Infiltration during Infusion Therapy
User Experience Network [Health Devices Jan 1998;27(1):39]
While using an infusion pump to deliver a saline bolus to an infant, our
staff noticed swelling and discoloration of the infant's forearm caused by infiltration.
The infusion was stopped, and the pump was removed from service for inspection. The pump
did not alarm during the infiltration, but we could not detect any problems with the
device. The supplier informed us that the device was not intended to detect or prevent
Infiltration—also called extravasation—is the extravascular
accumulation of a solution being infused. One consequence of infiltration is that it can
lead to necrosis; however, the primary consequence is that the patient is denied necessary
fluids or medications. Because vital intravenous (IV) medications are frequently delivered
to a patient by means of infusion therapy, infiltration can have serious effects on a
A number of infiltration incidents have been reported to ECRI implicating
all types of infusion pumps. However, infusion pumps typically play only an ancillary role
in such incidents, and the belief that the pumps themselves produce infiltration is
inaccurate. Rather, the usual causes of infiltration are dislodgment or improper insertion
of either a catheter or—in the case of a subcutaneous injection port—a needle.
Thus, to avoid problems, staff members should monitor IV sites of patients who are
receiving infusions through pumps at least hourly to ensure that catheter or needle
dislodgment and subsequent infiltration do not occur.
Another common misconception is that occlusion alarms on infusion pumps
will signal infiltration. In fact, pumps will alarm only when downstream pressure reaches
a specified value, and elevated pressures resulting from infiltration are typically far
lower than occlusion alarm triggering levels. ECRI is not aware of any currently marketed
infusion pump that can reliably detect infiltration. We addressed the various approaches
to infusion pump pressure detection in Health Devices
- During routine hospital training, instruct staff
members that infusion pumps do not detect infiltration and that patients
receiving infusions through these devices should therefore be supervised
closely and IV sites should be assessed hourly.
- Inform all clinical engineering personnel that
infusion pumps submitted for maintenance following infiltration incidents
can be returned to service after routine inspection and documentation.
- Instruct clinical engineering personnel to monitor the trends of repair
requests that indicate infiltration. If this problem is persistent,
additional staff training on avoiding infiltration may be needed.
- Infusion Pumps [16-495]
- Infusion Pumps, Ambulatory [16-491]
- Infusion Pumps, General Purpose [13-215]
Cause of Device-Related
Device factor: Failure of accessory
User error: Inappropriate
reliance on an automated feature
Mechanism of Injury or
Extravasation; Infiltration; Underdose