Vascular access and drug therapy in pediatric resuscitation

Intraosseous or Peripheral IV Access in Pediatric Cardiac Arrest? Results From the French National Cardiac Arrest Registry

OBJECTIVES

Despite the evolving recommendations that favor the use of intraosseous access in pediatric resuscitation, the impact of vascular access type on survival in young children has not been demonstrated. The aim of this study was to assess the impact of the intravascular injection route on the return on spontaneous circulation, survival to hospital admission (0 day), and 30 days or survival to hospital discharge, by comparing survival rates in young children having intraosseous and peripheral IV access. The second aim was to compare the rates of favorable neurologic outcome after 30 days or survival to hospital discharge.

DESIGN

This was a multicenter retrospective comparative study between July 2011 and October 2018.

SETTING

Based on the French cardiac arrest registry data.

PATIENTS

All prepubescent (males < 12 yr old, females < 10 yr old) victims of an out-of-hospital cardiac arrest.

INTERVENTIONS

Patients with adrenaline administration by intraosseous versus peripheral venous technique were compared, using propensity score matching.

MEASUREMENTS AND MAIN RESULTS

The analysis included 603 prepubescent patients, 351 (58%) in the intraosseous group and 252 (42%) in the peripheral IV group. Intraosseous group patients were younger, lighter, with more medical cause for arrest. The intraosseous group had lower survival rates at 30 days or hospital discharge (n = 6; 1.7%) than the peripheral IV group (n = 12; 4.8%) (p = 0.030). After matching, 101 pairs of patients were created. No difference was observed on return of spontaneous circulation or 0-day survival rates (odds ratio = 1.000 [95% CI, 0.518-1.930]; odds ratio = 0.946 [95% CI, 0.492-1.817], respectively) and on 30 days or hospital discharge survival (n = 3 in both groups) (odds ratio = 1.000 [95% CI, 0.197-5.076]). Meaningful statistical evaluation of neurologic status among survivors was precluded by inadequate numbers.

CONCLUSIONS

The type of injection route (intraosseous or peripheral venous access) does not appear to have an impact on survival of out-of-hospital cardiac arrest in a prepubescent population, but limitations of propensity matching limit a definitive conclusion.

Use of Intraosseous Needles in Neonates: A Systematic Review

BACKGROUND

The use of intraosseous (IO) access during resuscitation is widely accepted and promoted in paediatric medicine but features less prominently in neonatal training. Whilst umbilical venous catheterization (UVC) is a reliable method of delivering emergency drugs and fluids, it is not always achievable in a timely manner. IO access warrants exploration as an alternative.

AIM

Conduct a systematic review of existing literature to examine the evidence for efficacy and safety of IO devices in neonatal patients, from birth to discharge.

METHOD

A search of PubMed, Ovid, Medline, and Embase was carried out. Abstracts were screened for relevance to focus on neonatal-specific literature and studies which carried out separate analyses for neonates (infants <28 days of age or resident on a neonatal unit).

RESULTS

One case series and 12 case reports describe IO device insertion into 41 neonates, delivering a variety of drugs, including adrenaline (epinephrine) and volume resuscitation. Complications range from none to severe. Cadaveric studies show that despite a small margin for error, IO devices can be correctly sited in neonates. Simulation studies suggest that IO devices may be faster and easier to site than UVC, even in experienced hands.

CONCLUSION

IO access should be available on neonatal units and considered for early use in neonates where other access routes have failed. Appropriate training should be available to staff in addition to existing life support and UVC training. Further studies are required to assess the optimal device, position, and whether medication can be delivered IO as effectively as by UVC. If IO devices provide a faster method of delivering adrenaline effectively than UVC, this may lead to changes in neonatal resuscitation practice.

Review of Routes to Administer Medication During Prolonged Neonatal Resuscitation

OBJECTIVE

During neonatal cardiopulmonary resuscitation, early establishment of vascular access is crucial. We aimed to review current evidence regarding different routes for the administration of medications during neonatal resuscitation.

