Difficult neonate case - what would you do?

[deleted899865]

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[DocMcCoy]

6 week old with jejunal atresia, intermittent emesis, in house since birth, posted for urgent Broviac as 24g IV has failed and primary team is unable to get PICC or peripheral access. Child has been getting TPN and there is concern for hypoglycemia and dehydration. Pediatric surgeon, PICU and NICU attendings, unable/willing to perform awake femoral central line. Pediatric anesthesiologist attempts bedside u/s IV with no success. There are femoral vein targets.

Would you attempt awake central line or try putting 22g IV in femoral vein?

Would you decline mask inducing due to high risk of aspiration?

If you would mask induce, would you proceed with case if you were unable to obtain IV access after induction? Broviac would be available for meds 30 min after procedure start per surgeon. So no IV access for 30 min while under anesthesia. Surgeon does not feel comfortable performing a femoral central line in a neonate this small (doesn't maintain that skill).

Would you do an IO? If so, when? Pre-induction, post-induction, or only if trouble in the middle of the procedure?

Would you transfer emergently to tertiary pediatric hospital?

Brutane and us guided fem line attempt. or IO if SHTF... It’s a 6 weeker I’m not putting to sleep unless I absolutely have to. They will survive. If there are targets should be facile enough with ultrasound to get access somewhere.

im not peds and this is why, but handle pyloro kids more than I’d like to that show up with no or a non functioning iv.

send it out whether I’m successful or not if my “pediatric surgeon” can’t put a line in a pedi patient.

 

[dchz]

*I'm not peds fellowship trained. But I have done A LOT of pedi hearts for someone that's not peds trained (norwoods, glen, fontan, asd, pda, cdh, etc)

This case is hard to discuss on an online forum because this is not a decision problem. This is an EXECUTION problem. You said yourself there are femoral targets. Hit the target and resuscitate the kid. Someone on some team should step up. The decision is simple: gain central access, period.

There are femoral vein targets.

Would you attempt awake central line or try putting 22g IV in femoral vein?

I would get a femoral 5 fr central line awake with US guidance. It's the same poke but 5fr is much more secure.

Would you decline mask inducing due to high risk of aspiration?

Why? the whole point was to get access. why induce at all?

Would you do an IO? If so, when? Pre-induction, post-induction, or only if trouble in the middle of the procedure?

Nope. I would not do an IO in a child this young in a non-emergent situation (although urgent) in fear of the side effects of bone growth asymmetry. Also, i've already got a 5 fr femoral central line.

Would you transfer emergently to tertiary pediatric hospital?

No, I would resuscitate instead of punting. Because that's in the child's best interest. After I resuscitate and the patient is stable I'd tell the parents to somewhere with doctors that can step up. I know it's harsh and i'm just a random person behind a keyboard on the internet. But a central line in a 6 months old with femoral veins on ultrasound shouldn't involve 3 specialties circle jerking.

 

[Arch Guillotti]

*I'm not peds fellowship trained. But I have done A LOT of pedi hearts for someone that's not peds trained (norwoods, glen, fontan, asd, pda, cdh, etc)

This case is hard to discuss on an online forum because this is not a decision problem. This is an EXECUTION problem. You said yourself there are femoral targets. Hit the target and resuscitate the kid. Someone on some team should step up. The decision is simple: gain central access, period.


I would get a femoral 5 fr central line awake with US guidance. It's the same poke but 5fr is much more secure.


Why? the whole point was to get access. why induce at all?


Nope. I would not do an IO in a child this young in a non-emergent situation (although urgent) in fear of the side effects of bone growth asymmetry. Also, i've already got a 5 fr femoral central line.


No, I would resuscitate instead of punting. Because that's in the child's best interest. After I resuscitate and the patient is stable I'd tell the parents to somewhere with doctors that can step up. I know it's harsh and i'm just a random person behind a keyboard on the internet. But a central line in a 6 months old with femoral veins on ultrasound shouldn't involve 3 specialties circle jerking.

6 weeks, not 6 months.

 

[Wolverines83]

Hold the kid down. Stick the femoral vein.

