1
SP r n g 20 00 "'VAC 19 tiple medications through only one line, including parenteral nutrition, and we don't want to interrupt its infusion for a long period of time, a rapid infu- sion of the medication may result in it not being as well buffered or diluted by the blood, which can lead to vascu- lar damage and a short indwelling time for the peripheral N catheter. For example, drug textbooks state that one should infuse ampicillin over 3 to 20 minutes, and I was always a 3 minute infusion proponent-get it in as fast as you can. But if you watch the baby's response as you do that, the larger term infant will start to cry and pull their hand away dUring the infusion, which is a typical sign of pain. Ampi- cillin has a pH of 8 to 10, so it is an alkaline drug, and we know that those types of drugs can be more painful. So, we need to step back and consider what we are doing and why we are doing it and find better ways to do it. According to the mythology, a cen- tral venous catheter is too risky to use in an infant in the N1CU. In fact, in some facilities' data show that these catheters can be risky because of how they are utilized. If you consider the reported outcomes with central venous catheters, especially the very low rates of complications, central catheters may be a better approach. When I first started working with these small patients, I was working with a pediatric surgeon who required us to use every peripheral vein we could find until he would insert a central venous catheter. So we nurses became proficient at placing peripheral N catheters. But this practice forced us to look at all of the damage use of peripheral catheters did to those veins and the conse- quences/complications of infusing vari- ous medications through them. Now we have changed to a more proactive approach and babies are getting central lines much earlier in their stay, particu- larly if they are going to the operating room for a procedure Another myth is that central lines are too costiy. If you look at how you expense things out, it is not just dollars that we should be talking about, but also the physiological stress on the infants caused by replacing peripheral N catheters. Since an average indwelling time period of a peripheral N catheter is 20 to 40 hours, some babies will require multiple access devices. When you just touch many prema- ture infants, they can have significant episodes of oxygen desaturation or apnea because they just cannot tolerate the manipulation. Such a response indi- cates that we are taking a big physio- logical risk every time we touch them to do a procedure, so multiple insertions to replace peripheral N catheters can be castiy in terms other than money. Occluded central catheters must be replaced, some believe. Many N1CUs will not try to salvage occluded cathe- ters, whether they are umbilical cathe- ters or any central catheter because it is thought that the urokinase or tPA is too risky. There are some case reports available about using these agents to clear the cannulae of catheters, but there is not a lot of data to support their use in neonatal patients. How- ever, there have not been bad or poor outcomes reported with the use of these agents either. You really do have to weigh the risk and the benefit, and remember that most of the throm- bolytic agent will stay within the lumen of the catheter, and very lime of it gets out into the patient's system. A last, but perbaps not final, myth is that one should remove a central cathe- ter at the first sign of infection. If you have ever worked with babies, you know that anything they do that is abnonnaI is a sign of infection. Whether they throw up, have episodes where they stop breathing, have a fever, or dis- play other symptoms, they all can be a sign of infection. We need to evaluate the symptoms critically before removing the catheter because that central line catheter may be the only vascular access that baby has. If the infant truly has an infection, the infant may need good access for the infusion of antibi- otics until you can replace the current access (if you think in fact that it has been colonized and is the source of the infection). What many N1CUs are doing is a more proactive approach to manag- ing infections- they will draw the cul- tures, institute an antimicrobial treatment, then watch the baby's

Why are neonatal patients a challenge for IV therapy?

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S P r n g 20 0 0 "'VAC 19

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