Peripheral IV infiltration during clindamycin infusion in a toddler
A 2-year-old boy weighing 11 kg is admitted with facial cellulitis and receives IV clindamycin 110 mg every 8 hours, diluted in 50 mL and infused over 30 minutes through a 24-gauge catheter in the right antecubital fossa. Thirty minutes into the infusion, he becomes fussy and pulls at the arm. The nurse finds the forearm swollen, cool, and blanched around the site; the pump is still running at 100 mL/h. There is no blood return, and the site is tender. The child has received two doses through this catheter without problems. His mother reports that he has had two prior peripheral IVs, both in the right arm, and that he is difficult to access. The provider has ordered the next dose in 8 hours.
1. What are your immediate actions when you find the swollen IV site?
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Stop the pump and clamp the tubing immediately; do not flush the catheter. Disconnect the infusion, aspirate gently if your policy says to, and remove the catheter. Elevate the right arm and apply a compress according to institutional protocol; for a non-vesicant infiltration, cold is commonly used to reduce edema, but follow the approved policy. Assess distal pulses, capillary refill, sensation, motor function, and the size and color of the swollen area. Mark the border with a pen and measure it. Notify the provider and document the time, solution, estimated volume infused, appearance, and interventions. The child is fussy and the site is tender, so provide comfort and consider analgesia. Do not restart the infusion through the same catheter or the same distal area. Clindamycin is not a classic vesicant, but it can cause significant tissue irritation, so the site needs serial checks.
2. What access plan would you choose for the remaining doses, and how would you prevent another infiltration?
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Obtain new access in the opposite arm, avoiding the right antecubital area and the infiltrated site. Because he is difficult to access and needs multiple days of IV antibiotics, consider ultrasound-guided peripheral IV placement or a midline catheter rather than repeated blind attempts. A PICC is reasonable if therapy is expected to be prolonged or access continues to fail. Verify the clindamycin dose: 10 mg/kg every 8 hours for 11 kg is 110 mg, and 50 mL over 30 minutes is correct. Use a pump with appropriate pressure limits, secure the catheter with a stabilization device, and check the site at least hourly and more often during high-risk infusions. Teach the mother to call for swelling, pain, coolness, or fussiness. Document the access plan and escalate to the vascular access team if needed.
3. What quality and safety follow-up would you recommend after this event?
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Complete an incident report according to policy, but document the facts and the clinical response in the medical record. Review whether the site was checked at the required interval, whether the pump alarm limits were appropriate, and whether the antecubital site was a poor choice for a toddler who pulls at lines. Share the event in a safety huddle and consider a practice change: standardized site checks, securement, and early escalation for difficult access. Notify the provider and pharmacy if the infiltration volume is uncertain. Reassess the arm serially and arrange follow-up after discharge. Debrief with the family in plain language, explain what happened and what will be different, and document that conversation. The goal is not blame but prevention of the next infiltration.