Edit: if someone has attempted to put an IV in somewhere else, they felt they could hit a vessel that is smaller than the femoral. So....the femoral should be easier.

A 6 week old should be shallow enough that a 22 is enough but just to be safe I say put a 5f in there. No point in risking ruining a vessel when you’re probably running out of targets

to be quite honest I think mask inducing this kid for a line is malpractice. A kid with full stomach precautions gets an awake IV. Period.

 

[chocomorsel]

6 weeks, not 6 months.

There is a pediatric anesthesiologist and PICU/NICU attendings there. And a peds surgeon. WTF?
Did the anesthesiologist say why he or she couldn’t do a fem line?

 

[Justice4all]

If I was doing the case (peds trained), awake IV. Only 6 weeks old. All you u need is 24G, scalp, foot, saphenous and if all else fail central access. LMX to the site and puncture.

 

[coffeebythelake]

6 week old with jejunal atresia, intermittent emesis, in house since birth, posted for urgent Broviac as 24g IV has failed and primary team is unable to get PICC or peripheral access. Child has been getting TPN and there is concern for hypoglycemia and dehydration. Pediatric surgeon, PICU and NICU attendings, unable/willing to perform awake femoral central line. Pediatric anesthesiologist attempts bedside u/s IV with no success. There are femoral vein targets.

Would you attempt awake central line or try putting 22g IV in femoral vein?

Would you decline mask inducing due to high risk of aspiration?

If you would mask induce, would you proceed with case if you were unable to obtain IV access after induction? Broviac would be available for meds 30 min after procedure start per surgeon. So no IV access for 30 min while under anesthesia. Surgeon does not feel comfortable performing a femoral central line in a neonate this small (doesn't maintain that skill).

Would you do an IO? If so, when? Pre-induction, post-induction, or only if trouble in the middle of the procedure?

Would you transfer emergently to tertiary pediatric hospital?

Think about how this will play out in the courtroom when the plaintiffs lawyer asks you why you mask induced a baby with a bowel obstruction to put in an IV.

 

[Justice4all]

This situation is similar to coming from ED after spending umpteenth hours there and coming in for emergent case T&A, appendectomy, I&D abscess, orthopedic injurt etc. Patient shows up to Preop with no IV as ED told them anesthesia would place it once asleep. NO NO NO. IV will placed prior to induction. I will accommodate with LMX and sometimes nitrous.

 

[coffeebythelake]

This situation is similar to coming from ED after spending umpteenth hours there and coming in for emergent case T&A, appendectomy, I&D abscess, orthopedic injurt etc. Patient shows up to Preop with no IV as ED told them anesthesia would place it once asleep. NO NO NO. IV will placed prior to induction. I will accommodate with LMX and sometimes nitrous.

I've seen some pretty ridiculous **** from ED but I haven't seen this happen yet.

 

[WheezyBaby]

Unrepaired atresia at 6 weeks? Surgeon can fix an atresia but not place a CVL?

 

[2buckchuck]

IO immediately, wouldn’t think twice.

 

[dchz]

6 weeks, not 6 months.

Oops misread the date.

But my point still stands given that there are femoral targets on ultrasound.

 

[vector2]

I refuse to believe this is a story involving a hospital that has a pediatric anesthesiologist, pediatric surgeon and PICU/NICU attendings on staff.

This is the kind of amateur hour nonsense you hear about at OSH before transfer to a place that's used to taking care of kids.

 

[deleted899865]

There is a pediatric anesthesiologist and PICU/NICU attendings there. And a peds surgeon. WTF?
Did the anesthesiologist say why he or she couldn’t do a fem line?

Anesthesiologist (happened to be pedi) was the sole anesthesiologist for the hospital on that day (adult and pedi). Femoral target was obtained but while going to get a 4Fr 12cm line another stat case was called that trumped the 6 week old. By the time the stat was started and settled the neonate was already actively being transferred.

 

[chocomorsel]

Anesthesiologist (happened to be pedi) was the sole anesthesiologist for the hospital on that day (adult and pedi). Femoral target was obtained but while going to get a 4Fr 12cm line another stat case was called that trumped the 6 week old. By the time the stat was started and settled the neonate was already actively being transferred.

