Extravasation injury management for neonates and children: A systematic review and aggregated case series

Safety of Silver Dressings in Infants; a Systematic Scoping Review

Silver-based dressings are used to reduce infection risk and optimize conditions for wound healing. They are widely used in the management of burns and other complex wounds. However, reports of elevated serum silver and concern over systemic toxicity have meant that their use in young children has been questioned. The aim of the current study was to map the literature relating to the use of silver-based dressings in children under 1 year of age. A systematic scoping review was conducted according to the methodology described by the Joanna Briggs Institute. Sources were identified from major medical databases as well as the gray literature. Inclusion criteria were the use of silver-based dressing in children under 1 year of age. Outcomes of interest were complications or adverse events attributed to silver-based dressings and elevated serum silver levels. A total of 599 sources were identified through the search strategy, with 110 included for review. Complications were described in 31 sources, with the most frequent being wound infection. No cases of argyria, kernicterus, or methemoglobinemia were reported. Six sources documented elevated serum silver levels in infants but none reported adverse events related to this. On the basis of current evidence, we suggest reserving silver dressings in infants under 1 for wounds that are at high risk of infection. Wound area and duration of treatment should be considered when assessing the risk of systemic absorption of silver. Standardized data collection and recording of complications and adverse events is recommended to better inform future clinical decision-making.

Real world data on the management of non-cytotoxic drug extravasation: An observational retrospective study in paediatric and adult patients

BACKGROUND

The extravasation of non-cytotoxic drugs is a risk posed by intravenous therapy, particularly in critically ill patients who often require multiple intravenous medications. This risk must be promptly addressed to prevent morbidity, increased therapy costs and prolonged length of stay, especially in critical care units. Therefore, it is critical to define the specific measures that should be undertaken to approach each situation.

AIM

The aim of this research was to describe the extravasation of non-cytotoxic drugs occurring in a tertiary hospital and to assess the effectiveness and safety of the internal protocol applied.

STUDY DESIGN

This was a single-centre, retrospective, observational study based on real world data from adult and paediatric patients experiencing extravasation of a non-cytotoxic drug between June 2018 and June 2023. To perform the analysis, demographic, patient, intravenous therapy, extravasation and treatment variables were collected and computed using descriptive statistics.

RESULTS

The analysis included 61 patients. The median age was 63.0 (IQR 3.5-74.5) years, and participants were grouped into neonates, children and adults. Among the subjects studied, 80% had at least one risk factor that made them liable to experience an extravasation. Drug groups involved were radiological contrasts (42.6%), parenteral nutrition and electrolytes (29.5%), vasoactive and cardiovascular system drugs (14.8%), antibiotics (8.2%), other analgesics and antipyretics (1.6%), expectorants (1.6%) and alimentary tract and metabolism drugs (1.6%). Adequacy of the protocol was reported in 73.8% of the cases with complete recovery.

CONCLUSIONS

The work reported here contributes to improving evidence about the management of extravasation episodes. Our findings suggest that patient-centred team-based protocolizing is a key strategy to achieve the effectiveness and safety of non-cytotoxic drugs in real world practice. This protocol could allow other institutions to enhance safety related to intravenous therapy. Moreover, maintaining a surveillance strategy will enable the continuous collection of data on these adverse events, facilitating ongoing improvement and reinforcement of good practices.

RELEVANCE TO CLINICAL PRACTICE

Implementing a standardized protocol for managing non-cytotoxic drug extravasation can significantly enhance patient safety and improve outcomes in both adult and paediatric populations in critical care settings.

