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UA/UVC Lines and blue fingers/toes

NICU   (13,378 Views 15 Comments)
by nicu4me nicu4me (Member) Member

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Hi, just had a babe the other night 25 weeks, new admit whose fingers turned blue along with a streak across her abdomen that followed a path into her forearm and to the armpit. I drew labs off the UAC multilple times had dopamine going in because my means were so low and wasn't getting the response that I should have, the UA was zerod a couple of times, good wave form and after the two boluses I gave it stayed the same. Got an order for 0.2 mcg of dopamine per hour, no titration order. Means stayed in the low 20's or high teens for over 3 hours. Babe was on vent and asymptomatic (hr/sats ok). By 6:30 am I drew my last gas as we had been weaning her rate several times during the noc and I came back to add in my scheduled amp to the UVC and noticed the blue streaking and blue hand/fingers. Got an order to d/c the UA, and start a PIV for the dopamine. I immediately put the warm washcloth on the other extremity and got the doc. Within 15-20 minutes the streaking across the chest and arm were gone (doc said the bruising was there since delivery --- not so, babe was mine all noc) and before I left 1 hour after my shift was up, trying to get everything documented, the fingertips were still blue. I was taught to watch for flank, buttock, feet but I have never seen it happen to an upper extremity. I am new, this was my first noc with a UA and UVC, the babe was about 8 hours old when I got her, lines were measured at every check during her assessments, i had multiple lab draws, had someone else watch me as I had done it for the first time a month ago and performed it correctly. I also had a nippler going home who took 25 mins to nipple but was right next to this babe. Babe was still on open radiant warmer so I am sure that I was on top of any changes. Ironically the doc rounded on the babe and it wasn't five minutes when I went back to him and showed him my findings. The only thing different that I did between sending my gas was starting my amp in the UVC, and repositioning her hips slightly to the left (head was turned left) babe technically still on back due to lines. Can any of you explain why this happens? I am still new so of course someone told me that one time a kid lost his fingers, etc.... They say that it can happen quickly. I never sat down all night and know that it was a new finding with those minutes that I mentioned. I watch my babies more than some of the experienced RNs and things like this seem to happen to me. Fluids were at 3.3 and 1.0 (with the heparin) plus the dopamine at 0.2 if that makes any difference. The amp I gave was over 15 minutes with a 0.5 cc flush over 10 mins. Thanks for any help with the patho.

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BittyBabyGrower is a MSN, RN and specializes in NICU, PICU, educator.

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Was your dopamine going thru the UAC? If so, that is a big no-no and could have been one of the roots of the problem....the second is that the kid's tank was low and was having perfusion issues. We always give our Dopamine thru the UVC if available, peripheral only if no central line.

The other is that the UA lines were not in the correct position and were causing vessels to spasm when used. Were they in good position per xray?

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dawnebeth has 24 years experience and specializes in ICN.

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I had the same thought--was the dopamine going through the UAC? We never put anything in a UAC except NS or Na Ace, But whatever the case, at the first sign of blue extremities, the doctor should get an x-ray to check placement of the UAC, and quite possibly pull it. Yes, these things happen extremely quickly. The artery spasms off and there is almost complete loss of perfusion to those extremities.

I've never seen it happen in the hands either or a big blue stripe on the abdomen, but to me, that's a really bad sign and the line should be pulled immediately.

We had a baby lose a leg once because he was transported from another hospital with blue toes (bad line placement by the other hospital) and by the time he got to us, his leg from the knee down was black. Amputation was done at the hip.

Dawn

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300g has 9 years experience and specializes in NICU III/Transport.

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Yeah, I'm wondering about the dopamine infusion too. If infusing through the UAC, that could've definitely caused vasospasm after your gas draw. I have not worked at a hospital that infuses dopamine (or any inotropes) through UACs.

And not trying to be persnickety... but 0.2mcg dopamine per hour is not a proper order... maybe 2mcg/kg/min?

