Complications and Nursing Interventions

KEY TERMS

Air Embolism

Catheter Embolism

Cellular Toxicity

Debridement

Ecchymosis

Extravasation

Hematoma

Infiltration

Ischemia

Necrosis

Phlebothrombosis

Reflex Sympathetic Dystrophy (RSD)

Thrombogenicity

Thrombophlebitis

Thrombosis

UNDERSTANDING COMPLICATIONS

As many as 90% of all hospitalized patients in the United States receive some form of infusion therapy, and the number of patients in non-acute care settings continues to proliferate. Although most infusion therapy is administered without problems, some complications, ranging from minor to more serious, do occur. Such complications increase hospital length of stay, length of therapy, and may put the patient at risk for additional problems. Fortunately, most of these complications are preventable. A comprehensive knowledge of the inherent risks and measures to prevent their occurrence may eliminate many of the hazards associated with infusion therapy. The infusion nurse needs to recognize complications and respond with appropriate nursing interventions to ensure quality of care. Complications are varied and may be local or systemic. Local complications occur frequently but are rarely serious. Systemic complications, although more rare, are serious and frequently life threatening. They require immediate recognition and medical attention. Sentinel events, as defined by
The Joint Commission (TJC), are unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof. Tracking, reporting, and analyzing complications are critical to prevention.

LOCAL COMPLICATIONS

Local complications are those seen at or near the catheter insertion or exit site as a result of trauma to the vessel wall or as a result of mechanical failure. In general, they are easily corrected and are associated with no serious problems when appropriate interventions are initiated. Occasionally, local complications are not recognized until considerable damage occurs, making early recognition of complications a key factor in infusion therapy. Early recognition may prevent the following:

Extensive edema that deprives the patient of urgently needed fluid and medications
Necrosis (localized death of tissue)
Thrombophlebitis with the subsequent danger of embolism

Local complications that are mechanical in nature are generally resolved by correction of the mechanical failure, such as adjusting a tourniquet, insertion site, cannula, container, tubing, or patient position. Local complications may also occur as the result of trauma to the wall of the vein. Among the common local complications are ecchymosis or hematoma, infiltration, extravasation, phlebitis, postinfusion phlebitis, thrombosis, thrombophlebitis, and phlebothrombosis.

Ecchymosis/Hematoma

Ecchymosis denotes the infiltration of blood into the tissues; hematoma usually refers to uncontrolled bleeding at a venipuncture site, generally creating a hard, painful lump. Both are commonly associated with venipunctures that are performed by unskilled professionals or on elderly patients who have a tendency to bruise easily. Ecchymosis and hematomas often occur when multiple entries are made into a vein or when attempts are made into veins that are not easily palpated. These injuries may limit veins for future use.

PATIENT SAFETY

If ecchymosis occurs during venipuncture, the cannula should be removed and light pressure should be applied. If hematoma occurs during a venipuncture attempt, the cannula is immediately removed, direct pressure is applied to the area, catheter integrity is assessed, and the extremity is elevated until bleeding has stopped. A dry, sterile dressing is applied to the site, and the area is monitored for signs of breakthrough bleeding. Ice may be applied, and the area is observed for circulatory, neurologic, and motor function (INS, 2011).

Infiltration

Dislodgment of the catheter with consequent infiltration of fluid is common and frequently is considered of minor significance. In 1998, the Infusion Nurses Society (INS) published an infiltration scale as a part of the Revised Intravenous Nursing Standards of
Practice. The scale was revised in 2010 to include psychometric properties. The tool was edited for pediatric use by researchers from Children’s Medical Center of Dallas; Box 10-1. The infiltration scale was removed from the Standards of Practice, and a recommended scale is now available in INS’ Policies and Procedures for Infusion Nursing. (www.ins1.org/onlinestore)

With the increasing numbers of irritating solutions and the frequency with which potent drugs are infused in intravenous (IV) solutions, serious problems may occur when the fluid invades the surrounding tissues. Hypertonic, acid, and alkaline fluids are contraindicated for hypodermoclysis and are not intended for other than venous infusions. If they are allowed to infiltrate, necrosis may occur.

