studies/ or odds ratio/ or exp risk/ or case-control studies/ or (random$ or cohort$ or (case$1 adj
control$) or risk$ or (odds adj ratio$1) or causa$ or (relative$1 adj risk$) or predispos$).ti,ab. or (randomized controlled
trial or controlled clinical trial or practice guideline).pt. [ETIOLOGY - EBM lter - MEDLINE]
6749349
21 6 and 20 [EXTRAVASATION & ETIOLOGY] 3327
Citation: Bahl A, Haddad L, Hoerauf K, Mares A, Alsbrooks K (2023) The Clinical and Economic Burdens of Inltration and Extravasation with Peripheral Intravenous
Catheters: A Contemporary Narrative Review. Int J Nurs Health Care Res 6:1436. DOI: https://doi.org/10.29011/2688-9501.101436
5Volume 6; Issue 06
Int J Nurs Health Care Res, an open access journal
ISSN: 2688-9501
22 8 or 10 or 19 or 21 [EXTRAVASATION - ALL RESULTS - BROAD] 7549
23 limit 22 to yr=”2017 -Current” [5 yrs limit] 2105
Table 2: Inclusion and exclusion criteria.
PICOS Description
Population
• Adults (≥18 years of age)
• No specic disease indication
Intervention/Comparators • Extravasation, inltration
Outcome
• No restriction on outcomes. Interested in the following:
• Distinctions between inltration and extravasation in terms of vesicant and non-vesicants and common
references to these terms in the literature
• Causes of these events/complications
• Epidemiology (e.g., incidence, prevalence, key risk factors)
• Consequences of these complications, including pain, discomfort, other patient implications, follow-up
requirements and treatments
• Healthcare resource use and health economics of diagnosis and treatment of these events
Study Types • Published, peer-reviewed studies; Exclude abstracts and posters
Exclusions
• Non-English
• Articles ≥ the last 5 years
• Non-human
• Pediatrics
• Case reports, letters, viewpoints, opinions, abstracts
• Central catheters (i.e., central venous catheters, arterial catheters, peripherally inserted central catheters,
wound catheters, epidural, and ports (tip is central)
• Non-catheter related extravasation/inltration
Results and Discussion
Incidence and Risk Factors
Inltration and extravasation are well-established complications of PIVC use. Incidence rates for inltration and various types of
extravasations are presented in Table 3. A 2020 meta-analysis of 45 studies reported a pooled incidence of 13.7% for patients with either
inltration or extravasation [10]. Since more than 400 million short PIVCs are inserted annually in the U.S. [3], this would amount to
approximately 56 million people with these events. This meta-analysis also found that the pooled incidence rate for these events in the
Emergency Department (ED) was signicantly higher than other departments (25.2%; P = 0.022) [10]. In observational studies from
both European and Asian hospitals, the incidence of PIVC-related inltration has been reported to range from 16% to 20% (Table 3) [11-
14]; for extravasation, the incidence has been reported to range from <1% to 4.5% [15,16] (Table 3). The variability between studies may
be largely due to differences in patient populations, the medications and solutions infused, as well as the lack of a uniform or validated
standard for assessing inltration or extravasation. It has also been postulated that rates in the literature are vastly underreported [17]. For
instance, a study of PIVC failure in adults found that incidence rates for inltration were underestimated based on clinical examination
versus ultra sonographic evaluation (9.7% vs. 56.5%) [18].
Citation: Bahl A, Haddad L, Hoerauf K, Mares A, Alsbrooks K (2023) The Clinical and Economic Burdens of Inltration and Extravasation with Peripheral Intravenous
Catheters: A Contemporary Narrative Review. Int J Nurs Health Care Res 6:1436. DOI: https://doi.org/10.29011/2688-9501.101436
6Volume 6; Issue 06
Int J Nurs Health Care Res, an open access journal
ISSN: 2688-9501
The risk of inltration and extravasation can be inuenced
by multiple non-modiable and modiable factors (Table 4).
Examples of key non-modiable patient-related risk factors
include elderly patients [12,16], those who are female [14,19],
and presence of comorbidities including cancer, neurological
disorders, and circulatory disease [16]. While these inherent factors
are challenging to control, most factors are modiable, including
indwelling site and dwell time. In general, catheter placements in
areas of exion pose higher risk and should be avoided [4,16].
