Indwelling venous catheters are indispensable in pediatric medicine, providing reliable vascular access for medications, fluids, and nutritional support while reducing repeated venipunctures (1). These devices include central venous catheters (CVCs), peripherally inserted central catheters (PICCs), and peripheral intravenous catheters (PIVCs), the latter encompassing scalp vein sets and butterfly needles, each serving specific clinical needs based on treatment requirements and patient characteristics (1).

Despite their benefits, catheter fracture is a rare but potentially life-threatening complication. Published studies report an incidence of 0%–2.1% for indwelling venous catheters, including central venous devices and peripheral intravenous catheters (PIVCs) in pediatric patients (2, 4). Although central line fractures are well-documented, PIVC fractures remain underreported despite their widespread use (2). Retained catheter fragments pose significant risks, including vessel perforation, thrombosis, infection, pulmonary embolism, and cardiac arrhythmias due to fragment migration (2).

This case report presents two distinct instances of retained catheter fragments in pediatric patients: a 1-day-old female neonate with a fractured left axillary indwelling catheter and a 1-year-old male infant with a retained fragment from a right temporal superficial vein catheter. These cases are particularly noteworthy as they involve peripheral venous access devices rather than central lines, which are more commonly reported in the literature (2). By contrasting outcomes between promptly recognized vs. delayed identification of catheter fractures, this report highlights the critical importance of nursing vigilance, prompt recognition, and effective management across all vascular access device types (3). Furthermore, it aims to enhance awareness of PIVC

fracture risk factors, illustrate essential nursing interventions for prevention and management, and advocate for comprehensive vascular access protocols and specialized training programs to mitigate such risks in pediatric practice.

The occurrence of peripheral intravenous catheter (PIVC) fractures in pediatric patients is a rare yet potentially serious complication in clinical practice, with an estimated incidence ranging from 0 to 2.1% (2, 4). Unlike central venous catheter (CVC) complications, PIVC fractures are less frequently reported but can result in significant morbidity or even life-threatening events such as pulmonary embolism or cardiac arrhythmias if not promptly recognized (5, 6).

The iatrogenic fracture in Case 2, caused by cutting adhesive dressing with scissors in the presence of unshaved hair, underscores the importance of safe catheter removal techniques. Nurses should use adhesive removers or gentle manual separation to detach dressings, avoiding sharp instruments near insertion sites, particularly in agitated pediatric patients. Thorough hair clipping before insertion and standardized removal protocols can further mitigate such risks.

Nursing staff act as the first line of defense in detecting PIVC-related complications, given their constant proximity to patients and familiarity with catheter function. Early signs such as resistance during flushing, visible catheter damage, or localized swelling are critical indicators of catheter malfunction (7, 8). In the presented neonate, prompt identification of a catheter fracture by nurses, followed by immediate measures including proximal compression and limb immobilization, enabled the uneventful surgical retrieval of a 3.5 cm fragment, with no subsequent complications.In contrast, delayed recognition in another case led to a 6-day fragment retention and localized inflammation, illustrating the profound impact of timely nursing intervention on clinical outcomes.

Rapid and effective intervention is essential. Immediate actions, such as compression proximal to the fracture site and immobilization, are pivotal in preventing migration of the catheter fragment and reducing the risk of embolization or further complications (9, 10). Surgical retrieval of retained fragments, when indicated and executed promptly, is associated with better prognoses. In contrast, delays can result in adverse sequelae such as local inflammation, infection, or embolic events (11).

Diagnostic imaging plays a crucial role in confirming the presence and localization of retained PIVC fragments. Bedside ultrasonography offers a non-invasive and readily available modality for initial assessment, while computed tomography (CT) angiography provides superior spatial resolution, particularly when fragments are deeply embedded or migration is suspected. Both modalities were indispensable in our cases and in previously reported series, facilitating appropriate management decisions.

Several factors contribute to PIVC fractures in pediatric populations. These include excessive catheter manipulation, improper use of razors during site preparation, and agitation or uncontrolled movement of neonates and infants (12, 13). Inadequate training or inattention to secure fixation techniques further increases the risk of catheter damage. In our report and the reviewed literature, scalp vein catheters in neonates and infants were most commonly implicated, underscoring the vulnerability of this population.

Analysis of the case reports summarized in Table 1 reveals that PIVC fractures predominantly occur in pediatric patients, particularly those requiring scalp vein catheters. Of the 14 cases reviewed, 12 involved scalp venous indwelling needles in patients with an average age of 19.17 ± 8.96 months, highlighting the vulnerability of this young population. The primary causes of catheter fractures included improper use of razors during site preparation (8 cases), catheter folding (2 cases), and patient agitation (2 cases), underscoring the critical need for meticulous insertion techniques and secure fixation methods. Diagnostic imaging, such as bedside ultrasound and computed tomography (CT), played a pivotal role in confirming the presence and location of retained fragments, aligning with the importance of early and accurate detection discussed earlier. Treatment approaches varied from simple removal with hemostatic forceps to surgical interventions, with most cases achieving successful outcomes when addressed promptly. These findings reinforce the significance of nursing vigilance and immediate intervention, as delays in recognition and management can lead to complications such as localized inflammation or even embolic events, as seen in one case where a fragment was retained for six days.

Prevention must be prioritized through multiple strategies. Incorporating thorough hair removal (preferably by clipping, not shaving), secure but non-traumatic catheter fixation, and daily inspection of insertion sites can significantly reduce the incidence of catheter fractures (14). In addition, effective pain and agitation management, using comfort measures or pharmacological support, helps minimize inadvertent catheter dislodgement. Ongoing education and training for nursing staff on optimal catheter insertion, maintenance, and the early identification of complications are vital (15). The implementation of standardized institutional protocols for vascular access, as well as the introduction of innovative technologies such as advanced catheter materials and vein visualization devices, further enhances patient safety (16).

Furthermore, the preventive measures outlined in the case reports, including thorough hair removal and daily inspection of insertion sites, echo the recommendations for reducing catheter-related complications through standardized protocols and ongoing staff education.

The formation of specialized pediatric vascular access teams (VATs) has been linked to lower complication rates and improved outcomes, as these teams ensure standardized training and provide technical expertise to frontline staff. Institutional investment in such teams should be considered a best practice in modern pediatric care (17).

This report is limited by its dual case presentation and retrospective design, which inherently restricts generalizability. However, the purpose of this study is not to provide broadly applicable conclusions but to highlight the underrecognized risk of PIVC fractures in pediatric patients and promote awareness of preventive nursing strategies to enhance patient safety in such rare but critical situations. The insights provided reinforce the critical importance of nursing vigilance, prompt intervention, and structured preventive measures. Future research should focus on large-scale, prospective studies to better elucidate risk factors and evaluate the long-term efficacy of preventive strategies. Additionally, systematic follow-up of patients with retained fragments is warranted to assess the potential for delayed complications.

This case series reaffirms the indispensable role of nursing in the early detection, management, and prevention of PIVC fractures in pediatric patients. Through immediate action, adherence to evidence-based protocols, and integration of preventive measures into daily nursing practice, nurses can significantly improve patient safety and outcomes. The findings underscore the necessity of continuous education, institutional standardization, and the implementation of specialized vascular access teams to meet the complex demands of pediatric vascular care.