Use of Intraosseous Vascular Access During Neonatal Resuscitation at a Tertiary Center

Pediatric Burns: From Acute Care Through Reconstruction in 2024

Children are disproportionately affected by burn injuries. Differences between adult and pediatric burns range from epidemiologic characteristics to pathophysiological considerations, which vary between different age subgroups. All these factors must be considered in each phase of burn care. This article reviews the most important aspects of the management of a pediatric burned patient starting from the acute through reconstructive phases.

Nurses' knowledge and self-assessment of their clinical experiences of intraosseous access: A multicentre cross-sectional study

BACKGROUND

Intraosseous access is an effective and safe option when difficult vascular access occurs. The knowledge, competence, and clinical experience of nurses are collectively essential for the successful implementation of this approach in clinical practice. Education and clinical learning are the main pillars supporting this new practice to ensure patient safety. The aim of this study was to identify the nurses' knowledge and clinical experience of intraosseous access and the factors associated with the adoption of this procedure.

METHODS

A cross-sectional study was carried out from October to December 2020. A convenience sample of 432 nurses from four Italian hospitals were involved. A structured questionnaire was used to assess the nurses' knowledge of the intraosseous access guidelines and their clinical experience.

RESULTS

Most participants were female (71.5%) with more than 10 years of experience (63.7%) working in an emergency (38.9%) and medical (37.7%) setting. Most of the participants demonstrated their knowledge of the use of a device e.g., it is used if vascular access is not rapidly achieved in a child (83.1%) and the boluses of liquids required in the intraosseous procedure (72.7%). A few participants reported having placed intraosseous access (3.5%). A higher level of educational preparation and working in emergency and paediatric settings were associated with increased knowledge.

CONCLUSIONS

Our findings highlighted a sub-optimal level of knowledge of the IO procedure, little experience of this practice in clinical contexts, also associated with a lack of adequate protocols and devices available to nurses. Nurses need to develop their knowledge and practice the skill clinically to embed this practice. University and nurse educators should emphasise the relevance of this practice in nursing education and training, so as to improve the nursing care practice and level of patient safety.

Chest compressions and medications during neonatal resuscitation

Prolonged resuscitation in neonates, although quite rare, may occur in response to profound intractable bradycardia as a result of asphyxia. In these instances, chest compressions and medications may be necessary to facilitate return of spontaneous circulation. While performing chest compressions, the two thumb method is preferred over the two finger technique, although several newer approaches are under investigation. While the ideal compression to ventilation ratio is still uncertain, a 3:1 ratio remains the recommendation by the Neonatal Resuscitation Program. Use of feedback mechanisms to optimize neonatal cardiopulmonary resuscitation (CPR) show promise and are currently under investigation. While performing optimal cardiac compressions to pump blood, use of medications to restore spontaneous circulation will likely be necessary. Current recommendations are that epinephrine, an endogenous catecholamine be used preferably intravenously or by intraosseous route, with the dose repeated every 3-5 minutes until return of spontaneous circulation. Finally, while the need for volume replacement is rare, it may be considered in instances of acute blood loss or poor response to resuscitation.

Intraosseous access in neonates is feasible and safe - An analysis of a prospective nationwide surveillance study in Germany

BACKGROUND

This was a prospective surveillance study to investigate reports on the safety and frequency of use of intraosseous (IO) access in neonates.

METHODS

Over a two-year period, paediatric hospitals in Germany were asked to report all cases of IO access to the nationwide Surveillance Unit for Rare Paediatric Diseases (ESPED). Hospitals reporting a case submitted responses via an anonymised electronic questionnaire, providing details on indication, success rate, system used, location, duration to first successful IO access, complications, alternative access attempts and short-term outcome. We present a subset of data for IO use in infants of less than 28 days.

