# Very random question about IO in pre-term and newborn infants.



## Aidey (Mar 31, 2011)

Since secondary ossification centers in the epiphyses don't usually form until shortly before or after birth, how does IO work in preemies and newborns whose skeletons aren't fully ossified yet and don't have the spongy bone present? Is the cartilage able to absorb and transfer infused meds/fluids just as well as the spongy bone? Or are they inserting th IO into the medullary cavity?

All googling got me was a bunch of Pubmed abstracts of cases where IO was used sucessfully in preemies (including an 800 gram pt), so it obviously works, I'm just confused about the mechanism.


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## 18G (Mar 31, 2011)

Very good question! I'm interested in any information on this too.


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## usafmedic45 (Apr 1, 2011)

> Or are they inserting th IO into the medullary cavity?



Yeah, just like any other IO procedure you're aiming for the part of the bone with marrow in it. The length of the needle and size and age of the patient is going to determine whether you're in cortical bone or the medullary cavity.  In an adult it's preferable to hit the medullary cavity (not to mention the difficulty in doing so outside of the iliac crest and sternum) because of the presence of yellow marrow as opposed to red marrow since while both are well perfused, you're much less likely to occlude the needle in red marrow.

BTW, remember they originally developed IO by putting a needle into the sternum.  I'm talking about a straight steel needle.  One of the 1940s surgical textbooks I own described what happens if you go to far in a typically British understatement along the lines of:  "If one feels a second give after inserting the needle and meets with the return of frank bright red blood- especially without needing to aspirate the syringe- the most unfortunate of all medical misadventures has occurred."


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## Aidey (Apr 1, 2011)

Thanks, I finally made it to the hospital and asked my MD.

My confusion stemed from the fact that my book was using the humerus as an example to show the epiphysis and diaphysis, and in the humerus the epiphyseal plate is at the neck of the shaft. For some reason I was assuming that the epiphyseal plate in the tibia was at the neck also. Once I saw where it actually was it all made sense.


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## boingo (Apr 1, 2011)

If we are dealing with a neonate, why not just access the UV?  Really makes more sense than an IO in my opinion.


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## TransportJockey (Apr 1, 2011)

boingo said:


> If we are dealing with a neonate, why not just access the UV?  Really makes more sense than an IO in my opinion.



I know if I tried that, even though I would know what I'm doing for the most part, I'd get crucified by my medical director and supervisor. UV is considered a central line by them, not a peripheral line, so therefore it is way outside my scope.


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## cruiseforever (Apr 1, 2011)

If you are using the EZ-IO you would be limited to the size of the pt.  3-39kg is range the company recommends.


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## usafmedic45 (Apr 1, 2011)

> If we are dealing with a neonate, why not just access the UV? Really makes more sense than an IO in my opinion.



Because it's not as easy as it sounds.


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## boingo (Apr 1, 2011)

Really?  I don't work in a NICU, but I've placed my share and can't honestly remember any difficulty, certainly a better route than IO in the newborn.


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## Aidey (Apr 1, 2011)

Do some quick searching on PubMed, the general consensus of the studies I was reading there said that IO was quicker and had less complications than UV.


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## Veneficus (Apr 1, 2011)

boingo said:


> If we are dealing with a neonate, why not just access the UV?  Really makes more sense than an IO in my opinion.



I prefer them. 

But if you haven't ever done one, because some places it is not in the medic scope, it requires special equipment, you don't just stick an angiocath in the vein.

It also requires a bit of finesse as advancing it too far can be detrimental.

Like any skill though, the less yo use it, the worse you become. 

Chances are though, if it comes to an IO in a neonate, the game is up.


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## systemet (Apr 1, 2011)

I definitely agree with the comments on UVCs.  We had the ability to do these when I worked EMS, and I never really felt fully comfortable with it.  We used to cover them in training once a year, and I remember feeling pretty confident I could put one in a sick kid when I walked out the door.  But a month? 3 months? 6 months later?  It's one of those skills that most medics are unlikely to ever have to perform.  

Like many things in EMS, I think this is something the individual provider has to take some responsibility to ensure that they remain competent at.  Unfortunately not everyone does.  I was always worried that someone was going to end up doing harm attempting to use one.


