The most common intravenous (IV) complications reported in the Closed Claim Project include skin sloughing or necrosis, as well as swelling, inflammation, infection, nerve damage, and fasciotomy scars resulting from the treatment of compartment syndromes. Frequently, in cases of compartment syndromes, an extremity was tucked or covered and the peripheral IV was not visually or tactilely monitored. The infiltration therefore was not noted in a timely manner. Peripheral IVs can also be a source of other complications, such as air embolism, fluid overload, and infection.

In addition to the usual extremity sites, scalp veins may be selected for use in infants. Often, a branch of the superficial temporal vein is selected. This vein may have many branches helping to form the superficial venous network seen on the infant scalp. Most centers no longer shave the scalp prior to IV insertion. Stroking the vein with one end of the vein occluded by finger pressure may help you establish the direction of flow in the vein; drainage usually is toward the neck. Smaller tourniquets (even rubber bands) may be appropriately used on infants, and angiocath sizes used in infants are typically 22 or 24-gauge.

The saphenous vein deserves special mention as a site “of choice” for IV placement. The vein has a reliable anatomic location, lying just in front of the medial malleolus, and is often palpable, even in pudgy toddlers.

Before line placement, you should wash your own hands with an alcohol based solution prior to donning your gloves. Nonsterile gloves may be used for peripheral IVs, but maximum sterile barrier precautions (caps, masks, gowns, gloves, and drapes for the field) are required for central venous lines.

Proper securing of the line with clear, occlusive dressing, tape, a padded arm (or leg) board; and, then, an over wrap of gauze dressing prevents a carefully won site from being dislodged by vigorous thrashing. Be sure to leave the insertion site exposed so that it can be monitored for signs of leaking or infection. Infectious complications occur in as many as 25% of patients with indwelling intravenous catheters and can result in serious morbidity and mortality. If an infant or child arrives in the operating room with a covered IV site and a flush fluid needle is not easily injected into the infant or child, the IV site should be uncovered and inspected for skin infiltration. Heated compresses should not be used to treat an infiltration; serious burns have occurred with their use.

To prevent excessive fluid administration, microdrip delivery devices should be used. For patients weighing less than 10 kg, it is best to use a device with a calibrated delivery chamber (e.g., Buretrol). These devices should have a valve or seal that prevents air from entering the IV tubing once the chamber is empty. Careful flushing of all lines, including stopcocks, also is important to help to prevent air embolus. For very small patients (e.g., premature infants), placing all fluids on a regulated pump and avoiding gravity drips altogether is best.