How should I manage swelling and erythema at an intravenous (IV) site after an infusion?

Management of Swelling and Erythema at IV Site Post-Infusion

Stop any ongoing infusion immediately, assess for extravasation versus phlebitis, elevate the affected extremity, and apply cool compresses for most cases while monitoring closely for progression to tissue necrosis. 1

Immediate Assessment and Differential Diagnosis

First, determine whether you are dealing with extravasation (drug leakage into tissue) or phlebitis/thrombophlebitis (vein inflammation). 1

Key Distinguishing Features

Extravasation presents with:

• Immediate swelling at the IV site 1
• Blanching of skin 1
• Coolness to touch 1
• Severe pain that is out of proportion to clinical findings 1

Phlebitis presents with:

• Erythema along the vein tract 1
• Warmth at the site 1
• Tenderness and induration 1
• Hard lump or cord-like feeling along the vein 1

Critical Initial Actions

Assess the ABCs (Airway, Breathing, Circulation) immediately to rule out systemic hypersensitivity reaction, as swelling and erythema can be early signs of anaphylaxis. 1, 2

Document specific characteristics including size of induration, degree of erythema, presence of pain, warmth, and any skin changes such as blistering. 1

Do NOT apply pressure to the surrounding area, as this can spread extravasated solution further into tissues. 1

Management for Phlebitis (Most Common Scenario)

If the presentation is consistent with phlebitis (warmth, erythema, hard lump along vein without severe pain or blanching):

Conservative Management

Elevate the affected extremity above heart level to reduce swelling and promote venous drainage. 1

Administer oral NSAIDs for pain and inflammation control: ibuprofen 400-600 mg every 6-8 hours or naproxen 500 mg twice daily. 1

Apply warm compresses to the affected area to promote blood flow and reduce inflammation. 1

Common Pitfall to Avoid

Do NOT massage or apply pressure to the affected area, as this worsens inflammation and can spread any extravasated material. 1

Management if Extravasation is Suspected

If the presentation suggests extravasation (immediate swelling, blanching, coolness, severe pain):

Immediate Interventions

Attempt to aspirate as much extravasated solution as possible through the existing catheter before removal. 1

Apply cold compresses (NOT warm) for most vesicant drug extravasation to limit drug spread. 1

The critical exception: if vinca alkaloids were infused, apply warm compresses instead of cold. 1

Drug-Specific Antidotes

If the extravasated agent was an anthracycline (doxorubicin, daunorubicin), administer dexrazoxane within 6 hours: 1000 mg/m² IV on day 1,1000 mg/m² on day 2, and 500 mg/m² on day 3. 1

Monitoring and Follow-Up

Perform 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

Continue weekly follow-up thereafter until complete resolution of symptoms. 1

Warning Signs Requiring Immediate Escalation

Seek immediate medical evaluation if any of the following develop:

• Increasing pain despite treatment 1
• Skin discoloration progressing to purple or black 1
• Blister formation or development of ulceration 1
• Systemic symptoms such as fever, chills, hypotension, tachycardia, dyspnea, or chest pain 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

Special Considerations for Infusion Reactions

If the swelling and erythema developed during or immediately after a chemotherapy or monoclonal antibody infusion, consider this may represent an infusion reaction rather than local phlebitis:

For Grade 1-2 infusion reactions (mild to moderate), stop or slow the infusion rate and provide symptomatic treatment with antihistamines. 3, 2

For Grade 3-4 reactions (severe), stop the infusion completely, administer epinephrine 0.3-0.5 mg intramuscularly if anaphylaxis is suspected, and provide aggressive symptomatic treatment including corticosteroids. 3, 2

Patient Education

Inform the patient about the expected timeline for resolution (typically 7-14 days for phlebitis), warning signs requiring immediate return, and that delayed reactions can occur hours to days after infusion. 1

Advise the patient to avoid using the affected extremity for heavy lifting or strenuous activity until symptoms resolve. 1