What causes pain and redness in the arm after IV placement?

Pain and Redness After IV Line Placement

Pain and redness in the arm after IV placement most commonly indicates phlebitis (vein inflammation), which requires immediate cessation of the infusion, removal of the catheter, and application of ice with limb elevation. 1

Immediate Assessment and Management

Stop the infusion immediately when swelling, pain, or redness is observed to prevent progression of complications. 1 Leave the cannula in place initially only if aspiration of infiltrated fluid is needed, then remove it promptly. 1

First-Line Treatment Protocol

• Apply ice to the affected area for 10-15 minutes and elevate the limb while monitoring for symptom progression. 1
• Apply direct pressure if there is bleeding at the site, but avoid occluding the outflow distal to the site as this increases intraluminal pressure. 2
• Monitor vital signs including temperature, pulse, blood pressure, and respiratory rate every 4 hours to detect systemic complications. 3

Differential Diagnosis by Clinical Presentation

Phlebitis (Most Common)

Pain is the most common symptom (83% of cases), with erythema and edema the most common physical signs (63%). 4 Phlebitis can have mechanical, chemical, or bacterial causes and results in severe discomfort, treatment failure, and need for new IV access. 5

Infiltration/Extravasation

Infiltration occurs when the needle tip perforates the vein wall, causing swelling, bruising, and pain. 2 The size can vary from small diffuse areas to large firm masses that compress vessels and cause thrombosis. 2 Hematomas manifest with obvious discoloration and swelling. 6

Septic Phlebitis (Serious Complication)

80% of causative organisms are gram-positive bacteria, usually Staphylococcus aureus (41%) or Group A streptococcus (20%). 4 This presents with pain, erythema, edema, and systemic signs of infection (fever, chills). 3, 4

Inadvertent Intra-Arterial Cannulation (Life-Threatening)

Key warning signs include bright-red flash of blood in the cannula, pulsatile movement of blood in the IV line, and intense pain or burning at injection site. 7 This can lead to ischemia, gangrene, and limb loss if medications are injected intra-arterially. 7

Risk Factors and Predictors

Factors significantly associated with phlebitis include:

• Pain at the site (P < 0.001) 8
• Catheter presence for longer than 3 days (P < 0.05) 8
• Unclean dressing (P < 0.01) 8
• Women and patients over age 50 are more susceptible to complications 9
• Hand and wrist locations account for more than 50% of both minor and major complications 9

When to Escalate Care

Obtain Urgent Imaging

Order chest X-ray if the patient develops dyspnea or chest wall pain to rule out air embolism or other complications. 3

Perform urgent duplex ultrasound if unilateral arm swelling develops, as this indicates possible upper extremity deep vein thrombosis (UEDVT), which accounts for up to 10% of all DVTs. 6

Initiate Antibiotic Therapy

If septic phlebitis is suspected (persistent fever, systemic signs, or clinical deterioration after 24 hours), obtain cultures and start antibiotics. 4 Operative excision of the involved vein should be performed if septicemia persists despite 24 hours of conservative therapy. 4

Monitor for Compartment Syndrome

Major complications can include compartment syndrome, skin necrosis, compressive nerve lesions, and digital stiffness. 9 These require immediate surgical consultation. 9

Prevention Strategies

To minimize future complications:

• Select large veins in the forearm for peripheral administration, avoiding joints, inner wrist, lower extremities, or areas with poor venous access. 1
• Use flexible cannulae rather than winged steel "butterfly" needles. 1
• Check for blood return before administering medications and regularly throughout infusions. 1
• Rotate IV sites before 3 days to prevent phlebitis development. 8
• Ensure dressing cleanliness as this significantly impacts phlebitis rates. 8

Common Pitfalls to Avoid

Never apply pressure distal to an infiltration site as this increases intraluminal pressure and worsens the infiltration. 1

Do not dismiss unilateral swelling as benign—it indicates obstruction requiring urgent evaluation for UEDVT. 6

Be especially vigilant in patients over 50 years old, women, and those on anticoagulation, as they have higher complication rates. 9

Always consider inadvertent arterial cannulation when IV placement is in areas where arteries are in close proximity to veins (antecubital fossa, wrist), especially if there is intense pain or bright red pulsatile blood return. 7