What should be done for an adult patient with no known underlying health conditions who develops redness and a hard lump in the arm after an intravenous (IV) infusion?

Management of Redness and Hard Lump After IV Infusion

Stop any ongoing infusion immediately, assess for signs of extravasation versus phlebitis, and initiate conservative management with elevation, warm or cool compresses, and close monitoring for progression to tissue necrosis. 1

Immediate Assessment and Initial Actions

Determine if this represents extravasation (drug leakage into surrounding tissue) versus phlebitis/thrombophlebitis:

• Stop the infusion immediately and maintain IV access if still in place to allow aspiration of any remaining drug from the catheter 1, 2
• Do not apply pressure to the surrounding area, as this can spread the extravasated solution further into tissues 1
• Assess the ABCs (Airway, Breathing, Circulation) to rule out systemic hypersensitivity reaction, though localized symptoms without systemic signs suggest a local reaction rather than anaphylaxis 1, 2
• Document the specific characteristics: size of induration, degree of erythema, presence of pain, warmth, and any skin changes such as blistering 1

Distinguish Between Extravasation and Phlebitis

Key clinical features to differentiate:

• Extravasation presents with immediate swelling at the IV site, blanching of skin, coolness, and severe pain that is out of proportion to clinical findings 1
• Phlebitis/thrombophlebitis presents with erythema along the vein tract, warmth, tenderness, and a palpable cord (hard lump) representing the inflamed vein 3
• Timing matters: symptoms appearing during or immediately after infusion suggest extravasation, while symptoms developing hours to days later suggest phlebitis 3, 4

Conservative Management for Phlebitis (Most Likely Diagnosis)

For localized redness and hard lump without signs of extravasation or systemic reaction:

• Elevate the affected extremity above heart level to reduce swelling and promote venous drainage 1
• Apply warm compresses for 15-20 minutes several times daily to promote blood flow and reduce inflammation (warm compresses are preferred for phlebitis) 3
• Administer oral NSAIDs (ibuprofen 400-600 mg every 6-8 hours or naproxen 500 mg twice daily) for pain and inflammation control 1
• Avoid using the affected vein for future infusions 3

Management if Extravasation is Suspected

If clinical features suggest drug leakage into tissue:

• Attempt to aspirate as much extravasated solution as possible through the existing catheter before removal 1
• Apply cold compresses (not warm) for vesicant drug extravasation to limit drug spread, except for vinca alkaloids which require warm compresses 1
• Consider specific antidotes if the extravasated agent was an anthracycline (doxorubicin, daunorubicin): dexrazoxane should be administered within 6 hours at 1000 mg/m² IV on day 1,1000 mg/m² on day 2, and 500 mg/m² on day 3 1
• Photograph the site for documentation and comparison during follow-up 1

Monitoring and Follow-Up

Close surveillance is essential as initial symptoms can be subtle:

• Daily assessment for the first week to monitor for progression, as inflammation typically increases over the first few days with more redness, edema, and pain 1
• Weekly follow-up thereafter until complete resolution of symptoms 1
• Watch for warning signs of tissue necrosis: increasing pain, skin discoloration progressing to purple or black, blister formation, or development of ulceration 1
• Refer to plastic surgery if blistering, skin breakdown, or necrosis develops, as surgical debridement may be necessary 1

When to Escalate Care

Seek immediate medical evaluation if:

• Systemic symptoms develop: fever, chills, hypotension, tachycardia, dyspnea, or chest pain, which could indicate delayed hypersensitivity reaction or infection 1, 2
• Progressive worsening despite conservative management over 48-72 hours 1
• Signs of compartment syndrome: severe pain, paresthesias, pallor, or pulselessness in the affected extremity 1
• Skin breakdown or necrosis appears 1

Common Pitfalls to Avoid

• Do not apply heat to suspected extravasation of vesicant chemotherapy agents (except vinca alkaloids), as this increases tissue damage 1
• Do not massage or apply pressure to the affected area, as this spreads the extravasated drug or worsens inflammation 1
• Do not dismiss subtle early symptoms, as extravasation signs can be initially mild but progress to severe tissue damage over days to weeks 1
• Do not delay surgical consultation if tissue necrosis develops, as early debridement improves outcomes 1

Patient Education

Inform the patient about:

• Expected timeline: phlebitis typically improves within 7-10 days with conservative management 3
• Warning signs requiring immediate return: increasing pain, fever, spreading redness, skin discoloration, or blister formation 1
• Delayed reactions can occur hours to days after infusion, particularly flu-like symptoms, arthralgias, myalgias, and fever which are self-limited and managed with NSAIDs 1