Intravenous vs. Intraosseous administration of drugs during cardiac arrest (NLS 616): Systematic Review

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This Review is a draft version prepared by ILCOR, with the purpose to allow the public to comment and is labeled “Draft for Public Comment". The comments will be considered by ILCOR. The next version will be labelled “draft" to comply with copyright rules of journals. The final Review will be published on this website once a summary article has been published in a scientific Journal and labeled as “final”.

CoSTR Citation

de Almeida MF, Guinsburg R, Velaphi S, Aziz K, Perlman JM, Szyld E, Kim HS, Hosono S, Liley HG, Mildenhall L, Trevsianuto D, Kapadia VS, Rabi Y, Isayama I, Roehr CC, Schmoelzer G, Avis S, Anderson L, Wyllie JP and Wyckoff MH. Intravenous vs. intraosseus administration of drugs during cardiac arrest. [Internet] Brussels, Belgium. International Liaison Committee on Resuscitation (ILCOR) Neonatal Life Support Task Force, December 18, 2019. Available from http://ilcor.org

Collaborators

The Advanced Life Support and Pediatric Life Support Task Forces at the International Liaison Committee on Resuscitation (ILCOR).

Methodological Preamble and Link to Published Systematic Review

The continuous evidence process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review of available literature regarding the Intravenous vs. intraosseous administration of drugs during cardiac arrest (Granfelt A, 2019,. Evidence for neonatal literature was sought and considered by Life Support task forces. These data were taken into account when formulating the Treatment Recommendations.

Systematic Review

Reference not yet available

PICOST

The PICOST (Population, Intervention, Comparator, Outcome, Study Designs, and Time Frame)

  • Population: Neonates in any setting (in-hospital or out-of-hospital) with cardiac arrest (includes severe bradycardia and inadequate perfusion requiring chest compressions).
  • Intervention: Placement of an intraosseous (IO) cannula and drug administration through this IO during cardiac arrest.
  • Comparison: Placement of an intravenous (IV) cannula (umbilical vein in newly born infants) and drug administration through this IV during cardiac arrest.
  • Outcomes:
  • Death during event, within 24 hours and before hospital discharge;
  • Long term neurodevelopmental outcomes;
  • ROSC: any signs of cardiac output with HR > 60bpm, and time to ROSC;
  • Brain Injury [HIE stage 2-3 Sarnat (term only), IVH Grades III-IV, PVL (preterm only);
  • Time to secure access;
  • Morbidity related to IO (osteomylitis, fracture, epiphyseal plate injury, compartment syndrome)
    or to IV (extravasation, embolic phenomenon, phlebitis)

Study Designs:

  • Inclusion criteria: Randomized trials, non-randomized controlled trials, and observational studies (cohort studies and case-control studies) comparing IO to IV administration of drugs; Randomized trials assessing the effect of specific drugs (e.g. epinephrine) in subgroups related to IO vs. IV administration; Studies assessing cost-effectiveness for a descriptive summary.
  • Exclusion Criteria: Ecological studies, case series, case reports, reviews, abstracts, editorials, comments, letters to the editor, or unpublished studies
  • Search: All years and all languages were included as long as there was an English abstract. Medline (OVID interface), Embase (OVID interface), Cochrane Central Register of Controlled Trials – 1946 to Sep 12, 2019, and ongoing trials on International Clinical Trials Registry Plataform

A priori subgroups to be examined:

Cardiac and non-cardiac causes of circulatory collapse; Gestational Age [preterm <37 weeks and term >= 37 weeks]; Delivery Room OR other site; Hospital OR out of hospital; Central OR peripheral IV access; Paediatric trained personnel vs non paediatric

PROSPERO Registration: Pending notification

Consensus on Science:

We did not identify any evidence to address the outcome of death during event, within 24 hours and before hospital discharge; long term neurodevelopmental outcomes; ROSC; brain injury [HIE stage 2-3 Sarnat (term only), IVH Grades III-IV, PVL (preterm only); time to secure access; or morbidity related to IO placement in neonates with severe bradycardia and inadequate perfusion requiring chest compressions in any setting (in-hospital or out-of-hospital).

We did not identify any data on placement of an intraosseous cannula and drug administration through this IO in neonates with severe bradycardia and inadequate perfusion requiring chest compressions in the delivery room.