DATA SOURCES

We reviewed PubMed, EMBASE, and Google Scholar using MeSH terms "catheterization," "umbilical cord," "delivery room," "catecholamine," "resuscitation," "simulation," "newborn," "infant," "intraosseous," "umbilical vein catheter," "access," "intubation," and "endotracheal."

STUDY SELECTION

Articles in all languages were included. Initially, we aimed to identify only neonatal studies and limited the search to randomized controlled trials.

DATA EXTRACTION

Due to a lack of available studies, studies in children and adults, as well as animal studies and also nonrandomized studies were included.

DATA SYNTHESIS

No randomized controlled trials comparing intraosseous access versus peripheral intravascular access versus umbilical venous catheter versus endotracheal tube versus laryngeal mask airway or any combination of these during neonatal resuscitation in the delivery room were identified. Endotracheal tube: endotracheal tube epinephrine administration should be limited to situations were no vascular access can be established. Laryngeal mask airway: animal studies suggest that a higher dose of epinephrine for endotracheal tube and laryngeal mask airway is required compared with IV administration, potentially increasing side effects. Umbilical venous catheter: European resuscitation guidelines propose the placement of a centrally positioned umbilical venous catheter during neonatal cardiopulmonary resuscitation; intraosseous access: case series reported successful and quick intraosseous access placement in newborn infants. Peripheral intravascular access: median time for peripheral intravascular access insertion was 4-5 minutes in previous studies.

CONCLUSIONS

Based on animal studies, endotracheal tube administration of medications requires a higher dose than that by peripheral intravascular access or umbilical venous catheter. Epinephrine via laryngeal mask airway is feasible as a noninvasive alternative approach for drug delivery. Intraosseous access should be considered in situations with difficulty in establishing other access. Randomized controlled clinical trials in neonates are required to compare all access possibilities described above.

Strategies for Intravenous Fluid Resuscitation in Trauma Patients

Intravenous fluid management of trauma patients is fraught with complex decisions that are often complicated by coagulopathy and blood loss. This review discusses the fluid management in trauma patients from the perspective of the developing world. In addition, the article describes an approach to specific circumstances in trauma fluid decision-making and provides recommendations for the resource-limited environment.

Telesimulation: an innovative and effective tool for teaching novel intraosseous insertion techniques in developing countries

OBJECTIVES

Telesimulation is a novel concept coupling the principles of simulation with remote Internet access to teach procedural skills. This study's objective was to determine if telesimulation could be used by pediatricians in Toronto, Ontario, Canada, to teach a relatively new intraosseous (IO) insertion technique to physicians in Africa.

METHODS

One simulator was located in Toronto and the other in Gaborone, Botswana. Instructors and trainees could see one another, see inside each other's simulators, and communicate in real time. Learner's opinions and skills were evaluated. Before and after the curriculum, physicians completed a self-assessment questionnaire, a multiple-choice test, and during session 3, a demonstration of competence using an IO infusion system was timed and scored locally and via the Internet.

RESULTS

Twenty-two physicians participated. The scores on the pretest ranged from 1 to 12 out of 15. The range of scores on the posttest was 10 to 15 out of 15. The mean (±SD) score on pre- and post-multiple choice testing increased by +5 (±2.75; 95% confidence interval [CI] for mean difference = 3.92 to 6.35). Based on McNemar's chi-square test, physicians reported a significant improvement in their comfort and knowledge inserting IO needles (p < 0.01), familiarity with the EZ-IO infusion system (p < 0.01), and knowledge handling the IO equipment (p < 0.01). Postintervention, all physicians reported that telesimulation teaching was a worthwhile experience, and 95% felt more prepared to manage pediatric resuscitation. There was no evidence of a difference in scoring or timing of IO insertion tasks whether measured locally or remotely (mean ± SD score difference = -0.11 ± 1.22 [95% CI = -0.66 to 0.43]; mean ± sd time difference = 0.01 ± 0.15 seconds [95% CI = -0.06 to 0.08 seconds]).

CONCLUSIONS

Telesimulation is a novel method for teaching procedural skills. The session improved physicians' knowledge, self-reported confidence, and comfort level in inserting the IO needle. Accurate scoring is possible via the Internet. This modality offers potential for teaching other procedural skills over distances.