Question for you - newborn I/O

[Kaisu]

Hey there.

I have a question for you. First the facts -

2 1/2 week old newborn, born 5 1/2 weeks early in full arrest. Bystander provides effective 2-15 CPR. On our arrival, patient has a heartbeat and is cyanotic. We apply high flow O2, get some info, scoop the kid up and run. In the ambulance, the child improves, now pale centrally, mottled extremities and delayed cap refill. I put in an EZ-I/O into the right tibial plateau and begin administration of fluid. On arrival, the child is pink, spontaneous eye opening and crying. Now the question -

When I drilled the I/O, I aspirated marrow. 50ml of NS went in hard. I used a 20ml syringe and really had to push it. There was no effusion to the back of the leg and the kid definitely improved. However, on arrival at the hospital, the leg was turning red. No swelling, just a significant color change different from the rest of the skin color.

The I/O was pulled by nursing staff before x-rays to verify positioning. (they spent another 45 minutes getting a line - we didn't have 45 minutes. )

My question - what would have caused this leg to turn red? Any ideas? (PS - the I/O was firm - it did not dislodge.)

[FL_Medic]

With my experience, I always have to pressure infuse the line attatched to the EZ-IO. Not sure why, but our flight medics have told me they usually have to do the same thing. A little redness is expected in my opinion. Did the nurses attempt to aspirate marrow again? Did you administer Lido?

[akroeze]

I haven't met an ER nurse who would pull an IO. They would always leave that decision up to the doc.

[Camulos]

There’s redness and then there’s redness. A small degree of redness may be considered normal and is usually localised to only a small diameter around the actual insertion site. Redness of this nature is not normally of cause for concern for me.

In the original scenario however I note that the “leg was turning red”. Widespread redness covering an entire leg, or vast majority thereof, would definitely cause me concern as it would greatly raise the suspicion of fluid / drug extravasation. In a child this small, such extravasation can be devastating and could even result in loss of limb if large enough. It is also not uncommon for neonates to have clotting abnormalities. As I didn’t see it do you believe the redness could have been bleeding?

Despite the actual cause, and even though there was a lack of associated swelling, I would be keen to get this line out ASAP. I doubt x-ray would offer me much in this situation. Even if the x-ray confirmed the line was in the correct position, I would still be keen to remove it due to the degree of redness described.

I also note that the “I/O was firm”. In neonates you may not get the “firmness” that you would normally expect with older children and adults due to their relatively pliable bones.

I have also found that IO lines typically run better under pressure. In neonates however we don’t run fluids in this manner as everything is syringed in so as to ensure accurate weight based doses.

Lastly a question. Would re-aspiration of marrow be considered appropriate once fluid has been infused into this line?

Stay safe,

Camulos

[DartmouthDave]

Hello,

If the leg was red as described I would be keen to get the I/O pulled as well.

A bit slow with the line. But, they were able to get one.

Was the infant transfer from that ED or did the hospital have a NICU??

David

[Kaisu]

Thanks so much for the responses. To answer your questions, no on the lido... barbaric I know but in this backwoods part of the country, (Western Arizona) our esteemed medical director ignores standard of care in most parts of the country to go his own way. He pulled lido OUT of our protocols for I/O flush. In all honesty, with how sick that child was, the response I got when I pushed the first 20ml in was welcome. That stimulation did the baby a world of good. Regarding re-aspiration, that might have been an option. I had a very short transport time, and the leg did not begin to get red until seconds before arrival at the ED so I did not consider it. The child was admitted to the regional hospital, stayed 2 days and was released. No NICU at this hospital.

Thanks again for the input.

[fiznat]

Did your pedi meet the size requirements for the IO? I know they say we shouldn't be putting them in patients under 3kg.

[Kaisu]

Did your pedi meet the size requirements for the IO? I know they say we shouldn't be putting them in patients under 3kg.

Kid was weighed at the hospital... 6lbs 8 ounces. I estimated the kid at 6lbs. for total fluid bolus of 50ml. The child had arrested and I did not want him to arrest again. The call came up at run review and the consensus was that it was a good call with things done right. It was the first of my cases to come up for review and it was gratifying. I still run every call through my mental databases and the ones that I need help with I talk to you folks. Thank you for being there.

[Camulos]

Did your pedi meet the size requirements for the IO? I know they say we shouldn't be putting them in patients under 3kg.

Don't know how useful this info is with protocol restrictions and all but you can use an 18G needle in a neonate in place of an I/O needle if necessary. This is commonly done in NICU according to my wife who is both NICU and PICU trained. I have no experience with this though and she has only ever seen it in hospital.

Stay safe,

Camulos

[FL_Medic]

Don't know how useful this info is with protocol restrictions and all but you can use an 18G needle in a neonate in place of an I/O needle if necessary. This is commonly done in NICU according to my wife who is both NICU and PICU trained. I have no experience with this though and she has only ever seen it in hospital.

Stay safe,

Camulos

That is interesting, you would think a regular IV cath might be too flexible. I guess in a neonate, it doesn't take much.