Treatment Recommendations

We suggest umbilical venous catheterization as the preferred vascular access during newborn resuscitation (weak recommendation, very low certainty of evidence).

If umbilical venous access is not feasible, the intraosseous route as vascular access during newborn resuscitation is a reasonable alternative (weak recommendation, very low certainty of evidence).

Justification and Evidence to Decision Highlights

In making this recommendation we recognize the absence of data from human neonatal studies supporting any advantage of intraosseous over umbilical venous access. There are a number of case reports of serious adverse effects of intraosseous access in neonates (Vidal 1993, 1201; Katz 1994, 258; Ellemunter 1999, F74; Carreras-Gonzales 2012, 233; Oesterlie 2014, 413; Suominen 2015, 1389).

The rate of adverse effects attributable to emergency umbilical venous catheterization is unknown. The actual route used may depend on availability of equipment, training and experience.

Knowledge Gaps

There are many gaps related to IO access and umbilical vein access in newborn during resuscitation due to the absence of clinical trials, cohort studies and case-control studies. Even case series or case reports are not available on IO administration in neonatal resuscitation in the delivery room.

Specific research is required in preterm and term neonates:

  • Determination time from start of CPR to achieve successful IO placement;
  • Determination time from start of CPR to achieve successful IV umbilical vein placement;
  • Optimal IO device suitable for newly born infants;
  • Position of IO device (head of humerus, proximal tibia, other) to successful IO access;
  • Short and long-term safety of IO placement during newborn resuscitation;
  • Complications related to emergency umbilical venous catheterization;
  • Pharmacokinetics and plasma availability of IO compared to IV administration of drugs;
  • Training for IO placement and IV umbilical vein placement during neonatal resuscitation;
  • How to best secure and maintain any emergency vascular access devices;
  • Optimal method to determine correct placement of any emergency vascular access device;
  • Do animal and simulation models translate to clinical practice?
  • IO access during neonatal resuscitation outside the delivery room.