Regardless of the line you were infusing your dopamine through, I agree with BittyBabyGrower and Dawnebeth that it was most likely vasospasm. I've seen many o' blue toes, but never fingers like you've describe though. Interesting! I'd also like to see the positioning of the catheter on xray.

On a side note, does your unit promote midline positioning of the patient?

Edited by 300g
grammar (c:

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Thanks for the responses. It was nice to see the experience level of those that did. It was going through the UVC and yes, at 2mcg/kg/min, after I typed that I realized I didn't post it correctly. I had trouble with the BP all noc, even with the 2 boluses of NS and then 4 hours past the drip being started. I am just off orientation, so I had another nurse help me set up the med lines as the UA/UV were already in (babe was 8 hours old when I got her). Cap refill was at least 3 sec but not more than that. You know how ruddy pink they are. The lines were taped and measured correctly and I also rechecked my lines to make sure they were where they said they were supposed to be on the Kardex, they didn't move. Babe was on vent, not sedated but sleeping all noc. However, 300g's post (above mine) mentioned midline positioning. I turned her head and moved vent tubing twice during my 8 hours but closer to the time that I actually noticed the hand was when I changed her ob sponge diaper (homemade, hope you know what I mean) so I lifted her bottom to also double check for any darkening in the flank/buttocks/thigh areas. Very gently, I didn't manipulate any lines. However, I did then decide to turn her hips very, slightly towards the direction of her head in order to get her a little off her bum. I did not readjust my nest to keep her in that position, so it wasn't a full repositioning like I would normally do. I just scooted her hips to the left (same direction as her head) and it was the right side that got discolored. She had enough chest showing through the leads and mom had also been holding her hands so I know that it wasn't there for very long. I drew my last gas as I said, sent it and came back and I looked and saw it. I looked through my books and saw the vasospasm as the patho behind that and figured. I wonder if my blood pressure then was as bad as what we thought it was? The wave form was wonderful, I zerod it, it was at heart level, etc. But the peripheral ones were also in that low teen range (24 week kid). I had another nurse show me how to pull the line, so at least I learned how to do that. I just feel bad that things like this or odd things happen when I have work. I almost feel like it reflects poorly on me. I came from adults so I have to remember that kids can also go down quickly as well. A couple of weeks ago, I had a full assessment that I finished and the kid looked fine at 6:00 am and then came back that noc and found out at the 0800 assessment there were horrible loops and a previously discontinued peripheral IV line had a dark spot in the center from where it had been. I did not d/c nor have the iv line in during my shift. It was from a previous shift, which when one infiltrates on a previous shift and you have left over fluid in that area where the IV was, I always chart on it. So all these things weren't there before I left. I came back and they just said that babies that are really small can go down during your shift or after you leave, which is true but it makes me second guess myself. As for the other noc I had a more experienced nurse in my area and she was unhappy about the blood pressures and the lack of intervention by the NNP. And, I had to ask her for help because of my inexperience of drawing labs on a UA. Could I have done anything wrong during a lab draw that would have caused the vasospasm?? I drew 2.5 for "waste", drew a total of 1.2 cc for all of my many labs on the last draw (more than just my gas) and gently put back in the waste and the 0.5 cc flush. I had her watch me perform it when I started my shift and I did it that way all noc. So, thanks for the help. I know that UA/UV lines are very good to have for access but they really scare me now. Luckily this babe was on a radiant warmer and still a Q3 hour full check but I also had that nippler Q3. If the babe was in an isolette under photo, I don't know that I would have caught it as quick. Thanks, just found this website and wished that it was used more than what it is.

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300g has 9 years experience and specializes in NICU III/Transport.

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First of all,... don't be so hard on yourself. Sounds like you're doing a great job!

Just to clarify... I didn't mean to mention midline positioning in reference to the vasospasm. Midline positioning, although relevant to blood flow, has more to do with carotid supply to the brain and jugular drainage in prevention of IVH. Turning the neck like you explained restricts blood flow to/from the brain, so you should keep their entire body midline... also has a to do with developmental positioning, but that is another topic.

