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Scholarly Commons > HCA Healthcare Journal > Vol. 7 > Iss. 5 (2026)

 

Keywords

iatrogenic injury; patient safety; pediatric anesthesia; thermal burns; transillumination; vein finder

Disciplines

Anesthesia and Analgesia | Equipment and Supplies | Health and Medical Administration | Medical Education | Other Analytical, Diagnostic and Therapeutic Techniques and Equipment

Abstract

Background

Peripheral venous cannulation remains a cornerstone of pediatric anesthesia practice. Infrared vein finder devices have gained popularity as aids to improve venous visualization in children with difficult access. However, the thermal hazards associated with certain device types, particularly pocket flashlight-based models, remain underappreciated among clinical staff.

Case Presentation

We report 2 pediatric patients who sustained grade 2 thermal burns at peripheral venous access sites following the use of a pocket flashlight-based infrared vein finder during ophthalmic surgical procedures. The first patient, an 8-month-old girl born at term with appropriate developmental milestones undergoing congenital cataract surgery, developed a ruptured blister on her left elbow after 45 minutes of intermittent device application across multiple sites. The second patient, a 1-year-old boy, born preterm at 32 weeks gestation (birth weight of 1.9 kg) with delayed milestones scheduled for examination under anesthesia for congenital glaucoma, developed thermal blisters on his right palm. Retrospective review of operating room closed-circuit television footage confirmed the device had been in continuous contact with the right palm for approximately 5 minutes during the initial cannulation attempt. Notably, the contralateral palm remained unaffected, where device contact lasted only 2 minutes. Both injuries occurred in the absence of any underlying dermatological conditions.

Conclusion

These cases highlight a patient safety concern regarding pocket flashlight-based vein finders. We advocate for institutional protocol revisions including mandatory time limits for device application, preoperative skin assessments, and preferential use of LED-based devices with established safety profiles. Awareness of device-specific thermal risks is essential to prevent iatrogenic harm.

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