That is the problem. Where I trained, the pedi docs where only on call for pedi cases. Not both. And my hospital was only about a 450 bed hospital and not some behemoth like my fellowship. What kind of nonsense is this?
Is this an HCA residency? Or a private practice residency where money trumps proper care? Sounds like one.

 

[IlDestriero]

This is the kind of bullshiite that gets transferred to our children’s hospital from time to time, but when the kid gets here his glucose is 50, he’s looking obviously dehydrated, hypotensive, tachy, etc. and he’s lethargic and we are left scratching our heads wondering WTF is going on at that other hospital and how 12 or more hours passed with no IV before this kid ended up here. Though our transport team could probably have placed a line. And of course then they think he’s septic and maybe he gets an urgent exploration, tons of antibiotics, etc.
If you’re at a hospital that allegedly cares for kids and you can’t place a central line, that’s a big problem. The surgeon though I’m sure thinks he’s a superstar and that his/her care is better than here because we have trainees. (Who are probably more talented than he’s is.)
If I was consulted, I would place an awake femoral central line. Resuscitate. Reevaluate. Then repair, or picc, or whatever.
In reality if the kid was stable, and real pediatric specialists couldn’t get access or only a 24, IR would do a bedside PICC in the NICU.
If the kid is unstable, any trouble with the line, etc. then they get a IO line, resuscitation, then probably easy IV access. I did that once in a crazy neonatal catastrophe transfer. I placed IO, PICC placed by IR in OR, then IV, and emergent surgery. That was a crazy case. I thought the kid was dead when I started, for real, and he was extubated, awake and alert, pink, and moving all 4 extremities at the end. No brain injury. Miracle.

 

[chocomorsel]

This is the kind of bullshiite that gets transferred to our children’s hospital from time to time, but when the kid gets here his glucose is 50, he’s looking obviously dehydrated, hypotensive, tachy, etc. and he’s lethargic and we are left scratching our heads wondering WTF is going on at that other hospital and how 12 or more hours passed with no IV before this kid ended up here. Though our transport team could probably have placed a line. And of course then they think he’s septic and maybe he gets an urgent exploration, tons of antibiotics, etc.
If you’re at a hospital that allegedly cares for kids and you can’t place a central line, that’s a big problem. The surgeon though I’m sure thinks he’s a superstar and that his/her care is better than here because we have trainees. (Who are probably more talented than he’s is.)
If I was consulted, I would place an awake femoral central line. Resuscitate. Reevaluate. Then repair, or picc, or whatever.
In reality if the kid was stable, and real pediatric specialists couldn’t get access or only a 24, IR would do a bedside PICC in the NICU.
If the kid is unstable, any trouble with the line, etc. then they get a IO line, resuscitation, then probably easy IV access. I did that once in a crazy neonatal catastrophe transfer. I placed IO, PICC placed by IR in OR, then IV, and emergent surgery. That was a crazy case. I thought the kid was dead when I started, for real, and he was extubated, awake and alert, pink, and moving all 4 extremities at the end. No brain injury. Miracle.

And that is why you are a total, humble, superstar bad ass!
Go man!!! Stay bad!!! We need more like you around here.
Would they really take the kid to the OR before they scanned he/she? I don’t do peds but this seems like jumping the gun on such a tiny thing.

 

[Arch Guillotti]

If you’re at a hospital that allegedly cares for kids and you can’t place a central line, that’s a big problem.

A lot of us take care of kids. A lot of us place central lines. My guess is that not many of us have placed a central line in a kid in a long time.

 

[Arch Guillotti]

Anesthesiologist (happened to be pedi) was the sole anesthesiologist for the hospital on that day (adult and pedi). Femoral target was obtained but while going to get a 4Fr 12cm line another stat case was called that trumped the 6 week old. By the time the stat was started and settled the neonate was already actively being transferred.

What was the case that trumped the kid? And what exactly does it mean to "obtain" the target - see the image on ultrasound? This sounds like a screwup all around.

 

[chocomorsel]

A lot of us take care of kids. A lot of us place central lines. My guess is that not many of us have placed a central line in a kid in a long time.