Observational data show an increased risk of inltration with
the upper arm, antecubital fossa, and the forearm compared to
the back of the hand [8]. While veins on the back of the hand are
often easily observed, extravasation at this site can result in more
severe injury [20]. However, an SLR and meta-analysis found no
signicant difference between the forearm and the back of the hand
with respect to inltration or extravasation [21]. Nevertheless,
using the back of the hand as an insertion site should be considered
in the context of multiple factors, including frequent movement
leading to potential disruption of the catheter, the relatively thin
and sensitive skin, limited subcutaneous tissue, and the risk of
joint exion, which can cause discomfort, complications, and
catheter instability. In a Randomized Controlled Trial (RCT) of
3,050 participants involving clinically-indicated catheter removal,
the incidence of inltration from traditionally placed PIVCs was
statistically signicantly different between insertion sites (P =
0.01), with PIVCs located in the upper arm having a signicantly
higher incidence of inltration (28.6%) versus the cubital fossa,
hand, inner forearm, and outer forearm [22]. Ultrasound-guided
PIVCs were not used in this study [22]. A 2022 SLR found that
clinically-indicated replacement of PIVCs was associated with a
higher risk of inltration versus routine replacement every 72 to
96 hours [23], indicating that dwell time can be an important risk
factor. Multiple insertions and clinician inexperience are additional
modiable factors consistently shown to increase the risk of
inltration and extravasation; however, there are conicting data
on whether gauge size is a risk factor for these events [11,12,19].
Inltration rates have been shown to vary with catheter
length, another modiable factor. Most studies examined
inltration in relation to short PIVCs, which are generally inserted
into supercial veins, and incidence rates reported in Table 3
largely reect this. Two additional peripheral vascular access
devices are midline catheters and Long Peripheral Catheters
(LPC). Midlines are inserted into deep arm veins and terminate
just inferior to the axilla, while LPCs can be inserted in either
supercial or deep peripheral veins [4]. To insert LPCs, the
modied Seldinger approach is commonly used, which involves
using ultrasound to locate a blood vessel, followed by needle
insertion under ultrasound guidance. A guide wire is then passed
through the needle into the vein, providing stability for catheter
placement [24]. The adjusted complication rate for inltration
from a midline catheter was reported to be 1.93% in an SLR of
7 studies across 5 countries (Table 3) [25]. For long PIVCs in
hospitalized patients with difcult venous access, the unweighted
incidence of inltration was reported to be 0.9% from a smaller
SLR (Table 3) [24]. While both midline catheters and long PIVCs
have advantages over standard ultrasound-guided PIVCs and tend
to show lower mean inltration rates than those reported with short
PIVCs, they should only be used under the appropriate clinical
circumstances [24,25].
Infusate Types as Risk Factors
Inltrated or extravasated medications or solutions are
classied as ‘non-vesicants,’ ‘irritants,’ or ‘vesicants’ according
to their potential to cause damage when infused with a PIVC
[20]. According to the Infusion Therapy Standards of Practice,
solutions with extremes in pH and osmolarity should be avoided to
lessen vascular endothelial damage [4]. Furthermore, continuous
infusion of medications with irritant or vesicant properties should
be avoided and the risks and benets of intermittently infusing
vesicant medication for more than 6 days should be evaluated by
increasing catheter site surveillance [4]. As the association between
irritants and vesicants and the risk of inltration or extravasation
have been shown across many studies [11,12,14,19,26], it is
critical for clinicians to understand the risk of these complications
with the medication being infused, as infusate type is generally a
non-modiable factor. The BD Infusate Consideration Companion
(ICC) provides complication/adverse event information on select,
commonly used infusates (e.g., vesicants, chemical irritants,
chemotherapy) to aid in vascular access device selection. Infusates
are organized by drug family and are listed in tables, which include
pH range and noted complications, such as phlebitis, potential
damage from extravasation, recommendations on whether a
peripheral infusion site should be rotated, and if a central line is
preferred, amongst other vascular-access related complications/
adverse events. The ICC was informed based on several hospital
formulary lists, a comprehensive medication inventory database,
and expert clinician guidance [27-29].
Vasopressors, commonly classied as vesicants, are often
used in the treatment of patients in shock, and are ordinarily
administered via large central veins to constrict blood vessels
[30]. However, infusion of vasopressors through a PIVC is
sometimes performed to hasten the administration of this therapy
in critically ill patients [31]. Although extravasation rates related
to vasopressor use have ranged across studies from 0% to 13%,
most studies reported a rate less than 5% with PIVCs, including a
systematic review of seven studies (Table 3) [32-36]. Risk factors
for vasopressor-related extravasation are both modiable and non-
modiable and include those related to the infusate (dose, rapid
rate, high volume, prolonged or peripheral administration, saline
concentration, pH, and osmolarity), procedure (e.g., catheter
Citation: Bahl A, Haddad L, Hoerauf K, Mares A, Alsbrooks K (2023) The Clinical and Economic Burdens of Inltration and Extravasation with Peripheral Intravenous
Catheters: A Contemporary Narrative Review. Int J Nurs Health Care Res 6:1436. DOI: https://doi.org/10.29011/2688-9501.101436
7Volume 6; Issue 06
Int J Nurs Health Care Res, an open access journal
ISSN: 2688-9501
type), and patient characteristics (e.g., hemodynamic instability)
[17,37,38]. Of note, vascular risk factors, including hypertension,
diabetes, hyperlipidemia, and coronary artery disease, have been
suggested to increase likelihood of ischemic limb complications if
vasopressor extravasation was to occur [39].