Attachments

Evidence-to-Decision Table: NLS-616 IO vs IV

References

RCTs, cohort or case-control studies in children or neo


Task Force Systematic Review

Discussion

GUEST
Marcia Souza (265 posts)
I think the intravenous route through the umbilical catheterization should be indicated since most professionals who perform the resuscitation maneuvers are able to perform such procedure beyond the certainty of drug administration.
Reply
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D P (265 posts)
It already says: "We suggest umbilical venous catheterization as the preferred vascular access during newborn resuscitation"
GUEST
giselda silva (265 posts)
Não costumo fazer procedimento intra-ósseo em RN ,tendo condição de faze-lo por cateterismo venoso. Por isso acho difícil avaliar.
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giselda silva (265 posts)
I do not usually do intraosseous procedure when we can perform it by venous catheterization, I have no experience about it.
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FERNANDA RABELLO OHIRA (265 posts)
I think the recommendation to prefer umbilical access if it is available is correct. However, it is necessary to write - not to delay obtaining venous access if the umbilical vein is unsuccessful, and proceed to IO without delay. Encourage IO access in any neonatal emergency. My question is about the cost for availability and maintenance of intraosseous needles, currently in Brazil have very high cost. There is a risk of extrapolating the recommendation for inappropriate instruments which would increase the risk of adverse events.
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Marcos Moura de almeida (265 posts)
I agree
GUEST
Helen Secchin (265 posts)
Concordo
GUEST
Patrícia Marques (265 posts)
A administração intra óssea na reanimação em sala de parto não é conduta recomendada de rotina. Continuamos fazendo medicações pelo cateterismo venoso umbilical que é um procedimento com menos complicações ao RN. Gostaria de saber se algum estudo que avaliou os riscos de fraturas ósseas nos RN's.
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Andrea Lübe (265 posts)
In the services I work for, we do not use the intraosseous route in neonatal resuscitation. All doctors working in our neonatal units are able to perform the emergency venous umbilical catheterization procedure. The only time I had the opportunity to take IO medication was in a premature newborn with no possibility of vascular access. Our complication was the leakage of hydration to soft tissues. We do not have adequate material for the procedure, and the bone of these newborns is fragile and very small in width. Either way we need to define an alternative route for emergency medication in those neonates with abdominal wall malformation that impairs venous catheterization.
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Danilo Saad (265 posts)
Penso que o tempo gasto, tanto no acesso umbilical, quanto no acesso intra ósseo, não seja um fator de vantagem para um ou outro meio de acesso, sendo que me parece o intra ósseo mais invasivo e de maior comorbidades. Sendo a discussão qual método de eleição, imagino que cateterismo umbilical seja o de escolha e se não for possível, o intra ósseo como opção no caso de falha na cateterização da veia umbilical.
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VILMA HUTIM (265 posts)
No meu entendimento, como neonatologista, pela própria anatomia e fragilidade da estrutura óssea do recém nascido , tenho temor de maiores complicações e falha quanto ao tempo de conseguir acesso ,pois no caso do acesso na veia umbilical de emergência, não necessita de técnica para acesso central , mas periférico nesse momento. Pela vivencia , acho que o acesso na veia umbilical confere mais praticidade e maior segurança na emergência na ressuscitação neonatal.
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Aurimery Chermont (265 posts)
Não costumamos fazer IO em nossa unidade com 30 leitos. A equipe em consenso utiliza o cateterismo umbilical pq é um procedimento com menos complicações até o momento.
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Adriana Capila (265 posts)
Tenho experiência em administração de drogas por cateterismo umbilical, em nosso hospital, orientamos o mesmo, com menos riscos e muita rapidez, é um método seguro . Não temos experiência em IO em recém nascidos. Me preocupa o fato de não termos no Brasil, em muitos hospitais, materiais necessários para a infusão de drogas via IO.
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Geisa Hossokawa Neves (265 posts)
Nos serviços em que trabalho, público ou particular, não usamos a via intraossea em recém-nascido. Usamos a veia umbilical.
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Kathryn Browning Carmo (265 posts)
All those trained in birth attendance need to be trained in UVC access; IO may be an expensive secondary option and I worry will lead staff to not consider UVC or consider UVC too hard and go for less effective IO first. We have seen complications of IO in the newborn where the use is ubiquitous in NSW.
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GUEST
D P (265 posts)
Who would consider dropping UVC harder than I/O at birth ? It's likely the easiest procedure and in almost all cases fail proof, if attempted in delivery room
GUEST
Jessica Soares (265 posts)
Na minha opinião, o acesso venoso através do cateterismo umbilical é mais rápido e seguro para administração de drogas e volume. Esse sempre foi a minha escolha nos serviços onde trabalho. Não tenho experiência com intra-óssea em recém-nascidos.
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Frank Eifinger (265 posts)
UVC should be preferred, as newborn bone anatomy is not suitable for io.-access unless new and better devices are available for these patients. When using io.devices use the manually driven application form.
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Adriana Dias (265 posts)
I think that in emergencies in the delivery room, umbilical access is the fastest, easiest and safest. I believe the intraosseous route can be useful in the rare cases where we cannot use the umbilical route. But unfortunately in most hospitals in Brazil we do not have the proper needle and we also do not receive proper training so this increases the risks of the procedure.
