Patient Self-Assessment Tool · Bedside Triage

Infiltration vs. Extravasation Symptom Checker & Action Guide

An interactive clinical decision guide comparing localized site swelling, tactile skin temperature, sensations of burning, and medication types to determine whether an IV site complication requires immediate emergency antidote intervention.

Clinical Peer Review: Sarah Jenkins, MSN, RN, CRNI, VA-BC Published: October 2026 Verified Board Member →

1. Infiltration vs. Extravasation: Key Physical Differences

When fluid leaks out of a vein into surrounding arm or chest tissue, doctors and nurses classify it into two distinct categories based on the medication involved:

Physical Sensory Comparison:

  • Infiltration (Non-Vesicant Solutions): Occurs with non-irritating fluids (like normal saline, antibiotics, or potassium at normal concentrations). The skin typically feels puffy, tight, and COOL to the touch (like an ice pack). Pain is usually mild aching or feeling full. While uncomfortable, it does not cause chemical ulceration.
  • Extravasation (Vesicant Medications): Occurs with hazardous drugs (such as chemotherapy, calcium chloride, or high-strength vasopressors). The sensation is often described as intense stinging, burning like fire, or throbbing pain. Even small leakages can cause severe tissue necrosis, skin blistering, and permanent muscle damage if not treated with specific reversal antidotes within minutes!

Interactive Bedside Symptom Evaluation Tool

Select the observed symptoms below to evaluate infiltration versus extravasation severity in real time:

Normal / Minimal Infiltration (Grade 0)

Grade 0 · Routine

No acute extravasation or significant infiltration observed. Continue routine monitoring per unit protocol every 1 to 2 hours.

Bedside Action: Inspect insertion site, confirm brisk blood return, verify gravity drip or pump pressure baseline.
INS Infiltration & Extravasation Staging Continuum Bedside clinical decision algorithm detailing the 5-stage Infusion Nurses Society grading scale from Grade 0 normal through Grade 4 vesicant extravasation with edema dimensions, tissue assessment criteria, and emergency response actions. BEDSIDE TRIAGE ALGORITHM · INS STANDARD 44 COMPLIANCE Infiltration & Extravasation Staging Continuum Progressive clinical criteria: gross edema radius, capillary perfusion, sensory symptoms, and mandatory actions 0 ROUTINE Grade 0: Intact Catheter Site · Zero Complications Edema: 0 cm | Skin: Pink, warm, soft | Pain: 0/10 | Capillary Refill: < 2 sec | Blood Return: Brisk ACTION Continue Monitor q1-2h 1 MILD Grade 1: Localized Mild Infiltration Edema: < 2.5 cm (<1 in) | Skin: Blanched, cool to touch | Pain: Mild or absent (0-2/10) | Refill: Normal ACTION Discontinue & Elevate 2 MODERATE Grade 2: Moderate Infiltration / Acute Discomfort Edema: 2.5 to 15 cm (1–6 in) | Skin: Cool, marked pallor | Pain: Moderate stinging/aching | Refill: 2-3 sec ACTION Remove PIV, Mark Border 3 SEVERE Grade 3: Gross Deep Tissue Infiltration / Neurovascular Risk Edema: > 15 cm (>6 in) | Skin: Translucent, tight | Pain: Severe (6-8/10), numbness | Refill: > 3 sec delay ACTION Notify MD, Check Pressure 4 VESICANT Grade 4: Emergency Vesicant Extravasation / Impending Necrosis Criteria: ANY vesicant leakage, skin breakdown, discoloration, blister/leakage, severe burning (9-10/10) Pathology: Cellular apoptosis, ischemic compartment pressure, permanent tendon/nerve trauma CODE VESICANT Aspirate + Antidote CRITICAL CLINICAL OVERRIDE: Any extravasation of a vesicant, blood product, or concentrated irritant is automatically classified Grade 4 regardless of edema size.
Source: Infusion Nurses Society (INS) Infusion Therapy Standards of Practice, Standard 44: Infiltration and Extravasation. Bedside Decision Matrix

2. Bedside Staging Matrix & Patient Action Steps

TABLE 1: BEDSIDE SYMPTOM CHECKER & ACTION DIRECTIVES
INS Standard 44 Adaptation · Patient Action Rules
What You Feel & See Likely Staging Immediate Patient Action
Puffiness less than 1 inch (size of a quarter); skin feels cool; no severe pain. Grade 1 Infiltration (Mild) Press call bell. Tell your nurse your IV feels full or puffy. The nurse will stop the infusion, remove the small cannula, and elevate your arm.
Swelling 1 to 6 inches along arm; skin pale and cold; noticeable ache or tightness. Grade 2 Infiltration (Moderate) Call nurse immediately. Infusion will be halted. Elevate arm on two pillows above heart level.
Swelling extending past 6 inches; skin feels hard, stretched like a drum; numbness in fingers. Grade 3 Infiltration (Severe) Urgent call bell. Nurse will check pulse in wrist and notify physician to evaluate compartment pressure.
ANY burning like fire, stinging, blistering, dark skin color change, OR leakage of chemotherapy / calcium. Grade 4 Emergency Extravasation HIT CALL BELL IMMEDIATELY AND TELL THE NURSE TO STOP THE PUMP! Do not pull the needle out yourself—the nurse needs to aspirate the drug out and give an antidote through the tube first!

Evidence Base & Literature Citations

  1. Infusion Nurses Society. Infusion Therapy Standards of Practice, Standard 44: Infiltration and Extravasation. J Infus Nurs. 2024;47(1S):S1-S228.
Clinical Practice Boundary Notice

This protocol provides evidence-based guidance reflecting INS 2024 Standards of Practice and CDC recommendations. Clinical judgment, institutional policy, and patient-specific variables must guide individualized bedside care.