Life as a vascular access nurse can be very challenging and diverse in a pediatric hospital. A typical day is fast-paced and includes neonatal, pediatric, and adult patients. Veins may be small, tortuous and often found in unusual locations, eg an extremity or scalp vein. For many patients, imaging tools such as ultrasound are essential for successful placement of IVs, midline catheters, and PICCs. The Vascular Access Team sees patients in both the inpatient and outpatient settings. While many of our procedures are routine, a phone call in February 2017 forever changed the way we view our specialty of vascular access.
The caller on the phone was Amy from the Cincinnati Zoo Marketing Department. She described an urgent clinical situation with Fiona, a 3-week-old premature hippo who was dehydrated and needed IV access. The Zoo staff was desperate as Fiona was not taking any bottles and her IVs were only lasting 8–12 hours. Amy had previous experience with the Vascular Access Team when her daughter had surgery at our institution. She referred to our team as the “Vein Whisperer.” Amy wanted to know if we would be able to use the same tools we used on her daughter to gain IV access with Fiona.
Fiona was already a star in the eyes of the Cincinnati community. Fiona was born on January 24, 2017, the first premature hippo on record to survive. Fiona was small, around 30 pounds, and was being cared for by a specialized team of experts at the Zoo. Her day-to-day progress was being reported on social media and the local news.
My answer to Amy was, “Of course we can help Fiona!” In my mind, I was thinking of all the things we would need to bring to the Zoo. Supplies included an ultrasound machine, probe cover, ultrasound gel, skin antisepsis, varying sizes and lengths of IV and midline catheters, dressings, etc. I kept thinking…this is a premature hippo, what will we need to insert and maintain the catheter? I asked my colleague Blake to accompany me to the Zoo. Blake is an experienced vascular access nurse and is always up for a challenge! We gathered all our supplies and began our journey to the Zoo.
We arrived in the Hippo Cove area of the Cincinnati Zoo. We met two of the veterinarians who updated us on her condition. Fiona was dehydrated, on oxygen, and extremely weak. They described her condition as critical. We put on special scrubs and removed our shoes. As we were led into the small room where Fiona was, the room temperature was very warm as an effort to maintain Fiona’s body temperature. Fiona was on the floor, laying on a blanket.
Fiona was surrounded by 2–3 Hippo team specialists. Amid their worried looks, they quickly reviewed Fiona’s history, IV access issues, and her inability to take a bottle. Fiona was receiving nutrition through an intermittent naso-gastric tube.
Time was of the essence; we began setting up the 2D ultrasound machine and the necessary supplies. Initially, I scanned her head to assess for any scalp veins, there were no visible veins identified. Blake began scanning her hind leg; she was able to locate a viable vein, about 0.2 cm below the skin. The vein easily compressed and had a straight pathway. Based on her assessment and fluid requirements, we decided to use a 3Fr 8cm midline catheter.
The vein was accessed under ultrasound guidance, using a transverse approach. The midline catheter initially threaded with ease but we were unable to advance it fully. Fluids were connected to the catheter but it only lasted 20 minutes before leaking. The midline catheter was discontinued. Another vein was visualized under ultrasound guidance on the hind leg; the midline catheter was trimmed to 7 cm and threaded with ease. The midline catheter flushed and aspirated with ease.
Due to Fiona’s occasional activity of standing up, we really wanted a secure catheter. The midline catheter was sutured to her skin and a dressing was applied. We discussed the care and maintenance with the veterinary staff, and the decision was made to infuse continuous fluids through her midline catheter to maintain patency.
Over the next 2 days, Fiona gradually began to regain her strength. She began slowly taking her bottles and standing up. Fiona received 5 liters of fluids over 6 days through her midline catheter. The catheter was discontinued on day 6.
Fast forward and now Fiona has celebrated her 1st birthday. She did so with the Hippo team that provided the delicate care that she needed. The Vascular Access Team is so proud to have been part of her care. On that cold February day, we were able to use our 20+ years of experience and knowledge to provide the right catheter under imaging to provide her with the lifesaving fluids she needed.
Have you performed ultrasound in an unusual situation? Tell us your story by commenting below or letting us know on Twitter: @AIUM_Ultrasound.
Darcy Doellman MSN, RN, CRNI, VA-BC, is Clinical Manager of the Vascular Access Team at Cincinnati Children’s Hospital.