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## Melbourne MICA (Apr 3, 2011)

*To UV or not to UV that is the question.*

Please ignore - wrong UV


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## DitchDoctorGabe (Apr 3, 2011)

I agree with the UVC is a great route but not to knock anyone how often would one truly perform this procedure. The flight service I work with has a peds/neo transport team and they do this procedure fairly frequently. The other crew members are trained to do it but other than simulations we have not had many opportunities to do this. When I worked on a 911 service the physicians also stated it was a central line and we were not allowed to initiate one. I think it's interesting how each state/province can vary widely with treatment protocols.


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## Hockey (Apr 3, 2011)

UV? Umbillical Vein?  

Just wondering how difficult it is to do?  We went over it quickly in PEPP but never went much further than saying that is an option too


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## Veneficus (Apr 3, 2011)

Hockey said:


> UV? Umbillical Vein?
> 
> Just wondering how difficult it is to do?  We went over it quickly in PEPP but never went much further than saying that is an option too



It's like any other skill, if you do it a lot, you will be good at it and not find it difficult.

If you rarely ever do it, you will not be good at it and will find it difficult.


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## Melbourne MICA (Apr 4, 2011)

*UV vein -umbilical that is.*



Hockey said:


> UV? Umbilical Vein?
> 
> Just wondering how difficult it is to do?  We went over it quickly in PEPP but never went much further than saying that is an option too



Yep - umbilical vein. Never done one myself so I can't tell you what the sphincter factor is. Bit of a desperation measure really and seriously frowned upon by the Royal Childrens Hospital down here. One of our staff did it successfully but enquires were made and the RCH said no. Big risk of cannulating the artery instead, the vessels being so small and difficult to distinguish from each other.

SO it does not appear in our CPG's even in passing as a last gasp option.

MM

Venny  - you've done a few have you?


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## 8jimi8 (Apr 4, 2011)

Melbourne MICA said:


> Yep - umbilical vein. Never done one myself so I can't tell you what the sphincter factor is. Bit of a desperation measure really and seriously frowned upon by the Royal Childrens Hospital down here. One of our staff did it successfully but enquires were made and the RCH said no. Big risk of cannulating the artery instead, the vessels being so small and difficult to distinguish from each other.
> 
> SO it does not appear in our CPG's even in passing as a last gasp option.
> 
> ...



Of the 3 choices... It's the big one, no?


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## Melbourne MICA (Apr 4, 2011)

*Uv*



8jimi8 said:


> Of the 3 choices... It's the big one, no?



For a braver and more skilled practitioner than I - you bet.

MM

(Done plenty of IO's though. Still makes me cringe when you drill through the bone and hear that crucnhing sound. (We only just got BIG IO's can you believe - our ever penny pinching executives decided EASYIO was too expensive). So I'm talkin old fashioned manual drilling. You almost expect to hear some dastardly voice in the background going "WHOHAHAHAH!!!"

Still -  a great option in a pinch. We don't do any central type lines).

MM


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## 8jimi8 (Apr 4, 2011)

Melbourne MICA said:


> For a braver and more skilled practitioner than I - you bet.
> 
> MM
> 
> ...



But bravery goes out the window when you are trying to save someone's baby, eh?


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## Veneficus (Apr 4, 2011)

Melbourne MICA said:


> Big risk of cannulating the artery instead, the vessels being so small and difficult to distinguish from each other.?



What? Really? That sounds like a really poor excuse. Go to OB and ask to see the vein and arteries in a cut cord, Helen Keller could figure out where to put the catheter.

I have never even seen an mbilical artery large enough to put the prepackaged catheter in.

Infact, if you get the mother's permission to keep the cord (which isn't too hard because it is usually discarded anyway), you can actually practice on real veins in real cords. 




Melbourne MICA said:


> Venny  - you've done a few have you?



Indeed, in the hospital, not in the field. The biggest drawback I found was not putting it in too far in all the excitement and not wanting it to come out. It is definately one of those skills I felt better being coached through before doing it on my own.

The NP that taught me how to do it described it like trying to put a wet noodle into a hole in a piece of jello. I didn't find it that difficult.


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## systemet (Apr 4, 2011)

We carried kits on the ambulance, but I never had to use one.  I can't remember hearing second-hand of someone else doing it either -- although it must have happened.

Usually when we went to re-train on them, the first thing I'd do was end up dropping something on the ground.  Or brush the tip of the catheter somewhere full of bacteria.  But I guess that's why you revisit these skills periodically.  Perhaps I'm just clumsy.

