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Troubleshooting Pediatric Peripheral IVs: Phlebitis and Infiltration

Thursday July 1, 2004
Transparent tape allows for clear 
visualization of the IV site. 
Photo courtesy of Catherine Noonan, 
RN, PNP, Children's Hospital Boston.
Transparent tape allows for clear visualization of the IV site. Photo courtesy of Catherine Noonan, RN, PNP, Children's Hospital Boston.
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For an infant or a child, a peripheral IV can be a life-giving conduit in the face of dehydration or the carrier of curative antibiotics when sepsis threatens. But that same IV can be the source of tissue damage and permanent
disability when things go wrong. It takes the vigilance of a knowledgeable pediatric nurse to protect children from the consequences of peripheral IV therapy gone awry. Besides pain, children may suffer from delayed or inappropriate treatment. Complications may include partial- or full-thickness skin loss, infection, nerve and tendon damage, loss of limb function, or even limb loss.1
Common peripheral IV complications are infiltration and phlebitis, and as with much nursing care, the key is prevention and early intervention. Frequent assessment, such as hourly IV checks, help nurses detect the early warning signs and act before real trouble begins.2 In addition, the use of a standardized assessment tool, like the one used at
Children's Hospital Boston, can help nurses stage and manage problems caused by phlebitis and infiltration3 (see Figures 1 and 2).
Infants and Children: What Makes Them Especially Vulnerable?
Risks associated with peripheral IVs increase in pediatric patients because children's veins are small and sometimes fragile. The veins are often hard to locate and stabilize when inserting and securing a peripheral IV.4,5 What's more, young children are unable to understand and follow directions as simple as "please stay still." In 1999, a pediatric nurse developed a tool to gauge the severity of
difficulty for placing pediatric peripheral IVs. Her scoring criteria include: available access sites, patient age, patient cooperation, and parent cooperation.6 The risk of vessel wall damage during insertion increases significantly with a child who is kicking and crying. Add an anxious or frantic parent to the mix and the difficulty factor may climb a notch or two.
Once the IV is in place, "twiddler syndrome" sets in for many.7 Older infants and children love to manipulate and play with objects attached to them. "Twiddling" the IV can dislodge the catheter or cause it to
puncture and penetrate the vessel wall. Pediatric nurses often compensate for busy hands by firmly taping down and covering the IV site. But this solution can lead to much more unfortunate consequences. Peripheral IV sites need to be visible and accessible for hourly inspection and palpation.2 Infants and small children have
flexible subcutaneous tissue that easily distends to accommodate infiltrated fluids, so careful, hourly visualization and palpation are necessary to detect early infiltrations. Transparent adhesive dressing over the IV site is recommended to facilitate assessment.2 Just as critical is preventing tape constriction around the extremity with the peripheral IV. Tape wrapped too tightly can increase resistance to flow within the vessel wall, resulting in infiltration or phlebitis.
Infiltration and Extravasation
When a peripheral IV is difficult to start, trauma to the vessel wall can occur, which weakens the wall and increases the probability of infiltration from leakage. Infiltration is defined as "the inadvertent administration of a non-vesicant solution or medication into surrounding tissue."8 To prevent infiltration, place the cannula tip in a vessel wall where the tip is less likely to penetrate or break through the wall, and stabilize the IV catheter to prevent flexion or rotation of the tip within the vein wall. The risk of infiltration increases at joint sites, such as the antecubital fossa.
Irritants, such as nafcillin and clindamycin, shorten the dwell time, or lifespan, of peripheral IVs. They often trigger a mild pruritic allergic reaction related to histamine release. However, these "flares" usually
subside in about 30 minutes and do not require intervention.9 Other common irritants are cefotaxime and amphotericin B.
Extravasation refers to infiltration that occurs when vesicant medications or solutions are inadvertently infused into surrounding
tissue.3 Common vesicants include diazepam, dopamine, vincristine, and calcium chloride. Even minute amounts of infiltrated vesicants can cause significant cellular damage. Whenever a vesicant is involved, the severity of the infiltration automatically becomes a Stage IV (4), the most severe stage (see Figure 1). Concentrated vesicants cause deep tissue damage. Depending on the vesicant type, there may be pharmacy protocols for administering an antidote, such as hyaluronidase, which promotes the rapid diffusion of extravasated fluids. Increasing the surface area for more rapid absorption of the vesicant will reduce tissue destruction.1,10 Until the nurse knows whether an antidote will help, he or she must not remove the peripheral IV; in fact, antidotes can be injected through the catheter into the extravasated tissue.
To help disperse the vesicant for quicker absorption, the nurse can elevate the extremity. When there is an infiltration, it is important to consult with a pharmacist or pharmacy formulary to determine whether the infiltrated solution or medication is an irritant or vesicant before intervening.
Phlebitis
Stressed vessel walls also can develop phlebitis, an inflammation of the vein.3 Mechanical phlebitis is due to vein irritation, such as too large a catheter, manipulation of the IV, or a fast infusion rate. Chemical phlebitis occurs from medications or solutions that are acidic or alkaline: Risk of phlebitis increases with greater or lower pH. Particulate matter in the solution also can irritate the
vessel wall. The third type of phlebitis, bacterial, can be minimized with aseptic technique. However if purulent drainage appears at the site, a culture should be obtained to identify the bacteria. Common skin organisms, such as Staphylococcus aureus, can migrate up the catheter tip.11 Regardless of the source, the beginning signs of phlebitis include redness at the site. The site may or may not be painful. Unchecked phlebitis can develop into painful streaking along the vein or a distinctive, palpable "venous cord." When redness first appears, carefully monitor the peripheral IV site, and apply warm packs for comfort (see Figure 2).
Vigilance Is the Key
Table 1 summarizes what nurses need to know about phlebitis and infiltration. Infants and small children with their elastic skin and fatty, distensible subcutaneous tissue can make it difficult to detect tissue damage, so vigilance is critical. Knowing more about what is infusing through the peripheral IV also can avert injury. Is it an irritant or a vesicant? Is it acidic or alkaline?
An aggressive response to a clinical change in an IV must be the norm in pediatric nursing. Likewise, the use of standardized tools can ward off complications. They offer health care providers a common language to stage and manage infiltration or phlebitis should they occur.