The Prevalence and Associated Factors of Peripheral Intravenous Complications in a Thai Hospital

Abstract

Complications of peripheral intravenous catheters (PIVCs) remain a major contributor to health care costs and are a patient safety problem. The objective of this cross-sectional descriptive study was to examine the prevalence of complications and factors associated with complications from peripheral intravenous fluid administration. The study was conducted at a tertiary care hospital in Thailand. The instruments were developed from the literature review. Data were analyzed using SPSS statistics, version 22. The study examined 441 patients with a total of 497 PIVC sites. Phlebitis (level 1 and 2 only) occurred at 2.41% of all sites; infiltration (level 1 and 2 only) occurred at 1.01% of all sites, and extravasation (mild and moderate only) occurred at 0.60% of all sites. Factors associated with the occurrence of infiltration complications included receiving intravenous (IV) crystalloids (P = .03) and receiving IV analgesic drugs (P = .001). Age was statistically significantly related to extravasation complications (P = .001). Nurses should be aware of possible complications from peripheral intravenous fluid administration, especially in older patients and those receiving IV crystalloids or analgesic drugs.

INTRODUCTION

Peripheral intravenous catheters (PIVCs) are widely used to maintain intravenous (IV) access in clinical practice. Up to 80% of all hospital patients receive peripheral IV fluid administration, and nurses are key to preventing complications from this procedure.1 The use of peripheral intravenous catheters is associated with the risk of complications such as phlebitis, infiltration, and extravasation. Phlebitis is the irritation or inflammation of a vein wall and is categorized as mechanical (related to the action of the PIVC in the vein), chemical (related to infusate or medication), or bacterial (related to contamination at the insertion site, intravenous solution, or tubing).2 Infiltration is the leakage of fluid out of the vein, and extravasation is the leakage of a vesicant drug out of the vein. Phlebitis, caused by irritation of blood vessels due to friction from the catheter tip, is a common complication from peripheral IV fluid administration. Medications themselves can also cause inflammation, as can blood clots formed at the IV catheter tip. Swelling from infiltration and extravasation are also common. These complications cause discomfort and pain and can lead to higher treatment costs and longer hospital stays.3 These complications can lead to bloodstream infections, with a mortality rate of 12% to 25%. Prevention of complications must focus on proper technique, only using IV catheters when medically necessary and ensuring their prompt removal when no longer necessary, according to recommended guidelines.4 However, the magnitude of this risk is unknown.

Background

The use of PIVCs is associated with the risk of complications such as phlebitis, infiltration, and extravasation. Children are at greater risk of complications due to the smaller size of their veins and reduced blood flow around the catheter tip.5 The most frequent PIVC complication is phlebitis (with definition), which occurs in 19.3% of patients, based on clinical findings such as redness, swelling, tenderness, pain, warmth, palpable cord, or purulent discharge.5,6 Phlebitis can be classified according to the causative factors in mechanical phlebitis, bacterial phlebitis, postinfusion phlebitis, and chemical phlebitis.4 Phlebitis is identified and documented using a standardized phlebitis scale that utilizes a range of 1 to 4 to indicate severity (0 = no phlebitis; 1 = lowest in severity; 4 = highest in severity). The risk for phlebitis exceeds 50% by day 4 postcatheterization.7 Most articles (57.14%) associated phlebitis with risk factors, including patient's age, gender, current infection, catheter size, dwell time and/or anatomical area, antibiotics, and intermittent maintenance.8,9 An association between phlebitis and variable dwell time ≥72 hours resulted in higher risks for the development of phlebitis.9 Most previous studies reported the risk factors of PIVC complications, which comprised patient characteristics, therapy administered, practice of health care professionals, and materials used.10 Actions that promote the efficacy and safety of intravenous therapy include maintenance of venous access, infusion volume control, verification of signs of phlebitis during saline solution and medication administration, and constant monitoring through the use of transparent adhesive dressings to achieve frequent and adequate intravenous inspection of the intravenous area and reduce incidence of phlebitis.11