Chemotherapy is another important risk factor for
extravasation and it is estimated that about half of all chemotherapy
is infused with a PIVC in the U.S [40]. The rate of chemotherapy-
related extravasation with PIVCs has been reported to range
from 0% to 4.2% [40-45] (Table 3). However, in the two studies
reporting 0% extravasation (Table 3), patients in fact exhibited
persistent abnormalities, such as subcutaneous edema, which is an
early sign of chemotherapy extravasation [44,45]. Modiable and
non-modiable risk factors for chemotherapy extravasation from
a PIVC include certain patient characteristics and anatomy (e.g.,
older age, small, and/or fragile veins, circulatory problems, obesity,
excessive patient movement, impaired level of consciousness),
procedural (e.g., size of cannula, multiple insertions, indwelling
site, failure to secure the venipuncture site, untrained or
inexperienced staff etc.) and product/infusion-related factors (e.g.,
duration and/or volume of solution, vesicants and irritants) (Table
3) [9,20,40-42,46].
Another key type of infusate-related extravasation is
contrast-induced. Approximately 54 million diagnostic imaging
examinations using contrast media are conducted annually in
the U.S., including nearly all angiography and nearly one-half of
computed tomography (CT) scans [47,48]. Radiotracers used in
combination with CT or Positron Emission Tomography (PET)
are another source of extravasation [49,50]. Incidence of contrast-
related extravasation from PIVCs typically ranges below 1%,
with incidence reported to increase to 6.7% with involvement
of radiopharmaceuticals [51-58] (Table 3). A 2018 systematic
review reported that using an existing PIVC that has previously
been placed has higher risk of contrast extravasation than placing
a new PIVC [51]. Furthermore, there is limited research into the
impacts of ultrasound-guided PIVCs on contrast extravasation
rates. An SLR found that ultrasound-guided PIVCs were not
considered to have an impact on contrast extravasation [59], which
was supported in a retrospective cohort study in the U.S., which
compared ultrasound-guided placement of PIVCs versus LPCs,
which are placed under combined ultrasound and wire guidance
[60].
Table 3: Incidence of inltration and extravasation from PIVCs.
Study details Incidence Source
Pooled inltration/extravasation
SLR and meta-analysis (45 studies, 76,977 catheters) 13.7% [10]
Inltration
Portugese cohort study in a hospital medical clinic (n = 110) 15.8% [11]
Serbian observational cohort study at a tertiary healthcare clinic (n = 110) 16.3% [12]
Chinese prospective observational study (n = 1,477) 19.5% [13]
Chinese prospective observational study at a tertiary hospital (n = 1,069) 17.8% [14]
SLR including data from 5 countries (7 studies) for midline catheters (n = 8,783) 1.93% a[25]
SLR of 6 cohort studies including data for long peripheral catheters (n = 350) 0.9% [24]
Extravasation
French prospective study at an infectious disease unit (n = 509) 4.5% [15]
Chinese retrospective study at a hospital (n = 694,043) b 0.038% b[16]
SLR of 17 studies of patients undergoing contrast-enhanced MRI or CT (n = 1,104,872) 0.2% [51]
U.S. retrospective study of patients undergoing contrast-enhanced CT (n = 14,558) 0.34% [53]
South Korean retrospective study of patients undergoing contrast-enhanced CT (n = 142,651) 0.23% [52]
Taiwanese retrospective study of patients who received IV contrast media (n = 67,129) 0.04% c [54]
Citation: Bahl A, Haddad L, Hoerauf K, Mares A, Alsbrooks K (2023) The Clinical and Economic Burdens of Inltration and Extravasation with Peripheral Intravenous
Catheters: A Contemporary Narrative Review. Int J Nurs Health Care Res 6:1436. DOI: https://doi.org/10.29011/2688-9501.101436
8Volume 6; Issue 06
Int J Nurs Health Care Res, an open access journal
ISSN: 2688-9501
German prospective study of patients undergoing contrast-enhanced CT (n = 3,514) 0.71% [55]
Australian retrospective analysis of CT/PET study (n = 296) 1.3% [57]
Study pooling PET and CT scans from U.S. and Australia (n = 863) 6.7% [58]
A quality improvement CT/PET study (n = 5,541) 6.2% d [56]
U.S. study - national benchmark rate from 11 cancer centers (739,812 infusions) 0.09% [40]
Retrospective study at a U.S. community cancer center (12,872 infusions) 0.17% [41]
Japanese cross-sectional observational study of patients undergoing chemotherapy (n = 12,475) 0.18% [42]
Japanese cross-sectional observational study of patients undergoing chemotherapy (n = 24) 4.2% [43]
Japanese prospective study of outpatient chemotherapy (n = 41) 0% [45]
Japanese prospective study of outpatient chemotherapy (n = 63) 0% [44]
SLR of 7 studies on complications after PIVC-infused vasopressors (n = 1,382) 3.4% [32]
Dutch retrospective study on PIVC-infused norepinephrine (n = 14,385) 0.035% [33]
U.S. retrospective study of long-term use of vasopressors by midlines (n = 248) 0.004% [34]
Australian retrospective study of critically ill patients receiving vasopressors (n = 212) 13% [35]
Rwandan prospective cohort study of critically ill patients receiving vasopressors (n = 64) 2.9% [36]
aAdjusted complication rate. bStudy includes different drugs including hypotonic or hypertonic drugs, contrast media, strong acid or alkali drugs,
antineoplastic agents, inotropic agents, and other drugs. cLarge-volume contrast media extravasation (≥20 ml) rate ((27/67,129). dAggregated
unadjusted inltration rate (adjusted rate was 5.7%).