RESULTS

A total of 161 neonates (145 term and 16 preterm born infants) with 206 IO access attempts were reported. In 146 neonates (91%), IO access was successfully established, and success was achieved with the first attempt in 109 neonates (75%). There was no significant impact of gestational age or provider's educational level on success rates. In 71 infants with successful IO access (79%), the estimated duration of placement was less than 3 min. The proximal tibia was the predominant site used. A semiautomatic battery-driven device was used in 162 attempts (88%). The most often applied medications via IO access were crystalloid fluid and adrenaline. Potentially severe complications occurred in 9 patients (6%).

CONCLUSION

Within this surveillance study, IO access in neonates was feasible and safe. IO access is an important alternative for vascular access in neonates.

The Use of a Disposable Umbilical Clamp to Secure an Umbilical Venous Catheter in Neonatal Emergencies—An Experimental Feasibility Study

Recent guidelines recommend the umbilical venous catheter (UVC) as the optimal vascular access method during neonatal resuscitation. In emergencies the UVC securement may be challenging and time-consuming. This experimental study was designed to test the feasibility of new concepts for the UVC securement. Umbilical cord remnants were catheterized with peripheral catheters and secured with disposable umbilical clamps. Three different securement techniques were investigated. Secure 1: the disposable umbilical clamp was closed at the level of the inserted catheter. Secure 2: the clamp was closed at the junction of the catheter and plastic wings. Secure 3: the setting of Secure 2 was combined with an umbilical tape. The main outcomes were the feasibility of fluid administration and the maximum force to release the securement. This study shows that inserting peripheral catheters into the umbilical vein and securing them with disposable umbilical clamps is feasible. Rates of lumen obstruction and the effectiveness of the securement were superior with Secure 2 and 3 compared to Secure 1. This new approach may be a rewarding option for umbilical venous catheterization and securement particularly in low-resource settings and for staff with limited experience in neonatal emergencies. However, although promising, these results need to be confirmed in clinical trials before being introduced into clinical practice.

Delivery Room Care for Premature Infants Born after Less than 25 Weeks' Gestation-A Narrative Review

Premature infants born after less than 25 weeks' gestation are particularly vulnerable at birth and stabilization in the delivery room (DR) is challenging. After birth, infants born after <25 weeks' gestation develop respiratory and hemodynamic instability due to their immature physiology and anatomy. Successful stabilization at birth has the potential to reduce morbidities and mortalities, while suboptimal DR care could increase long-term sequelae. This article reviews current neonatal resuscitation guidelines and addresses challenges during DR stabilization in extremely premature infants born after <25 weeks' gestation at the threshold of viability.

Successful Postnatal Cardiopulmonary Resuscitation Due to Defibrillation

An asphyxiated term neonate required postnatal resuscitation. After six minutes of cardio-pulmonary resuscitation (CPR) and two doses of epinephrine, spontaneous circulation returned, but was shortly followed by ventricular fibrillation. CPR and administration of magnesium, calcium gluconate, and sodium bicarbonate did not improve the neonate’s condition. A counter shock of five Joule was delivered and the cardiac rhythm immediately converted to sinus rhythm. The neonate was transferred to the neonatal intensive care unit and received post-resuscitation care. Due to prolonged QTc and subsequently suspected long-QT syndrome propranolol treatment was initiated. The neonate was discharged home on day 14 without neurological sequelae.

Delivery Room Management of Asphyxiated Term and Near-Term Infants

Approximately 800,000 newborns die annually due to birth asphyxia. The resuscitation of asphyxiated term newly born infants often occurs unexpected and is challenging for healthcare providers as it demands experience and knowledge in neonatal resuscitation. Current neonatal resuscitation guidelines often focus on resuscitation of extremely and/or very preterm infants; however, the recommendations for asphyxiated term newborn infants differ in some aspects to those for preterm infants (i.e., respiratory support, supplemental oxygen, and temperature management). Since the update of the neonatal resuscitation guidelines in 2015, several studies examining various resuscitation approaches to improve the outcome of asphyxiated infants have been published. In this review, we discuss current recommendations and recent findings and provide an overview of delivery room management of asphyxiated term newborn infants.