preventing/identifying infiltrates

[shelbs3, BSN, RN]

I am a newer peds nurse who works on a peds heme onc unit and primarily deal with central lines and ports. I have recently been floated several times to different units which primarily have IV access. I am able to identify IV infiltrates on the older kiddos but have been having difficulty identifying infiltrates on the babies,especially if they are a little chubby. Obviously if it will not flush, the baby cries when flushing ect then I know its bad but other wise I have a hard time telling. I recently had a baby who didn't cry when flushing or touching around the side and the surrounding site was not cool to touch as it sometimes is with infiltrates however when we looked at the IV at change of shift the nurse thought it was slightly swollen. I didn't think it was however after removing the armboard and dressing it clearly was. I felt horrible that I didn't notice it but her arms were so chubby I really didn't see it. It was not a bad infiltrate however I do not want this to happen again. Any tips/tricks advice? thanks.

[tryingtohaveitall]

Yes, chubby patients make identifying an infiltrate tough. Compare with the opposing side to see if the size is different. As you mentioned, see how the PIV flushes. If child is crying when you flush, wait til they calm, flush again to see if it causes an immediate painful response. Monitor closely and make sure you are able to get a good visual on it. Experience is a great teacher.

[clueless8556]

I have had this happen to me when I was newly qualified and I felt truly awful.

So now I am extra super special careful when checking peripheral IV sites.

Even though it takes forever I take the splint/backboard off at every check, also tight t shirts or name bands can mask infiltration/extravisation.

I always set my I've pump pressures on the lowest they can be set. Which does mean I am constantly silencing alarming pumps when babies wriggle but I'd rather that than miss something.

I find feeling the site more useful than just eyeballing it as puffiness feels different to Chubby baby arm :) and you can also feel for hardness or coolness.

And like the previous poster said comparing the two hands or feet is always helpful.

Don't be hard on yourself lines can go quickly and it may have been fine all day until that last check at handover time.

[yuzzamatuzz]

Unfortunately IV infiltrates in babies can happen pretty quickly. A small amount of fluid, say 30 cc, is going to make an infant's hand pretty swollen when it would hardly be even noticeable in adults. Babies also can't vocalize when it is uncomfortable and they may not cry until it gets very bad. Babies also have small fragile veins that blow easily. Combine that with the fact that they move their limbs erratically and will put any foreign objects in their mouths (i.e. the IV board) and you have a recipe for disaster.

There are a few things I do to try to prevent infiltrates. When I put in an IV, I wrap the armboard in such a way that I have a small window to view around and above the insertion site. There are some nurses on my floor who will use a ton of tape to stabilize the armboard and it drives me crazy because you can't see above the insertion site at all (I often will re-tape these when I first see the patient). You want to make sure the arm board is on well enough to hold the patients arm in place and also that it isn't too tight. First, a tight arm board can be very uncomfortable. Second, tight arm boards make chubby kids look chubbier. As an above poster said, you definitely want to compare the IV arm to the non-IV arm. IVs in babies often are positioned in odd ways because their limbs are small. Depending on what IVs you use at your hospital, the t-connector can protrude from the patient in ways that make it prone to being knocked out...I usually wrap these parts with gauze to make them less likely to be knocked out. If you are putting in your IVs yourself, I personally have found the AC to be one of the best places in an infant (there are quite a few people who would disagree with me on this though). The AC has big veins and IVs often last longer there. Babies also can't put their AC in their mouth nearly as easily as their hands and feet. I look at my IVs at least every hour. I tell my parents that infiltrates do happen occasionally and to let me know if they think the IV might be getting swollen.

You can't beat yourself up over an infiltrated IV. Even if you do everything in your power to prevent it, they will still happen. The best thing you can do is to check the site frequently so that if it does infiltrate, you won't have a bad infiltrate on your hands.