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Extravasation injury in neonates | Signal

Reference number
1104 C
Issue date24 September 2009

This ‘Signal’ is about the risk of harm to neonates from intravenous infusions, including amputations.


Extract from incident reported to the RLS:
“Extravasation injury of TPN from peripheral cannula into right hand and surrounding tissues. Colour of the area initially appeared blue. 12 hours later discolouration of the hand is darker and appears black and gangrenous…”


Preterm infants often depend on intravenous infusion for their survival. They are particularly vulnerable to extravasation and tissue damage because of the fragility of their vascular system and skin. The flexibility of tissue may make it difficult to detect.


Following a trigger incident, the National Reporting and Learning Service (NRLS) identified 184 relevant incidents. As these were drawn from a sample, we estimate the total database contains around 1,400 neonatal extravasation injury reports.


We identified 18 serious harm incidents including two cases with likely amputation of the hand, plus others showing necrotic areas and full thickness injury and burn. Most incidents related to peripheral lines, with a range of infusions. Litigation data over 10 years showed a further 30 incidents, including one case requiring amputation of all digits.


The incident reports suggest inconsistent management, including whether or not injured babies were referred to plastics or tissue viability teams. There are currently no national guidelines for infusion therapy for neonates (despite general infusion standards by the Royal College of Nursing), although many units have developed local policies. The actions to prevent harm are not clear, so we are unlikely to develop a Rapid Response Report (RRR) at this stage. Further research is needed to provide clearer pointers on best practice and this will be discussed further with the Royal College of Paediatrics and Child Health.


We would like to hear from you – please contact us  with anonymised copies of local investigations or information about your initiatives to reduce risks in any of these areas. 


Signals are notifications of key risks emerging from review of serious incidents reported and shared by the NRLS.



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