Interosseous Access for the Neonate in Need

The neonate in shock strikes fear into even the most veteran physicians (and certainly makes my brain slip a gear or three). Part of the reason is that it happens relatively infrequently (why simulation training is helpful); however, another reason is that many times this critically ill patient is difficult to get IV access on. They have small vessels, under a relatively large amount of subQ tissue, and they are often profoundly dehydrated.

Options:

• Umbilical Vein – Emergent (not prolonged) access
  • Recall that the recently born comes with ready-made central access.
  • The umbilical vein can be used up to ~2 weeks of age.
  • The location of the cord clamp will affect your decision.
  • It is not a difficult procedure… but does take planning and practice. (see video on Blog for instructions).

• Interosseous Line – yes, even in neonates and newborns!
  • May be used in any age patient (newborn to elderly).
  • May be quicker and more easily performed than umbilical vein catheterization.
  • The marrow space functions as a non-collapsible vein.
  • Absorption from the medullary cavity to the systemic circulation is rapid (although slower than intravenous).
  • Tibia and Femur are the preferred sites because of their well developed marrow cavity, even in neonatal period.
  • Even after obtaining interosseous access, peripheral or central access should still be obtained as the interosseous route has a slower rate of infusion and, therefore, cannot reverse hypovolemic shock easily.
  • All pediatric resuscitation drugs may be given through IO.
  • Blood aspirated from IO may be used for electrolytes, glucose, BUN/creatinine and blood type and cross-match.
    • A CBC will be erroneous.

Hodge, D., Intraosseous Infusion, in Textbook of Pediatric Emergency Procedures, 2nd Edition, C. King and F.M. Henretig, Editors. 2008, Lippincott Williams & Wilkins. p. 281-288.
Ellemunter, H., et al., Intraosseous lines in preterm and full term neonates. Arch Dis Child Fetal Neonatal Ed, 1999. 80(1): p. F74-5.
Abe, K.K., G.T. Blum, and L.G. Yamamoto, Intraosseous is faster and easier than umbilical venous catheterization in newborn emergency vascular access models. Am J Emerg Med, 2000. 18(2): p. 126-9.
Garro, A.C. and J.G. Linakis, Umbilical Vessel Catheterization, in Textbook of Pediatric Emergency Procedures, 2nd Edition, C. King and F.M. Henretig, Editors. 2008, Lippincott Williams & Wilkins. p. 483-491.