Recurrent peripheral intravenous catheterization in neonates: A case series

Neonatal peripheral intravenous catheters (PIVCs) can be difficult to insert, often requiring multiple attempts, with each attempt causing pain and delaying treatment. The aim of this study was describe the clinical characteristics of neonates requiring multiple PIVCs during hospitalization. A secondary case series of neonates requiring three or more PIVCs during their admission were identified from a cohort admitted to an Australian Neonatal Unit between October 2020 and February 2021. Data were collected at PIVC insertion and removal; with variables including patient characteristics (weight, gestational age, acuity) and device characteristics (treatment indication, location), and outcomes (completion of treatment or failure). Outcomes are reported descriptively. In total, 19 of 248 (7.6%) neonates received three or more PIVCs (n = 101 PIVCs). Median gestation and weight were 26.6 weeks (interquartile-range [IQR] 24.6-28.6 weeks) and 728 grams (IQR 640-1050 g), respectively; all neonates required intensive care admission. The most common anatomical location was the hand (41.5%, n = 42). The maximum number of PIVCs required by a single patient was 12. The median dwell time was 49 h (IQR 35.0-73.5 h), with maximum dwell 263 h. In total, 57% (n=58/101 PIVCs) failed from complications, and 58% (n=59) of failed PIVCs required re-insertion. Despite common clinician perceptions that large babies require more PIVCs, our results found extremely low birth weight babies required frequent cannulation, with many PIVCs failing prior to treatment completion. There is a need for further investigation regarding decision-making, advanced inserter skills and optimization of alternate vascular access device selection for this vulnerable population. Clinical teams caring for neonates, particularly those of low birth weight and/or gestation, are recommended to take extra time considering the device they choose to insert, and the inserting clinicians. The aim of these recommendations is to reduce the number of treatment failures and device complications causing preventable treatment delays and ongoing injuries in neonatal critical care.

Drug Extravasation in a Tertiary Referral Children Hospital: A Prospective Cohort Study

Extravasation injuries are prevalent in pediatric hospitals and often result in tissue damage and extended hospital stays. However, limited data exist regarding risk factors for extravasation in children. This study aimed to identify these risk factors in pediatric patients receiving intravenous (IV) therapy. This prospective cohort study included 500 children aged 1 month to 18 years who had undergone either central or peripheral catheterization and were admitted to the pediatric intensive care unit (PICU) at Imam Hossein Children's Hospital in Isfahan, Iran, between July 2020 and July 2021. Data were collected on age, gender, length of hospitalization, catheter type, instances of extravasation, drugs administered, and treatment protocols. The median age was 36 months, and approximately 56% of participants were male. Among the cohort, the prevalence of extravasation was 9.8% (49 patients). Female gender (P = .002), central venous catheterization (P = .002), prolonged hospitalization (P < .001), reduced consciousness (P = .012), and the use of taping for vein fixation (P = .004) were all significantly associated with a higher risk of extravasation. This study underscores the need for health care providers to carefully assess risk factors for extravasation to mitigate injury risk, particularly in vulnerable pediatric populations.

Extravasation Identification and Management in Neonates and Pediatrics: A Cross Sectional Survey

OBJECTIVE

To explore current practice and guidelines surrounding the identification and management of extravasation injuries in Australian and New Zealand neonatal and pediatric settings.

METHODS

Between February and September 2023, an internet-based descriptive cross-sectional survey was distributed to Australian and New Zealand neonatal and pediatric clinicians using exponential nondiscriminative snowball sampling. Survey data domains included demographics, extravasation identification, management, local guidelines, and resources.

RESULTS

Of the 141 responses, the majority of respondents were registered nurses (n = 96, 68.1%), with greater than 20 years of experience (n = 51, 36.2%). Over two-thirds of respondents had no extravasation identification and management training (n = 98, 69.5%). Half of the respondents (n = 70, 49.6%) reported that increased presentation of risk factors did not alter monitoring frequency. Extravasations were primarily associated with the hand and wrist region (n = 118, 43.7%). Maintenance fluids, antibiotics and parenteral nutrition accounted for extravasation events. Acute management practices (immediate cessation of infusion) showed consistency (n = 124, 87.9%), whereas varying degrees of adoption were observed for aspirating the residual fluid. The majority of respondents (n = 119, 84%) reported the absence of a formal grading scale for extravasation severity.

CONCLUSIONS

Clinicians reported challenges and inconsistencies in neonatal and pediatric extravasation injury identification and management. This underscores the need for effective monitoring and identification, standardized management practices, and education to minimize the burdens of extravasation for patients, families, and the health care system.