At the risk of a thread derail, sometimes having a bunch of skills on paper, and having a large scope of practice, doesn't always translate into the ability to perform unless there's lots of opportunities for practice.  Suturing and femoral central lines were in my scope of practice (we carried kits for neither; carried an adult IO, and were strongly discouraged from attempting femoral venous access).  My suturing, at it's absolute best, was barely passable.  I have never started a femoral central line on a real person.

A lot of these things aren't necessarily complex.  Most of the "fancy" physician skills that occasionally filter down into EMS usually aren't that difficult to perform, it's often more a question of whether a paramedic has gets enough opportunity to use these skills to maintain competency, and whether they have the diagnostic tools and judgment skills to use them appropriately.


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## WTEngel (Apr 4, 2011)

I hate to say this... Maybe I don't have enough faith. For 99% of you talking about doing UVCs one of three things is going to happen.

You will most likely not use proper sterile technique and give the neonate a horrendous infection or introduce air into the cardiovascular system.

You will advance too far and end up in the left atrium by way of the foramen ovale or some sort of ASD.

You will false track and be nowhere near where you need to be, coiling 10 or 15 cm of catheter into the abdominal cavity doing God only knows what...

Please don't be so flippant about such an invasive procedure. There's a reason most prudent medical directors do not allow this skill for typical paramedics.


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## systemet (Apr 4, 2011)

I'm not sure if that was directed at me, but I can assure you -- I was well aware of the potential risks, and duly and appropriately scared by them.


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## 8jimi8 (Apr 4, 2011)

WTEngel said:


> I hate to say this... Maybe I don't have enough faith. For 99% of you talking about doing UVCs one of three things is going to happen.
> 
> You will most likely not use proper sterile technique and give the neonate a horrendous infection or introduce air into the cardiovascular system.
> 
> ...



Engel, where do you get 10-15cm angiocaths?  No one is trying to put a foley in an umbilical vein...


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## WTEngel (Apr 4, 2011)

I wasn't directing it at anyone particularly, I just didn't want people to get the impression that UV catheterization was easy or low risk.

As far as 10-15 cm angiocaths, I really hope that was not a serious question.


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## 8jimi8 (Apr 4, 2011)

Searching for images of uv cath kits as we speak, on my phone.  No luck so far.  In nursing or EMS education no one has described the procedure other than mentioning that it can be done for emergency resus. Could someone post a clear image and educate me please.


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## boingo (Apr 4, 2011)

WTEngel said:


> I hate to say this... Maybe I don't have enough faith. For 99% of you talking about doing UVCs one of three things is going to happen.
> 
> You will most likely not use proper sterile technique and give the neonate a horrendous infection or introduce air into the cardiovascular system.
> 
> ...



Really?  :glare:

You do know that in the resus of a neonate one does not need to place the catheter any further than beyond the abdominal wall, right?  We are looking for a route for resus meds and maybe glucose, it will be changed after the kid is stabilized.  Our neonatologists train us in using both UV catheters and a plain old angiocath, found on every ambulance on the planet.


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## systemet (Apr 4, 2011)

There's a standard description of the procedure here:-

http://www.cma.ca/index.php/ci_id/36769/la_id/1.htm

This was pretty much what I was taught to do.  We used a 5F catheter, were taught to advance it about 5cm from the cord (cut about 2 cm from the surface of the abdomen), and use the bridge technique for taping.  In the link they mention using a suture to help secure the catheter.  We weren't taught to do this.


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## 8jimi8 (Apr 4, 2011)

boingo said:


> Really?  :glare:
> 
> You do know that in the resus of a neonate one does not need to place the catheter any further than beyond the abdominal wall, right?  We are looking for a route for resus meds and maybe glucose, it will be changed after the kid is stabilized.  Our neonatologists train us in using both UV catheters and a plain old angiocath, found on every ambulance on the planet.



Thanks Boingo.  I dont feel crazy now.


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## WTEngel (Apr 4, 2011)

Here is a copy from Parkland NICU of a general UVC/UAC policy:

http://www.parklandhospital.com/other_services/pdf/900_04.pdf

Here is a link to a picture of a UVC:

http://www.utahmed.com/umbilicath.htm

Boigo, a placement just inside the abdominal wall should provide adequate access for resus, however any hypertonic fluid being administered directly into the hepatic system is bad news. I would agree that just beyond the abdominal wall is safe to say we are not in the liver. This does not mean that it is right, or what is in the best interest of the patient, especially in the presence of alternative methods of access like IO placement, or dare I say, a peripheral IV.

