What is the management for intravenous (IV) iron infiltration?

Management of IV Iron Infiltration

Immediately stop the infusion and switch the IV line to normal saline at keep-vein-open (KVO) rate to maintain access while preventing further tissue damage. 1

Immediate Actions

When IV iron infiltration is suspected or confirmed, take these steps in sequence:

• Stop the infusion immediately and switch to normal saline at KVO rate 1
• Monitor vital signs including blood pressure, pulse, respiratory rate, oxygen saturation, and temperature until stable 1
• Perform a physical assessment to determine if the infiltration is isolated or associated with systemic symptoms (flushing, urticaria, chest tightness, back pain, headache) that might indicate a concurrent hypersensitivity reaction 1
• Document the event in the patient's medical record, including the medication infiltrated, estimated volume, location, and clinical findings 2

Clinical Evaluation

Assess the infiltration site for:

• Extent of tissue involvement: swelling, discoloration, pain, skin temperature changes 3
• Signs of tissue damage: necrosis, eschar formation, ulceration, or full-thickness wound formation (though these are uncommon, occurring in only 3.2% and 1.9% of infiltrations respectively) 3
• Vascular compromise: though compartment syndrome has not been reported with IV infiltrations in large case series 3
• Associated symptoms: yellow facial discoloration may occur and can persist for weeks to months but typically fades gradually 2

Conservative Management

Most IV iron infiltrations can be managed conservatively without specialist consultation:

• Elevate the affected extremity to reduce swelling 3, 4
• Apply warm or cold compresses based on institutional protocol, though evidence for heat/cold therapy remains controversial 4
• Monitor for complications including superficial soft tissue infection (8.6% of cases), necrosis (3.2%), or ulceration (1.9%) 3
• Reassure the patient that most infiltrations resolve without long-term functional deficits—only 5.1% result in any long-term defects, and none cause functional impairment of the extremity 3

When to Consult a Specialist

Specialist consultation (plastic surgery or orthopedics) is needed in only about 25% of infiltration cases and is rarely emergent:

• Significant tissue necrosis or full-thickness wounds developing over days to weeks 3
• Progressive symptoms despite conservative management 3
• Large volume infiltration with extensive tissue involvement 5

Note that in a large retrospective review, no infiltrations required emergent surgical intervention, only 1.4% required bedside procedures, and 1.4% underwent non-acute operations 3

Concurrent Hypersensitivity Reaction Management

If the infiltration occurs alongside systemic symptoms suggesting a hypersensitivity reaction:

• For mild symptoms (isolated headache, myalgias): NSAIDs are first-line treatment 1
• For moderate reactions (multiple symptoms): Consider hydrocortisone 100-500 mg IV, famotidine 20 mg IV, and second-generation antihistamines (loratadine 10 mg orally or cetirizine 10 mg IV/orally) 1
• Avoid first-generation antihistamines (diphenhydramine) and vasopressors, as these can convert minor reactions into hemodynamically significant events 1, 6
• For severe reactions (hypotension, angioedema, respiratory compromise): Administer epinephrine 0.3 mg IM and call emergency services 1

Prevention for Future Infusions

• Ensure proper IV line placement and secure catheter to prevent extravasation 2
• Use slower infusion rates, as faster rates increase reaction risk 1, 2
• Consider alternative iron formulations if infiltration or reactions recur 2
• Educate patients to report pain, burning, or swelling at the IV site immediately 4

Key Pitfalls to Avoid

• Do not aggressively treat self-limited infusion reactions with antihistamines or vasopressors, as most reactions are complement activation-related pseudo-allergy (CARPA), not true IgE-mediated hypersensitivity 7, 6
• Do not assume surgical emergency—most infiltrations resolve with conservative management and primary team monitoring 3
• Do not overlook proper IV technique—the European Society of Cardiology emphasizes that proper line placement is the primary prevention strategy 2