In reference to xray confirmation of line placement... they may not have been in correct position when initially placed. Your assessment was probably fantastic... but if they're not in the correct position from the start then your fantastic assessment wouldn't really matter. :wink2: Can you recall your patients weight and the cm mark of the lines? Your UAC should be 3 times the pt weight in kg plus 9 and your UVC should be 1/2 the UAC plus 1.

example: 1kg x 3 = 3 + 9 = 12 for UAC and 1/2 x 12 = 6 + 1 = 7 for UVC

Then confirm placement via xray... UAC line tip should be between T6-T9 and UVC line tip should be just above the level of the diaphragm.

Also sounds like your BP was low. Mean BP should have been around 25 mmHg. At 2mcg/kg/min, you had a lot of room to move up on your dopamine. Your NNP may have needed to watch that patient closer. Your waveform can still be peaked, especially if you've set your monitor at 'optimum'. Dampened waveform is more a symptom of a poorly functioning line than patient's BP. If your BPs are low via arterial line readings, you can usually confirm pretty accurately with a peripheral (like you did) and measure the right upper arm, if possible.

I'm sure you drew your labs just fine. The only thing I would add is that it should take no less than 40 seconds to withdraw or replace your blood from the line. This helps prevent rapid changes in blood pressure and subsequent perfusion.

Hope that helps!

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twinkletoes53 specializes in NICU.

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Did the baby have a double-lumen UVC? The Dopamine should have been infusing in a line all by itself, or at least Y'd in with maintenance IV fluids at a steady rate. If your Dopamine infused through a single-lumen UVC, and let's say that you gave a dose of antibiotic through the same line, or the MD ordered a fluid bolus. Dopamine should be going at a constant rate; your dose would be disrupted when it's mixed with the different rates at which your antibiotic or fluid bolus was given. The infusion may have been interrupted while the faster rates of the other medications were infusing.

I have seen blue fingers and toes in babies with lines. Remember that if a baby doesn't have an adequate BP, her body will "shunt" the blood away from her extremites, and automatically send it to the organs that need it the most (her brain, kidneys, heart, etc). I can't remember the rationale, but we put heel warmers on the extremity or arm that is opposite to the extremity that is blue. If they're both blue, we use heel warmers on both extremities. Now considering the size of these little ones, a heel warmer does a great job as a leg-warmer.

Also, without other facts I couldn't say why the baby was hypotensive. Had she had a HUS? Was she bleeding into her brain? (IVH). She may have needed a transfusion. On new VLBW babies, we like to keep their Hct above 40. Did her blood gases show a metabolic acidosis that needed to be corrected? The dose of Dopamine she was on was minute; there was room to titrate her up to a mean BP of about 25. We start our babies at a dose of 2.5 mcg/kg/min.; then per MD order, will go up every 15 minutes or so to a maximum of 10mcg. The MD could have also added Dobutamine to assist with cardiac contractility.

And remember that sometimes you do all you can, correctly and meticulously; some of the VLBW babies are just not ready for our world.

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BittyBabyGrower is a MSN, RN and specializes in NICU, PICU, educator.

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I am guessing now it was the BP and the kid as fluid depleted, and when you are fluid depleted, vasopressors won't help much. Her MAP should be about equal to her gestational age...ie her lowest map should be around 25. Were her gases metabolic? This can also indicate hypovolemia.

You did good!

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Honnête et Sérieux specializes in Flight Nurse, Pedi CICU, IR, Adult CTICU.

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Can I just say that my first impression was NEC; I've seen 'blue bellies' on babies with dead gut.

Also, I may have missed the underlying diagnosis, but if this baby had a ductal dependent defect or some mixing cardiac anomaly, then the cyanosis of the fingers and toes is not really too alarming.

I have seen "blanching" on a very rare occassion (maybe once) when flushing a UV or UA line, but never persistent discoloration related to line placement.

