Saw this article in the NY Times this morning and it got me thinking about the infants that come into our ED with fevers. WebMD has an article for parents on the same topic. If you're a parent and found this post because your infant has a fever, call your doctor to decide what to do.
If you read the article, you'll get the basic idea of if and how we decide to treat a 1-3 month old infant with fevers. If you didn't read the article, here's how things go at our institution:
- <1> 38 C (100.4 F): CBC, blood culture, cath urinalysis, cath culture, and CSF studies. An IV is placed and heplocked, unless the baby has been vomiting or "diarrhea-ing" - then they get IV fluids. As soon as all cultures have been obtained, the infant is started on IV antibiotics (generally ampicillin and cefotaxime, and if maternal history of herpes, Acyclovir). A chest x-ray is often ordered. The infant is then admitted to the floor for scheduled IV antibiotics and observation, regardless of lab results.
- >1 month old and <3>1 month old and <3 size="4">Helpful Tips!
One of the most common patient transfers we get is infants with fever. The outlying hospital is often unable to place the IV, obtain CSF, and/or obtain urine and blood. I thought I might offer a few tips for those adult people out there who hate taking care of kids.
Pain control: We use Sweet-Ease (a very, very, very sweet sugar water that works by blocking the pain receptors) to ease the pain associated with venipuncture, catheterization, and spinal tap. Just dip the pacifier into the liquid and let the baby suck on it. If they aren't sucking well, you can use a 1cc syringe (without needle - duh) to drip the liquid into the babies mouth. Sweet-Ease is supposed to work up to 6 months of age, but seems to work best in the younger ones. I've used it and the baby did not cry once for the IV placement, blood draws, or urine catheterization. Other times it doesn't seem to help at all.
Parents: Explain to the parents what you are doing. This is a very traumatic experience - if your hospital allows them to stay in the room, give them the option to stay. Also, be sure to let them know it is OK for them to leave the room if they would rather not watch. Tell them if you'll be using Sweet-Ease (or substitute) to help with the pain.
Yourself: Don't be too proud to not stick. If you don't feel comfortable, don't do it. You could ask for a NICU nurse to come help. Or, have your local pediatric hospital take the patient. Save the baby and the parents the trauma of multiple sticks (plus, it makes you look bad when you try 18 times for an IV, then send the baby to the children's hospital and we get it first try). Unless the baby is in distress, an hour or two is not going to make a huge difference in their recovery.
Urine: Get urine first - if the baby hasn't been feeding well, you don't want to lose the urine when they pee while you're sticking them with needles. Use a 5 French catheter. Little boys are fairly easy, you just have to work a bit to get past the prostate sometimes. It helps to pull the penis towards the ceiling while you're inserting the catheter. Little girls are slightly more difficult. Newborn females have anatomy that is a little (OK, a lot) different than older females. Have your holder hold the baby's legs spread and up (think lithotomy position). With your non-dominant hand spread the labia, then pull them up to expose the urethra. When you're cleaning the area, look for the "wink" - the urethra will open up and close when you touch it with your swabs. Aim for that wink, and go for it.
IV: Look ar
ound! Don't automatically think AC (think about it: infants are always waving their arms around - not being able to bend the elbow is a pain). The pudgier the infant, the more difficult to find an AC, in most cases. Infants often have good hand/wrist veins, but try to avoid those very superficial, skinny veins. The saphenous vein tends to be a good place as well - even if you can't see it, it's there (just anterior to the medial malleolus - see the picture). Scalp veins are amazingly easy to put an IV into, but are a little freaky looking for the parents. It takes a little extra work to secure the IV as well. Finally, if your institution has a NICU, ask one of their nurses to come help you out - they're wizards with baby IVs.
Blood: If the IV is bleeding well, go ahead and get your CBC from that - about 0.5 cc is all that is necessary. The blood culture should be obtained via a separate stick than the IV to avoid contamination. Look wherever your IV isn't - hands, AC, feet, ankles, etc. I personally have a harder time drawing labs than placing IVs, so if I don't find a promising vein, I'll have someone else draw.
CSF: The physician or physican's assistant will perform the tap - a lot of our docs like to have the baby in a sitting position. If your hands are big enough, you can pull down on the baby's shoulders with your thumbs and push their abdomen with your fingers to flex their spine. It looks uncomfortable, but it makes the vertebrae open up nicely. Don't forget to use Sweet-Ease - you may need one other person to dip and hold the pacifier for the baby.
I hope this has been helpful. I may try to post more pediatric tips in the future. Do you have any tips or stories about taking care of babies with fevers in the hospital (or as a parent)?
Regarding older kids with fevers, Ian at ImpactEDNurse has a much more well written post, if you're interested.
