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Wilkins and Emmerson1 highlighted the lack of consensus on the management of extravasation injuries in neonates. Modern neonatal infusion pumps can measure inline intravenous pressure and could theoretically detect early infiltration and subsequent extravasation injuries.2 But in clinical practice, extravasation injuries appear to occur even when inline pressures are monitored and cannulae sites are inspected hourly. However, it is a common misconception that occlusion alarms on infusion pumps will signal infiltration. In fact, pumps will alarm only when downstream pressure reaches a specified value, and elevated pressures resulting from infiltration are typically far lower than occlusion alarm triggering levels.3 In infants, monitoring of inline intravenous pressure is not useful for predicting or detecting infiltration of peripheral catheter sites.4 Resistance measurements may be useful in detecting infiltration injuries, but are not widely available and at present there are no commercially available infusion pumps that can reliably detect infiltration.3,5 We undertook a telephone survey of 14 tertiary neonatal centres to determine whether there was consensus on monitoring infusion pumps and pressures, cannulae sites, and the management of any resulting tissue burns.
Only two units had their own written guidelines on the monitoring of infusion pumps and pressures, cannulae sites, and the management of any resulting tissue burns. A variety of volumetric (43% Ivac) and syringe (50% Alaris) pumps were used. Monitoring of infusion pressures were by either actual inline pressure readings or a standardised “bar” system depicting pressure readings, or by both methods. Pressure alarms were calibrated for individual babies, set to 10 to 150 “units” above the baseline reading, or preset by the manufacturer to arbitrary settings. Pressure readings were recorded hourly on either the fluid or intensive care charts (78%), and the remainder only observed the pressure readings.
Some units used cannulae for total parenteral nutrition (four), 15% dextrose or higher (six), and inotropes (one). A selection of cannulae were used, although none of the units had written guidelines on the removal of presumed tissued cannulae. All units used clinical judgment for deciding on the removal of presumed tissued cannulae regardless of the pressure reading. A variety of procedures were undertaken including flushing the cannula and checking the cannulae site more frequently. Cannulae removal was recorded on either fluid charts or intensive charts, nursing or medical notes, or care plans.
This study has highlighted the lack of consensus on how tertiary neonatal centres monitor and manage infusion pumps and pressure readings and cannulae and the lack of written guidelines. The lack of consensus on the use of neonatal infusion pumps and their pressure readings probably stems from the lack of evidence that at present monitoring infusion pump pressures reduces the incidence of extravasation injuries. Nevertheless, this study has further consolidated the need for standardisation in the overall management of extravasation injuries, and calls for further research in this neglected field of neonatology.
Competing interests: none declared