In the studies reviewed for the current study, IV catheter failure is infiltration. With a range of 15.7% to 33.8% and a mean incidence of 23.9%, infiltration is the most common form of IV catheter failure.12 The most frequent PIVC complication was infiltration/extravasation, which occurred in 13.7% of patients.2 Infiltration leads to infusion of fluids and/or medications into the surrounding soft tissues, resulting from erosion or penetration of the catheter into or through the venous wall. Extravasation, the infiltration of a known vesicant or caustic agent, is a particular subgroup of infiltration that can lead to extensive soft tissue injury and loss with devastating results.12

The severity of infiltration was labeled with the infiltration scale range from grade 1 through grade 4.4 Data were collected from incidence of peripheral intravenous infiltration, which was assessed for several risk factors, such as age, diagnosis, comorbidities, dwell time, size of catheter use for insertion, and the number of medications being administered intravenously.8,13 The risk factors of infiltration for hospitalized children who received peripheral intravenous injection therapy were lower limb (odds ratio [OR] = 1.72), phenytoin (OR = 11.03), 10% dextrose (OR = 6.55), steroids (OR = 6.21), vancomycin (OR = 4.10), high-concentration electrolytes (OR = 3.49), and ampicillin/sulbactam combination (OR = 3.37).14

Extravasation is a medication-related adverse event occurring when an irritant or vesicant injectable drug (which may cause tissue necrosis) leaks into the perivascular or subcutaneous spaces. Of all the irritant and vesicant substances that may extravasate, cytotoxic and contrast agents are already subject to a relatively well-defined management strategy in health care institutions.15 The incidence of extravasation varies between 0.01% and 7.00%, depending on the study.16 The severity of extravasation was labeled with the extravasation scale, from grade mild to moderate to severe extravasation.17 The risk factors of extravasation include infused high volume per day (≥1000 mL), type of medical procedure, infused agents with high osmolarity, and poor vein condition. The severity of extravasation was related to the large volumes of drug or special drugs (high-osmolarity, high-risk, low pH, etc).18 However, numerous drugs that are used on a daily basis in most general care institutions may cause patients serious harm in the case of extravasation, including hyperosmolar agents (eg, parenteral nutrition solutions, magnesium sulfate, potassium chloride, sodium bicarbonate), acidic (eg, metronidazole, vancomycin, nicardipine) and basic compounds (eg, furosemide, phenobarbital), and vasopressors (eg, norepinephrine, epinephrine, dobutamine, dopamine).15

Numerous characteristics might be included as patient considerations, including small and fragile veins, brittle skin, and age: young children and the elderly are more likely to have small rolling veins.19 Patients who are unconscious, confused, or have communication difficulties may be incapable of addressing pain or discomfort caused by the cannula position. Patients with comorbid conditions that can result in diminished feeling or poor circulation, such as peripheral vascular disease, diabetes mellitus, or obesity, may also experience diminished sensation or poor circulation. Depending on the agent, coexisting medications such as anticoagulants, analgesics, antifibrinolytics, vasodilators, hormone therapy, diuretics, steroids, antihistamines, and intravenous antibiotics may increase blood circulation, decrease inflammatory response, and decrease pain sensation, among others.16 Other risk factors associated with PIVC complications found on the prevalence surveys on PIVC complications performed in 2020 at Chiang Mai University Hospital depended on the agent, such as blood, blood component, colloid, crystalloids, and whether a sterile transparent dressing was used.20

Maharaj Nakorn Chiang Mai Hospital is a 1400-bed university hospital located in the north of Thailand. It serves about 50 000 patients per year, of whom approximately 80% receive PIVCs. Prevalence surveys on phlebitis were performed in 2020 and found that 4.69% of patients with a peripheral catheter had phlebitis, and 3.35% of patients had infiltration.20 The related PIVC complications had no documentation to improve maintenance and care. Therefore, the current study proposed to examine the prevalence of complications and factors associated with complications from peripheral IV fluid administration.

METHODS

Study Design

This cross-sectional descriptive study aimed to analyze the prevalence of complications and factors associated with difficulties from peripheral IV fluid administration. Data were collected at a tertiary care hospital in Thailand on December 17, 2021.

Setting and Subjects

This cross-sectional study was conducted among the patients who received peripheral intravenous IV fluid administration at the Faculty of Medicine, Chiang Mai University. The subjects were patients who received peripheral IV fluid administration from 10 nursing sections.

