Running Head: IV INFILTRATION/EXTRAVASATION
Recognizing and Treating IV Infiltration/Extravasation in Neonate and Pediatric Patients
Sydonie J Stock
Ferris State University
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RECOGNIZING & TREATING IV INFILTRATION/EXTRAVASATION IN NEONATE
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Recognizing and Treating IV Infiltration/Extravasation in Neonate and Pediatric Patients
Intravenous administration is a widely used method of managing medication in a hospital
setting. It is necessary to use an IV when a patient needs a certain medicine to be administered
over a period of time. This method is not without its risks, however. Two problems that could
occur while a patient is receiving IV medication are infiltration and extravasation.
Infiltration/Extravasation
Before a Nurse or any healthcare provider can recognize a possible problem with an
intravenous administration, she or he needs to know what is considered a ‘problem’.
Extravasation and infiltration are two issues that can occur while administering medications via
an IV. Extravasation, as defined by the online medical dictionary Medline Plus, is when fluid
passes through the “proper vessel or channel” by either infiltration or effusion. Infiltration is
defined as permeation by “penetrating [a vessel’s] pores or interstices” (Medline Plus, 2012). In
simpler terms, both extravasation and infiltration occur when the fluid that is supposed to be
added to a vein starts to collect in the tissues outside the vein.
Amjad, et al, and the study performed by Rodica Simona further clarifies that the “major
difference between infiltration and extravasation is the type of fluid infused”. Infiltrations are
when “nonvesicant fluids like sterile saline” seep through the wall of the vein and into the
surrounding tissue. Extravasation is more severe as it involves “vesicant solutions like dopamine,
caffeine, and many chemotherapeutic agents” (Amjad, et al, 2011).
Risk Factors
According to the case study performed by Laura Kuensting, RN “premature infants,
neonates, and young children” are more likely to sustain injury from extravasation than an adult.
It is estimated that 11% of neonates in a neonatal intensive care unit experience extravasation. In
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44% of those cases the injury is so extreme that the effected skin starts to “slough” off
(Kuensting, 2010).
In the study performed by Amjad, et al, it was stated that “up to 78% of IVs [in NICU]
are estimated to become infiltrated.” His study also reiterated the 11% extravasation estimate.
Because infants and neonates have “fragile veins” and more the catheter is not as easily
stabilized, they will have more complications due to infiltration (Amjad, et al, 2011) (Simona,
2012).
Though adults may also suffer from infiltration, it is usually less severe. Since adults can
voice their concerns over new or increased pain, the infiltration is caught early. Infants,
especially if they are intubated, cannot make their needs as well known (Amjad, et al. 2011).
Harmful Effects
Kuensting states that the harmful effects of extravasation or infiltration can vary
depending on multiple factors. These factors include “the agent” or drug being administered, the
concentration of the drug or its “potency” (Amjad, et al, 2011), the amount of the drug, and how
long the drug was infiltrating or seeping into the tissue before being treated. In the case study,
the six day old neonate was estimated to have extravasation for up to eight hours before it was
noticed (Kuensting, 2010).
Tissue necrosis, or tissue death, is a possible effect of infiltration or extravasation. Other
less severe but still unwanted effects include pain in the affected area, infection, prolonged
hospital stay and increased cost, and even disfigurement (Kuensting, 2010). Extravasation can
cause blisters or chemical burns due to the types of liquid collecting in the tissues (Amjad, et al,
2011).
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Assessment - Infiltration Grading Scale
A widely accepted grading scale was developed by the Infusion Nurses Society (INS) in
2006 and can be reviewed in Appendix A. Amjad, et al, found that the scales currently in use do
not take into account the size of the patient. For example, swelling found on an adult that
measures two inches involves only a small portion of the body. However, two inches on an infant
or neonate could be involving half the foot or forearm (Amjad, et al, 2011) (Simona, 2012). They
created a grading scale that “more accurately represents concerns relating to infant and neonatal
populations” (Amjad, et al, 2011). This scale can also be found in Appendix A.
In Simona’s study, “a group of IV experts and staff nurses from a large universityaffiliated pediatric tertiary care facility” analyzed the INS Grading Scale and made adjustments
to the clinical criteria to better describe pediatric patients (Simona, 2012). This scale can be seen
in Appendix A.
