Resuscitation by intraosseous infusion in newborn

Abstract

Establishing vascular access in a child in shock, may be difficult and delay can compromise resuscitation [1]. Intraosseous Infusion (IOI) is an alternate method if peripheral venous access is not established within three attempts or 90 seconds [2]. IOI an alternate route for neonatal resuscitation if unbilical vein catherization (UVC) or other direct venous access is not readily available [3]. Case 1 A term male neonate was received in hospital gasping. He was delivered to a 24 yr old second gravida in a vehicle en route to the hospital. A neighbor, travelling along assisted the delivery and attempted to separate the cord but failed. On examination, the neonate was gasping, heartbeat was 187 bpm, capillary refilling time>3 sec, hypothermic with gross pallor and unrecordable SpO2. There was no cry and neonatal reflexes were absent. Umbilicus was unhealthy with mud applied to it. A working diagnosis of shock due to hemorrhage was made. Immediate attempt for establishing intravenous and umbilical cannulation were unsuccessful. Intraosseous cannulation in the right tibia was done through which resuscitative fluids followed by dextrose and antibiotics were given (Fig. 1). The condition stabilized and peripheral venous access was established after 2 hours and intraosseous cannulation discontinued. The neonate improved with 2 units of blood transfusion that brought up the hematocrit. He was discharged on the 11th day and followed up till the age of 4 months. Fig. 1 Showing a 18 G disposable needle used as an intraosseous needle. A guard of any sternal or bone marrow needle is used. Case 2 A 12 day old female preterm neonate was referred from a civil hospital for recurrent apnea. Born to a primi in hospital at 34 weeks, with a birth weight of 1.7kg, she was managed conservatively and discharged on the 5th day but readmitted on the 9th day for lethargy. She was treated with antibiotics but her condition deteriorated. On admission the neonate was in shock with prolonged periods of apnea and severe bradycardia. Immediate resuscitative measures with bag mask ventilation and chest compression were started. Vascular access could not be obtained due to shock and punctured thrombosed veins due to the prior treatment. Intraosseous infusion of drugs and fluids was given and finally her condition stabilized. The IOI was discontinued after 5 hours when peripheral cannulation was established. Investigations revealed right sided pneumonia with severe septicemia. She was managed accordingly and discharged 3 weeks later and regularly followed up.