Instruments

The research instruments were developed from the literature review and included the following (see Appendix 1):

1. general patient information, including ward data and diagnosis;

2. information on factors associated with complications from peripheral intravenous fluid exposure, including gender, age, diagnosis, comorbidities, level of consciousness (Glasgow Coma Scale [GCS] score), IV infusion setting, PIVC catheter size, insertion site, PIVC dressing, treatment affecting immunosuppression, receiving IV crystalloids, receiving IV colloid, receiving IV vascular regulators, receiving IV antibiotics, receiving IV hyperosmolar agents, receiving IV anticoagulant, receiving IV antiplatelet, receiving IV antifibrinolytics, receiving IV analgesic drugs, and catheter dwell time (days); and

3. PIVC complication data (phlebitis, infiltration, and extravasation) using the phlebitis scale, infiltration scale, and extravasation scale.17

To verify accuracy of the contents (content validity), validity of the instruments was checked by 3 infection control specialists, including an infection control associate professor, infection control advanced practice nurse (APN), and infusion nurse specialist. The content validity index (CVI) was calculated with a value equal to 1. To determine reliability of the tools, a complication assessment sheet was used to evaluate 10 patients. After recording complications of the PIVC, interrater reliability was calculated to 0.98. Then, the nursing action observation sheet was used to observe 10 nurses. The interrater reliability of this instrument was 0.95.

Data Collection and Analysis

The data were collected by 26 research assistants, who assessed the peripheral intravenous complications at 10 nursing sections at the Faculty of Medicine, Chiang Mai University, on December 17, 2021. These research assistants were trained in degrees of peripheral intravenous fluid complications, including phlebitis, infiltration, and extravasation, and the interrater reliability of the research assistants was tested. The CVI was 1.0 in a test of 30 items of degree of PIVC complications.

The exclusion criterion was unwillingness to participate. The participant or the parent/guardian was asked to sign a consent form. The research assistants recorded the data by using the research instruments that were developed from the literature review and included general patient information, including ward data and information on factors associated with complications from peripheral intravenous fluid exposure.

Data were analyzed using the SPSS statistics program, version 22 (IBM, Armonk, NY), by frequency and percentage. Factors associated with complications from peripheral IV fluid administration were investigated using χ² analysis statistics.

Ethical Approval

This study was approved by the research ethics committee of the Faculty of Medicine, Chiang Mai University (research ID: NUR-2564-08607, Certificate Code 535/64).

RESULTS

Prevalence of Complications From Peripheral Intravenous Fluid Exposure

The study included a total of 441 patients treated in 10 nursing sections, with 497 peripheral IV catheter sites. Among them, 27.8% were patients with cancer, 38.0% had comorbidities, 55.5% were men, 43.3% were over the age of 60 years, and 5.6% were younger than 1 month (Table 1) Information on complications from peripheral intravenous fluid exposure shown at Table 2. Phlebitis (level 1 and 2 only) was found at 2.41% of all sites; infiltration (level 1 and 2 only) occurred at 1.01% of all sites; and extravasation (mild and moderate only) was found at 0.60% of all sites (Table 3).

TABLE 1. Characteristics of Study Participants and Factors Associated with Complications from Peripheral IV Fluid Exposure (n = 497).

