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IV infiltrate

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Tracie Major

on 11 January 2013

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Transcript of IV infiltrate

Amjad, I., Murphy, T., Nylander-Housholder, L., & Ranft, A. (2011). A new approach to management of intravenous infiltration in pediatric patient: pathophysiology, classification, and treatment. Journal of Infusion Nursing, 34, 242-249. doi:10.1097/NAN.0b013e31821da1b3

Anson, L., Edmundson, E., & Teasley, S. (2010). Implications of evidence-based venipuncture practice in a pediatric health care magnet facility. The Journal of Continuing Education in Nursing, 41, 179-185. doi:10.3928/00220124-20100326-03

Jacinto, A.K., Avelar, A., & Pedreira, M. (2011). Predisposing factors for infiltration in children submitted to peripheral venous catheterization. Journal of Infusion Nursing, 34, 391-398. doi:10.1097/NAN.0b013e3182306491

Doellman, D., Hadaway, L., Bowe-Geddes, L., Franklin, M., LeDonne, J., Papke-O’Donnell, L.,...Stranz, M. (2009). Infiltration and Extravasation: Update on prevention and management. The Journal of Infusion Nursing, 32, 203-211. doi:10.1097/
NAN.0013e3181aac042

Dougherty, L. (2008). IV therapy: Recognizing the differences between infiltration and extravasation. British Journal of Nursing, 17, 896-901. Retrieved from http://www.internurse.com References Our patients deserve the best care
we can provide! $86,000 Projected Net Loss to date from infiltrates Collaborative Data OLOL Children’s Hospital Infiltrate Data (Anson, 2010) *Inconsistent use of topical analgesia
*Number of allowable IV attempts per nurse
*Use of Child Life Specialist for procedural distraction
*Ability to be present during IV placement Parental Concerns regarding IV Therapy: (Flint, 2009; Hetzler, 2011) Continuous infusion increase the risk of infiltrations

*Cochrane Review
No evidence that intermittent use decreased cannula life or had other disadvantages.

*Discuss need for continuous fluid on daily rounds – request saline lock when appropriate. Continuous versus Intermittent infusions (INS, 2011) INS Infiltration Scale *IV Start
*Gauge of catheter
*Discontinue
*INS Infiltrate Scale
Grade 1 - 4
Anyone less than 10 years, starts out at a grade 2 according to NDNQI Documentation INS Position Paper Recommendation of the Short Peripheral Catheter Site Site Assessment (Amjad, 2011; INS, 2012) INS Position Paper Recommendation
of the Short Peripheral Catheter Site
*Published July 2012
*Recommends when an infusion is
running :
Every one hour site assessments for
the pediatric patient

Site assessments should include visual assessment, palpation, and subjective information from patient. Site Assessment (Dougherty, 2008; Dychter, 2012; Hadaway, 2007) *Coolness or blanching
*Swelling
*Tenderness/ discomfort
*Skin taunt
*Change in flow of infusion
*IVF leaking from tissue Signs of an Infiltration (Dougherty, 2008; Hadaway, 2007) Antimicrobials
Fluroquinolones
Gentamicin
Naficillin
Penicillin
Vancomycin
Cefotaxime
Electrolytes
Sodium Bicarbonate
Calcium Chloride and Gluconate
Potassium Vesicants that increase the risk of Tissue Injury (Walsh, 2012) Evidence Base Recommendations: Prevention is the key!!! Infusion Nurses Society (INS) sets standards for infusion therapy (Dychter, 2012) Infants and small children are particularly prone to infiltration due to:
*Small fragile veins
*Inability to communicate pain
*Activity
*Lack of cooperation (Amjad, 2011; Doellman, 2009) Infiltration Risk Factors (Amjad, 2011)
Infiltrations are considered “reasonable preventable events” and thus reimbursement for any additional care required is the responsibility of the hospital. “Reasonable preventable Event” So What? *Identify the “so what” of this evidence-based improvement project.
*Distinguish between infiltration and extravasation events.
*Discuss key factors that impact infiltrates in the pediatric patient.
*Identify signs of infiltrates.
*Identify evidence base strategies to decrease infiltrates.
*Review Infusion Nurses Society (INS) infiltration scale.
*Review OLOL infiltrate data, collaborative data, and proposed improvement strategies. Objectives: This project is part of the speakers
Doctorate of Nursing Practice (DNP) System Based Improvement Project. No Conflicts of Interest Tracie Major MSN, APRN, CNS, CPN Decreasing IV Infiltrates in the Pediatric Patient (INS, 2012) INS recommends:
Families members should be provided with:
*General information on PIV
*Potential risks
*Instructions to promptly report signs of infiltration Parental Involvement (INS, 2011) Should not rely on alarms from pump to detect infiltrations.
Pumps do not cause infiltration but they can exacerbate the problem. Infusion Pumps (Doellman, 2009; INS, 2011) *Stop the infusion
*Try to aspirate fluid/medication
*Remove catheter
*Assess capillary refill, pulses, skin integrity
*Notify MD
Hot/cold application
No evidence to support efficacy
Elevation
Comfort measures
Surgery consult
*Document in electronic record
*Complete safety event report When an Infiltration Occurs *Full-thickness skin loss
*Muscle and tendon necrosis
*Significant scarring
*Limited extremity function
*Complex regional pain syndrome
*Amputation Consequences of Infiltrates: (Hadaway, 2007; Dougherty, 2008) Cytotoxic Agents
Cisplatin
Dactinomycin
Daunorubicin
Vincristine
Many others…………
Vasconstrictive Agent
Vassopressin
Norephinephrine Acyclovir
Amphotericin
Phenytoin
Digoxin
Diazepam
Dextrose
Mannitol
Nutrition/Lipids
IVIG
Radiographic contrast Vesicants that increase the risk of Tissue Injury What affects the severity of an infiltration? (Amjad, 2011; Doellman, 2009; Dychter, 2012 ) Nursing Sensitive Indicator (Hadaway, 2007; INS, 2011) *Taping techniques are inadequate and require significant nursing time
*Tape does not adhere well to catheter and skin
*Tape obscures site
*Dressing should be transparent and without excessive tape
*INS recommends when possible a catheter stabilization device should be considered the preferred method. Securing Infiltration Inflammation of vessel wall Phlebitis (Amjad, 2011; Doellman, 2009; Dychter, 2012) Inadvertent leakage of a nonvesicant
solution into surrounding tissue Inadvertent leakage of a vesicant solution into surrounding tissue Extravasation Phlebitis, Infiltration and Extravasation Events Infiltration Risk Factors Show me the evidence Site Selection,Catheter Size, and Insertion Locked peripheral IV catheters
Sites should be assessed with every catheter access/infusion or at a minimum of twice per day. Dressing Trial Business Case Infiltrate Workgroup Team: Project Consultants: Dychter, S., Gold, D., Carson, D., & Haller, M. (2012). Intravenous therapy: A review of complications and economic considerations of peripheral access. Journal of Infusion Nursing, 35, 84-91. doi:10.1097/NAN.0b013e31824237ce

