Routine IV Insertion Leads to Permanent Nerve, Muscle, and Soft Tissue Damage

One of the most common procedures in hospitalized patients is peripheral intravenous cannulation- the insertion of an IV. We use IVs to administer medications, fluids, and contrast media for certain imaging and IVs are often left in place for the duration of the hospitalization. They are assessed regularly for patency, placement and signs of site irritation. IV insertion is a skill that takes practice and it is not uncommon to ask a more experienced colleague for help when a patient has limited potential access sites. The process for IV insertion begins with applying a tourniquet to dilate veins. Once a suitable vein is located, the tourniquet is released and the site is cleaned and supplies are prepared. The tourniquet may then be reapplied just prior to IV insertion. This method of double applications shortens the length of time that the tourniquet is in use to prevent cell injury.

I once worked with a nurse who was taking care of a vulnerable patient in need of a new IV. The patient had acute metabolic encephalitis and was unable to verbalize her needs or ask for help. My colleague was not confident she would be successful with an IV insertion and asked our clinical leader if he would take a look. Minutes go by and we see our clinical leader wave to us on his way out of the unit. “Twenty gauge in the right forearm,” he said. My colleague, grateful to have that task completed, began rounding on her other patients, performing assessments, and administering medications. When it was this patient’s turn, my colleague entered the room and began a physical assessment. The right hand was purple and cool to the touch. She quickly lifted the sleeve of the gown to reveal a bright orange tourniquet in place, restricting blood flow to the extremity. She quickly released the tourniquet and waited anxiously for signs of reperfusion: the skin color to lighten, the arm to warm up, the capillary refill to hasten. The patient was able to wiggle her fingers but was unable to reliably verbalize if she had intact sensation.

Why this is a problem: Two minutes is the recommended length of time that a tourniquet is in place during intravenous cannulation and longer lengths of time can result in tissue ischemia or necrosis (cell death). In this case, the tourniquet was in place much longer than the recommended two minute maximum and caused permanent injury to the patient. All of the cells distal to the tourniquet were deprived of adequate circulation, and therefore oxygen, which causes the cells to die. Muscles, nerves, blood vessels, and skin are all impacted. This could mean the patient never regains movement, strength or sensation in her arm. All of this because a trusted RN forgot to release the tourniquet after inserting an IV in a vulnerable patient without the ability to ask for help. The hospital is a scary place.