If necrosis is avoided, edema may nevertheless

Deprive the patient of fluid and drug absorption at the rate essential for successful therapy
Limit veins available for venipuncture, complicating therapy
Predispose the patient to infection

BOX 10-1 PEDIATRIC PERIPHERALLY INSERTED IV (PIV) INFILTRATION SCALE

Grade	Appearance
0	Asymptomatic Flushes easily
1	Localized swelling Flushes with difficulty Discomfort at site
2	Evidence of slight swelling at site or below site Redness Discomfort at site
3	Moderate swelling Pain at site Skin cool to touch Blanching present Diminished pulse below the site
4	Severe swelling Infiltration Skin cool to touch Blanching Necrosis Blistering Diminished or absent pulses Pain at site Capillary refill > 4 seconds
Adapted from Pop, R. (2012). A pediatric peripheral intravenous infiltration assessment tool. Journal of Infusion Nursing, 35(4), 243-248.

Extravasation

Extravasation is the infiltration of a medication that causes tissue necrosis or damage. Edema may be present, due to infiltration or tissue damage. Comparing the infusion area with the identical area in the opposite extremity can help the nurse identify swelling.

In many cases, the edema is allowed to increase to great proportions because of the misconception that backflow of blood into the adapter is significant proof that the infusion is entering the vein. This is not a reliable method for detecting possible infiltration because the point of the IV catheter may puncture the posterior wall of the vein, leaving the greater portion of the bevel in the lumen of the vein. Blood return is obtained on negative pressure, but if the infusion is allowed to continue, fluid seeps into the tissues at the point of the catheter, thereby increasing the edema.

Occasionally, a blood return is not obtained on negative pressure. This may occur when the needle occludes the lumen of a small vein, obstructing the flow of blood. Evidence of backflow should not be the sole criterion for confirming extravasation.

Drugs that contribute to necrosis as a result of extravasation are most often osmotically active or ischemia-inducing or they cause direct cellular toxicity. Mechanical compression in the infiltrated tissue can increase the extent of damage, as can infection of the resulting wound. If only superficial tissue loss occurs and the area remains free of infection, debridement yields a clean bed capable of granulation. If deep structures are involved, however, spontaneous wound healing may be averted, resulting in the need for wide excision, debridement, and grafting or amputation to restore tissue integrity.

Phlebitis

Phlebitis, or inflammation of the intima of the vein, is a commonly reported complication of infusion therapy. The inflammatory process occurs as a result of irritation to the endothelial cells of the vein intima, creating a rough cell wall where platelets readily adhere. Phlebitis is characterized by pain and tenderness along the course of the vein, erythema, and inflammatory swelling with a feeling of warmth at the site.

An intact skin surface is the first line of defense, and when it has been violated, patients are at risk for bacterial infection. Hand hygiene is the most important preventive activity, followed by thorough cleaning of the site prior to cannulation and applying a sterile dressing after insertion. Maintenance of the site and the peripheral IV (PIV) catheter also involves good handwashing prior to dressing or tubing changes. Manipulation of the PIV catheter during patient movement or dressing/tubing changes can be a key factor in the development of phlebitis (Washington & Barrett, 2012). Phlebitis may be mechanical, chemical, or bacterial. See Box 10-2, Factors Contributing to Venous Inflammation; Box 10-3, Phlebitis Rating Scale; and Figure 10-1, Visual Infusion Phlebitis (VIP) score.

Mechanical phlebitis is associated with cannula placement; cannulas placed in areas of flexion may result in mechanical phlebitis. As the extremity is mobilized, the cannula may
irritate the vein intima, causing injury and resultant phlebitis. The cannula should closely approximate the lumen of the vessel to avoid mechanical phlebitis. Proper taping and securement are essential.

Bacterial phlebitis is an inflammation of the vein intima associated with a bacterial infection. The condition may be serious and predispose the patient to systemic complications addressed later in this chapter. Handwashing is the single most important procedure for preventing nosocomial infections, and aseptic technique is essential in the preparation and care of venipuncture sites (APIC, 2011).

Chemical phlebitis is associated with a response of the vein intima to chemicals producing inflammation. The inflammatory response is created by the administration of solutions or medications or as a result of certain cannula materials. We know that the normal blood pH is 7.35 to 7.45 and is slightly alkaline. The normal pH for solutions is 7.0, which is neutral. The pH of dextrose solutions ranges from 3.5 to 6.5. Acidity is needed to prevent caramelization of the dextrose
during sterilization and to maintain the stability of the solution during storage. Solutions and medications with a high pH or osmolality predispose the vein intima to irritation. The more acidic an IV admixture, the greater the risk. In addition, additives such as potassium chloride, vancomycin hydrochloride, and many antineoplastic agents can contribute to chemical phlebitis.

