Neonatal Infusion Therapy: Reducing the Risks of Complications

Intravenous (IV) therapy is a crucial aspect of neonatal care, but it comes with potential risks and complications. As healthcare professionals, it’s essential to understand these risks and implement strategies to prevent and manage them effectively. In this blog post, we’ll explore the intricacies of neonatal infusion therapy, focusing on reducing complications and ensuring the best possible outcomes for our tiniest patients.

Challenge your brain

Understanding IV Therapy Complications

Before we talk into prevention and management strategies, let’s first identify the common complications associated with IV therapy in neonates:

1. Infiltration: This occurs when a non-vesicant solution is inadvertently administered into the surrounding tissue.
2. Extravasation: Similar to infiltration, but involves the inadvertent administration of a vesicant or blistering solution into the surrounding tissue.
3. Phlebitis: An inflammatory response caused by damage to the intimal layer of the vein.
4. Leaking: This may be isolated or a symptom of phlebitis or infiltration.
5. Occlusion: The formation of a thrombus caused by fibrin or coagulated blood products.
6. Infection: Colonization of the catheter tip by microorganisms, which can occur through various routes.

Peripheral Venous Anatomy: A Closer Look

To better understand how these complications occur, it’s crucial to have a good grasp of peripheral venous anatomy. The vein wall consists of three layers:

1. Tunica Intima: A single layer of endothelial cells that provides a smooth surface. Injury to this layer can initiate inflammatory and coagulation processes, leading to phlebitis and thrombosis.
2. Tunica Media: A thick layer of elastic and smooth muscle fibers that allows the vein to elongate and dilate.
3. Tunica Adventitia: Loose connective tissue with collagen and elastic fibers that allows the vein to roll.

IV Site Selection: Key Considerations

When selecting an IV site, several factors should be taken into account:

1. Osmolality: This describes the number of particles suspended in a solution. The Infusion Nurses Society (INS) recommends limiting the osmolality of peripherally infused substances to 500 mOsm/kg.
2. pH: The normal range is 7.35 – 7.45. Repeated infusion of solutions with pH <5 or >9 can cause vein damage.
3. Chemical properties of the solution or medication.

Preventing Complications

Infection Prevention

To minimize the risk of infection, follow these steps:

1. Wash hands thoroughly
2. Minimize entry into the line
3. Maintain a closed system
4. Thoroughly clean the catheter hub injection port

Understanding Why Fluid Escapes from the Vein

Fluid can escape from the vein due to various reasons:

1. Mechanical factors: Such as trauma during insertion or inadequate stabilization of the catheter.
2. Obstructed blood flow: Due to thrombosis or vessel narrowing.
3. Obstructed fluid flow: Often caused by fibrin accumulation on the catheter.
4. Inflammatory reaction: Cellular injury can trigger chemical mediators causing fluid leakage.

Types of Thrombotic Occlusions

There are four main types of thrombotic occlusions:

1. Intraluminal Thrombus
2. Fibrin Tail
3. Fibrin Sheath
4. Mural Thrombus

Identifying Complications

Phlebitis

Phlebitis can be classified into four stages:

• Stage I: Mild redness above IV site; no pain, edema, hardness, or palpable cord
• Stage II: Painful IV site with moderate redness, warmth, and/or edema above IV site; no palpable cord or hardness
• Stage III: Painful IV site with redness, edema, possible induration, venous cord/hardness palpable at insertion site
• Stage IV: Painful IV site, redness, edema, induration with palpable cord extending above IV insertion site, purulent drainage, frank vein thrombosis

Infiltration

Similarly, infiltration is classified into four stages:

• Stage I: Pain at IV site, no erythema, no swelling
• Stage II: Painful IV site, slight swelling at site, presence of redness, 1-2 second capillary refill distal to site, good pulse distal to site, no blanching
• Stage III: Painful IV site, moderate swelling above or below insertion site, blanching, skin cool to touch, 1-2 second capillary refill distal to insertion site, good pulse distal to insertion site
• Stage IV: Severe swelling above or below site, blanching, painful IV site, decreased or absent pulse distal to insertion site, capillary refill >4 seconds above or below insertion site, skin cool to touch, skin breakdown or necrosis

Managing Complications

When phlebitis or infiltration is identified, the appropriate actions should be taken based on the assigned stage:

Stage I

Continue assessments at least hourly and consider initiating an alternate site.

Stage II

Stop the infusion immediately, discontinue the IV catheter, and initiate an alternate site. Avoid tape or pressure to the site for at least 24 hours or until the site is healed. Document the effectiveness of intervention at least every 12 hours until signs of complications are resolved.

Stage III and IV

For both stages, take the following actions:

1. Stop the infusion immediately
2. Attempt to aspirate the offending solution if infiltrated
3. Notify the physician/nurse practitioner
4. Elevate the extremity for 24 hours
5. Avoid tape or pressure to the site until healed
6. If phlebitis is present without infiltrate, apply warm moist packs for 20 minutes every 6 hours until symptoms resolve
7. Administer antidote as indicated (requires MD order)
8. Inform parents of findings and plan of care
9. Report the event to Risk Management
10. Document the effectiveness of intervention each shift until complications resolve

For Stage IV, additional steps include culturing drainage at the insertion site and the cannula tip if purulent drainage is present.