We can hope that we are not in the liver, we can hope that we are not infiltrating air or germs, we can hope that we did not false track into some unknown region, or we can simply do it correctly with the correct equipment and trained providers. I guess if it was my baby, I would choose the latter option.

An IO is a much safer method for the inexperienced provider, and also offers a bit more safety when administering hypertonic fluids without x ray confirmation of proper placement. 

While you may have experience with UVC and UAC placement, please do not make it sound so easy as to encourage other providers to do so without any regard for the potential dangers or complications. 

I am not directing this at you, so please don't think I am trying to make a personal insult, but this may be a skill where a little bit of knowledge is a very dangerous thing for many people.


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## boingo (Apr 4, 2011)

No worries, I don't take anything here personal, at least I try not to.  I agree, there are risks, and without adequate training and experience (or protocol) they should not be attempted.  IO is great, I just think of the 1000 Gm premie where the cord is a god send.


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## 8jimi8 (Apr 4, 2011)

WTEngel said:


> Here is a copy from Parkland NICU of a general UVC/UAC policy:
> 
> http://www.parklandhospital.com/other_services/pdf/900_04.pdf
> 
> ...



Engel,  thanks for your efforts and links.  I must point out... The first sentence of the parkland protocol says ASEPTIC.  While im not foolish enough to pretend that this shouldnt be a sterile technique.  Why do you think it doesnt say sterile?  

Are you saying that you would use the IO device that is intended for a larger neonate (>3kg ) rather than an angio cath for a resus?  ( being that you wot be able to xray /p inserting the uvc from the kit? ) sorry not trying to put words in your mouth just want access to your critical thought process.


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## WTEngel (Apr 4, 2011)

If you read through the procedure it describes using a sterile field and the steps taken to maintain a sterile environment for the provider inserting the UVC to work in. I believe the word aseptic is being used to describe the measures taken to maintain a sterile field.

The EZ IO places a minimum weight of > 3 kg for their device to be used. This does not mean that other manual devices can not be used in accordance with the manufacturer's guidelines. There has been a documented case of neonatal IO infusion in a patient around 800 grams. It all depends on what device you are using, and what your protocols state.

What would I do? I would properly place a UVC and get x ray confirmation post placement. If I was unable to get x ray confirmation (unlikely) I would be comfortable with my placement because proper measurement and insertion would have been performed. I would use the UVC with reasonable caution and get x ray confirmation as soon as possible in this case.

I would also be satisfied with a peripheral IV in most cases, and lastly an IO.

This is specific to my circumstances working on a pedi/neo specialty team. For other providers, they need to follow their protocols. If I was a medical director, I would recommend IV or IO access first. The reason being that likelihood of 
prehospital providers coming across a neonate less than 3 kg is very low. If the unlikely does occur, then the medics need to be online with medical control anyway. This is a specific enough circumstance that it needs to be dealt with on a case by case basis. 

I have no issue with medics receiving training and being familiar with UVC insertion, however I have a huge issue with medics feeling like the 4 hour CE they had on neonates that included 10 minutes of UVC material makes them qualified to up and be able to throw in a central line. Especially in the presence of other vascular access methods that the medics are more familiar with and carry lower risk of complication in many cases.


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## usafmedic45 (Apr 4, 2011)

Hell, with a neonate you can do an IO with a butterfly needle.  No need for the EZ-IO, which just seems like overkill in my book.


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## usafmedic45 (Apr 4, 2011)

> prehospital providers coming across a neonate less than 3 kg is very low



I don't know about you, but all two of the four babies I have delivered have been at or below 6.6 lbs.  6lbs 4 oz and 6 lbs 8 oz respectively.  It's not THAT uncommon.


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## Aidey (Apr 4, 2011)

Didn't realize how big of a can of worms I was opening up here.

At my service we are basically screwed. We have the EZ-IO, which bottoms out at 3kg, and typical angiocaths. No butterflys, no UV kits, etc. In theory the needle end of a twin pack would probably work, but the heck if I'm trying it. As much as I HATE to say it, the drugs would be going down the tube since that is still in the protocol.