Also, have to agree on the dopa dose; should be wt based, and below 3 mcg/kg/min, it's not really very useful for blood pressure improvement...actually, it needs to be 5 mcg/kg/min ideally to improve the blood pressure...with exceptions.

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Yes, I had a double lumen UVC with my UA. The dopamine went into the UVC, my other port had not been used except for when I gave my boluses and later in the shift the amp. The dopamine dose was small, babe however was over 1000 g. but I can't remember how big, so if we calculate the true weight using the formula of the previous poster, for dosing as well as line placement, maybe I will get a good idea of what happened with the lines ... (when I go back for my next shift) That's why other RN was watching and complaining to me about not seeing any difference in my readings. She was just sitting at the pod and complaining about the NNP, I wasn't being negligent just did not realize like she said that I should have not had to wait for 2 back to back 11cc NS boluses given over one hour each before the NNP decided to start the drip. Then she wasn't as agressive by starting such a low rate that that in itself also was delaying my progress. And not to have a titration order (which I have had in the past), so I was left asking her questions about how long should I let it go before I call and tell that it has been effective (or not!) Low teens for my whole shift on a babe that was about 7-8 hours old when I got her and nothing was done. Gases were metabolic acidosis.

As far as the mildine positioning goes, the whole positioning thing is what I have picked up on and have been taught in our unit. Not a whole lot, except I can make a good nest that is appropriate, however having a babe supine and charting head L or head R is what everyone does. That is called repositioning, now obviously with my U lines, I can't flip but otherwise people put abd R or abd L. Some babies I go all three ways side/abd/back with each of my checks but it depends upon their digestion and if they have spells. So to the OP that said midline position are you saying that it is the best practice to have a babe on their back with head always midline? (I got it with the U lines) It makes sense to me as I said but learning my way by following others may not always be the best example. In adults you had better charted q 2 hour turns and offloading, so I do feel that I have an idea of how to position appropriately even in neonates. I have only seen/followed one person who made a flat washcloth covered in ob sponge and wrapped for placement under an abdomen of a babe on BCPAP and also a cushion for under their hoses from the head gear so they don't just float. Now I do this too. Thanks for replies. I will get back to you all on my line info.

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300g has 9 years experience and specializes in NICU III/Transport.

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babe however was over 1000 g. but I can't remember how big, ...11cc NS boluses

I'm guessing your baby was 1100g. :wink2: (NS dose of 10cc/kg)

So to the OP that said midline position are you saying that it is the best practice to have a babe on their back with head always midline?

Not really. Supine with head midline is good, so is Left or Right, or partially Left or Right... just so long as the head is midline. When you turn the patients head, it can obstruct blood flow to/from the brain. That's all I was trying to say. There really isn't any reason that umbilical lines would prevent positioning to the Left or Right... except for maybe an individual hospital's policy (that may need to be updated :D )

And just to add my :twocents: again... the baby may have been hypovolemic causing low BPs, but I disagree with the others that hypovolemia has anything to do with the finger/abdominal discoloration. I'm sticking with vasospasm due to the rapid recovery after proper intervention.

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Thanks for all the responses. Recently went back and talked with a transport RN and despite excellent placement on x-ray that sometimes vasospasms happen and the lines need to be pulled regardless. Even if we really really want them in. This tx rn has seen hesitancy to pull UAC lines because they looked perfect on xray but had obvious blue fingers/toes. Had to be persistant with NNP/MD's. So in this RN's opinion my order to pull was appropriate but the NNP hesitancy to use dopamine to get my bp up should have been more aggressive about getting a titration order. One helpful piece of advice is that sometimes the newer RN's report things that others may not and we kinda get overlooked and it may take someone with a longer term relationship to make that call to say hey, it's real do something or get up and take a look, she's reporting it as it is. So thanks for all the time and troubleshooting with me. Can't believe that it took up so much from my time off (worrying). Great network here.

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