Do we even have pedi CVC kits? That’s a problem. Could I do it in a bind? Sure. I would have to Google what size and how deep to hub it. Obviously this is a pedi anesthesiologist and pedi surgeon. No excuses.

 

[IlDestriero]

And that is why you are a total, humble, superstar bad ass!
Go man!!! Stay bad!!! We need more like you around here.
Would they really take the kid to the OR before they scanned he/she? I don’t do peds but this seems like jumping the gun on such a tiny thing.

They’d likely scan the kid, find some equivocal findings, then consult surgery who may be aggressive or not. But if you sit on brewing sepsis and possible dead bowel for long and the kid is dead, so it would depend if they perked up with a couple 20cc/kg boluses and some d10. The assumption would be that every decision made prior to transfer was faulty based on the disaster upon arrival.
I’ve seen that too many times as well. Kid circling the drain in a podunk NICU somewhere and they wait 24-72 hours more before transfer and they are floridly septic on arrival with a positional 24 g piv and skipped a ABX dose due 12 hours earlier, of course at 2am as well.

 

[Arch Guillotti]

I am just having a hard time understanding how a place with a pediatric anesthesiologist, pediatric surgeon, NICU and PICU can transfer out a kid who needs access. Seems like the arrangement for the transfer as well as the transfer itself would take longer than the emergency that "rolled in".

 

[Hork Bajir]

I am just having a hard time understanding how a place with a pediatric anesthesiologist, pediatric surgeon, NICU and PICU can transfer out a kid who needs access. Seems like the arrangement for the transfer as well as the transfer itself would take longer than the emergency that "rolled in".

Right? Plus, I have NEVER placed a pedi CVC... But I’m pretty facile with US, I’ve done enough adult CVCs to consider myself expert. Maybe I fail to understand what is an fundamentally different about a neonate, but as long as I could see the target on US I would just place the line (and can’t imagine it would take more than 30 minutes start to finish, allowing time to d1ck around with an unfamiliar kit and marvel at how tiny all the pieces are). Anyone who does pedi care to tell me what I’m missing here?

 

[dchz]

This is the kind of bullshiite that gets transferred to our children’s hospital from time to time, but when the kid gets here his glucose is 50, he’s looking obviously dehydrated, hypotensive, tachy, etc. and he’s lethargic and we are left scratching our heads wondering WTF is going on at that other hospital and how 12 or more hours passed with no IV before this kid ended up here. Though our transport team could probably have placed a line. And of course then they think he’s septic and maybe he gets an urgent exploration, tons of antibiotics, etc.
If you’re at a hospital that allegedly cares for kids and you can’t place a central line, that’s a big problem. The surgeon though I’m sure thinks he’s a superstar and that his/her care is better than here because we have trainees. (Who are probably more talented than he’s is.)
If I was consulted, I would place an awake femoral central line. Resuscitate. Reevaluate. Then repair, or picc, or whatever.
In reality if the kid was stable, and real pediatric specialists couldn’t get access or only a 24, IR would do a bedside PICC in the NICU.
If the kid is unstable, any trouble with the line, etc. then they get a IO line, resuscitation, then probably easy IV access. I did that once in a crazy neonatal catastrophe transfer. I placed IO, PICC placed by IR in OR, then IV, and emergent surgery. That was a crazy case. I thought the kid was dead when I started, for real, and he was extubated, awake and alert, pink, and moving all 4 extremities at the end. No brain injury. Miracle.

Niicely done.

How do you know the kid didn't have any brain injury? They can have entire hemisphere removed at 10 years of age and function normally. Even if the kid had a brain injury it'd prob never manifest clinically. Such a luxury!!!

Right? Plus, I have NEVER placed a pedi CVC... But I’m pretty facile with US, I’ve done enough adult CVCs to consider myself expert. Maybe I fail to understand what is an fundamentally different about a neonate, but as long as I could see the target on US I would just place the line (and can’t imagine it would take more than 30 minutes start to finish, allowing time to d1ck around with an unfamiliar kit and marvel at how tiny all the pieces are). Anyone who does pedi care to tell me what I’m missing here?