Flint, A., McIntosh, D., & Davies, M. (2009). Continuous infusion versus intermittent flushing to prevent loss of function of peripheral intravenous catheters used for drug administration in newborn infants. Cochrane Database of Systematic Reviews, 4. Art. No. CD004593. doi: 10.1002/14651858.CD004593.pub2

Hadaway, L. (2007). Infiltration and extravasation: Preventing a complication of IV catheterization. American Journal of Nursing, 107, 64-72. Retrieved from http://www.nursingcenter.com

Hetzler, R., Wilson, M., Hill, E., & Hollenback, C. (2011). Securing pediatric peripheral IV catheters - Application of an evidence-based practice model. Journal of Pediatric Nursing, 26, 143-148. doi:10.1016/j.pedn.2010.12.008

Infusion Nursing Society (2012). INS Position Paper: Recommendation for frequency of Assessment of the short peripheral catheter site. Retrieved from http://www.ins.org

Infusion Nursing Standards of Practice. [Special issue]. (2011). Journal of Infusion Nursing, 34(1S).

Tofani, B.F., Rineair, S.A., Gosdin, C.H., Pilcher, P.M., McGee, S., Varadarajan, K.R., & Schoettker, P.J. (2012). Quality improvement project to reduce infiltration and extravasation events in a pediatric hospital. Journal of Pediatric Nursing, 27, 682-689. doi:10.1016/j.pedn.2012.01.005

Walsh, K. (2012). Nursing practice & skill intravenous therapy: Preventing and treating infiltration. Retrieved from http://ceu.cinahl.com References Peds 1 Peds 2 Peds 3 Peds 4 PICU Tandra Davison Belt Black
Ralph Serpas Green Belt
Dr. Susan Steele Green Belt
Dr. Kemmerly
Becky Hedglin
Susan Dixon
Nancy Luttrell
Rachel Mathews
Courtney Wilson Jacque Walter – Peds 1
Bethany Berendsen – Peds 2
Lorri Fontenot– Peds 3
Melissa Catalanotto – Peds 4
Shelli Lavinge-Sims – PICU
Regina London – Peds ER
Danielle Hatch – Child Life
Tippy Ventress – Peds 1(Yellow Belt)
Debra Stone-Williams – Peds 2 Team October 2011 - July 2012 n = 124 Decrease IV infiltrates by 10% in Children’s Hospital by May 30th

Overall baseline rate 9.0

Decrease infiltrate rate by 10% on peds 1 and peds 2 by May 30th

Peds 1 baseline rate – 9.8
Peds 2 baseline rate – 9.0 Project Goals: (Tofani et al., 2012) (Doellman, 2009; Hadaway, 2007; INS, 2011) (Doellman, 2009; Dougherty, 2008) (Dougherty, 2008; INS, 2011; Walsh, 2012) *Select best site available - when possible avoid joints/points of flexion
Patient movement can cause
cannula to erode the vein wall!!!!
*Use smallest catheter to accomplish therapy
*Avoid cannulation below a previous venipuncture or a failed attempt
*Only 2 attempts per nurse (Hadaway, 2007) 74% of tape specimens tested in one hospital, pathogenic bacteria contaminated the tape. (Hadaway, 2007) PCYPAS
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