Abbreviations: CI = Condence Interval; CT = Computed Tomography; ICU = Intensive Care Unit; NR = Not Reported; PET = Positron Emission
Tomography; PIVC = Peripheral Intravenous Catheter; SLR = Systematic Literature Review; U.S. = United States.
Additional modiable and non-modiable risk factors that have been reported to increase risk of contrast-related extravasation,
such as with CT, PET and/or MRI, have been reported to be female sex, inpatient status, older age, high injection rates, catheter location,
high-density contrast, failing to warm up viscous contrast media, and indwelling site [51-53,56,59,61-63]. In reference to radiotracers,
the dose absorbed into the tissues depends on the initial amount of paravenous radioactivity, the mass of inltrated tissue, the type of
radiopharmaceutical, and the length of time the extravasated product remains near the injection site [64]. The length of time is inuenced
by the patient’s anatomy, vascular health, and injection rate [64]. Other risk factors include female sex, higher glucose levels [57], lower
body weight [56], indwelling site, and ush volume [56,57,64].
Overall, a comprehensive understanding and awareness of both modiable and non-modiable factors (Table 4) will likely aid in
more efcient diagnosis and treatment, and ultimately improve preventative efforts to reduce inltration and extravasation from PIVCs.
Table 4: List of modiable and non-modiable risk factors for inltration and extravasation.
Modiable factors Non-modiable factors
Excessive patient movement [20] Patient age [12,51]
Indwelling site [16], particularly use of the
upper arm [8] Patient sex [51]
Multiple insertions [11,20] Patients with small and/or fragile veins [9,20]
Catheter gauge/size [9,20] Patients with cancer, neurological-related diseases, and circulatory-related diseases [16]
Catheter dwell time [14] Patients with communication difculties, cognitive/function impairment, or impaired
consciousness [9,16,19]
Use of power injectables and high injection
rates [51] Patient body weight [9,20]
Citation: Bahl A, Haddad L, Hoerauf K, Mares A, Alsbrooks K (2023) The Clinical and Economic Burdens of Inltration and Extravasation with Peripheral Intravenous
Catheters: A Contemporary Narrative Review. Int J Nurs Health Care Res 6:1436. DOI: https://doi.org/10.29011/2688-9501.101436
9Volume 6; Issue 06
Int J Nurs Health Care Res, an open access journal
ISSN: 2688-9501
Flush volume [56] Hospital setting [52]
Securing the venipuncture site [9,20] Vesicants and irritants, and solutions with extremes in pH and osmolarity [9]
Untrained or inexperienced staff [9,20] Duration and/or volume of solution [9]
Frequency of monitoring high-risk medications
[38] Radiotracer dose [56]
Using an existing PIVC [51,52]
Use of ultrasound-guided PIVCs [95]
High-density/high viscosity contrast media [52]
Abbreviations: PIVC = peripheral intravenous catheter.
Diagnosis
Detection of inltration or extravasation starts with patients
and healthcare professionals monitoring for early symptoms or
signs, which include uid leakage around the catheter, infusion
rate slowing or stopping, and issues with blood backow. While
the Infusion Therapy Standards of Practice recommends (evidence
rating = IV) the use of a standardized tool or denition to assess
inltration or extravasation that is valid, reliable, and clinically
feasible [4], there are currently no existing tools that meet this
criteria for adult populations. However, several tools are still used
despite these limitations. The extravasation assessment tool scores
the severity of symptoms described above with similarities to
inltration (i.e., color, edema, pain, and skin temperature), but with
additional signs/symptoms of extravasation which may include
reduced mobility, skin tissue necrosis, and/or fever [20]. Previous
examples exist of extravasation injuries being categorized as mild,
moderate, or severe based on the drug, clinical symptoms, and
extravasation volume [65,66]. The National Institute of Health’s
Common Terminology Criteria for Adverse Events can also be used
to grade extravasation severity from painless edema (grade 1), to
erythema with associated symptoms (e.g., edema, pain, induration,
phlebitis) (grade 2) to severe tissue damage (e.g., ulceration or
necrosis) (grade 3) or even life-threatening consequences (grade
4) or death (grade 5) [46,67]. As noted, extravasation assessment
tools for adults have not been tested for validity and interrater
reliability [4]. Appropriate tools need to be developed and tested so
assessment of inltration or extravasation is not based on clinical
assessment alone.
