How should I manage an infiltration of an intravenous iron infusion?

Management of IV Iron Infiltration

Stop the infusion immediately 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

• Discontinue the infusion immediately upon recognition of infiltration (pain, swelling, or discoloration at the site). 2, 1
• Switch to normal saline at KVO rate to maintain IV access. 1
• Do NOT apply manual pressure over the extravasated area, as this can worsen tissue damage. 2
• Leave the cannula in place initially and attempt to gently aspirate as much extravasated solution as possible; document the volume removed. 2
• Monitor vital signs (blood pressure, pulse, respiratory rate, oxygen saturation, temperature) until stable. 1
• Perform a physical assessment to determine if the infiltration is isolated or associated with systemic hypersensitivity symptoms. 1

Local Management of the Infiltration Site

• Apply dry cold compresses for 20 minutes, 3-4 times daily for 1-2 days to minimize tissue damage and pain. 2
• Avoid alcohol compresses. 2
• Elevate the affected limb to reduce swelling. 2
• Administer analgesia as necessary for pain control. 2

Skin Discoloration Management

• Yellow facial or skin discoloration (staining) can occur at the infiltration site and may persist for weeks to months but typically fades gradually without specific intervention. 2, 1
• This is caused by iron deposition in the tissue and is primarily a cosmetic concern rather than a medical emergency. 2

Assessment for Concurrent Hypersensitivity Reactions

Since infiltration may occur alongside infusion reactions, assess for systemic symptoms:

• For mild symptoms (isolated headache, myalgias, arthralgias): NSAIDs are first-line treatment. 3, 1
• For moderate reactions (flushing, urticaria, chest tightness with stable vital signs): Consider hydrocortisone 100-500 mg IV, famotidine 20 mg IV, and second-generation antihistamines (loratadine 10 mg orally or cetirizine 10 mg IV/orally). 3, 1
• Avoid first-generation antihistamines (like diphenhydramine) and vasopressors, as they can convert minor reactions into hemodynamically significant events. 3, 1
• For severe reactions (hypotension, angioedema, respiratory stridor, bronchospasm): Administer epinephrine 0.3 mg IM immediately and call emergency services. 3, 1

Documentation and Follow-up

• Document the event thoroughly in the patient's medical record, including the medication infiltrated, estimated volume, location, and clinical findings. 1
• Rest the access site for at least one treatment before attempting to use it again. 2
• If the same vein must be used again, cannulate above the site of infiltration, never below it. 2

Prevention Strategies for Future Infusions

• Ensure proper IV line placement and secure the catheter to prevent extravasation—this is the primary prevention strategy. 2, 1
• Use slower infusion rates, as faster rates are associated with higher risk of both infiltration and infusion reactions. 2, 1
• Assess carefully for signs of infiltration (pain, swelling, discoloration) throughout the infusion. 2
• Monitor closely during the first 10 minutes of infusion when immediate reactions are most likely. 2
• Consider alternative iron formulations if infiltration or reactions recur with a specific product. 1

Key Pitfalls to Avoid

• Do not apply pressure before removing the needle/catheter, as this can force more medication into the tissues. 2
• Do not use corticosteroids for local injection into the infiltrated area, as retrospective data suggests this may increase the need for surgical debridement. 2
• Do not attempt to use the infiltrated site immediately; allow adequate healing time. 2
• Most infusion reactions are complement activation-related pseudo-allergy (CARPA), not true IgE-mediated hypersensitivity, so avoid aggressive treatment with antihistamines or vasopressors for self-limited reactions. 2, 1