“Concerned About IV TPN Burn on Infant’s Foot: What Could be the Long-Term Effects on Walking? #medicalquestion #IVburn #footinjury
Hello medical professionals,
I have a 11-month-old son who experienced an interstitial IV TPN burn when he was just 2 days old. As a result, he is now having issues with his foot when it comes to walking. Can you help me understand how bad this burn could have been and how long the IV could have been running interstitial before it was noticed?
Background:
– 2-day-old male, born healthy via c-section at 41+3 weeks
– Transferred to NICU for possible sepsis with increased respiratory breaths
– IV administering TPN went interstitial, causing chaos in NICU
Any insights or advice would be greatly appreciated as my son’s mobility is affected. Feel free to check out the photo sequence in the comments section for a better understanding. Thank you in advance for your expertise.”
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https://preview.redd.it/5o9f9yzstwwc1.jpeg?width=1290&format=pjpg&auto=webp&s=5a2c98de7d6ebacf70067f083293dba66c5360e8
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Disclaimer – I’ve never worked with babies, but I’ve had to place IVs several times on those older than 2 weeks.
This was bad. I’m not surprised there was chaos when it was discovered. TPN is considered a vesicant, meaning that if it infiltrates and goes into the tissues, it can cause severe tissue damage exactly as I see in your photos. In adults, I’ve never seen it given peripherally, only in a central line due to the risk. With that damage right at the joint, I would not be surprised if this was causing mobility issues but I think that’d be for a doctor to evaluate.
I can’t comment on how long it was running because I don’t know the common rates for babies. I also can’t comment on how quickly this would be visible with a baby’s skin (I’d guess quickly though since there’s less tissue).
How was this addressed at time of discovery? What treatment did they do? What did they explain to you?
I’d want to know what their policies are on administering/monitoring these kinds of infusions and if there is documentation of assessments.
Edit – can you post a Pic of what it looks like now? Honestly I’m questioning if this should have been surgically cleaned for better healing. Maybe someone better versed in wound care can answer.
I’m assuming it was PPN, which is Tpn that goes through a peripheral IV. In my experience, yes, things have to infuse for a bit before you can see that it infiltrated. Not to the fault of the nurse, but your tissue isn’t going to show signs after the first drop or two. Sometimes IVs are still in the vessel and get “leaky” which are tough because they look completely intact but are leaking into the tissue. I actually had an infiltration recently and the IV drew back blood beautifully, but was still leaking into his arm pretty significantly.
Another unpopular opinion, these things do “just happen”. In peds we’re putting these thin hair needles in even thinner veins. Most IVs that size Go bad fairly quickly, infiltration being one of the ways. It is a pretty decent burn, but have I seen worse? Also yes.
I’m not verified yet as a neonatal nurse practitioner here, so I will speak to you as an RN. I’ve worked in the NICU for 9 years. I’ve seen a handful of really bad burns from IV infiltrates. The worst situation I ever saw resulted in an infant losing their limb. That being said, this is bad. I’ve read through your comments and looked at the photos. It’s impossible to say how exactly this happened without working at that facility and knowing all the facts. Every facility has different policies, but usually as a rule of thumb, IV sites must be assessed every hour. If an infant is swaddled, the extremity must be unbundled and left out so it can be eyeballed (we don’t want to unswaddle and disturb a baby every hour). Does this always happen? No. Sometimes if the nurse has a busy assignment, it can go longer without being assessed. I don’t know what was going on in the unit that day, but it’s very possible there was another very sick baby who was getting all the attention. That’s not an excuse though for what happened to your baby. A burn like this doesn’t usually happen in an hour. This looks to me like it was running for a while without being assessed, but that is purely speculation on my part. Hyaluronidase is likely the injections he got. We give it to babies with bad infiltrates like this because it helps decrease tissue damage.
I’m not sure why he would be on TPN, but I don’t doubt it was for him if it was running. We scan the TPN and double check it with another nurse. That’s protocol for every hospital because it’s a high risk medication. I wouldn’t be surprised if he was NPO (no feeding) due to concern for sepsis, especially if he was having respiratory distress. What likely happened is he was made NPO so he was started on IV fluids. I usually see a D10W hung if it’s a short period of time the baby isn’t eating. But it’s not outside the realm of possibility that TPN was ordered give him proper nutrition. That’s solely based on the unit policies and procedures.
If I had seen this on my unit, we would order a wound care consult (sounds like they did) along with plastic surgery (also sounds like they did). We have wound care come every day (maybe every other day) to assess and re-dress. There are different ways to treat burns like this, but we usually keep the area moist for a while to promote healing. Given that it’s on the joint, we might have looked into an orthopedic consult as well, possibly even physical therapy. That’s not the standard though.
I’m very sorry this happened to your baby. There are certainly risks to everything we do in the NICU. We evaluate whether the benefits outweigh the risks. Sometimes there are things that go wrong and adverse events happen. I can’t say whether or not negligence occurred here. I have seen accidents like this happen through no fault of anyone, but I’ve also seen them happen because of negligence. As far as the charting goes, I don’t have an answer for that. It seems weird. If an IV fluid is running, it should be documented in the intake/output section of the chart. We have the ability to look up past orders, so you can absolutely find out how long the TPN was ordered for and when it should have been discontinued.
I guess the main takeaway from this is that IV infiltrates like this do happen. It’s a risk of TPN. We do our absolute best to prevent them by assessing the IV site every hour. Sometimes we aren’t able to do that if we have a really busy assignment. If this does happen, we should be transparent with the parents and explain how it happened and what we are doing to fix it. I would possibly ask for a physical therapy referreral, maybe even orthopedics. I don’t think plastic surgery will be helpful anymore at this point because the skin is healed (someone correct me if I’m wrong and you think plastics would still be beneficial).
Again, I’m so sorry this happened to you. I hope you can get some answers.