Emergency Measures

In cases of severe complications, several emergency measures can be taken:

1. Aspiration: Attempt to remove the infiltrated solution.
2. Antidotes:

• Hyaluronidase: Indicated for high osmotic solutions and other miscellaneous drugs. It modifies the permeability of connective tissue to enhance distribution and absorption of infiltrated solutions.
• Phentolamine: Used with vasopressive drugs. It’s an alpha-adrenergic blocking agent that decreases local vasoconstriction and ischemia.
• Corticosteroids: Have an anti-inflammatory effect. Hydrocortisone sodium succinate is commonly used.
• Glycerol trinitrate: Promotes local vasodilation to improve perfusion to the affected area.

1. Saline washout
2. Liposuction: Requires local or general anesthesia
3. Gault procedure: A combination of hyaluronidase instillation, saline flush out, and gentle liposuction of the surrounding area
4. Elevation of the affected area

Principles of Wound Care

Understanding wound care principles is crucial for managing complications effectively:

1. Normal wound healing requires proper circulation, nutrition, immune status, and avoidance of negative mechanical forces. The process usually takes 3-14 days and involves three phases: inflammation, proliferation, and remodeling with wound contraction.
2. Moisture and occlusion are important factors:

• Wounds heal twice as rapidly when covered with moisture-retentive occlusive dressings
• Excessively dry wound healing environments can cause further tissue death
• Occlusive dressings decrease infection rates
• Overhydrated, macerated tissue can delay wound healing

1. Bacterial colonization versus infection:

• Colonization may hasten wound healing by increasing wound bed perfusion
• Wounds become clinically infected when host defenses are overwhelmed

1. Debridement: The process of removing slough, eschar, exudate, bacterial biofilms, and callus from the wound bed

Types of Debridement

There are several types of debridement, each with its advantages and disadvantages:

1. Surgical: Generally definitive removal of eschar, but requires general anesthesia
2. Chemical (enzymatic): Facilitates softening of eschar tissue and aids in clearing debris from the wound
3. Autolytic: Allows the body to use natural processes; noninvasive but may take longer

Topicals and Irrigants for IV Extravasation Wound Care

Various topical treatments can be used in wound care:

• Bacitracin: Effective against gram-positive organisms
• Silver sulfadiazine: Effective for gram-negative organisms, but with potential risks in neonates
• Aquaphor: Used for superficial wounds to provide a moist wound environment
• Amorphous hydrogels: Used for treatment of sloughy or necrotic lesions

Basic Wound Dressings

Different types of dressings can be used depending on the wound characteristics:

• Gauzes: Inexpensive and accessible, but can be drying
• Films: Moisture-retentive and transparent, but offer no absorption
• Hydrogels: Moisture-retentive and provide pain relief, but may over-hydrate
• Hydrocolloids: Long wear-time and absorbent, but can trap fluid
• Alginates and hydrofibers: Highly absorbent and hemostatic
• Foams: Absorbent and provide thermal insulation

IV Infiltrate Wound Care

When dealing with IV infiltrate wounds, follow these steps:

1. If the skin is intact (even if blistering):

• Cleanse with sterile normal saline
• Cover the wound with a sterile semi-permeable transparent dressing
• Leave the dressing in place until healed or as long as the skin covering the wound remains intact

1. If the skin is broken:

• Cleanse with sterile normal saline using a syringe with an IV catheter attached
• Apply hydrogel to the wound (not surrounding skin)
• Cover with non-stick gauze, then wrap with sterile gauze
• Change dressing and re-apply hydrogel every 6-12 hours until wound edges appear pink
• Once wound edges are pink and the wound bed has a red, moist appearance, cover with a sterile semi-permeable transparent dressing

1. If the wound bed is covered with eschar:

• Cover with a sterile semi-permeable transparent dressing
• Leave in place to soften eschar
• Once eschar is completely moist or every 5-7 days, gently remove the transparent dressing
• Cleanse wound with sterile normal saline and proceed as above, depending on the condition of wound edges

1. Consider consultation with an enterostomal therapist if needed

Conclusion

Neonatal infusion therapy is a critical aspect of care that requires vigilance, knowledge, and skill. By understanding the potential complications, implementing preventive measures, and knowing how to identify and manage issues when they arise, we can significantly improve outcomes for our neonatal patients. Remember, continuous education and adherence to best practices are key to providing the highest quality of care in this delicate field of medicine.

As healthcare professionals, it’s our responsibility to stay informed about the latest developments in neonatal infusion therapy and to apply this knowledge in our daily practice. By doing so, we can ensure that we’re providing the best possible care for the most vulnerable patients in our healthcare system.