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Hans-Martin Lode (265 posts)
In My opinion this recomendation reflects the reality in most of the NICU's in Germany. The intraosseus line for drug Administration is meanwhile well known for pediatric patients even as for adult patients in cardiac arrest and it is an oportunity even for newborns. But the smaller the patient is the more difficult is the correct placement of the needle and the greater is the risk for having severe undesireable adverse effects. So the personel has to be trained verry good in the handling of this tool when it is used in the resuscitation of newborns. On the other hand the umbilical vein is relatively easy to determine an it is a verry fast procedure to put an vascular canula inside it just for a view centimeters to use it as a emergency access. Even this procedure has to be trained carefully, but it's easy to learn. So i think you are right to give this recomendation even so there is poor evidence for it. On the other hand
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GUEST
Paulo Nader (265 posts)
Em todas as nossas reanimações usamos a veia umbilical, em nenhum caso foi preciso IO. O nosso HU atende 400 partos por mês com 30 leitos de UTI, com volume considerável de reanimações. A IO é muito mais invasiva e apresenta muito mais complicações pelo procedimento. Usamos em último caso. Devemos considerar também que este procedimento necessita de uma equipe muito bem treinada.
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GUEST
Scott DeBoer (265 posts)
Greetings - I have a bit of different insight for this query regarding UVC vs IO - As a transport nurse and medic, as many have mentioned, in the hospital setting with trained personnel, UVC is a great choice. However, where I feel that IO access with newborns truly has a place is for the out of hospital deliveries or deliveries in the emergency department. With medics & many ER physicians, UVC is not a technique they are very familiar with, practice with, or are credentialed to perform (medic protocols). In these rare, but very real situations & environments, when neo staff are not immediately available, I feel that IO access can be lifesaving. Medics & ER physicians are far more comfortable & have far more experience with placing IO's (for peds & adults) than with accessing the umbilical vein. In the situation where a newborn delivers in a rural emergency department or side of the road with a long ETA to the hospital, IO access can be obtained in seconds for initial delivery of fluids and meds. When the baby is in the presence of someone comfortable with placing umbilical lines - great! But "my world" is not in the hospital setting & when babies deliver out there, I believe that IO access truly still has a place.
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Catherine Allgood (265 posts)
I agree. Many paediatric trainees nowadays have never been involved with UVC insertion and many complete their training with little confidence in UVC insertion and may be called upon to attend a newborn requiring immediate access. They may though have skills of IO insertion as may their adult colleagues who may be called upon to help in such a situation.
GUEST
Bethanie Szydlowski RN VA-BC (265 posts)
Conflicts of interest: Other financial entities
Full disclosure I work for PerSys Medical the manufacturer of the NIO IO device. My background is in emergency care, critical care and vascular access. I agree with Scott DeBoer's comments. In emergency medicine and pre-hospital arrests UVC route is often not a skill that is regulary taught or maintained. Many pre-hospital EMS systems do not have UVC in their protocols. This leads to potential failed access or delayed access. I agree with the Infusion Nursing Society INS 2016 Standard 55.1 "In the event of adult or pediatric cardiac arrest, anticipate use of the IO route if intravenous access is not available or cannot be obtained quickly. Pediatric Advanced Life Support (PALS) support guidelines suggest the use of the IO route as the initial vascular access route. (II)" Per the INS 2016 guidelines Umbilical Catheters Standard 30.1 Practice criteria E." Confirm the catheter tip location by radiography, echocardiography, or ultrasonography before catheter use" Confirming catheter UVC tip prior to use outside of hospital is not obtainable in most cases. Many studies support the use of IO as a faster route than the placement of UVC without the increase of complications. Oustide of NICU theater I would highly recommend the use of IO access as the first preferred route.
GUEST
Charles Sheppard (265 posts)
I totally agree with Scott (not surprising) but in the prehospital/ED world IO is often a much more available/usable option and given the lack of any good evidence should not be treated as a "bad" choice
Lloyd Jensen (2 posts)
Great discussion of a very important point. Agree that for those in the Delivery Room with experience and equipment, the UVC is a simple , fast and reliable method. As long as it is only placed in 2 to 4 cm, there is no need for radio-graphic confirmation during an emergency. Agree completely with Scott De Boer regarding situations outside of the DR.- ie the responder/provider in the ED, in the field, in facilities without experience in UVC placement, or where you did not get the emergent UVC, or the neonate with a dried cord. The skill to place a IO can be life saving. This skill has to be practiced. The task training to place an IO is a critical skill for those responding to emergencies. If one does not have a "drill" or a "manual" IO devise a larger spinal needle could be used- 13, 18. (or 20 gauge) .The problem is the length of those needles. My opinion is that it is a skill that should be included in neonatal resuscitation training-especially for non NICU/DR providers.
GUEST
Jola Berkman (265 posts)
Agree. UVC is the preferred route but if it can't be placed (i.e. week old infant) and peripheral access is not easily obtained an IO is the only other option.
GUEST
Monica Pinheiro (265 posts)