Treatment
Throughout the three studies examined, it has been established that there are many
methods of treating injuries due to infiltration and extravasation in pediatric and neonate patients.
Hyaluronidase Enzyme
In the case with the neonate and extravasation, the physician ordered a subcutaneous
administration of 1 mL of the hyaluronidase enzyme, rHuPH20. Hyaluronic acid is the substance
that holds tissue together. By adding hyaluronidase to the body, tissues are not being held so
tightly because the new drug ‘distracts’ the hyaluronic acid from its job. This means that the
medication that has infiltrated into the tissue can be reabsorbed into the veins more easily
(Kuensting, 2010).
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recombinant human hyaluronidase vs. animal-derived hyaluronidase
In Kuensting’s case study, the physician ordered rHuPH20, which is made from human
recombinant-DNA. There are several reasons why rHuPH20 is preferable over the animalderived version. Use of the animal-derived hyaluronidase has been known to cause allergic
reactions, sometimes resulting in anaphylaxis. Also, using the animal-derived version required
several small injections throughout the affected area, whereas the recombinant human version
requires one injection with favorable outcomes (Kuensting, 2010).
Less Invasive Interventions
According to Amjad, et al, “a multidisciplinary team consisting of a clinical nurse
specialist, a clinical pharmacist for an NICU, and a pediatric plastic surgeon” met and developed
a treatment plan that is less invasive than the current practices. Using the grading scale
developed by Amjad, et al, they formed an algorithm, or flow chart, depicting the actions one
should take given a certain scenario (Amjad, et al, 2011). This flow chart can be found in
Appendix B.
Theory
The theory I believe most relates to this topic is the Adaptation Theory. Adaptation is
defined in our textbook as “the adjustment of living matter to other living things and to
environmental conditions” (Taylor, et al, 2007). Like the body continually adjusting to internal
and environmental changes, so must healthcare adjust to changes in established best practice.
Conclusion
From examining these three articles, written by Kuensting, Simona, and Amjad, et al, two
key points can be made relating to neonatal, infant, and pediatric IV infiltration and
extravasation. First, infiltration and extravasation are more likely to have deleterious effects on
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patients of this age range than on adults. Second, there needs to be a uniform grading scale
tailored to patients of smaller size.
Further study in pediatric, infant, and neonate IV infiltration and extravasation will be
needed to determine, more precisely, how to best identify and treat the problem. “More
widespread understanding of the causes of infiltration and steps in its progression will allow for
better treatment through prevention and less traumatic, less expensive hospital stays” (Amjad, et
al, 2011).
RECOGNIZING & TREATING IV INFILTRATION/EXTRAVASATION IN NEONATE
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Appendix A
Infusion Nurses Society (Amjad, et al, 2011)
Specified for neonatal and infant patients (Amjad, et al, 2011)
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INS Grading Scale modified for pediatric patients (Simona, 2012)
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Appendix B
Less Invasive Intervention (Amjad, et al, 2011)
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References
Amjad, I., Murphy, T., Nylander-Housholder, L., & Ranft, A. (2011).
doi:10.1097/NAN.0b013e31821da1b3. A new approach to management of intravenous
infiltration in pediatric patients: pathophysiology, classification, and treatment. Journal of
Infusion Nursing, 34(4), 242-249. Retrieved November 20, 2012, from CINAHL
database.
Kuensting, L. (2010). doi:10.1016/j.pedhc.2010.02.001. Treatment of intravenous infiltration in a
neonate. Journal of Pediatric Healthcare, 24(3), 184-188. Retrieved November 20, 2012,
from CINAHL database.
Medline Plus. (2012). Merriam-Webster. Merriam-Webster, Inc. Retrieved November 20, 2012,
from http://www.merriam-webster.com/medlineplus/.
Simona, R. (2012). A pediatric peripheral intravenous infiltration assessment tool. Journal Of
Infusion Nursing, 35(4), 243-248. Retrieved November 20, 2012, from CINAHL
database.
Taylor, C., Lillis, C., LeMone, P., & Lynn, P. (2011). Fundamentals of Nursing: The Art and
Cience of Nursing Care (7th ed). Philadelphia, PA: Wolters Kluwer/ Lippincott,
Williams, & Wilkins.