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## 8jimi8 (Apr 4, 2011)

WTEngel said:


> If you read through the procedure it describes using a sterile field and the steps taken to maintain a sterile environment for the provider inserting the UVC to work in. I believe the word aseptic is being used to describe the measures taken to maintain a sterile field.
> 
> The EZ IO places a minimum weight of > 3 kg for their device to be used. This does not mean that other manual devices can not be used in accordance with the manufacturer's guidelines. There has been a documented case of neonatal IO infusion in a patient around 800 grams. It all depends on what device you are using, and what your protocols state.
> 
> ...



Engel, thanks for the elucidation.
  A further question, considering the fact that xray is not available outside of a hospital. I can also see that emergent births outside the hospital could have the possibility of being someone who does not have prenatal care.  Or of a lower socioeconomic class :. Also being at risk for a lower end birthweight.  
  Given that Scenario and adding in Aidey's.  Would you use the ez io for an underweight? Given that the average paramedic/RN is probably not on a specialized nicu transport team (i.e. May not be confident with a peripheral stick on a newborn) would you consider an angioath in the uvc over an offlabel use of the ezio.  Or would you have to go to the ett as Aidey mentioned.  Granted every high risk birth should be in contact c OLMC.  

Lastly, do you feel that the average paramedic is incapable of maintaining a sterile field inside the ambulance?


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## WTEngel (Apr 5, 2011)

I would not support the use of the EZIO on a patient that did not meet the manufacturer's stated criteria.

In regards to a medic choosing a UVC with angiocath over PIV access because of lack of confidence with a PIV attempt, I suppose it is all situational. My opinion is that anything worth doing is worth doing right. If a medic has the ability, equipment, and training to appropriately insert a UVC then by all means, go for it. If a medic simply decides that they aren't confident with PIV access, then I would question what their level of confidence on UVC access would be. I don't mean to come down or judge anyone, but like I mentioned earlier, if I am going to do it, I am going to do it correctly.

In a resus situation the risk benefit analysis shifts a bit. each provider will have to make a decision about what is best for the patient in conjunction with established protocols and OLMC. Whatever method the provider chooses for access, it should be done correctly.

Last, I do not believe that the vast majority of medics are capable of maintaining a sterile environment in any location, let alone the back of an ambulance. Lack of education and training....plain and simple.

If you take all of the field births you will come across in your career and remove the ones that will not need resus, I would venture to guess that most of us could count the number on one hand. The chances that the medic will even make it past airway are low. How many ambulances carry 0 and 00 blades in their airway kits? If they make it to vascular access and choose to do a UVC with whatever means they have, then they own that and defend it. The bottom line is that in times of crisis we all do the best we can with what we have. Some people's best is not as good as other people's best, and some people have more toys than others. We all do what we can with what we have.


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## 8jimi8 (Apr 5, 2011)

WTEngel said:


> I would not support the use of the EZIO on a patient that did not meet the manufacturer's stated criteria.
> 
> In regards to a medic choosing a UVC with angiocath over PIV access because of lack of confidence with a PIV attempt, I suppose it is all situational. My opinion is that anything worth doing is worth doing right. If a medic has the ability, equipment, and training to appropriately insert a UVC then by all means, go for it. If a medic simply decides that they aren't confident with PIV access, then I would question what their level of confidence on UVC access would be. I don't mean to come down or judge anyone, but like I mentioned earlier, if I am going to do it, I am going to do it correctly.
> 
> ...



Engel, thank you for your candid reply.  
I agree, it is situational and what interventions a provider initiates must eventually be legally justified.  

I appreciate your willingness to consider my questions.  I do; however disagree, about the ability of paramedics regarding sterility.  I posit that a hospital can be just a much of a breeding ground for contaminants.  If it is education, properly educated medics already have an understanding of microorganisms and further, nursing education covering sterile technique was a 2 hour lecture at most.  

Thanks again for posting up. I agree central venous access is not to be undertaken lightly.  Resuscitation being the goal, would also put me in a serious mindset.


Are pivs easy to achieve in neonates?  I will have NICU rotations in my upcoming paramedic clinicals.  I am very extremely excited.


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## Melbourne MICA (Apr 5, 2011)

*Run away, run away!!@*###*

I just bump up the dosages on my own meds, seems to help!!!

Seriously - you do what you have to do but can't ever forget that a new shift brings new patients and new situations. And in reality, bravery doesn't come into it at all. Were pro's and work as pro's. You go home at the end of the day knowing you did what you could, you did it the way it was supposed to be done and above all - you're not perect. Mistakes come with the territory.

Cheers

MM


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