Treatment of a neonatal peripheral intravenous infiltration/extravasation (PIVIE) injury with hyaluronidase: a case report
Intravenous therapy-related injury, its prevention, and treatment are ubiquitous topics of interest among neonatal clinicians and practitioners. This is due to the economic costs, reputational censure, and patents' wellbeing concerns coupled with the possibility of potentially avoidable serious and life-long harm occurring in this vulnerable patient population.
A term infant receiving a hypertonic dextrose infusion for the management of hypoglycemia developed a fulminating extravasation shortly after commencement of the infusion. This complication developed without notification of infusion pump pressure changes pertaining to a change in blood vessel compliance or early warning of infiltration by the optical sensor site monitoring technology (ivWatch®) in use. The injury was extensive and treated with a hyaluronidase/saline mix subcutaneously injected into the extravasation site using established techniques. Over a period of 2 weeks, the initially deep wound healed successfully without further incident, and the infant was discharged home without evident cosmetic scarring or functional effects.
This article reports on a case of a term baby who postroutine insertion of a peripherally intravenous catheter showed an extreme reaction to extravasation of the administered intravenous fluids. We discuss the condition, our successful management with hyaluronidase, and the need to remain observationally vigilant of intravenous infusions despite the advances in infusion monitoring technology.
In a neonatal population peripheral infusion therapy-related complication rates have been reported to be as high as 75%
Peripheral IV infiltration and extravasation (PIVIE) is implicated in up to 65% of IV-related complications
PIVIE injury has the potential to cause serious harm
Prompt recognition and timely appropriate intervention can mitigate many of these risks
Adhering to the 5Rs for vascular access optimizes infusion therapy and potentially reduces complications
Ensuring safe vascular access for the delivery of intravenous (IV) therapies is a cornerstone of everyday neonatal practice.1,2 IV access is obtained via peripheral and central veins with peripheral vein cannulation being the most frequently performed procedure in the Neonatal Intensive Care Unit (NICU).3,4 However, obtaining and maintaining IV access in the neonatal patient population is often challenging and can be a common cause of iatrogenic complication and injury.5
While many complications are minor, the risk of peripheral IV infiltration and extravasation (PIVIE) injury has the potential to cause more serious harm. The reported risk of a peripheral IV-related complication in this patient population is variable with some authors of single and multicenter studies reporting complication rates of 63.5% to 75%.3,5–6 Pooled figures for extravasation incidence from meta-analyses also show considerable heterogeneity.7 In part, this variation is due to differing classifications of what constitutes a complication, definitional overlap, and amalgamation of complication incidence in reported figures (eg infiltration, extravasation, and leakage reported together). Furthermore, various confounding factors such as weight, gestational age, the nature of the infusion fluid, the use of vascular access technology to evaluate potential insertion sites, chosen vein, underlying pathology, and practitioner skill all influence risk.2,8 According to several sources, PIVIE is implicated in 65% of neonatal IV complications.3,9,10,11 Because of this high prevalence, numerous evidence-based measures have been implemented to reduce the likelihood and severity of complications. These interventions include care bundles, site selection, and evaluation tools (eg VeinViewer© [Christies], and the touch, look, compare mnemonic), catheter design and material innovations, dynamic inline occlusion pressure monitoring, and insertion site optical monitoring technology (eg ivWatch®). In the neonatal literature, treatment of PIVIE is underreported.12 In the case we describe, we discuss our current practice in the treatment of PIVIE.
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