Neonatal infections — MCQs

Question 71: A 3-week-old boy is brought to the emergency department by his parents because of a 3-day history of progressive lethargy and difficulty feeding. He was born at term and did not have difficulty feeding previously. His temperature is 39.4°C (103°F), pulse is 220/min, respirations are 45/min, and blood pressure is 50/30 mm Hg. Pulse oximetry on 100% oxygen shows an oxygen saturation of 97%. Examination shows dry mucous membranes, delayed capillary refill time, and cool skin with poor turgor. Despite multiple attempts by the nursing staff, they are unable to establish peripheral intravenous access. Which of the following is the most appropriate next step in management?

• A. Intraosseous cannulation (Correct Answer)
• B. Ultrasound-guided antecubital vein cannulation
• C. Internal jugular vein cannulation
• D. Intramuscular epinephrine
• E. Rapid sequence intubation

Explanation: ***Intraosseous cannulation*** - This infant is in **pediatric septic shock** with signs of **poor perfusion** (delayed capillary refill, cool skin, poor turgor, hypotension) and **difficulty obtaining peripheral intravenous access**. - **Intraosseous (IO) access** is recommended in pediatric emergencies when IV access cannot be established rapidly, providing a route for fluids, medications, and blood products. *Ultrasound-guided antecubital vein cannulation* - While ultrasound can improve success rates for peripheral IVs, the **critical condition** of this infant necessitates immediate vascular access, making IO a faster and more reliable option when peripheral attempts fail. - Delaying definitive fluid resuscitation and medication administration to attempt a more technically challenging peripheral IV could worsen the patient's outcome. *Internal jugular vein cannulation* - **Central venous access (e.g., internal jugular)** is a more invasive and time-consuming procedure with higher risks (e.g., pneumothorax) and is not the first-line access in an emergent, unstable pediatric patient due to the time constraint. - **IO access** is a quicker and safer route for immediate life-saving interventions in pediatric emergencies. *Intramuscular epinephrine* - **Intramuscular epinephrine** is primarily used for the treatment of **anaphylaxis** or in certain cardiac arrest algorithms, neither of which is the primary concern here. - This patient is in septic shock requiring fluid resuscitation and likely antibiotics, which cannot be adequately delivered via intramuscular injection. *Rapid sequence intubation* - While intubation might be considered if the patient's respiratory status deteriorates further or for airway protection, the **immediate priority** is to address the **shock** and **poor perfusion** through vascular access and fluid resuscitation. - **Intubation** alone will not correct the underlying circulatory collapse and shock state.