IVs on baby-Am I too sensitive?

KelRN215, BSN, RN · Apr 25, 2012

My question is shouldn't we have given the baby a break to rehydrate? She could take in fluids just fine- (she had RSV so she could take in fluids it was just difficult because of her congestion). I think a break after being restrained is protocol right?? We were in there for about an hour and only took off the restraints for about 2 minutes total.

No. There was a reason this baby needed the IV. She couldn't keep herself hydrated so she needed IV hydration. Restraining an infant for a procedure is not the same as keeping adults or even older children restrained to the bed. And even so, those restraints are only released q 2hrs and for only enough time to perform passive ROM and check CSM. At least that's how we did it when I worked in the hospital. So 2 minutes in an hour is actually longer than your average restrained person would get out of restraints. But this is not a comparable situation.

You get used to holding down babies and young children for things (like IVs) that need to be done. I think the most people I've ever had holding down a child for such a procedure was 6. I did once have the entire night shift in a room to help me replace an NG tube on a teenager with autism. That said, an infant doesn't need to be strapped down to place an IV. You wrap them tight in a blanket and pull out the extremity you're placing the line in.

rn/writer, RN · Apr 25, 2012

I had to hold down my grandson with spina bifida in a PICU once. His mom had gone home to the other kids and I was staying overnight when his IV blew. He was a notoriously hard stick. The floor nurses couldn't get anything in. Even the CRNAs and the flight nurses were having a hard time.

Finally, with three of us holding him down, someone got a good IV going.

Yes, it was wrenching to watch him suffer. But he needed the IV and there was no two ways about it.

Now, the new protocol for him is to sedate him in pre-op and place a PICC line that will be the saving grace for all of us during his stay. But if there is no surgery, they give him Ativan beforehand, and they try to use foot veins where he doesn't have sensation (he also doesn't have great circulation, which is why they don't just use leg and foot veins all the time). The upshot is that he is mighty protective of his IVs and reminds other people, even staff, to steer clear of them.

It's great to minimize discomfort and fear whenever possible, but sometimes the serious medical needs outweigh the niceties. Rough IV starts on a baby or very young child are like a relaxing birth with low lights, soft voices and warm water vs. a loud and rigorous shoulder dystocia delivery or crash c-section. You do what you have to do and smooth the ruffled feathers after the danger has passed.

I hope you can find a way to tolerate your internal discomfort when it's necessary.

applewhitern, BSN, RN · Apr 25, 2012

I worked in Pediatric ICU for 6 years at a large teaching hospital. We never "strapped them down." We simply held the hand, foot, or whatever. After a little practise, I could hold a baby or toddler by myself and still insert a proper IV. Please remember that a baby can "go down" very quickly. They can look fine one minute, and be coding the next. IV sticks sure beats a dead baby. One thing about that particular PICU~ we never let the parents watch or be with us during any procedure, esp. an IV. You are a lot more nervous with parents watching. I did some PRN work at other hospitals where the parents were allowed to stay, and it was awful. A mother threw a fit because we shaved a head for a scalp vein.

wooh, BSN, RN · Apr 25, 2012

Think like NCLEX "what's the best answer" or Maslow's. Which is worse, rough IV start or dead?

Crying? Actually not a bad thing in RSV. Opens up those lungs, clears out the snot.

No tears? Get that IV in now or it's going to be an IO or it's going to be dead of hypovolemic shock.

I'm not a fan of this strapping down thing, as said abolve swaddling in a blanket with whichever limb out that you're trying to poke works better.

And sometimes it takes some digging. And if the kid is dehydrated, they need the tourniquet. You could start an IV on me without one. On old people it's sometimes preferred. But think how tiny the vein is that they're sticking. Tinier than usual as the kid is dehydrated. You need the extra plump of the tourniquet.

I'd have probably tried some sweetease and a paci, but a 6 month old? Probably not going to help much.

Likely I'd have probably tried an NG tube with some Pedialyte, see if the baby could tolerate it, if we were having trouble with getting the IV. But what was this, three tries? On a chubby dehydrated baby? That's not bad.

Peds requires a lot of doing what's not fun or comfortable or nice for the patient. We try to make it better, but stopping to give this baby a break? That just prolongs the suffering and could be the time difference that makes the difference between some IV fluids and having to start that IV during a code.

ETA: And an NG tube might not be a bad idea even with the IV. When they're stuffed up like that, they use almost as much energy trying to eat as they take in from the bottle/boob. I know studies are now showing that if a kid has to get a high flow nasal cannula with bronchiolitis that an NG tube shortens the time they require supplemental O2. I'm not sure if studies have focused on if it helps when they aren't needing O2, but I imagine it could be a good idea for some kids.

rn/writer, RN · Apr 25, 2012

Just a reminder that kids compensate and compensate until they can't. Then they crash. So even though this kid looked like he/she had plenty of fight left, that may not have been the case.

Also, giving a break can be just enough to allow the child to settle down--and then wind up even more when the fight resumes. Continuing until the job is done--however distasteful that may be--tires the child sooner and allows the necessary actions to be taken.