Furthermore, clinical examination of signs and symptoms
may not be sensitive enough to detect cases of inltration
and extravasation in earlier stages. Alternatively, the use of
technologies including ultrasound may be useful for early detection
of inltration and extravasation [68]. A study of PIVC failure in
adults found that 9.7% of participants presented with subcutaneous
edema on clinical exam, versus 56.5% of participants based on
ultra sonographic evaluation [18]. Similarly, a study of PIVC
failure in children reported PIVC-associated venous changes
in 73% of accessed veins with ultrasound [69]. This potential
underestimation of inltration and extravasation highlights the
need for better detection in clinical practice. In addition, patient
education and monitoring are important for timely detection and
treatment [70].
Treatment
Timely and appropriate treatment of inltration or
extravasation can help limit adverse effects, and often depends on
the type of infusate used. Inappropriate treatment of extravasation
is related to more frequent skin surgery, and treatment delays are
associated with serious tissue-related harms [9,42,71,72]. Thus,
effective monitoring during PIVC administration is critical to
provide the best care for patients.
Recommended initial treatment options for inltration
include immediately stopping IV administration and disconnecting
the IV tube from the IV device, but leaving the catheter in
place [4]. Nurses should then attempt to aspirate the inltrated
uid; the catheter can then be removed [4]. Next, the physician
should be notied and the affected limb should be elevated
to reduce edema and promote drainage [4]. Similar rst-line
treatment is recommended for extravasation (including contrast,
chemotherapy, and vasopressor extravasation), with the addition
of administering a drug-specic antidote [4,20,66,73]. Examples
Citation: Bahl A, Haddad L, Hoerauf K, Mares A, Alsbrooks K (2023) The Clinical and Economic Burdens of Inltration and Extravasation with Peripheral Intravenous
Catheters: A Contemporary Narrative Review. Int J Nurs Health Care Res 6:1436. DOI: https://doi.org/10.29011/2688-9501.101436
10 Volume 6; Issue 06
Int J Nurs Health Care Res, an open access journal
ISSN: 2688-9501
include dexrazoxane to treat anthracycline extravasation [9] and
phentolamine, a vasodilator and nonselective, reversible alpha1
antagonist, to treat vasopressor extravasation [4,70,73]. Due to
issues in accessing phentolamine, alternative treatment algorithms
involving terbutaline injection and nitroglycerin ointment have
been recommended with reasonable evidence (i.e. second-line
treatment), but further research in this area is needed [4,73].
While mild and moderate events are sufciently managed
by initial nonoperative treatments, severe events generally require
an additional intervention [65]. Surgical consultation is based on
signs and symptoms and their progression (e.g., compartment
syndrome, tissue necrosis), rather than a specic inltration or
extravasation volume threshold [4,74]. Recommended options
for treatment include subcutaneous irrigation with or without
hyaluronidase, open incision and irrigation, fasciotomy, and
debridement [4,65,66].
Although clear benet has not been demonstrated with
thermal applications, it remains a standard supportive care (i.e.,
second-line treatment) [20,75]. For non-DNA-binding vesicants
and vasopressors, local warming is recommended to induce
vasodilation to disperse the drug and reduce accumulation in the
local tissue. For DNA-binding vesicants (except vasopressors),
local cooling is recommended to induce vasoconstriction and limit
drug dispersion [4,20,66,73].
Beyond rst-line treatment including surgery for
neurovascular compromise or compartment syndrome, additional
invasive treatments for IV contrast extravasation include
hyaluronidase, aspiration, and irrigation with local incisions,
or manual expression of extravasate with local incisions [66].
However, there is limited evidence to support and recommend
these third-line interventions [66,74]. Additional anecdotal
evidence includes heparin ointment dressing with cooling [76].
For more detailed information related to treatment, The
Infusion Therapy Standards of Practice [4], Kim et al, 2020 [20],
and documentation from the American College of Radiology
Committee on Drugs and Contrast Media [66,74] are useful
resources.
Clinical Burdens
Inltration and extravasation, alone or in combination with
other complications, are commonly reported causes of catheter
failure and removal across studies (Table 5). A pooled analysis
of seven RCTs and two prospective cohort studies from Australia
found that PIVC failure due to vessel injury (which included
occlusion, inltration, or extravasation) occurred in 19% of all
PIVCs [77]. As PIVC failure from inltration and extravasation
requires the insertion of a new device, this can commonly result in
treatment delays for patients [78,79].
Table 5: Proportion of PIVC failures caused by inltration or extravasation.
Study details Sample Size PIVC failures Proportion of PIVC failures Source
Australian pilot RCT comparing standard care with
insertion by a vascular access specialist (n = 138)
54% (standard
care); 48%
(specialists)
Caused by inltration: 19% (standard
care); 18% (specialists) [91]
Australian prospective observational cohort study of
patients receiving ED-inserted PIVCs (n = 391) 31% Caused by inltration: 32% [90]
Japanese prospective observational study of PIVC
failure in medical and surgical wards
(2,442
catheter
removals)
18.8% Caused by inltration: 41.3% [92]
Australian prospective cohort study in medical and
surgical wards (n = 1,000) 32% Caused by inltration/occlusion: 14% [79]
Australian prospective cohort study of two cancer
units (n = 200) 34.9% Caused by inltration/occlusion: 18.7% [93]
Chinese prospective cohort study in adults
undergoing a rst-time insertion of a PIVC (n = 5,345) 54.1% Caused by inltration/extravasation:
13.8% [94]
Abbreviations: ED = Emergency Department; NR = Not Reported; PIVC = Peripheral Intravenous Catheter; RCT = Randomized Controlled Trial.
