IV infiltrate: Lessons Learned

[NeoRN11]

A little background: I've been a nurse for over 20 years. My specialties have included Pediatrics and Mother/Baby. In February, I switched to NICU. I took an 8 week orientation course and had 12 weeks orientation on the unit, and I've been independently taking care of four Level 2 babies per shift for about 6 weeks (our unit routinely gives us 4 level 2 babies, which I know is unusual compared to most facilities).

Two nights ago, I was supposed to have my four babies back from the night before but at the last moment (literally 10 minutes before my shift, after I had looked up all my orders), my assignment was changed. Instead of 4 grower-feeders, I was given one of my grower-feeders back, one baby on HFNC and one baby on continuous TPN via PIV.

This was the first time I independently took care of a baby on a HFNC as well as the first time I had a baby with a continuous IV and TPN, so I was nervous but doing everything I could to be extra vigilant because the HFNC baby kept pulling out her OG tube and I was terrified she would aspirate on her gavage feeds, and the TPN baby was 4200 grams, a really hard stick, and on Q 3 hour accuchecks. She was PO feeding 10mls Q 3 hrs and her TPN was running at 16ml/hr, which I understand is quite a high rate. At 0415, I noticed the IV site in her thigh was starting to leak. I stopped the infusion, pulled the IV, and another 2 nurses helped me get a new IV into her AC. At 0515 we restarted her TPN and at 0530 and 0630, her IV site looked good and was infusing well.

Change of shift 0720, me and the oncoming nurse opened the blanket and her already fat arm was noticeably swollen and firm. We stopped the infusion immediately and pulled the IV. To say I felt terrible is an understatement; I was unsuccessfully trying not to cry as I finished my charting. My ex-preceptor, bless her heart, saw that I was upset and pulled me aside. She was almost more upset for me than I was. She felt I wasn't given a safe assignment based on my clinical experience, so we went to the manager. The manager was very kind and understanding, even told me of her own experience with a bad infiltrate early in her NICU career... so I know it happens. But damn, I still feel incompetent and wonder if there is anything I could have done to prevent it. The baby is fine now; elevating the extremity was the only intervention needed.

Lessons learned:

Don't just look at/palpate the IV site, observe the area around the IV including the dorsal/dependent side, basically the entire extremity! Compare both extremities.

Don't rely on the pump! It may not alarm even with the increasing pressure!

Always manually prime the tubing, then use the pump prime feature before infusing. (I learned this after doing some internet sleuthing on syringe pumps.)

Finally: check those PIVs more than once per hour if at all possible. It only takes a few minutes and could prevent a bad outcome.

Looking back, I wonder if I should have questioned the TPN order (knowing she was a hard stick and we lost the site on her thigh that took 3 nurses an hour and a half to find) or asked the Neo if we could increase her feeds and decrease the TPN rate...

If anyone else with more experience can offer additional advice, I would be so grateful!! Thank you!

[meanmaryjean, DNP, RN]

You cannot prevent infiltrates. They happen. The only thing you can prevent is them progressing for very long. On a fat baby- it's super hard to see at times.

Don't beat yourself up over this- it happens. You learned something. And your manager sounds AMAZING!

[NICU Guy, BSN, RN]

We only run TPN through a peripheral IV if they are only going to be on TPN for a day or two. If they are going to be on TPN for longer, we put in a PICC line.

[PeakRN]

We only run TPN through a peripheral IV if they are only going to be on TPN for a day or two. If they are going to be on TPN for longer, we put in a PICC line.

Same story, we don't give TPN through a peripheral, we will only give up to D10. At a minimum we need a low line to give TPN/D12.5/Lipids.

[babyNP., APRN]

you'll learn from this, as others have said, it happens. I don't know how to explain this but you'll also get a feel for those pIVs that you don't trust and check more often. But then again...I had an IV blew that occurred within 15 minutes. Can you imagine if another 45 minutes had gone by? Not saying this to scare you but just be vigilant. I often had the extremity with the IV unwrapped out of the swaddle and then placed a blanket over the extremity (so it wouldn't get cold) to have easy access to check them.

[creynolds28]

It's normal to feel bad in situations like this, but I sincerely hope you've let yourself off the hook for this one! You did what any prudent nurse would do. Baby is fine. You learned how quickly IVs can go bad. We've all been there. Continue being the great nurse you are!