BOX 10-3 PHLEBITIS RATING SCALE

Grade 0 No symptoms

Grade 1 Erythema at access site with or without pain

Grade 2 Pain at access site with erythema and/or edema

Grade 3 Pain at access site with erythema and/or edema, streak formation, palpable venous cord

Grade 4 Pain at access site with erythema and/or edema, streak formation, palpable venous cord > 1 inch in length; purulent drainage

From Infusion Nurses Society. (2011). Infusion nursing standards of practice. Journal of Infusion Nursing, 34(1 Suppl), S47.

FIGURE 10-1 Visual Infusion Phlebitis scale. (From Gallant, P., & Schultz, A.A. (2006). Evaluation of a visual infusion phlebitis scale for determining appropriate discontinuation of peripheral intravenous catheters. Journal of Infusion Nursing, 29(6), 338-345.)

Postinfusion Phlebitis

Postinfusion phlebitis refers to inflammation of the vein that usually presents within 48 to 96 hours of cannula removal or after administration of a specific drug. Factors contributing to the development of postinfusion phlebitis include the following: poor cannula insertion technique, a debilitated patient, poor vein condition, hypertonic or acidic solutions,
ineffective filtration, placement of a large-gauge cannula in a small vessel, and failure to change tubings, dressing, injection site caps, and cannulas consistent with the INS Standards of Practice. Measures for preventing postinfusion phlebitis are provided in Box 10-4.

BOX 10-4 MEASURES FOR PREVENTING POSTINFUSION PHLEBITIS

Ensure that a skilled clinician is performing venipuncture.
Apply antiseptic technique.
Check compatibility of solutions and medications prior to mixing/administering.
Use filters to prepare medications and solutions.
Use final filtration, as recommended, for administering medications and solutions.
Add a buffer agent to known irritants.
Rotate peripheral infusion sites.
Change the solution container per INS recommendations.
Change accessories, including caps and needleless devices, at the time of peripheral catheter change and as needed.

Thrombosis

Any injury that roughens the endothelial cells of the venous wall allows platelets to adhere and a thrombus to form (Figure 10-2). Because the point of the IV catheter traumatizes the wall of the vein where it touches, a thrombus or thrombi form on the vein and at the tip of the catheter. The result of local thrombi obstructing the circulation of blood is thrombosis. Thrombi not only
obstruct circulation but also form an excellent trap for bacteria, whether the bacteria are carried by the bloodstream from an infection in a remote part of the body or enter the body through a subcutaneous orifice. Khalidi, Kovacevich, Papke-O’Donnell, and Btaiche (2009) found that “The use of needleless positive pressure connector valves (PPVs) on venous access devices (VADs) has helped to decrease VAD occlusion rates, but catheter-related bloodstream infections (CRBSI) rates vary.”

FIGURE 10-2 Sources of vascular catheter-related infection.

Occlusion remains a concern for short- and long-term catheters, including peripherally inserted central catheters (PICCs). Occluded catheters place the patient at risk for mechanical complications, including pneumothorax and hematoma as well as delays in treatment.

Thrombosis of the deep veins (axillary, subclavian, innominate, internal jugular, and superior vena cava) and subsequent risk of infection occur when catheters are placed in the venous system. The device that poses the greatest risk of iatrogenic bloodstream infection is the central venous catheter (CVC) in its numerous forms (Centers for Disease Control and Prevention [CDC], 2011). Bennett and Brachman’s classic studies addressed patients with PICCs, implanted venous access ports, and CVCs (Jarvis, 2013).

Bloodstream infection remains the most common life-threatening complication associated with central venous access (Sadfar, Jacobs, & Gaines, 2012). Central line bundles are groupings of best practices that individually improve care but when applied together result in substantially greater improvement. According to the Institute for Healthcare Improvement (2013), the science supporting the bundle components is sufficiently established to be considered standard of care.

Risk of bloodstream infection associated with various devices may be found in Table 10-1. See Chapter 14 for detailed information regarding central venous access.

