IV infiltration

Specialties PICU

Published

I am a 23 year peds nurse. I work nights. I had a toddler with an IV in his foot, it was heavily taped. All I could see was a small window at the insertion site and his toes. He slept in the parents arms all night. I assessed the IV every hour, I palpated it, he never flinched in pain when I touched it, it was soft, in the dark I thought it was pink. I thought I did everything right. But when I came back the next night, I found out it had infiltrated to a Grade IV. I apologized to the parents and they were very gracious. I may lose my job. The hospital hasn't decided yet. This happened 2 days ago. I can't eat, I can't sleep, I feel beyond horrible. I don't know how I'm going to get past this. I really need some support, but I am not allowed to talk about the incident, per hospital policy.

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Specializes in NICU, PICU, PCVICU and peds oncology.

I'm so sorry this happened to your patient... and to you. But IVs infiltrate. Especially with kids. If you lose your job over it, so should just about every other peds nurse in the world. Small comfort, I know. But let's look at it objectively. The child had no overt signs of infiltration on any of your assessments and was sleeping in his parent's arms. Sure, you could have turned on the light every hour so you could get a really good look at the site. But all of them would have had their sleep disrupted and in my experience, the last thing a parent sleeping in their child's room wants is to be awakened for any reason. Even in the ICU we're expected to carry out our work in the pitch dark, with the aid of a tiny flashlight, so we're not waking mom or dad up. Let's say you did that, and the IV was fine in the morning. You'd have been hauled across the carpet for waking them up! It's a classic Catch 22. You could have aspirated hourly to check for blood return, but in the real world, only about 5% of peripheral IVs in kids will have blood return, and you run the risk of losing the IV altogether. That's why we don't use PIVs to draw labs. Unless there was something particularly irritating or vesicant running in the IV, it will likely heal without a scar. My son has two extravasation scars from vinblastine, one on each hand, that occurred when he was 2 1/2... with the nurse holding his hand and watching the site the WHOLE TIME. Did I blame the nurse who gave the drug for that? Of course not. So take a deep breath and get back in the game. You can't be blamed for something that you had little control over.

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Thank you for that. They don't know yet if he will need skin grafts but by the next morning it was red not white anymore but with some blistering. All that was running in it was his maintenance.

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Working in the pitch black with just a flashlight in ICU - wow. Amazing there aren't more mishaps than there already are. I believe in parents

being with their kids but that's going too far.

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Specializes in NICU, PICU, PCVICU and peds oncology.
Working in the pitch black with just a flashlight in ICU - wow. Amazing there aren't more mishaps than there already are. I believe in parents

being with their kids but that's going too far.

I know, right? We used to have a rule that parents couldn't sleep at the bedside - for several reasons, not the last being easy access to the PATIENT if things went sideways - but it has fallen by the wayside. I feel like we're moving away from family-centered care into the realm of family-directed care. When we were planning our unit's renovations the family advisory group were insistent on having a place to sleep at the bedside, complete with more storage and amenities than the staff will have, plus FIVE private parent overnight rooms... for those nights when they "just really need to get away". What's wrong with home?

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Specializes in Pediatrics, Pediatric Float, PICU, NICU.

Just take this as a learning lesson and apply it to your practice from here on out. I keep a mini flash light on my lanyard and use it every single night when I do my hourly IV checks - I cover it with a piece of tape so that it is dimmer than what it would usually be, and most kiddos don't usually wake up. Also in the future maybe using the TLC approach to assessing your pediatric IV site (touch-look-compare to the other extremity) may help catch the infiltration early on. It would be ridiculous for you to lose your job though, good luck.

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Thank you for your support. I did use my pen light, but with dad holding the child and the child's legs in between the dad's and the child uncooperative because he was afraid of us and the IV board on the bottom of the foot, assessment was hard. I have gone over this a million times, what I could have done different, what I didn't do, what I should have done, and on and on. The only thing I can do is pray that the child has no lasting effects, and educate myself more about IV infiltration's a learn from my mistake. I just hope I don't lose my job. You would think after 23 years that I would known everything about IV infiltration.

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Over-taping IV sites on kids was one of my biggest pet peeves. I never found it necessary to use strip after strip of tape, even on toddlers. Sometimes I had to get creative but it was imperative that not only the insertion site but the area proximal to the end of the actual cannula and the joint above were visible at all times for the very reason that it's almost impossible to see an infiltration if there's too much tape. Unfortunately the most accessible sites on kids are also the ones most fraught with potential problems. I'm so sorry this happened to you and the possibility that you actually might lose your job over this is ridiculous.

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Specializes in PICU.

I completely understand what you are experiencing. I had a similar situation a couple years ago. I walked into one of my rooms to find another nurse checking my iv for me, she said it had been beeping because it was occluded. We both broke the IV down together and assessed it, it was just taped weird and we were able to fix it up and restart the MIVF. I went back about 10 minutes later to make sure all was good and it was. When I did my next hourly check the little guy (6 months) was screaming and mom said he'd been crying since the last time I left. His arm was huge and the skin was tight and shiny. I cut his ID band off because it was tight and left another nurse to stay with him while I went for help. I was absolutely sick. We had to do vitrase and even an US to make sure he had good blood flow to the arm. I went to my manager in the morning and I was crying and braced to lose my job or get a warning, she just laughed and said it happens to all of us and she'd seen it a million times. She told me it probably had a small leak and on a kiddo that small a bad IV running for an hour could get out of control very quickly. My saving grace was I had a witness in the room with me. To be honest, my manager being as nonchalant and light as she was didn't help much. It made me feel like I was overreacting. It took me a couple months to get over the feelings of guilt from that experience. I will never forget the feeling of thinking I may have caused serious harm to an infant. It has definitely made me more vigilant about my checks and when in doubt, I start a new IV!

Don't beat yourself up. You were checking the IV, sometimes we miss things, it is really hard on a chubby little taped up toddler extremity.

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