Citation: Bahl A, Haddad L, Hoerauf K, Mares A, Alsbrooks K (2023) The Clinical and Economic Burdens of Inltration and Extravasation with Peripheral Intravenous
Catheters: A Contemporary Narrative Review. Int J Nurs Health Care Res 6:1436. DOI: https://doi.org/10.29011/2688-9501.101436
11 Volume 6; Issue 06
Int J Nurs Health Care Res, an open access journal
ISSN: 2688-9501
Beyond PIVC failure, the clinical consequences of inltration
from PIVCs can be extensive and include pain, bruising, skin
blisters, scarring, and nerve damage [4]. In a U.S retrospective
review, chemotherapy extravasation (vesicant) versus inltration
(non-vesicant) led to a signicantly increased rate of short-term
complications (e.g., supercial soft tissue infection, necrosis/
eschar etc.) and long-term sequelae (e.g., cosmetic defects, chronic
pain etc.) [8]. Thus, the consequences for extravasation may be
more severe and include soft tissue injury, necrosis or eschar
formation, ulceration or full-thickness wound formation, persistent
numbness, skin discoloration, chronic pain, chronic disease
exacerbation, cosmetic disgurement, deep vein thrombosis, and
even fatality [8,16,80]. Data from the Premier database (2013 to
2015) found that patients with versus without PIVC complications
(including extravasation) showed higher rates of death (3.6% vs
0.7%; P < 0.001) [81].
Clinical consequences are also apparent with specic types
of extravasations. While evidence generally shows that surgical
intervention is rare with contrast extravasation [53,54,82], if
severe contrast extravasation is left untreated, there is a risk of
ischemia from venous congestion and low arterial gradient causing
necrosis, serious neurovascular compromise, or even limb loss
[66]. Similarly, if chemotherapy extravasation is left untreated or if
treatment is delayed, blistering, peeling, sloughing of skin, tissue
necrosis, and nerve and tendon damage, as well as functional and
sensory impairment of the affected area, can occur [9,42,72].
Health Economic Burdens
Alongside the clinical consequences, inltration and
extravasation are both associated with a moderate economic
burden, as demonstrated by evidence from the United Kingdom
(U.K.), the U.S, Australia, and China. A report from the National
Health Services (NHS) Resolution from the U.K., stated that claims
relating to extravasation injuries between 2010 and 2021 cost the
NHS £16 million, including legal fees and damages [80]. Claims
data from the U.S. which compared patients with versus without
PIVC complications (including extravasation) found that mean
hospitalization cost was $10,895 versus $7,009 per patient using
adjusted analyses of the Premier database (2013 to 2015) [81].
In addition to claims, an exploratory analysis using government
websites and the literature to estimate the overall annual cost of
PIVC insertion in adult Australian ED found that the annual cost
of PIVC use related to occlusion/inltration and dislodgement
was estimated at $14.01 million (Australian dollars). Specic to
inltration, an observational, prospective study of 1,069 patients
at a tertiary teaching hospital in China demonstrated that median
medical treatment costs were 31.7, 37.9, and 52.8 CNY for Grade
1, Grade 2, and Grade 3 inltration from PIVCs, respectively [14].
The authors state that 25.5% of patients were likely to receive
PIVC replacement in the present study, which would cost 13,000
CNY. Lastly, a European economic modeling study of the risk of
developing complications of IV administration of morphine, found
that the cost of managing PIVC complications (IV prescription
errors, phlebitis, and extravasation) was the main model driver
of the results and accounted for 73% of the total costs. However,
costs of extravasation alone were marginal (€0.01– €0.02 per
patient) [83]. Further studies would help to inform a more holistic
representation of costs related to managing inltration and
extravasation.
Inltration and extravasation are associated with various
types of healthcare resource usage, an important contributor
of which is higher hospital stay. Complications resulting from
catheter use can compromise patient care, potentially causing
cancellations or delays, necessitating catheter replacement, or
interrupting drug administration, which can increase consumption
of healthcare resources [84]. For example, for those receiving
treatment for infections (e.g., antibiotics), PIVC failure can result
in delays and increase hospital length of stay (LOS) [85]. In an
adult Australian ED from July 2019 to June 2020, clinicians spent
approximately 27,383 days inserting PIVCs, including reinsertions
due to complications such as occlusion and inltration, and
dislodgement, which is time that cannot be ‘saved’ or ‘reimbursed’
[86]. Data from the Premier database (2013 to 2015) suggests that
PIVC complications (including extravasation) are associated with
higher spending, as well as longer and more intensive care, all of
which create burdens for the healthcare system and the patient.