It would be nice if such a frightened, resistant child could be sedated, but that isn't always feasible or safe.

BelgianRN · Apr 25, 2012

Am I the only one that thinks it is unacceptable to remove the tourniquet like you did? If I was sticking the IV I'd probably have been upset by you for doing it, and probably you'd be upset after I spoke my mind. Even if you felt the others forgot it, why not simply mention it? I've seen many procedures fail because someone else assumed X was forgotten, when it turns out it wasn't but simply avoided or done in a different order.

Same thing applies for me. If someone is sticking a kid and I'm restraining, I won't interfere with the one doing the procedure unless asked for input. If I see something go wrong I might try to formulate a polite question about it, why add to the stress level by meddling. But you can't drive a car with two drivers, and you can't put an IV in with two nurses. One has to drive and one has to observe ^^.

ShantheRN, BSN, RN · Apr 25, 2012

Sticking a kid sucks....but you have to do what you have to do. When they're that small you don't have an option but to kinda be a bully, unfortunately. I had to reaccess a toddler's port the other night and I brought two nurses with me. One laid across her torso to hold her steady, the other kept an eye on flailing limbs. Poor thing screamed the whole time - who can blame her, I imagine getting a needle pushed into your chest isn't pleasant - but it had to be done. It's better to have screaming hydrated kids than quiet ones in hypovolemic shock.

I don't like the restraints though. Is that policy or the preference of your coworkers? There are easier ways to do it. For the smaller ones, we burrito with blankets like someone else mentioned. For older kids, using your body to keep them pinned is actually quite effective. We don't ever sedate for IVs. It would take too long. Same with giving breaks. It's better to just get it over with. From how you describe it, that's a typical scene for a hard stick on a 6 month old. After a while, you learn to block out the screaming and get the task accomplished. Once it's done, you can love on them and after a while they'll forgive you :)

mama_d, BSN, RN · Apr 25, 2012

I'm sorry, but I agree with the above...if it was me starting the line and you popped the tourniquet off, I'd be a little peeved. Maybe next time say something along the lines of, "I can pop that off for you if you're done with it."

When our youngest was 2 mo old, he ended up septic. I had no idea a fontanel could get so depressed...it was over an inch deep. I didn't care what they did to him, as long as they got that line in. As an example of how quickly babies can crash, he was fine and dandy when I got home from work that morning around 8 am; he fought getting swabs for flu & ESV like a demon child at 11 am; by 2 pm he was virtually unresponsive, limp, and his kidneys were shutting down.

I wasn't there, but I can say that sometimes you gotta do what you gotta do. Peeved off baby is better than crashing or dead baby. By all means, look into EBP and research on how to make it less traumatic, but as long as they don't have the mental capacity to process what's going on, all they can do is fight us tooth and nail when we're hurting them.

Good Morning, Gil · Apr 25, 2012

You're not over sensitive. This is exactly why I don't work in peds. I probably could handle the little kids because at least you can explain that this is to make you feel better, but babies just cry and cry, couldn't do it. That's why there's many different nursing areas. I'm glad that you made the extra effort to comfort the baby, and seasoned nurse or not, that should be done if multiple sticks were required (if not an emergency situation).

Best of luck to you!

MattNurse, MSN, RN · Apr 25, 2012

24 lbs sounds huge for a 6 month old!

jadelpn, LPN, EMT-B · Apr 25, 2012

Making sure the baby can't wiggle out of the way is, in my opinion, the key to being able to get a good IV on an infant. Parents can not usually hold their own child down and will often say "forget the IV" should it be a tough stick. That could be more dangerous than the IV insertion. I have also used blankets before, and bound the baby in them with an arm out. A third person to hold the arm steady is also an idea. It sucks, it is tough, but better red than dead. And if the baby was dehydrated (vomiting?) the LAST thing you want to add to this is more PO fluid to have the child apsirate it. A binky is a good idea, a little sugar water dipped is a good idea--but a full out have a bottle is not. Here's the good news--the baby was lively, and thrashing and crying....good signs, as the sickest infants I worry the most about are the ones who passively lay there and don't cry or turn red. Tourniquets are necessary, as you often can't "see" a vein on a 6 month old, unless they are really, really small babies, and even then, not always. (and at 24 pounds at 6 months, not so much). You need to feel for them, and the tourniquet helps to do that. The best thing you can do is to really get a feel for all sorts of veins. They should feel like an elastic band that has stretched and bouncy. Once you feel it, and practice feeling for it, the better you get to the point of knowing it when you feel it.

classicdame, MSN, EdD · Apr 25, 2012

Our pedi dept uses ultrasound guided IV insertion. Prevents multiple sticks and is a patient satisfier (keyword to use to justify cost). Also, I have found the vein in the forehead to be more accessible in 6 mo olds who are chunky but dehydrated. BTW, crying only dehydrates further. Talk to mgr about this and have some suggestions to offer.