Guideline for IV Infiltrations in Pediatric Patients

Pediatric Nursing, March, 1999 by Lou Ann Montgomery, Kirsten Hanrahan, Kris Kottman, Angela Otto, Tami Barrett, Bettina Hermiston

When an intravenous (IV) infiltration occurs, it can be devastating for the patient as well as the staff. While adverse outcomes from an infiltration can occur even with the most prudent care, prevention and treatment of adverse outcomes can be a realistic, attainable goal. In 1993, Children's and Women's Services at the University of Iowa Hospitals and Clinics became interested in trying to prevent and minimize the adverse effects of infiltrations. Nursing staff noted that incident reports described varied approaches to treating and not treating infiltrates in our pediatric inpatient population. At the same time that new literature regarding pediatric IV infiltration was emerging, staff identified the need to develop an IV infiltration guideline. A task force was appointed to survey the literature, integrate multidisciplinary feedback, and make recommendations for practice changes. The process of developing the subsequent guideline using the Iowa Model[C] for research utilization (see Figure 1) is described elsewhere (Montgomery & Budreau, 1996). The purpose of this article is to describe relevant clinical recommendations, the application of the guideline, and outcomes evaluation.

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Literature Review

Infiltration is defined as the unplanned administration of a nonvesicant solution/medication into a surrounding tissue; the situation in which the IV access device pulls out of the vein/piercing the vein; or the diffusion or accumulation in a tissue or cells of substances not normal to it or in an amount in excess of normal (Hicher, 1988; Intravenous Nurses Society, 1998a). A nonvesicant is defined as a solution/medication that does not cause blistering. Signs and symptoms of an infiltration include swelling, pain, coolness, leakage at the site, induration, and, in some cases, the lack of a blood return (Fieldstein, 1986).

A related term, extravasation, is defined as the unplanned administration of a vesicant solution or medication into surrounding tissue (Intravenous Nurses Society, 1998a,b). A vesicant is an agent causing blistering. Signs of an extravasation are similar to an infiltration and include swelling, discomfort, pain at the site, coolness of skin, and, in addition, blistering (Fieldstein, 1986; MacCara, 1983). In this article, the term infiltration will be used for both infiltration and extravasation.

Pharmacological Interventions

The literature regarding methods for administration of pharmacologic antidotes as well as literature related to specific pharmacologic antidotes and antidotes for infiltrations of chemotherapeutic agents was reviewed, and reported as follows.

Methods for administration of antidotes. Interpretation of the research and clinical literature regarding how to administer antidotes for infiltration with selected agents may lead readers to draw different interpretations regarding treatment. For example, there are no definitive recommendations regarding how long after an infiltration occurs that administration of an antidote will provide benefit. Many clinicians report that intervention with antidotes as soon as possible, but no longer than 12-24 hours after the event, is best. There are also no clear recommendations for how often an antidote can be given to treat the same infiltration event. For this reason, clinicians are encouraged to use their best judgment (Oncology Nursing Society, 1992).

Additionally, there is controversy and no definitive recommendation in the literature regarding whether to leave the IV access device in or take it out once an infiltration has occurred. If the IV access device is left in and an antidote is to be administered, the access device is withdrawn 1-2 mm to avoid direct IV antidote administration. The antidote is injected through the IV access device into same plane of tissue as the infiltrate (Flemmer & Chan, 1993; Lewis & Hecker, 1991).

In some cases, tissue damage from an infiltration may be such that it might be desirable to remove the IV access device and not use it for antidote administration. Prior to removing the IV access device, an attempt often is made to aspirate any remaining infiltrated infusion. Once the IV access device has been removed, the antidote is administered intradermally/ subcutaneously after prepping the site (Ignoffo & Friedman, 1980). The needle is directed from the edge of the infiltration toward the center of the site. Four to five injections are given in this manner in sites rotated like the numbers on a clock, with a new 25-to-27 g needle used for each injection (Banta & Noerr, 1992). After the antidote is given, the site may either be covered with a sterile gauze to collect weepage or left open for visualization (Oncology Nursing Society, 1992).

Specific pharmacological antidotes. Hyaluronidase can decrease or prevent damage to tissue when infiltration occurs from a wide variety of agents (Banta & Noerr, 1992; Elam, Dorr, Lagel, & Pond, 1991; Raszka, Kuesnet, Smith, & Bass, 1990). Hyaluronidase is a protein enzyme that modifies the permeability of connective tissue through the hydrolysis of hyaluronic acid, a polysaccharide found in the intracellular ground substance of connective tissue. It is thought that this breakdown of hyaluronic acid by hyaluronidase results in the enhanced distribution and absorption of irritating infiltrated IV solutions. The literature supports the use of hyaluronidase secondary to the infiltration of vinblastine and vincristine (Dorr, 1994; Oncology Nursing Society, 1992). There is some anecdotal support for its use in treating infiltrations secondary to administration of calcium solutions, cephalothin, chloramphenicol, erythromycin, methicillin, nafcillin, oxacillin, penicillin, potassium chloride, theophylline, total parenteral nutrition (TPN), tromethamine, vancomycin, and high concentration dextrose solutions (Banta & Noerr, 1992; MacCara, 1983; Raszka et al., 1990; Young & Magnum, 1998a). Hyaluronidase is reported as used by protocol at pediatric hospitals including The Children's Hospital of the King's Daughters (Norfolk, VA) (Flemmer & Chan, 1993) and Children's Hospital (St. Louis, MO) (NICU, personal communication, 1994). It is also included in pediatric pharmacological reference books such as NeoFax '98 (Young & Magnum, 1998a).