Specically, patients with versus without PIVC complications
(including extravasation) showed longer hospital LOS (adjusted
mean 5.9 days vs 3.9 days, P < 0.001) and higher rates of being
admitted to the ICU (20.4% vs 11.0%; P < 0.001) [81]. The
economic burden associated with inltration and extravasation
necessitates investment and adoption of cost-effective technologies
and protocols to help reduce overall costs (for further details, see
Prevention Strategies) [82,87,88].
Prevention Strategies
Guidelines for the prevention of inltration and
extravasation (including chemotherapy) involve considerations
related to insertion-related variables (i.e., equipment selection,
insertion site), administration of the drug, and specic strategies
for contrast extravasation [4,9,20]. For insertion-related variables,
it is recommended to use an appropriately sized cannula for the
anticipated ow rate and the chosen vein [66] (ideally use the
smallest cannula and largest vein possible) [9], and use of a buttery
needle should be avoided [9,58,74]. Insertion technique should be
meticulous, by conrming location through blood aspiration, and
ushing the catheter with a test injection [74]. After insertion, it
is critical to watch for blood backow, edema, inammation, and
pain around the cannula [20]. Insertion at the level of the joints
should be avoided because the catheter is difcult to secure, and
Citation: Bahl A, Haddad L, Hoerauf K, Mares A, Alsbrooks K (2023) The Clinical and Economic Burdens of Inltration and Extravasation with Peripheral Intravenous
Catheters: A Contemporary Narrative Review. Int J Nurs Health Care Res 6:1436. DOI: https://doi.org/10.29011/2688-9501.101436
12 Volume 6; Issue 06
Int J Nurs Health Care Res, an open access journal
ISSN: 2688-9501
if extravasation occurs it can cause neural damage and tendon
injury [20,74]. Placement of the cannula in the antecubital fossa
area should also be avoided as it is extremely difcult to detect
extravasation at this site [9,20,74]. While veins on the back of the
hand are often easily observed, extravasation at this site can result
in more severe injury [20]. Instead, veins found on the dorsal and
ventral surfaces of the upper extremities, including the metacarpal,
cephalic, basilic, and median veins are preferred for both short
and long PIVCs, while the upper arm site is preferred for midline
catheters [4]. Lastly, ultrasound-guidance to ensure the quantity
of catheter residing within the vein may help with prevention of
catheter failure. A study of adult emergency department patients
with ultrasound-guided IVs showed that optimum catheter survival
occurs when ≥65% (or two-thirds) versus when < 30% (or one-
third) of the catheter resides in the vein, which is highly correlated
with the hazard of failure within 72 hours [89].
In addition to insertion site and catheter gauge, staff are
required to have knowledge of drug characteristics, comply with
manufacturer recommendations, and educate patients on risks
associated with PIVC administration [9]. When administering
the drug, the catheter should be secured but not covered with
opaque gauze (which would obstruct observation) [9,20]. Vesicant
drugs should be administered by a new IV route; if there is an
existing IV route, it is recommended to re-insert the PIVC for drug
administration [20]. If possible, stimulant drugs should be diluted
and administered at an appropriate rate.
Lastly, based on risk factors, there are specic
recommendations for additional preventative and minimization
measures related to contrast extravasation [66]. Grade B
recommendations (Consistent level 2 or 3 studies or extrapolations
from level 1 studies) include: 1) warming contrast medium,
especially for more viscous uids [52]; 2) minimizing the injected
contrast medium based on the indication and patient size [66]; 3)
using the catheter-appropriate pressure and ow rates [66]; and
4) having effective detection protocols for early diagnosis (e.g.,
observation or extravasation detection accessories for high-risk
patients) [66]. Furthermore, protocols can be implemented to
reduce contrast extravasation-related complications from PIVCs
and should be updated regularly [87]. For instance, use of a four-
phasic contrast media administration protocol was associated with
a 65% reduction in extravasations versus a three-phasic approach
in cardiac CT angiography [87]. This protocol, distinguished by
the saline pacer bolus, is easy to implement and has no additional
costs. Similarly, a quality-improvement study involving contrast-
enhanced CT, found a statistically signicant reduction in IV
contrast extravasation after modifying the intake process (0.47%
of patients [38/8,009] preintervention versus 0.28% [24/8,521]
postintervention, P = 0.04) [82].
Importantly, staff should receive continuous education on all
aspects related to risk of inltration and extravasation and always
document and report any case that occurs.
Discussion and Future Directions
This narrative review characterizes the incidence,
symptoms, modiable and non-modiable risk factors, and
clinical and economic consequences of PIVC-related inltration
and extravasation, as well as strategies for prevention. This
evidence applies to a broad range of patients and includes some
large, multicentre studies, systematic reviews, and meta-analyses.
