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IVs on baby-Am I too sensitive?

RN4kidz11 RN4kidz11 (New) New

I graduated 3 years ago. I am new to the peds floor. Yesterday we started an IV on a 6 month old baby who was slightly dehydrated and VERY chunky (24 pounds). I was comforting the baby while the IV team nurse and my trainer were attempting to start the IV. I am very traumatized but here is what happened:

Strap baby down on table across the chest and legs. Baby is wiggling a lot and rubbing herself red where the restraints are. She's screaming crying. They tie the tourniquet and baby screams and cries even more. Arm turns red and face turns red, no tears bc baby is dehydrated. IV is inserted and baby gasps for air and screams harder and keeps turning her face. There is no blood return so the nurse wiggles cath around. This goes on for about 15 secs-I removed the tourniquet bc they forgot to. They decide the IV is useless and they take it out. This took about 3-4 mins. They find another site and attempt again. this time they mess with the IV for about 4-5 mins bc it has a kink in it but it is in the vein. Baby is reacting the same way and I'm getting worried bc she has been crying like this for about 10 mins, rubbing herself raw against the restraint and she is continuously red from crying. They finally decide to take the IV out. I take the restraint off and sit the baby up and try to comfort her. They joked that they are cold hearted and they can tell I'm new. They want to attempt her legs now. So we lay her back and begin again. This goes on for about 20 more mins. They need more supplies so I leave. I asked if I should get a paci and they said it wouldn't help. I got one anyways. I come back and had some water so I could keep dipping the paci in it bc I noticed the baby's lips were now chapped and her mouth had no moisture. The baby keeps falling in and out of sleep these last few times which lasted about 15 minutes. The baby only had two very very small breaks (about 1 minute each), we were in there for 45mins to an hour, the baby had nothing to drink except what I was offering from dipping water on the paci. I am so upset about this. This was over 24 hours and I am so sad. I am going to the mgr and asking about a different process for insertion of IVs on babies. I'm new to the unit and hospital and I don't want to overstep but I feel this could have been done a better way.

What do you think?

there have been studies on pain in newborns given glucose or a sweetened pacifier, but i don't know if they extend to a 6-month-old. maybe you can find out.

a certain amount of cold-bloodedness is necessary to be able to do a life-saving procedure on a baby, but i think it might have been better to give the kid a little sedation or a bottle of glucose water to suck on. not a peds nurse ... but i would kill any smartass staff who did this to my baby.

IVs hurt, but if the baby was not having tears it sounds like it was essential to get the line (also the falling in and out of sleep sounds like the baby was getting a little lethargic??), and to get it as quickly as possible. With a dehydrated, chubby baby, I can see how getting a line in could be very challenging even for skilled nurses and techs. I'm wondering why you removed the tourniquet before they got their flash that first time- it sounds like they were't in the vein yet. Were you helping to hold the baby in addition to the restraints? Why were you giving a dehydrated baby water and not pedialyte on the paci (or better yet sweet-ease)? Did your team try warm packs or warm wet diapers on the potential IV sites to help dilate the veins? Sometimes you can use a light to help illuminate veins- an otoscope can work if you don't have the fancy vein light thingies.

It can be upsetting to see babies ad kids cry during procedures, but often they cry as much if not more about being restrained than the actual pain of the procedure. Giving the baby breaks in between attempts is a nice idea, but it sounds like this patient was more than "slightly" dehydrated and needed that IV.

Thank you for the feedback. To answer your questions-in nursing school I was taught that a tourniquet really isn't necessary unless you absolutely need it and it is painful. I personally think a tourniquet is worse than the IV on me so I took off the tourniquet after they got in, perhaps I shouldn't have. Pedialyte is stored at the opposite end of the unit and when I was sent to get supplies I had to hurry so the room we were in had water and that's what I used to moisten the baby's mouth. Maybe 1 mL was total all that she got. They did not use a light or warm packs but that is a very good idea that I wish I would have thought about.