Characteristics/factors	Number	Percent
Gender Male Female	276 221	55.5 44.5
Age group <1 mo >1 mo to 1 y >1 y to 15 y >15 y to 30 y >30 y to 60 y >60 y	28 4 28 91 131 215	5.6 0.8 5.6 18.3 26.4 43.3
Bacterial sepsis Yes No	0 497	0 100
Comorbidities Yes No	189 308	38.0 62.0
Treatment affecting immunosuppression Yes No	117 380	23.5 76.5
Level of consciousness (GCS score) Score 1-5 Score 6-10 Score 11-15	156 35 306	31.4 7.0 61.6
IV infusion setting Continuous Intermittent	270 227	54.3 45.7
PIVC catheter size Unknown 18 gauge 20 gauge 22 gauge 24 gauge	8 28 68 290 103	1.6 5.6 13.7 58.4 20.7
Insertion site Arm Hand Arm crook Leg Instep Head Ankle	262 159 29 27 11 7 2	52.7 32.0 5.8 5.4 2.2 1.4 0.4
PIVC dressing Sterile transparent Nonsterile transparent	483 14	97.2 2.8
Receiving IV crystalloids Yes No	234 263	47.1 52.9
Receiving IV colloid Yes No	9 488	1.8 98.2
Receiving IV vascular regulators Yes No	6 491	1.2 98.8
Receiving IV antibiotics Yes No	263 234	52.9 47.1
Receiving IV hyperosmolar agents Yes No	10 487	2.0 98.0
Receiving IV anticoagulant Yes No	29 468	5.8 no
Receiving IV antiplatelet Yes No	13 484	2.6 97.4
Receiving IV antifibrinolytics Yes No	3 494	0.6 99.4
Receiving IV analgesic drugs Yes No	66 431	13.3 86.7
Catheter dwell time, d <4 >4 Unknown	474 16 7	95.4 3.2 1.4

Abbreviations: GCS, Glasgow Coma Scale/Score; IV, intravenous; PIVC, peripheral intravenous catheter.

TABLE 2. Information on Complications from Peripheral Intravenous Fluid Exposure (n = 497).

IV Complications Prevalence	Number	Percent
Phlebitis scale grade 0 1 2 3 4	485 10 2 0 0	97.6 2.0 0.4 0 0
Infiltration scale grade 0 1 2 3 4	492 1 4 0 0	99.0 0.2 0.8 0 0
Extravasation scale grade Normal Mild Moderate Severe	494 1 2 0	99.4 0.2 0.4 0

TABLE 3. Data on the Prevalence of Complications from Peripheral Intravenous Fluid Exposure (n = 497).

Complications encountered	No. (times)	Prevalence of complications (per 100 peripheral intravenous catheter sites)
Phlebitis	12	2.41
Infiltration	5	1.01
Extravasation	3	0.60
Total	20	4.02

Factors Associated With Complications From Peripheral IV Fluid Exposure

The factors investigated for association with complications from peripheral IV fluid exposure included in this study can be found above, under “Instruments.” The study found that IV infusion setting (P = .03), receiving IV crystalloids (P = .04), and receiving IV analgesic drugs (P = .01) were statistically significantly associated with overall IV complications (phlebitis, infiltration, and extravasation). Statistically significant factors associated with infiltration were receiving IV crystalloids (P = .04) and receiving IV analgesic drugs (P = .01). Age was statistically significantly related to the occurrence of extravasation complications (P = .001; Table 4).

TABLE 4. Analysis of the Factors Associated with PIVC Complications.

Factors/IV complications	Phlebitis (P value)	Infiltration (P value)	Extravasation (P value)	Complications included (P value)
Gender	.12	.27	.70	.61
Age range	.60	.81	.001**	.37
Diagnosis	.43	.55	.99	.45
Comorbidities	.35	.40	.17	.90
Level of consciousness (GCS score)	.29	.21	.89	.45
IV infusion setting	.37	.12	.06	.03*
PIVC catheter size	.78	.46	.92	.93
Insertion site	.21	.87	.85	.65
PIVC dressing	.71	.87	.77	.44
Treatment affecting immunosuppression	.90	.21	.67	.70
Receiving IV crystalloids	.33	.03*	.63	.04*
Receiving IV colloid	.63	.76	.81	.53
Receiving IV vascular regulators	.70	.22	.63	.27
Receiving IV antibiotics	.70	.22	.63	.27
Receiving IV hyperosmolar agents	.11	.75	.80	.33
Receiving IV anticoagulant	.38	.58	.67	.26
Receiving IV antiplatelet	.57	.71	.78	.45
Receiving IV antifibrinolytics	.79	.86	.89	.72
Receiving IV analgesic drugs	.92	<.001**	.20	.01*
Catheter dwell time, d	.10	.59	.93	.28

Abbreviations: GCS, Glasgow Coma Scale/Score; IV, intravenous; PIVC, peripheral intravenous cathether.

χ² test.

*Significant P < .05.

