The following assignment from NURS 307 relates to the VCU School of Nursing Program Outcome 3: professional nursing practice grounded in the translation of current evidence. This paper is a literature review that analyzes current evidence on the topic of pediatric IV infiltration. Literature reviews combine skills essential for evidence based practice, such as reading, analyzing, and performing quality assessments on current and relevant nursing literature.
Pediatric Peripheral Intravenous Infiltration: A Literature Review
April 22, 2021
Virginia Commonwealth University
Peripheral intravenous catheter (PIV) placement is common for inpatient pediatric patients. Despite their frequent use, PIVs do fail, and can place the patient at risk when failure occurs. PIV failure can lead to delayed patient care, pain, the need for surgery to repair tissue damage, or possibly permanent tissue damage (Park et al., 2016). Failure rates for pediatric IVs range from 34% to 56%, which is higher than in the adult population (Inderwati et al., 20210). The following literature review seeks to present current evidence within the discipline of nursing to provide background information about pediatric PIVs, PIV infiltration, and preventing infiltration.
The research conducted by Inderwati et al. sought to ascertain the incidence of PIV failure in children. Because it is a systematic review, the research is considered Level I evidence (Inderwati et al., 2020; Stillwell et al., 2010). The study reviewed experimental studies published from 2000 to 2019, which reported PIV failure or complications in pediatric patients (age zero to 18 years old). 32 studies were included in their systematic review, reporting on a sum total of 11,100 patients. Little detail about the methods of statistical analysis were included in the report. The included studies were all at risk for moderate to high degrees of bias due to “unclear methods to control for confounders” (Inderwati et al., 2020).
Overall PIV failure among all studies was 38%. Ten percent of PIVs infiltrated. This study indicates that approximately one in three pediatric PIVs fail, with infiltration being the most common problem. Given the prevalence of IV failure and infiltration, the researchers recommend “optimizing visualization of the site and regular assessment.” The metaanalysis revealed that while PIV “care bundles” to prevent failure do demonstrate improved outcomes, they lack standardization. Furthermore, there is an overall lack of high quality evidence regarding standard care. Additional evidence regarding these interventions could be beneficial for IV failure prevention (Inderwati et al, 2020).
The systematic review by Inderwati et al. is useful in that it established a consensus that the PIV failure rate in pediatric patients is approximately 38%. It also established that infiltration is the most common problem for pediatric PIVs, with 10% of PIVs affected by infiltration. For the bedside nurse, this elucidates the importance of frequent assessments for pediatric PIVs, particularly when a medication is infusing. Due to the lack of standardization regarding reassessment frequency, PIV dressing methods, and regimens for flushing and infusion, there are numerous areas for further research to advance understanding of pediatric PIVs within the discipline of nursing.
The study by Park et al. sought to evaluate the impact of implementing a PIV infiltration management program on the rates of PIV infiltration in pediatric patients. The study participants included 2,894 pediatric patients (age zero to 19) in a hospital in Korea who had a PIV inserted. The control group was historical, and included pediatric patients admitted from August 1 to October 31, 2011 who received standard care. Standard care included educational posters, educating the patient’s parents about assessing the site for abnormalities, and documenting the IV site upon insertion. The experimental group were pediatric patients admitted to the same hospital and unit from November 1, 2011 to February 28, 2012. The experimental group received standard care, plus the PIV infiltration management program, which asked nurses to assess vein size and quality before attempting an IV. Nurses were also asked to monitor the PIV insertion site, and document findings each shift. Four percent of PIVs infiltrated in the control group, compared to 0.9% of PIVs in the experimental group. This showed a statistically significant decrease in PIV infiltration rate after implementing a PIV infiltration management program, p = 0.007 (Park et al., 2016). This study suggests the importance of vein selection in preventing PIV infiltration in the pediatric population. Beyond choosing the “largest and most pliable vein,” areas of curvature and joints should be avoided for securing PIVs. Frequent assessment of PIV insertion sites is crucial for preventing harm (Park et al., 2016).
The evidence provided by Park et al. is considered Level III, because study participants were nonrandomly placed in a treatment and control group (Park et al., 2016; Stillwell et al., 2010). However, it is a high quality quasi-experimental study. The study participants were similar, with well defined control and experimental groups. The methods used for assessing infiltration by nurses were also well-defined, because staff nurses were educated about infiltration classification using the criteria recommended by the Infusion Nurses’ Society (Park et al., 2016). Statistical analysis was clearly described by the research team. Furthermore, the results are relevant and useful for pediatric nurses because it highlights the great importance of IV insertion site selection in preventing infiltration.
However, the study did have some limitations. The study participants all came from a single hospital in Korea, and so the results may not be generalizable to a global population. Additionally, although nurses were taught to use the same scoring method for classifying infiltration, individual nurses may interpret the criteria differently, which could skew or affect results for the study.
In summary, the current literature indicates that PIV failure rate in the pediatric population is approximately 38%, with the most common problem being infiltration, which is seen in about 10% of pediatric PIVs (Inderwati et al., 2020). The literature suggests that the chances of an IV infiltrating may be significantly decreased if nurses are careful to choose the largest and most pliable vein, and avoid placing an IV in areas of curvature and joints (Park et al., 2016). Given the heterogeneity of care bundles identified by Inderwati et al., hospitals should consider the recommendations of Park et al. as a standard component of any care bundle implementation process for the care of pediatric IVs (Inderwati et al., 2020; Park et al., 2016). More generally, the nursing literature reveals an overall lack of high quality evidence about best practices for pediatric PIV care. The development of standardized best practices for decreasing failure and complications for pediatric PIVs through further research would both increase nursing knowledge and help promote patient safety.
Inderwati, F., Mathew, S., Munday, J., & Keogh, S. (2020). Incidence of peripheral intravenous catheter
failure and complications in paediatric patients: systematic review and meta analysis. International Journal of Nursing Studies 102, 1-11. http://dx.doi.org/10.1016/j.pedn.2015.10.013 0882-5963
Park, S., Jeong, I., Kim, K., Park, K. Jung, M., Jun, S. (2016). The effect of intravenous infiltration
management program for hospitalized children. Journal of Pediatric Nursing 31, 172-178. https//dx.doi.org/10.1016/j.pedn.2015.10.013 0882-5963
Stillwell, S., Fineout-Overholt, E., MeInyk, B., Willamson, K. (2010). Searching for the evidence: strategies
to help you conduct a successful search. AJN 110(5), 41-47.