Dear Nurse Beth
I missed an infiltrated IV and it turned into a Grade IV infiltration. It was on a child in his foot. I feel horrible. It was heavily taped and all I could see was a small area at the insertion site and his toes. And this was on a night shift. How long would it take to get that bad?
Dear Grade IV pediatric infiltration,
I'm so sorry, and I'm sure anyone reading reading can relate: "There but for the grace of God go I" because we all make mistakes. Another’s mistake can feel like a close call for all of us. I know it's one you will never make again.
Infants and young children are vulnerable to infiltration and extravasation due to small and fragile veins. Stabilization of veins is much more difficult in pediatric patients and there can be a tendency to visually occlude the site, which is what happened in your case.
It’s recommended to use clear tape, and arm boards where applicable. Regularly assess for patency by ease of flushing and aspiration of blood.
Depending on the rate of the infusion and resulting tissue infiltration, yes, it can happen quickly and easily within a single shift. Noticeable swelling in an infant or child requires far less fluid than in an adult. It’s also entirely possible that the early signs of infiltration were missed on the previous shift.
It's important to use a pediatric assessment tool. One such tool, reviewed by the Infusion Nurses Society (INS) uses a pediatric infiltration scale from 0-4:
0 no infiltration
1 localized swelling, flushes with difficulty, pain at site
2 slight swelling, redness, pain at site
3 moderate swelling, skin cool to touch, blanching, diminished distal pulse
4 severe swelling, skin cool to touch, blanching, skin breakdown/necrosis, blistering, diminished or absent pulse, pain at site, capillary refill > 4 seconds
A Grade IV infiltration will require an incident report, physician notification, and possible treatment. Some reasons that can result in missed signs include:
- The infusion pump (pressure sensors) did not alarm
- Swelling and coolness of distal toes missed (compare to other foot)
- Restlessness or signs of discomfort
- Change in (tissue) color not recognizable due to poor lighting at night
- Abbreviated assessment due to child sleeping
Forgive yourself with lesson learned and move forward,
Author, "Your Last Nursing Class: How to Land Your First Nursing Job"...and your next!