What is the appropriate workup for a small bump on the forearm following IV (Intravenous) placement?

Workup for Small Bump on Forearm After IV Placement

The appropriate workup for a small bump on the forearm following IV placement should begin with assessment for signs of thrombophlebitis, infiltration, or infection, as these represent the most common complications requiring intervention.

Initial Assessment

Visual Inspection

• Examine the bump for:
  • Size and extent of swelling
  • Redness or erythema
  • Skin discoloration (pallor, blanching)
  • Visible track marks along the vein
  • Skin necrosis or breakdown

Physical Examination

• Palpate the area to assess:
  • Temperature (warmth may indicate inflammation)
  • Tenderness or pain
  • Induration (hardening of tissue)
  • Pulsatility (to rule out inadvertent arterial cannulation)
  • Extent of swelling beyond the immediate IV site

Differential Diagnosis

Common Causes

1. Infiltration: Fluid leakage into surrounding tissue

   • Usually presents as non-tender swelling
   • May cause skin pallor or blanching
   • Common in older patients and women 1

2. Thrombophlebitis: Inflammation of vein with clot formation

   • Presents as tender, warm, erythematous area along vein tract
   • May feel firm or cord-like on palpation
   • Accounts for approximately 41% of minor IV complications 1

3. Cellulitis: Bacterial infection of skin and subcutaneous tissue

   • Presents with erythema, warmth, tenderness
   • May have poorly defined borders
   • Accounts for approximately 13% of minor IV complications 1

4. Hematoma: Collection of blood in tissues

   • More common in patients on anticoagulants 1
   • Usually resolves spontaneously

Less Common but Serious Causes

1. Septic thrombophlebitis: Infected thrombus

   • Presents with fever, severe pain, purulent drainage
   • Requires urgent intervention

2. Inadvertent arterial cannulation: Accidental placement in artery

   • May present with pulsatile flow or bright red blood
   • Can lead to ischemia and tissue necrosis if medications administered 2

Laboratory and Imaging Studies

When to Consider Further Testing

• For persistent symptoms (>48 hours)
• For signs of infection (fever, increasing erythema, purulence)
• For significant pain or functional limitation

Appropriate Tests

• Complete blood count: If infection suspected
• Blood cultures: If systemic infection or septic thrombophlebitis suspected
• Ultrasound: To evaluate for deep vein thrombosis or extensive thrombophlebitis
• Doppler studies: If arterial injury suspected

Management Based on Findings

For Minor Infiltration or Thrombophlebitis

• Elevation of the affected limb
• Warm compresses to improve circulation and reduce inflammation
• Monitoring for resolution

For Moderate to Severe Cases

• Topical treatments: Heparinoid or diclofenac gels may help reduce pain 3
• Oral NSAIDs: May reduce inflammation and symptoms 3
• Antibiotics: Only if clear evidence of infection

When to Consider Specialist Referral

• Signs of compartment syndrome (severe pain, pallor, paresthesia, pulselessness)
• Evidence of tissue necrosis
• Persistent symptoms despite conservative management
• Suspected arterial injury

Prevention of Future Complications

• Select IV sites free from veins, lesions, heavy hair, bruises, scars, and muscle ridges 4
• Clean site with antiseptic swab using circular motion from center outward 4
• Position the extremity properly during insertion 4
• Consider clinically-indicated IV replacement rather than routine replacement 5
• Regular monitoring of IV sites for early signs of complications

Special Considerations

• Older patients (>50 years) and women are at higher risk for IV complications 1
• Patients receiving chemotherapeutic agents are at increased risk for tissue damage
• Long-term IV drug users may develop chronic lymphatic obstruction leading to "puffy hand syndrome" 6

Remember that most small bumps following IV placement represent minor complications that resolve with conservative management, but careful assessment is necessary to identify potentially serious complications requiring intervention.