The quality of cardiopulmonary resuscitation using supraglottic airways and intraosseous devices: A simulation trial

Nursing Staff Knowledge on the Use of Intraosseous Vascular Access in Out-Of-Hospital Emergencies

In healthcare practice, there may be critically injured patients in whom catheterisation of a peripheral venous access is not possible. In these cases, intraosseous access may be the preferred technique, using an intraosseous vascular access device (IOVA). Such devices can be used for infusion or administration of drugs in the same way as other catheterisations, which improves emergency care times, as it is a procedure that can be performed in seconds to a minute. The aim of this study was to analyse the level of knowledge of nursing staff working in emergency departments regarding the management of the intraosseous vascular access devices. To this end, a cross-sectional online study was carried out using an anonymous questionnaire administered to all professionals working in emergency and critical care units (ECCUs) in Granada district (Spain). The results show that 60% of the participants believe that with the knowledge they have, they would not be able to perform intraosseous vascular access, and 74% of the participants believe that the low use of this device is due to insufficient training. The obtained results suggest that the intraosseous access route, although it is a safe and quick way of achieving venous access in critical situations, is considered a secondary form of access because the knowledge of emergency and critical care professionals is insufficient, given the totality of the participants demanding more training in the management of intraosseous access devices. Therefore, the implementation of theoretical/practical training programmes related to intraosseous access (IO) could promote the continuous training of nurses working in ECCUs, in addition to improving the quality of care in emergency and critical care situations.

Implementation of a Pediatric Emergency Department Cardiopulmonary Resuscitation Quality Bundle

BACKGROUND AND OBJECTIVES

We have previously demonstrated that standardized handoff from prehospital to hospital clinicians can improve cardiopulmonary resuscitation performance for out-of-hospital cardiac arrest (OHCA) patients in a pediatric emergency department (ED). We leveraged our previous quality improvement initiative to standardize performance of a bundle of 5 discrete aspects of resuscitation for OHCA patients: intravenous or intraosseous catheter (IV/IO) access, epinephrine administration, advanced airway placement, end-tidal capnography (ETCO2) application, and cardiac rhythm verbalization. We aimed to reduce time to completion of the bundle from 302 seconds at baseline to less than 120 seconds within 1 year.

METHODS

A multidisciplinary team performed video-based review of actual OHCA resuscitations in our pediatric ED. We designed interventions aimed at key drivers of bundle performance. Interventions included specific roles and responsibilities and a standardized choreography for each bundle element. To assess the effect of the interventions, time to performance of each bundle element was measured by standardized review of video recordings from our resuscitation bay. Balancing measures were time off the chest and time to defibrillator pad placement.

RESULTS

We analyzed 56 cases of OHCA from May 2019 through May 2021. Time to bundle completion improved from a baseline of 302 seconds to 147 seconds. Four of 5 individual bundle elements also demonstrated significant improvement. These improvements were sustained without any negative impact on balancing measures.

CONCLUSIONS

Standardized choreography for the initial minutes of ED cardiac arrest resuscitation shows promise to decrease time to crucial interventions in children presenting to the pediatric ED with OHCA.

Using briefing, simulation and debriefing to improve human and system performance

Safety, effectiveness and efficiency are keys to performance in all high-risk industries; healthcare is no exception, and neonatal-perinatal medicine is one of the highest risk subspecialties within healthcare. Briefing, simulation and debriefing are methods used by professionals in high-risk industries to reduce the overall risk to life and enhance the safety of the human beings involved in receiving and delivering the services provided by those industries. Although relatively new to neonatal-perinatal medicine, briefing, simulation and debriefing are being practiced with increasing frequency and have become embedded in training exercises such as the Neonatal Resuscitation Program (NRP) of the American Academy of Pediatrics (AAP). This chapter will define these terms and offer examples as to how they are used in high-risk activities including neonatal-perinatal medicine.