**Significant P <.001.

DISCUSSION

The study found phlebitis (level 1 and 2 only) in 2.41% of the 497 peripheral IV sites investigated. This was significantly less than the Centers for Disease Control and Prevention.21 In comparison, the One Million Global study reports an overall prevalence of 10%, with the highest prevalence seen in Asia, at 16%.22 Infiltration (level 1 and 2 only) was found at 1.01% of all sites, which is much less than that reported in a Serbian study of 1428 IV cannula insertions in a tertiary care hospital, which found a 16.30% rate of infiltration, and less than a previous study in a Thai university hospital, which found a rate of 6.20%.8,23 The extravasation rate of 0.6% found in this study was much less than that in a study from Thammasat Chalermprakiat Hospital in Thailand24 and slightly higher than the 0.5% rate found in the previous study.24,25

The relatively low complication rates found in this study could be attributed to active promotion, support, monitoring, and evaluation of the quality of peripheral IV fluid administration and using updated practices, which had increased the list of drugs and fluid agents that could cause extravasation.26 The new organizational guidelines were published in January 2021, media and educational materials were created, and the use of the guidelines was promoted.26 An online knowledge test was conducted in August 2021, with the assessment passing the threshold at 100%, which increased compliance with the guidelines. In September 2021, more than 80% of the IV assessments met the criteria, showing that nursing staff were knowledgeable and able to assess extravasation.

This study found that IV infusion setting was statistically related to complications (P = .03), which was consistent with studies on infusion therapy, in which rapid hydration increases the risk factors of leakage.27 It was also in line with the study of Norrasarn,28 showing that high osmolarity increases the risk of phlebitis. It was shown that osmolarity values >290 mOsm/L cause high osmotic pressure, causing fluid to move from inside the cells, which makes the cells lose their function.

Crystalloid exposure was also statistically significantly related to complications from overall IV fluid administration. Isotonic, hypotonic, and hypertonic solutions all require control of infiltration volume and infusion rate, thus increasing the pressure of the drug in the vein. In most cases, fluid administration uses infusion therapy, which provides rapid and continuous hydration, which increases the risk factors of fluid leakage and the risk of venous injury.2,11 The hypertonic solution was reported to damage the vascular endothelium and cause phlebitis because it is a chemical substance and its osmolarity is higher than the osmolarity of blood.4 There are studies indicating that the type of infusion fluid is important in the development of phlebitis, particularly the use of hyperosmolar solutions, antibiotics, and fluid with potassium chloride (KCl), which increase the risk for phlebitis.29

This study also found that exposure to analgesic drugs was statistically significantly related to complications from overall IV fluid administration (P = .01), which corresponds to studies in England where extravasation occurred in patients receiving analgesic drugs (Table 4).4 As analgesics reduce the pain response, when a drug or fluid leak occurs, severe extravasation can occur.30 Finally, this study found that age was statistically significantly related to the occurrence of extravasation complications from IV fluid administration (P = .001; Table 4). This was consistent with a study by Pathomjaruwat,24 which found that patient age was a risk factor for drug leakage or extravasation. It found that young children and the elderly were at greater risk, as they were less associated with skin strength and stiffness.31 Infants and young children have relatively thin blood vessels, thus, making it difficult to perform venipuncture and more likely to damage blood vessels.32 Moreover, infants and young children are more likely to move and have poor compliance; thus, it is difficult to properly stabilize the infusion site during infusion. Elderly patients have decreased body functions; decreased skin elasticity, which is prone to needle displacement; atherosclerosis of the blood vessels causing diminished blood flow; and reduced blood fluidity. Consequently, the risk of extravasation in older adults is greatly increased.

Study Limitations

Limitations of this study are that, although data were representative of the population surveyed, the sample size was relatively small, and the survey was only conducted in 1 tertiary care university hospital at 1 point in time.

CONCLUSIONS

Nurses are important workers in the care and monitoring of complications from peripheral IV fluid administration. Nurses should be aware and develop guidelines for preventing complications from peripheral IV fluid administration. This survey has identified priority areas for improvement related to PIVC insertion and management, which are key to preventing PIVC failure and associated complications in the future for patients.

APPENDIX 1