Thrombophlebitis

Thrombophlebitis denotes a twofold injury—thrombosis plus inflammation. The development of thrombophlebitis is easily recognized. Classic symptoms of tenderness, erythema, and swelling are seen the longer a catheter remains in place. A painful inflammation develops along the length of the vein. If the infusion is allowed to continue, the thrombosis progressively obstructs the circulation and the vein becomes hard, tortuous, tender, and painful. Early detection may prevent an obstructive thrombophlebitis that can slow and eventually stop the infusion. This condition, which is painful, may persist indefinitely, incapacitating the patient and limiting available veins for future therapy.

CONTRIBUTING FACTORS

Any irritation involving the wall of the vein predisposes the patient to thrombophlebitis. Duration of the infusion is a significant factor in the development of thrombophlebitis. As the duration increases, so do the incidence and degree of inflammation.

TABLE 10-1 APPROXIMATE RISKS OF BLOODSTREAM INFECTION ASSOCIATED WITH VARIOUS TYPES OF ACCESS DEVICES

Type of Device			Representative Rate	Representative Range
Short-term temporary access^a
	Peripheral IV cannulas
		Winged steel needles	<0.2	0-1
	Peripheral IV catheters
		Percutaneously inserted	0.2	0-1
		Cutdown	6	0-1
	Midline catheters		0.7	0.7-0.8
	Arterial catheters		1	—
	Central venous catheters
		All-purpose, multilumen	3	1-7
		Pulmonary artery	1	0-5
		Hemodialysis	10	3-18
	Long-term indefinite access^b
		Peripherally inserted, CVCs	0.20	—
		Cuffed central catheters	0.20	0.10-0.53
		Subcutaneous central venous ports	0.04	0.00-0.10
Based on data from recently published, prospective studies.
^aNumber of bloodstream infections per 100 devices. ^bNumber of bloodstream infections per 100 device-days.
IV, intravenous. From Bennett, J.V., & Brachman, P.S. (2007). Hospital infections (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

The composition of the solution may play a role. Venous irritation and inflammation may result from the infusion of hypertonic glucose solutions, certain drug additives, or solutions with a pH significantly different from that of the plasma. Dextrose solutions are irritating to the vein. The United States Pharmacopeia (USP) specifications for pH of dextrose solutions range from 3.5 to 6.5; acidity is necessary to prevent caramelization of the dextrose during autoclaving and to preserve the stability of the solution during storage. Studies show a significant reduction in thrombophlebitis when buffered glucose solution has been infused. Neut, a sodium bicarbonate 1% solution, may be added to increase the pH of acid IV solutions. This additive, however, poses a problem of incompatibility when added to solutions containing drugs. The greatest number of incompatibilities may be produced by changes in pH (Bennett & Brachman, 2007). As an example, tetracycline hydrochloride, with a pH of 2.5 to 3.0, is unstable in an alkaline environment.

The infusion site can be a factor contributing to thrombophlebitis. The veins in areas over joint flexion undergo injury when motion of the catheter irritates the venous wall. The veins in the lower extremities are especially susceptible to trauma, which may be enhanced by stagnant blood in varicosities and stasis in peripheral venous circulation.

The infusion catheter may occlude the entire lumen of the vein, obstructing the flow of circulating blood; the solution then flows undiluted, irritating the wall of the vein.

Venipuncture technique can mean the difference between a successful infusion and the complication of thrombophlebitis. Only minimal trauma results from a skillfully executed venipuncture, whereas a carelessly performed venipuncture may seriously traumatize the venous wall. Phlebitis associated with sepsis may be related to the technique of the clinician. Infection is always a risk if sterile technique is not zealously observed. Thorough cleansing of the skin is important in preventing infections. Maintenance of asepsis is essential during long-term therapy, particularly in the use of the through-the-needle catheter.

Infusion methods for parenteral solutions may foster septic thrombophlebitis. This complication is most often associated with the through-the-needle catheter. Infrequently used, the catheter threaded through the needle remains sterile and does not come in contact with the skin but provides a large subcutaneous orifice facilitating entry of bacteria around the catheter and seepage of fluid.

The over-the-needle catheter is not without fault because it comes in direct contact with the skin before being introduced into the vein. However, the tight fit through the skin may bar further bacterial entry.

TREATMENT

Most cases of superficial thrombophlebitis respond to prompt removal of the IV catheter and local application of heat, although the affected vein may remain firm for several months.

