Why are neonatal patients a challenge for IV therapy?

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tiple medications through only oneline, including parenteral nutrition, andwe don't want to interrupt its infusionfor a long period of time, a rapid infu­sion of the medication may result in itnot being as well buffered or dilutedby the blood, which can lead to vascu­lar damage and a short indwelling timefor the peripheral N catheter. Forexample, drug textbooks state that oneshould infuse ampicillin over 3 to 20minutes, and I was always a 3 minuteinfusion proponent-get it in as fast asyou can. But if you watch the baby'sresponse as you do that, the largerterm infant will start to cry and pulltheir hand away dUring the infusion,which is a typical sign of pain. Ampi­cillin has a pH of 8 to 10, so it is analkaline drug, and we know that thosetypes of drugs can be more painful. So,we need to step back and considerwhat we are doing and why we aredoing it and find better ways to do it.

According to the mythology, a cen­tral venous catheter is too risky to usein an infant in the N1CU. In fact, insome facilities' data show that thesecatheters can be risky because of howthey are utilized. If you consider thereported outcomes with central venouscatheters, especially the very low ratesof complications, central catheters maybe a better approach. When I firststarted working with these smallpatients, I was working with a pediatricsurgeon who required us to use everyperipheral vein we could find until hewould insert a central venous catheter.So we nurses became proficient atplacing peripheral N catheters. But thispractice forced us to look at all of thedamage use of peripheral catheters didto those veins and the conse­quences/complications of infusing vari­ous medications through them. Nowwe have changed to a more proactiveapproach and babies are getting centrallines much earlier in their stay, particu­larly if they are going to the operatingroom for a procedure

Another myth is that central lines aretoo costiy. If you look at how youexpense things out, it is not just dollarsthat we should be talking about, butalso the physiological stress on theinfants caused by replacing peripheral N

catheters. Since an average indwellingtime period of a peripheral N catheter is20 to 40 hours, some babies will requiremultiple access devices.

When you just touch many prema­ture infants, they can have significantepisodes of oxygen desaturation orapnea because they just cannot toleratethe manipulation. Such a response indi­cates that we are taking a big physio­logical risk every time we touch them todo a procedure, so multiple insertionsto replace peripheral N catheters can becastiy in terms other than money.

Occluded central catheters must bereplaced, some believe. Many N1CUswill not try to salvage occluded cathe­ters, whether they are umbilical cathe­ters or any central catheter because it isthought that the urokinase or tPA is toorisky. There are some case reportsavailable about using these agents toclear the cannulae of catheters, butthere is not a lot of data to supporttheir use in neonatal patients. How­ever, there have not been bad or pooroutcomes reported with the use ofthese agents either. You really do haveto weigh the risk and the benefit, andremember that most of the throm­bolytic agent will stay within the lumenof the catheter, and very lime of it getsout into the patient's system.

A last, but perbaps not final, myth isthat one should remove a central cathe­ter at the first sign of infection. If youhave ever worked with babies, youknow that anything they do that isabnonnaI is a sign of infection. Whetherthey throw up, have episodes wherethey stop breathing, have a fever, or dis­play other symptoms, they all can be asign of infection. We need to evaluatethe symptoms critically before removingthe catheter because that central linecatheter may be the only vascularaccess that baby has. If the infant trulyhas an infection, the infant may needgood access for the infusion of antibi­otics until you can replace the currentaccess (if you think in fact that it hasbeen colonized and is the source of theinfection). What many N1CUs are doingis a more proactive approach to manag­ing infections- they will draw the cul­tures, institute an antimicrobialtreatment, then watch the baby's