An ASA 3 patient with a BMI 45 received general anesthesia (GA) for a cranioplasty. The antecubital I.V. was placed with ultrasound by a provider who was not part of the anesthesia team. There was no documentation of any difficulty, but the attending anesthesiologist was not aware that a standard-length I.V. had been placed in a relatively large arm with ultrasound guidance. Anesthesia was induced uneventfully and maintained with sevoflurane. The patient’s arms were secured such that the I.V. site was not visible. The administered medications had the expected effect throughout the case. Mannitol was administered with an infusion pump without triggering a pressure alarm. At the end of the anesthetic, the forearm distal to the I.V. was swollen and tense and the patient complained of pain in her arm. The anesthesiologist consulted with a hand surgeon who diagnosed compartment syndrome and the need for fasciotomy. The anesthesiologist placed a right internal jugular line and re-induced anesthesia. After the fasciotomy, the patient recovered without a functional deficit. A malpractice claim was filed because of the pain, prolonged recovery, and scar from the fasciotomy. After a protracted defense, a verdict was rendered in favor of the anesthesiologist.

“What is important for the anesthesiologist to know pragmatically is which medications can cause I.V. failure directly and/or lead to injuries that are disproportionate to the infiltrated volume.”

A multiparous woman presented for a trial of labor after previous C-section. After artificial rupture of membranes, the umbilical cord prolapsed, and an emergency C-section was performed under GA as the labor epidural could not be dosed in time. The C-section was complicated by hypotension and postpartum hemorrhage requiring a hysterectomy. Three units of PRBCs, 3 liters of crystalloids, 5% albumin, hetastarch, phenylephrine (boluses and infusion), calcium chloride (CaCL) (1 gm), and sodium bicarbonate (100 meq) were administered through the two peripheral I.V.s. In the PACU, the patient noted pain in the right-hand I.V. site. The forearm was swollen and discolored, and the patient noted hand numbness. The Doppler exam revealed intact arterial flow but poor capillary refill. Fasciotomies of the hand and forearm and a carpal tunnel release were performed. The patient returned to the OR six days later for debridement and again in a month for further debridement and skin grafting. After extensive PT and OT, hand function was eventually described as normal. A suit was filed citing pain, scarring, and restriction in function causing a delayed return to work. The claim went to trial, with a verdict for the defense after significant costs to the insurer.

Considering the centrality of the administration of I.V. medications to the practice of anesthesia, significant patient injury due to I.V. infiltration/extravasation is an uncommon occurrence. When it does occur, however, devastating complications can arise that include compartment syndrome, tissue necrosis requiring surgical intervention, loss of hand function, complex regional pain syndrome, and, rarely, limb amputation. Although often used interchangeably, the terms I.V. infiltration and extravasation should be differentiated, with infiltration being defined as the inadvertent administration of a non-vesicant medication/solution into the tissue around an I.V. catheter; extravasation is the same phenomenon involving a vesicant (Am J Nurs 2007;107:64-72). The formal definition of vesicant is an agent that can cause blistering. Many vesicants are administered in anesthesia practice through peripheral I.V.s without consequence. What is important for the anesthesiologist to know pragmatically is which medications can cause I.V. failure directly and/or lead to injuries that are disproportionate to the infiltrated volume.

These two cases highlight some important themes among I.V. infiltration closed claims:

  • I.V.s that cannot be inspected during the case
  • The failure of high-pressure infusion pump alarms to warn of infiltration
  • Resuscitations with multiple medications and large volumes of fluid
  • I.V.s placed with ultrasound guidance
  • The delayed appearance of extensive injury with vesicant medications.

These cases involve vesicants and a vasopressor: CaCl (1,500 mOsm/L), NaHCO3 (1,000 mOsm/L), and phenylephrine in one case and mannitol (825 mOsm/L) in the other. The Table is a list of medications (not intended to be comprehensive) outlining whether they pose a higher risk for injury with infiltration and whether there are specific treatments to be considered for infiltration/extravasation.

Table: Incomplete list of medications that may pose a higher risk for injury with infiltration, and specific treatments for infiltration/extravasation.

Table: Incomplete list of medications that may pose a higher risk for injury with infiltration, and specific treatments for infiltration/extravasation.

CaCl deserves special attention, as it is the most frequently implicated vesicant medication in the Closed Claims Database. It causes endothelial injury with its hypertonicity, and it causes prolonged contraction of precapillary and postcapillary smooth muscle sphincters, directly causing I.V. failure. According to published guidelines, fluids and medications with an osmolarity greater than 600 mOsm/L should not be infused through a peripheral vein, as animal and human studies have demonstrated that these fluids are associated with the highest risk of endothelial damage (Am J Nurs 2007;107:64-72). The usual conduct of anesthesia would be impossible if this guideline was strictly applied, but precautions should be taken when administering hypertonic medications in a peripheral vein. The package insert for CaCl indicates that if central venous administration is not possible, it should be administered through a deep vein at a maximum rate of 1 mL or 100 mg/minute.

As with any injuries associated with malpractice claims, the primary focus should be on meeting the standard of care for prevention and treatment. If an injury occurs and a claim of malpractice is made, the accurate documentation of preventive efforts and post-incident care is crucial for defending the care provided. Specific considerations for meeting the standard of care for prevention of infiltration/extravasation events include the prudent choice of peripheral veins for I.V. placement, careful verification of free-flowing I.V. function (particularly for I.V.s that cannot be examined during the case), inquiring about and communicating the provenance of any I.V.s that were challenging to place, heightened vigilance when administering vesicant medications or solutions, avoiding overreliance on infusion pump alarms, and early visual inspection of I.V. sites if infiltration is suspected. If I.V. infiltration does occur, the treatment considerations include the need for evaluation for compartment syndrome and knowledge of whether there are specific treatments or antidotes for the medications involved.