Infant TPN Extravasation in the OR

Editor’s note: This case is for paying subscribers. Free subscribers will see a paywall.

A male infant was admitted to the NICU upon birth, diagnosed with esophageal atresia, imperforate anus, and a recto-urethral fistula.

A gastrostomy tube and ostomy were placed to maximize nutrition and growth prior to multiple future surgeries.

At 3 months of age he was scheduled for a laparoscopic-assisted pull through.

The night before surgery his tube feeds were held and the NICU ordered TPN to be infused.

The TPN was given through his single 24g PIV in the right lower extremity.

He was brought to the OR at 8:00am where anesthesiologist Dr. F placed a new 22g PIV in the left lower extremity.

Lower extremity IVs were necessary as there was a large hemangioma on the right arm and multiple failed sticks on the left arm.

The anesthesiologist Dr. F brought up central access, but surgery stated it would not be necessary as the gut would be used soon and TPN discontinued.

After induction surgical positioning included the use of stockinettes on both lower extremities, completely covering both IV sites.

The baby was positioned in lithotomy, TPN infusing at 23ml/hr through the RLE PIV and the LLE PIV used for fluids and medications.

The case was complicated by difficult foley placement requiring peds urology.

Total case time ran from 8:00am-4pm.

There were multiple anesthesiologists signed in:

• Dr. F 8:00-1:35

• Dr. B 1:35-2:30

• Dr. P 2:30-4:00

The IV pump infusing TPN never once alarmed throughout the case.

At the end of the case the drapes were removed and the right foot and ankle were discovered edematous with blistering and blanching.

An intraop plastics consult was called and an escharotomy performed.

Subscribe to read the rest.