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

[Aidey]

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.

 

[18G]

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

 

[usafmedic45]

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."

 

[Aidey]

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.

 

[boingo]

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

 

[TransportJockey]

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.

 

[cruiseforever]

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

 

[usafmedic45]

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.

 

[boingo]

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.

 

[Aidey]

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.

 

[Veneficus]

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.

 

[systemet]

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.

 

[Melbourne MICA]

To UV or not to UV that is the question.

Please ignore - wrong UV

 

[DitchDoctorGabe]

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.

 

[Hockey]

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

 

[Veneficus]

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.

 

[Melbourne MICA]

UV vein -umbilical that is.

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?

 

[8jimi8]

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?

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

 

[Melbourne MICA]

Uv

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

 

[8jimi8]

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

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