Pediatric Patient IV Infiltration- Is it My Fault?

[Nurse Beth, MSN]

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?

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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,

Best wishes,

Nurse Beth

Author, "Your Last Nursing Class: How to Land Your First Nursing Job"...and your next!

[meanmaryjean, DNP, RN]

Perhaps the private email address should be edited out?

[Nurse Beth, MSN]

Thank you!

[ta2lady]

There is a non-invasive device called ivWatch that can detect iv infiltration before it is even visible on assessment. It is similar to a pulse ox, and alarms when fluid is detected in the tissue near the iv insertion site.

[sunny time]

checking the site every 2 hours feel the foot and toes for coolness and edema. because this is a child and under a cover the site needs to be checked and rechecked. children move and kick, are turned over to change diapers or put on bed pans. feeling horrible is good for you, but how does the child feel. good for you because this will make you more aware of your assessments and timing. once a shift is not enough check, check and check again. working nights is no excuse, if you are slack at night because you are tired then you need to go to days. DO NOT EVER use working night shift as an excuse. this could get you terminated. this is the shift you contracted with the job. go to your manager and ask if a day shift opens could you please have it.

[sunny time]

BTW is it your fault? yes because you did not catch it.

[riggy3, MSN, RN]

An IV infiltrate can happen fast even with the IV controllers pressure sensors they still happen. If there is one thing I tell students is always look at that IV anytime they are with the patient. When infusions are rapid rate these especially need watching. While the site may look terrible as long as vesicants were not in use it will get better in time. Any nurse who tells you infiltrates never happened to them it is because they ignored the problem. Learn and move on providing excellent care.

[Dafabb, LPN]

BTW is it your fault? yes because you did not catch it.

I think you already know the answer as to how bad you feel but unlike Ms. Tactful just know we have all had this happen more than once/twice/thrice, be it adult or child. It tends to make us more diligent and yet it will still happen on the occasion. I work nights and carrying a flashlight of your own is always a big help and yet that squirmy little man rolled over and was laying on it for the last 2 hours and there goes the buzzer and there is that big arm... stop it, change it, heat pack wrap it and go on. The best of the best has had it happen....