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures

The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of appropriately trained staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

Randomized controlled trials of simulation-based interventions in Emergency Medicine: a methodological review

The number of trials assessing Simulation-Based Medical Education (SBME) interventions has rapidly expanded. Many studies show that potential flaws in design, conduct and reporting of randomized controlled trials (RCTs) can bias their results. We conducted a methodological review of RCTs assessing a SBME in Emergency Medicine (EM) and examined their methodological characteristics. We searched MEDLINE via PubMed for RCT that assessed a simulation intervention in EM, published in 6 general and internal medicine and in the top 10 EM journals. The Cochrane Collaboration risk of Bias tool was used to assess risk of bias, intervention reporting was evaluated based on the "template for intervention description and replication" checklist, and methodological quality was evaluated by the Medical Education Research Study Quality Instrument. Reports selection and data extraction was done by 2 independents researchers. From 1394 RCTs screened, 68 trials assessed a SBME intervention. They represent one quarter of our sample. Cardiopulmonary resuscitation (CPR) is the most frequent topic (81%). Random sequence generation and allocation concealment were performed correctly in 66 and 49% of trials. Blinding of participants and assessors was performed correctly in 19 and 68%. Risk of attrition bias was low in three-quarters of the studies (n = 51). Risk of selective reporting bias was unclear in nearly all studies. The mean MERQSI score was of 13.4/18.4% of the reports provided a description allowing the intervention replication. Trials assessing simulation represent one quarter of RCTs in EM. Their quality remains unclear, and reproducing the interventions appears challenging due to reporting issues.

Intraosseous Infusion as a Bridge to Definitive Access

Intraosseous (IO) needle placement is an alternative for patients with difficult venous access. The purpose of this retrospective study was to examine indications and outcomes associated with IO use at a Level 1 trauma center (January 2008–May 2015). Data points included demographics, time to insertion, intravenous (IV) access points, indications, infusions, hospital and intensive care unit length of stay, and mortality. Of 68 patients with IO insertion analyzed (63.2% blunt trauma, 29.4% penetrating trauma, and 7.4% medical), 56 per cent were hypotensive on arrival and 38.2 per cent asystolic. The most common indications for IO infusion were difficult IV access (69%) and rapid sequence intubation (20.6%). The median time to IO access was three minutes. IV access was gained after IO in 72.1 per cent of patients. Through IO access, 30.9 per cent patients received crystalloid, 29.4 per cent received Advanced Care Life Support (ACLS) medications, 25 per cent rapid sequence intubation medications, 20.6 per cent blood products, and 2.9 per cent seizure medications. Overall, 80.9 per cent were intubated in the Emergency Department (ED), 26.5 per cent had ED thoracotomy, and 20.6 per cent had a laparotomy. Median crystalloid infused through IO was 180 cc in pediatric patients and 1 L in adults, respectively. Extravasation, the most common complication, was experienced by 7.4 per cent of patients. Inhospital mortality was 72.9 per cent. IO access should be considered when there is a need for rapid intervention requiring vascular access.

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016

The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

The versatility of intraosseous vascular access in perioperative medicine: a case series

Intraosseous vascular access is a time-tested procedure that is reemerging in popularity. This is primarily a result of the emphasis on intraosseous access in the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Advanced Cardiac Life Support. Modern intraosseous insertion devices are easy to learn and use, suggesting the possibility of use beyond the resuscitation setting. We present a case series of recent intraosseous insertions for a variety of indications by anesthesiologists at our institution to demonstrate the potential utility of this alternative access technique.

Vascular Access in Resuscitation

Intraosseous vascular access is a time-tested procedure which has been incorporated into the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation. Intravenous access is often difficult to achieve in shock patients, and central line placement can be time consuming. Intraosseous vascular access, however, can be achieved quickly with minimal disruption of chest compressions. Newer insertion devices are easy to use, making the intraosseous route an attractive alternative for venous access during a resuscitation event. It is critical that anesthesiologists, who are often at the forefront of patient resuscitation, understand how to properly use this potentially life-saving procedure.