Use of tissue adhesive for neonatal intravenous access devices: A scoping review

Neonates often require vascular access devices for medication or fluid therapy, but a third of devices fail before treatment completion or end with a complication. For adults and children, securing these devices with tissue adhesive (TA) increases the dwell and reduces complications. However, there is a lack of evidence for the neonatal population. This scoping review aimed to assess the evidence of TA for vascular access devices in neonates. The Arksey and O'Malley's (2005) framework was used. The inclusion criteria covered studies published from 2007 (when TA was first reported for use in vascular access devices) to June 2024, available in English, Portuguese, and Spanish, across six databases. Two independent reviewers assessed the studies using Covidence software, with a third reviewer resolving conflicts. Quality assessment was performed using the Mixed Methods Appraisal Tool. From 981 identified studies, 12 were included. Most studies (n = 5, 41.7%) enrolled between 100 and 500 neonates with vascular access devices. Publications originated from four regions and were observational studies (n = 6, 50%), quasi-experimental (n = 3, 25%), and case series (n = 2, 16.7%) with one randomized controlled trial (8.3%) focusing on umbilical venous catheters (UVC). The most common TA composition used was a combination of n-butyl- and 2-octyl- cyanoacrylate (n = 4, 33.3%). The amount of TA applied varied across studies, and often TA was part of a bundle (n = 7, 58.3%). Most studies applied TA to central venous access devices (n = 10, 83.3%) and 2 (16.7%) in peripheral devices. Although there was variation in device failure, the studies generally indicated a reduction in complications such as dislodgment (central catheter: 11.3% [peripherally inserted central catheter {PICC}] to 24.6% [UVC] in non-TA group vs 0.7% [PICC] to 7.7% [UVC] in TA group), device-associated bloodstream infections (central: 7.7% [UVC] and incidence of 2.76/1000 catheter days [PICC] in non-TA group vs 3.1% [UVC] and incidence of 0.99/1000 catheter day [PICC] in TA group), and phlebitis (13% in non-TA group vs 3% in TA-group), as well as increased dwell time in peripheral catheters. Most studies included both term and preterm neonates but did not differentiate between them in their analyses. Skin assessment, life of first dressing, and follow-up of catheters and patients were not reported in most studies.

CONCLUSION

TA may reduce complications in vascular access devices, but the evidence in neonates is limited and varied. Many studies include TA as part of bundle, making it difficult to isolate its effects. Additionally, the current evidence lacks robustness due to the design limitations of the studies. Future research should focus on randomized controlled trials to evaluate TA's effectiveness and safety in preventing device failures and complications in neonates, considering different subgroups, to ensure the safety of TA in these nuanced populations.

WHAT IS KNOWN

• Research in adults and pediatrics provides evidence supporting the use of tissue adhesive (TA) for vascular access devices, showing a positive impact in reducing failures and complications. • The use of TA in neonates needs to be carefully considered due to their unique characteristics.

WHAT IS NEW

• There is a gap in the literature on the use of TA for securing vascular access devices in neonates, particularly regarding its safety and effectiveness in preventing failures and complications. • Further studies are needed to provide robust evidence verifying the effectiveness and safety of TA in this population.

Application of Fetal Membranes and Natural Materials for Wound and Tissue Repair

The human fetal membrane is a globally accepted biological biomaterial for wound and tissue repair and regeneration in numerous fields, including dermatology, ophthalmology, and more recently orthopedics, maxillofacial and oral surgery, and nerve regeneration. Both cells and matrix components of amnion and chorion are beneficial, releasing a diverse range of growth factors, cytokines, peptides, and soluble extracellular matrix components. Beside fetal membranes, numerous natural materials have also been reported to promote wound healing. The biological properties of these materials may potentiate the pro-healing action of fetal membranes. Comparison of such materials with fetal membranes has been scant, and their combined use with fetal membranes has been underexplored. This review presents an up-to-date overview of (i) clinical applications of human fetal membranes in wound healing and tissue regeneration; (ii) studies comparing human fetal membranes with natural materials for promoting wound healing; and (iii) the literature on the combined use of fetal membranes and natural pro-healing materials.

Development of an Evidence-Based List of Non-Antineoplastic Vesicants: 2024 Update

Infiltration of a vesicant, called extravasation, can result in severe patient injuries. Recognition of vesicants and their relative risk of injury is essential to extravasation prevention, early recognition, and appropriate treatment. In this article, the Vesicant Task Force (VTF) updates the previously published Infusion Nurses Society (INS) vesicant list from 2017. The 2024 INS list diverges from earlier vesicant lists, such as the 2017 VTF list, by adopting a risk stratification approach based upon documented patient outcomes, in contrast to the reliance on expert consensus or only surrogate risk indicators, such as pH and osmolarity. The methodology used to create the updated list is explained, and the criteria for high- and moderate-risk vesicants and cautionary vesicants are defined.