This review showed that inltration occurs in up to 20% of PIVCs,
making it the second most common PIVC complication. Although
generally reported to be less frequent than inltration, extravasation
is sometimes associated with more severe consequences, and the
incidence varies between different types of extravasations (e.g.,
contrast / radiopharmaceutical, chemotherapy, and vasopressor).
However, it is likely that these rates are underestimated, as many
cases may go undocumented [17].
The type of medication or solution infused determines
whether inltration or extravasation will occur, and both modiable
and no modiable risk factors are associated with PIVC-related
inltration and extravasation. While initial signs and symptoms
of these events appear immediately, some physical symptoms can
arise days to weeks later [20]. Thus, education for and monitoring
by patients and clinicians is critical to enable timely detection,
diagnosis, and treatment. Key published guidance includes the
Infusion Therapy Standards of Practice, which aims to promote
consistency in patient care, inform clinical decision-making,
and improve skill [4]. When inltration or extravasation occurs,
conservative acute treatments are often recommended (e.g., limb
elevation), with limited evidence for more invasive treatments.
Inltration and extravasation are associated with important
clinical and economic burdens. While the severe sequalae of
inltration and extravasation may not be frequent, when these
harms occur, they can have serious consequences, such as functional
decits, chronic pain, and possible limb loss. Management of
these consequences is costly, including additional hospital stay,
emphasizing the need for more consistent implementation of
preventative strategies to reduce the risk of these events given
the substantial volume of PIVC insertions in healthcare settings.
Preventative measures include techniques and protocols around
the equipment, insertion site, administration, and monitoring,
with patient and clinician education being crucial to successful
procedures and responsive monitoring of complications.
Although the most recently available data related to
inltration and extravasation was included, some evidence gaps
were identied. First, there is a lack of literature on the economic
Citation: Bahl A, Haddad L, Hoerauf K, Mares A, Alsbrooks K (2023) The Clinical and Economic Burdens of Inltration and Extravasation with Peripheral Intravenous
Catheters: A Contemporary Narrative Review. Int J Nurs Health Care Res 6:1436. DOI: https://doi.org/10.29011/2688-9501.101436
13 Volume 6; Issue 06
Int J Nurs Health Care Res, an open access journal
ISSN: 2688-9501
burdens of inltration and extravasation; most studies looked at
overall costs related to complications, rather than providing a
comprehensive assessment of the different cost types involved.
Second, since multiple insertions are a risk factor for extravasation
[11,12,19], further research evaluating strategies and protocols for
improving rst time PIVC insertion success are warranted. Third,
additional studies assessing the importance of hospital setting as a
risk factor are needed; in one prospective cohort from Australia,
inltration accounted for 32% of all post-insertion failures of
ED-inserted PIVCs [90]. This nding emphasizes the need for
educational training for all staff inserting PIVCs, especially in
certain settings. Finally, although use of a reliable, validated,
and standardized assessment tool for inltration/extravasation is
recommended, few assessment scales have been published, and
only one pediatric tool has been tested for validity and interrater
reliability [4]. Development, validation, and reliability testing of
assessment tools are needed to address this important component
of inltration/extravasation diagnosis and assessment.
This narrative review has limitations. First, it was informed
by a TLR rather than a specic systematic review. This was
intentional so the broad scope of this review was feasible, and a
dened search methodology was still used. As such, it is possible
that some relevant papers were missed. Second, most of the
data involved smaller observational studies. However, wherever
possible, clinical guidelines, RCTs, systematic reviews, and meta-
analyses were included and discussed. Finally, this review outlines
the evidence on PIVC inltration and extravasation, diagnosis,
treatment, and prevention strategies, but all clinicians are
recommended to review manufacturer’s indications for use before
considering product options in their region or setting of care.
As demonstrated in this review, inltration and extravasation
are common complications of PIVC use. Future research should
focus on preventative efforts, including RCTs, to reduce the
clinical and resulting economic burdens associated with inltration
and extravasation. Despite the evidence presented in this narrative
review of the burdens associated with PIVC-related inltration and
extravasation, clinicians routinely insert PIVCs in most patients
reexively. In actual practice, when considering PIVC insertion,
more time needs to be devoted to the awareness of: (1) decision-
making in the context of the clinician’s own experience, (2)
cognitive biases and (3) patient-centered factors. Such awareness
will support an appropriate risk assessment, which will benet the
patient, clinician, and healthcare system.
Acknowledgements
We thank Desarae Smith, Nicole Ferko, Teige Bourke, and
Barkha Patel for their contributions to this manuscript.
Funding
Becton Dickinson and Company funded this study and
participated in the study design review and approval of the
publication.
Financial Disclosures
A.B. has research grant support from B. Braun Medical,
Becton-Dickinson, Teleex, Adhezion, Medline Industries, and
Access Vascular. A.B. is a paid consultant for B. Braun Medical,
Teleex, Lineus Medical, and Interad Medical. K.H, A.M, and
K.A, are employees of and receive stock options from Becton
Dickinson and Company. L.H is a paid consultant and faculty for
Medtronic and BD/Bard and a clinical board member for Health
Trust Group.
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