A sterile inflammation usually develops from a chemical or mechanical irritation. When the inflammation is the result of sepsis, however, the condition is much more serious and carries with it the potential danger of septicemia and acute bacterial endocarditis. Additional treatment measures are required, possibly including excision of the infected vein. The wound is then left to heal secondarily. Antibiotic therapy then begins and continues for 7 to 10 days.

An additional complication is embolism when thrombosis occurs. The more pronounced the inflammation and the more intense the pain, the more organized the thrombus is likely to become. Embolism is less likely to occur from the well-attached clot of thrombophlebitis than from phlebothrombosis.

PREVENTIVE MEASURES

In performing venipunctures, the nurse exercises every caution to avoid injuring the wall of the vein needlessly. Multiple punctures, through-and-through punctures, and damage to the posterior wall of the vein with the point of the catheter can lead to thrombosis. The nurse can minimize the risk of phlebitis by implementing these measures:

Refrain from using veins in the lower extremities.
Select veins with ample blood volume when infusing irritating substances.
Avoid veins in areas over joint flexion and use an arm board if the vein must be located in an area of flexion.
Anchor the catheter securely with a stabilization device to prevent motion, which may loosen the catheter.

To prevent septic phlebitis, thorough preparation of the skin, together with aseptic technique and maintenance of asepsis during infusion, is imperative. Periodic inspection of the injection site will detect developing complications before serious damage occurs.

Complaints of a painful infusion make it necessary to differentiate between early phlebitis and venospasm from an irritating solution. In the case of venospasm, slowing the infusion and applying heat to the vein dilates the vessel and increases the blood flow, thereby diluting the solution and relieving the pain. After a hypertonic solution infusion, infusion with an isotonic fluid flushes the vein of irritating substances.

If inflammation accompanies the pain, a change in the injection site should be considered. Continuing the infusion leads to progressive trauma and limits available veins. Adherence to routine replacement time limits for removal of the catheter reduces the incidence of phlebitis (INS, 2011). During removal of the infusion catheter, care must be taken to prevent injury to the wall of the vein; the catheter should be removed at an angle nearly flush with the skin. Pressure should be applied for a reasonable length of time to prevent extravasation of blood.

Phlebothrombosis

Phlebothrombosis denotes thrombosis and usually indicates that the inflammation is relatively inconspicuous. It is thought to give rise to embolism because the thrombus is poorly attached to the wall of the vein. Both thrombophlebitis and phlebothrombosis have a degree of inflammation and are associated with potential embolism. Factors that promote thrombosis are summarized in Table 10-2.

SYSTEMIC COMPLICATIONS

Serious, even life-threatening systemic complications range from septicemia to embolism to shock and infection. These complications need to be prevented or identified as soon as possible and treatment interventions begun.

Septicemia

Septicemia is caused by invasion of the bloodstream by microorganisms or their by-products, including bacteria, fungi, mycobacteria, and, rarely, viruses. Clinical manifestations of septicemia include chills, fever, general malaise, and headache (see Chapter 14).

TABLE 10-2 GENESIS OF THROMBOSIS

Type	Clinical Manifestation	Contributing Factors
Fibrin sheath thrombosis	Inability to aspirate blood; catheter occlusion	Thrombogenic catheter material
Vascular mural thrombosis	Vein obstruction; classic symptoms of thrombosis	Difficult insertions; multiple attempts at venipuncture; sustained contact of the catheter with the venous wall

CONTRIBUTING FACTORS

Certain predisposing factors put the infusion therapy patient at risk:

Age younger than 1 year or older than 60 years
Granulocytopenia
Immunocompromised state
Loss of skin integrity
Distant infection that might contribute to hematogenous seeding.

Also contributing to the development of septicemia are catheter-related factors, such as the size of the catheter, number of lumens, function and use of the catheter, catheter material, bacterial adherence, and thrombogenicity.

PREVENTIVE MEASURES

Because intravascular systems should be considered potential portals for infection, prevention programs support the use of 0.2-µm air-eliminating, bacterial-retentive filters. In addition, good handwashing techniques, line care protocols, and adherence to the INS Standards of Practice for monitoring, maintenance of infusion, tubing changes, and catheter care all contribute to an environment that does not readily support development of septicemia in patients receiving infusion therapies.

