What is the appropriate management if intravenous fluid is inadvertently infused into an artery rather than a vein?

Immediate Management of Inadvertent Intra-Arterial Fluid Infusion

If IV fluid is accidentally infused into an artery, immediately stop the infusion, leave the catheter in place, and urgently consult vascular surgery or interventional radiology before attempting removal—particularly for catheters 6Fr or larger, or any arterial catheter in the neck or chest. 1

Recognition and Initial Response

Identifying Arterial Cannulation

• Suspect arterial placement if you observe bright red pulsatile blood return, excessive bleeding along the guidewire, retrograde flow within the catheter/infusion set, or activation of high-pressure alarms on infusion pumps 1
• Attach manometer tubing to differentiate venous from arterial placement if uncertain 1
• Confirm with pressure transduction showing an arterial waveform (ensure settings are for arterial range) 1
• Ultrasound imaging can confirm guidewire position, and contrast injection or CT will definitively demonstrate arterial flow 1

Immediate Actions

• Stop all infusions immediately through the suspected arterial line 1
• Do not remove the catheter—leaving it in place may be preventing significant hemorrhage, as the catheter can be partially occluding the arterial defect 1
• Obtain urgent vascular surgery or interventional radiology consultation before any attempt at removal 1

Risk Stratification by Catheter Size and Location

Large Catheters (≥6Fr)

• Must be left in place and managed by vascular specialists 1
• Removal requires interventional radiology or vascular surgery expertise due to high risk of uncontrolled hemorrhage, pseudoaneurysm formation, or arteriovenous fistula 1

Small Catheters (<5Fr) - Femoral Location

• May be managed with removal followed by direct pressure for 10 minutes (or until hemostasis achieved), then 6 hours bed rest 1
• This approach mirrors standard practice after femoral artery catheterization for radiology procedures 1

Carotid or Neck Vessels

• Highest risk location due to potential for stroke and airway compromise from expanding hematoma 1
• Even 21G needle puncture can cause stroke, particularly with existing arterial disease 1
• Expanding neck hematoma may fatally compromise the airway and require emergency intubation and surgical intervention 1
• Always consult specialists before removal, regardless of catheter size 1

Anticoagulated Patients

• Mandatory specialist consultation before removing any arterial catheter, regardless of size or location 1
• Significantly increased risk of uncontrolled bleeding 1

Monitoring for Complications

Immediate Complications

• Hemorrhage: May be external or covert into pleural space, pericardium, peritoneum, or retroperitoneum (especially with femoral access) 1
• Hematoma formation: Monitor for expanding hematomas that may cause local pressure effects requiring surgical evacuation 1
• Hemodynamic compromise: Watch for signs of hypovolemic shock from occult bleeding 1

Delayed Complications

• Stroke risk: Particularly with carotid artery involvement, even from small needle punctures 1
• Arteriovenous fistula: Can develop if needle traverses both artery and vein 1
• Pseudoaneurysm formation: May develop at puncture site 1
• Thrombosis and distal ischemia: Monitor distal perfusion, pulses, and limb viability 2, 3

Definitive Management

Specialist-Guided Removal

• Interventional radiologists may use endovascular techniques for larger catheters 1
• Vascular surgeons may perform open repair if indicated 1
• Post-removal monitoring includes direct pressure, bed rest, and serial neurovascular examinations 1

Anticoagulation Considerations

• Routine anticoagulation is NOT recommended following short-term accidental arterial catheterization 1
• Decision should be individualized based on presence of thrombus, arterial injury pattern, and patient risk factors 1

Critical Pitfalls to Avoid

• Never remove large-bore arterial catheters (≥6Fr) without specialist consultation—this can precipitate life-threatening hemorrhage 1
• Never assume hemostasis is adequate based on external appearance alone—significant bleeding may be occult in tissue planes or body cavities 1
• Do not delay specialist consultation for neck vessel involvement—airway compromise can develop rapidly 1
• Avoid removal in anticoagulated patients without specialist guidance and reversal planning 1