Infant intraosseous infusion

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.

Vascular access through the intraosseous route in pediatric emergencies

Obtaining venous access in critically ill children is an essential procedure to restore blood volume and administer drugs during pediatric emergencies. The first option for vascular access is through a peripheral vein puncture. If this route cannot be used or if a prolonged period of access is necessary, then the intraosseous route is an effective option for rapid and safe venous access. The present work is a descriptive and exploratory literature review. The study's aim was to describe the techniques, professional responsibilities, and care related to obtaining venous access via the intraosseous route in pediatric emergencies. We selected 22 articles (published between 2000 and 2011) that were available in the Latin American and Caribbean Health Sciences (LILACS) and MEDLINE databases and the SciELO electronic library, in addition to the current protocol of cardiopulmonary resuscitation from the American Heart Association (2010). After the literature search, data were pooled and grouped into the following categories of analysis: historical aspects and physiological principles; indications, benefits, and contraindications; professional assignments; technical principles; care during the access; and possible complications. The results of the present study revealed that the intraosseous route is considered the main secondary option for vascular access during the emergency response because the technique is quick and easily executed, presents several non-collapsible puncture sites, and enables the rapid and effective administration of drugs and fluid replacement.

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.

Infant trauma

Trauma forms the second largest cause of death in children under 1 year of age. Infants form a difficult cohort of patients; their range of development, differing physiology and inability to communicate or understand treatment makes them a challenge for any healthcare worker. Several factors compound this problem including a general lack of familiarity within non-specialised trauma services and the difficulty in studying infants as a cohort in academic research. This article aims to summarise the common problems encountered in dealing with infants in a trauma setting and specific differences in their management compared to other children or adults. Where possible it details current evidence most appropriate to the age group.