[jennylee321]

Agree with what the others above said. Infiltrations happen and all we can do is learn from them and be vigilant going forward. Here is my advice from what I've learned over the years.

1. Never trust a crying baby with a PIV, always ensure that the IV isn't why they are crying for

2. Infiltrated IVs can be much harder to detect in chubby babies. Don't just look, feel and compare the site to the other limb every hour

3. Like you said the pump won't always ring, but keep your pressure limits set low

4. Any baby with a PIV I want that limb completely viewable so I can eyeball it when I'm doing other things/in and out of the bed space between my hourly checks

Hope that's helpful, but always remember that IVs infiltrate very frequently in our population because we are often desperately trying to keep them in until there gone, and they don't last forever. It somehow feels worse when it happens at shift change, you don't want the other nurse to think you'd just left it and not checked. It's just bad luck. It also sucks because you are leaving so you just remember the swollen arm when you leave. Whereas if it had happened at the beginning of your shift, you would have seen it go down and felt less bad. Side note, I think the assignment you were given sounds appropriate.

[Seriously?!, ADN, LPN, RN]

I've been a NICU nurse for about 18 months now, and I just had my first bad iv infiltrate last week. It was a preemie with iugr, 960g. I felt sooooo awful because she was my only patient- she was counting on me and I let her down. I was checking it every hour, but I made the mistake of only checking the insertion site and the area immediately surrounding it. I should've untaped the arm board and I would've seen it sooner. Now I know to do that and also always think about where the catheter ends, that's where the infiltrate occurs, not the insertion site. I learned a very valuable lesson but I still haven't completely forgiven myself. It was tpn and lipids, I had to administer wydase. í ½í¸­

[preemiepoweredRN]

It sounds like you did the best that you could have done in this situation. The fact that you are able to reflect now is good thing and by doing so you will definitely be even more vigilant with all your IVs going forward. No matter what you do to prevent it and how vigilant you are, the IV will STILL go bad and you will feel bad each time. It happens to everyone. Those baby veins just don't hold up long especially with high IV rates. I've had IVs infiltrate within an hour, even after flushing it in every position the baby could move and protecting the site with tape/cotton balls/armboards/other deterrants. It's inevitable. I think the one thing I would have done ( which you mentioned) is advocate to increase feeding volumes to try and decrease IV rate/discontinue to the IV sooner; however with IDM babies this plan often back fires. The baby may not tolerate increased feeding volumes, blood sugars won't stay up. Also, depending on the concentration of glucose in the TPN, it may be a slower process to wean, so then the discussion switches back to placing the PICC ( which is great, but those come with their own risk as well). Just remember : You grow through what you go through! Good luck to you!

[NeoRN11]

"I've been a NICU nurse for about 18 months now, and I just had my first bad iv infiltrate last week. It was a preemie with iugr, 960g. I felt sooooo awful because she was my only patient- she was counting on me and I let her down. I was checking it every hour, but I made the mistake of only checking the insertion site and the area immediately surrounding it. I should've untaped the arm board and I would've seen it sooner. Now I know to do that and also always think about where the catheter ends, that's where the infiltrate occurs, not the insertion site. I learned a very valuable lesson but I still haven't completely forgiven myself. It was tpn and lipids, I had to administer wydase."

SeriouslyRN,

I'm so sorry that happened to you. Thank you for including the lessons you learned through your experience... like thinking about where the catheter ends - makes sense. The take-away is that we can learn from this and from others who have experienced it, then pass those lessons on to new nurses coming into the NICU. :)

[NeoRN11]

PreemiepoweredRN,

Thanks for taking the time to reply and share your experiences. "You grow through what you go through" - I like that!

[MamaBear15]

You are going to be a fabulous NICU nurse! Chubby babies are so hard and at such a high rate, it was bound to happen quickly. It sounds like you have great management behind you, and that you have learned from the mishap. I agree with above posters, never swaddle and IV limb. In my experience, it increases chances that the IV will go out sooner and like you said, you cannot visualize it well. You will get so good, that you will be able to quickly glance at an IV and know its out. But continue to feel and assess like never before. You've got this!