Ah, ok, 1ml isn't a big deal. Definitely try the heel warmers/warm packs or a warm wet diaper over the spots you plan to look- that can make a huge difference. We do hands/forearms and then feet and lower legs (depending on the age). Just make sure the water in the diaper if you use that isn't too hot and then let it sit for a few minutes. I keep my tourniquet on until I'm ready to flush- either until I have the labs drawn that I need or until I confirm placement by seeing a nice flash/blood return.

We usually use sheets to restrain our kids that need extra restraint other than what 1 person can hold- we do basically a burrito wrap with the patient as the filling and whatever extremity we're working on held out. If your restraints are really rough on the skin you might try that.

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.

She wasn't making tears though, so she hadn't been hydrating well at all. It doesn't sound like she suddenly became dehydrated during the IV attempts, but that she was getting the IV specifically because she needed the IV rehydration. I wasn't there, but from what you describe it sounds like she needed that IV (no tears, "falling asleep" during the IV attempts). It needed to get done, and allowing breaks for the baby to calm done would have just made the whole thing take longer, delaying rehydrating the baby.

Altra, BSN, RN

Specializes in Emergency & Trauma/Adult ICU.

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.

A kiddo whose fluid deficit has progressed to the point of dry mouth/no tears/decreased urine output -- NEEDS IV FLUIDS. A break to attempt to rehydrate orally? Does this fit into the urgency of the planned interventions?

I also think you're applying principles of restraint used in adults for behavioral purposes to an infant, and they just don't apply.

Crying does not in itself harm infants -- otherwise the human population would have died out a long time ago.

This sounds like the basis for an indepth discussion with your preceptor or unit educator.

As a mom, I have a hard time when my babies are crying and upset, and I can't do anything to help them. I went through an episode where my then 3 month old little girl got dehydrated because she had gastroenteritis. As much as I absolutely HATED the idea of anybody poking needles in my little girl.. I knew that it was in her best interest. I believe that as a nurse, I will have to deal with similar situations. The baby you described obviously needed the IV, and although it's unfortunate that it had to happen the way it did, the IV was necessary. Although, I will say this.. if someone had tried a couple time to get IV access on my baby and failed, I would have asked for someone else to try. Any nurse can have a bad day in the IV dept., which is why I personally think letting someone else try gives a fresh perspective and approach to the "problem."

klone, MSN, RN

Specializes in Women's Health/OB Leadership. Has 14 years experience.

A 6mo who is ill with RSV cannot rehydrate on his/her own. She needs the IV to rehydrate. And yes, the tourniquet is necessary, especially if dehydrated, and especially with chubby infant limbs.

I think that a pacifier with some Sweetease might have been a better option to try than water.

The dozing-in-and-out was probably a stress response, "shutting down" in response to the IV starts.

This is a perfect example that many student nurses who wish to work in peds should first hear about...just for starters.


Specializes in NICU.

1. The baby NEEDED an IV.

2. The tourniquet is needed.

3. The dozing off wasn't exhaustion, but shutting down to escape the noxious stim.

4. Restraints? Seriously? I worked at a Regional Pediatric Medical center for 7 years and we always used people to restrain babies/kids. Ideally the parent can hold most of the baby/child. A nurse or aide can hold the limb in questions, which a 2nd nurse starts the IV.

5. The pacifier and/or bottle should have been offered from the get-go. 10% glucose water would be my choice. The baby may not have taken them, but they should have been available.

6. Babies and toddlers will scream and carry on. A lot. It's all they can do. As long as they don't turn blue, just keep doing what needs to be done.

KelRN215, BSN, RN

Specializes in Pedi. Has 10 years experience.

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.

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.

Edited by rn/writer

applewhitern, BSN, RN

Specializes in ICU. Has 30 years experience.

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.

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.

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.

Edited by rn/writer


Specializes in GICU, PICU, CSICU, SICU. Has 6 years experience.

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 ^^.