Pulmonary Embolism

Pulmonary embolism occurs when a substance, usually a blood clot, dislodges and floats freely, propelled by the venous circulation to the right side of the heart and into the pulmonary artery (Metheny, 2012). Emboli may obstruct the main pulmonary artery or the arteries to the lobes, occluding arterial apertures at major bifurcations. Obstruction of the main artery then results in circulatory and cardiac disturbances. Recurrent small emboli may eventually result in pulmonary hypertension and right heart failure (Metheny, 2012). See Chapter 14.

Precautions for preventing this serious complication include the following:

Filter infusions of blood or plasma through an adequate filter to remove any particulates that could promote small emboli formation.
Do not perform venipuncture in the veins of the lower extremities. These veins are particularly susceptible to trauma that predisposes the patient to thrombophlebitis. Although superficial veins rarely seem to
be the source of emboli (INS, 2011), a thrombus may extend into the deep veins, resulting in a potentially viable clot; superficial and deep veins unite freely in the lower extremities.
Avoid applying positive pressure to relieve clot formation.

Check for patency of the lumen of the catheter by kinking the infusion tubing approximately 8 inches from the catheter. Then, kink and release the tubing between the catheter and the pinched tubing. If the tubing becomes hard and meets with resistance, obstruction is evident. The catheter should be removed and the infusion reinstated.
Take special precautions with drug additives. Reconstituted drugs must be completely dissolved before being added to parenteral solutions because it is the inherent nature of red blood cells to adhere to particles, adding to the danger of clot formation.
Examine fluids to detect particulate matter.

Air Embolism

Although air embolism is a significant possible complication with air-dependent containers, it is more frequently associated with central venous lines. There is a potential risk for air embolism to result from the insertion of a CVC, inadequate sealing of the tract before disconnecting a CVC, disconnection of central lines, and bypassing the pump housing of an electronic volumetric pump with an IV piggyback connection. Smart pump technology has eliminated some of the potential for error.

Symptoms associated with air embolism arising from sudden vascular collapse include cyanosis, drop in blood pressure, weak, rapid pulse, rise in venous pressure, and loss of consciousness.

CONTRIBUTING FACTORS: GRAVITY INFUSIONS

If a vented container is allowed to run dry, air enters the tubing, and the fluid level drops to the proximity of the patient’s chest. The pressure exerted by the blood on the walls of the veins controls the level to which the air drops in the tubing. A negative pressure in the vein may allow air to enter the bloodstream. Negative pressure occurs when the extremity receiving the infusion is elevated above the heart (Metheny, 2012).

Infusions flowing through a CVC carry an even greater risk of air embolism as the container empties than when infusions flow through a peripheral vein. Because the central venous pressure is lower than the peripheral venous pressure, a negative pressure that could suck air into the circulation is more likely. The nurse needs to take precautions while changing the administration set of a central venous infusion.

Running solutions simultaneously is a key factor. One empty vented container becomes the source of air for the flowing solution. This happens because the atmospheric pressure is greater in the open tubing to the empty container than below the partially restricted clamp on the infusion side. Recurrent small air bubbles are constantly aspirated into the flowing solution and on into the venous system. The introduction of air may be prevented by running one solution at a time. Vigilance is imperative if vented solutions are prescribed to run simultaneously. The tubing must be clamped off completely before the solution container is allowed to empty.

This principle is also involved in the piggyback setup for secondary infusions. The potential danger of air embolism exists whenever solutions from two vented sets run simultaneously through a common catheter. Again, advanced technologies have minimized the use of piggyback setups.

All connections of an infusion set must be tight. Any faulty opening or defective hole in the set allows air to be emitted into the flowing solution. If a stopcock is used, the outlets not in use must be completely shut off.

The regulating clamp on the infusion set should be located no higher than the patient’s chest. Because the pressure exerted by the blood on the venous wall normally raises a column of water from 4 to 11 cm above the heart, a restricting clamp placed above this point results in a negative pressure in the tubing. If great enough, the pressure can suck air into the flowing solution should a loose connection or a faulty opening exist between the clamp and the catheter. The lower the clamp, the greater the chance of defects occurring above the clamp, where positive pressure can force the solution to leak out.

If the fluid container on a continuous infusion should empty, fresh fluid will force trapped air into the circulation and air embolus may result. Table 10-3 addresses the method to help ensure that air does not enter the patient’s system during administration.

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