Their skin is doughy!! Your needles and sutures will have a tough time getting through the skin.

Also their targets are smaller than one thinks. If you're facile with ultrasound it's no problem. But if you do the ultrasound-assisted central line instead of true ultrasound-guided, you're gonna have a hard time.

Lastly, length matters, both in life and in pedi central lines. So take time to measure out how far you truly want the catheter to be in before you dilate. But in general if you're good with ultrasound, neonate central lines are not a problem.

 

[GassYous]

Right? Plus, I have NEVER placed a pedi CVC... But I’m pretty facile with US, I’ve done enough adult CVCs to consider myself expert. Maybe I fail to understand what is an fundamentally different about a neonate, but as long as I could see the target on US I would just place the line (and can’t imagine it would take more than 30 minutes start to finish, allowing time to d1ck around with an unfamiliar kit and marvel at how tiny all the pieces are). Anyone who does pedi care to tell me what I’m missing here?

I've done a pedi a line on a cardiac baby and it was pretty much the same thing except smaller.

 

[Beeftenderloin]

Doing CVCs on pedi hearts we would drop a 22g angiocath and a micro wire onto the field > US guided 22g in the IJ or fem, then typical seldinger technique from there. You just need to make sure you have the right size wires to fit through a 22g.

Or, in the case of this patient, just stop at the 22g IV and BOOM “single lumen CVC.”

 

[IlDestriero]

Niicely done.

How do you know the kid didn't have any brain injury? They can have entire hemisphere removed at 10 years of age and function normally. Even if the kid had a brain injury it'd prob never manifest clinically. Such a luxury!!!

Niicely done.

How do you know the kid didn't have any brain injury? They can have entire hemisphere removed at 10 years of age and function normally. Even if the kid had a brain injury it'd prob never manifest clinically. Such a luxury!!!



Their skin is doughy!! Your needles and sutures will have a tough time getting through the skin.

Also their targets are smaller than one thinks. If you're facile with ultrasound it's no problem. But if you do the ultrasound-assisted central line instead of true ultrasound-guided, you're gonna have a hard time.

Lastly, length matters, both in life and in pedi central lines. So take time to measure out how far you truly want the catheter to be in before you dilate. But in general if you're good with ultrasound, neonate central lines are not a problem.

Niicely done.

How do you know the kid didn't have any brain injury? They can have entire hemisphere removed at 10 years of age and function normally. Even if the kid had a brain injury it'd prob never manifest clinically. Such a luxury!!!

They scanned him a couple days later when he recovered from sirs/early sepsis and his brain was normal. No seizures, back to normal, etc.
Might have lost a few IQ points, so maybe only Yale in his future?

 

[WholeLottaGame7]

Anesthesiologist (happened to be pedi) was the sole anesthesiologist for the hospital on that day (adult and pedi). Femoral target was obtained but while going to get a 4Fr 12cm line another stat case was called that trumped the 6 week old. By the time the stat was started and settled the neonate was already actively being transferred.

Were they trying to get an IJ bulb sat from the femoral vein? 12 cm is way too long. 8cm line.

 

[WholeLottaGame7]

Theoretically you could also do a caudal and then femoral/lower extremity tunneled line, if you wanted to knock out the access/procedure all at once.

But as others have said, awake central line or IO. Don't overthink it.

 

[WholeLottaGame7]

Right? Plus, I have NEVER placed a pedi CVC... But I’m pretty facile with US, I’ve done enough adult CVCs to consider myself expert. Maybe I fail to understand what is an fundamentally different about a neonate, but as long as I could see the target on US I would just place the line (and can’t imagine it would take more than 30 minutes start to finish, allowing time to d1ck around with an unfamiliar kit and marvel at how tiny all the pieces are). Anyone who does pedi care to tell me what I’m missing here?

I think the biggest difference is the wire. Instead of the coiled wire in the adult kits, it's like a braided synthetic material. I usually do a "pinch-push" technique instead of threading it off with my thumb. Also super easy to bend if you're not careful when threading or dilating, and then it's a PITA to correct.