Embora pareça muito simples o acesso via umbilical, em alguns momentos me deparei com dificuldade de progredir o cateter e com eventos de má perfusão vascular, principalmente em RN prematuros. Pensar numa outra via alternativa, como a via óssea, é muito importante mas conjuntamente importante é desenvolver material adequado e de baixo custo para o melhor acesso osseo possivel e seguro. Sendo assim, creio que no momento o melhor acesso é o vascular umbilical e numa segunda opção o intra-ósseo.
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Thais Queiroz (265 posts)
O acesso venoso através do cateterismo umbilical é mais rápido e seguro para administração de drogas e volume. Essa sempre foi a minha escolha nos serviços onde trabalho. Nunca realizei intra-ósseo em RN. Realizei intra-óssea em lactente de 2 meses - muito mais difícil e tempo gasto é maior. Vejo intra-ósseo como opção para aqueles que via umbilical não foi possível.
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GUEST
JOâO HENRIQUE LEME DE ALMEIDA (265 posts)
I agree that it is importante to have a second option in case of administration of drugs when ressuscitation is mandatory. Doctors and nurses are well trained for vascular access but not for bone injections Intraosseous access may be used as alternative but the professionals involved should be trained specifically for this procedure
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Mariza Silva (265 posts)
Não costumo fazer procedimento intra-ósseo em RN ,tendo condição de faze-lo por cateterismo venoso. Por isso acho difícil avaliar.
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Giuseppina Rinaldi (265 posts)
Conflicts of interest: Consulting
Acho a melhor via a umbilical , e até inclusive a facilidade de realização E segurança
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Holger Freymann (265 posts)
We train the rescue service, anaesthesiologists and obstetricians in the use of an umbilical vein access with a blunt hollow cannula. Although this is not a central venous access, but you get an easy and fast venous access.
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GUEST
Maria Ventura (265 posts)
In our state, Ceará, we practice umbilical catheterization instead of the intraosseous pathway.
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GUEST
Michael Rushing (265 posts)
Many NICU transport teams are not permitted to perform UVCs. IO is now their go to device for resuscitation use. IO placement is easily completed rapidly compared to attempting UVC access.
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GUEST
Adele Sullivan (265 posts)
My comments would be that (whilst I have not done a literature search or research on this) that I was always told historically that the neonatal bone is not calcified well and this increase risk of going straight through the bone, current IO needles are developed for paediatrics/adults only and drills create increased risk as you are unable to feel the pop (which is minimal on premature infant) Umbilical vein is usually very accessible and neonatal staff are usually skilled to perform the task. There are risks involved with emergency UVC also of course. My personal opinion is to continue UVC in emergency but research and equipment manufacturing could be evolved.
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Janaína Eberhardt (265 posts)
I believe IO is more complicated since there would have to be many sizes and preterm babies are much more fragile. EV is very quickly acessible by most neonatologists independent of the type of arrest and weight/ corrected age of the newborn.
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Janaína Eberhardt (265 posts)
I believe IO is more complicated since there would have to be many sizes and preterm babies are much more fragile. EV is very quickly acessible by most neonatologists independent of the type of arrest and weight/ corrected age of the newborn.
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Rossiclei Pinheiro (265 posts)
I think that if there are no advantages of the intraosseous route compared to the umbilical vein and most neonatologists have easier umbilical catheterization, then we should keep this preference.
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Susan Niermeyer (265 posts)
The knowledge gaps are especially important, as they highlight areas in which information/approach could be improved around the predominant technique of UVC access.
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Roland Hentschel (265 posts)
The blog reveals: The predilection for either the i.o. access or the UVC spreads along the border “neonatologist” vs. “pediatric intensivist/emergency physician”, respectively corresponding nurse specialization. The primary goal must be: be as quick as possible. The European Resuscitation Council Guideline of 2015 clearly demands to have an i.v. access in pediatric emergencies within 1 minute, otherwise to switch to the i.o. access, which obviously means: within 2 or 3 minutes the access to the vascular system must be finished. There is no reason to believe that during newborn resuscitation we have more time! So ask yourself the critical question: with which of the available techniques will I have safe access within 2 or 3 minutes! Having experience with newborn and pediatric resuscitation for more than 35 years and practicing i.o. access as well (also in premature infants below 1.0 kg) I can say: in a newborn with a persisting soft umbilical stump (i.e. in the first 24 hrs) the umbilical access with a blunt hollow cannula is by far faster and more promising than the i.o. access. This also holds true for physicians, who rarely practice this procedure (obstetricians, anesthetists etc.), provided that they were familiarized with the technique. To repeat the comment by Susan Niermeyer (who has been a member of the ILCOR editorial board for a long time) from this blog: “The knowledge gaps are especially important, as they highlight areas in which information/approach could be improved around the predominant technique of UVC access”. 3 further recommendations: (1) Use fresh umbilical cord pieces for dry runs of this procedure at a bench to train this route of access at least twice per year with your whole team; (2) forget the traditional UV catheter and use a plastic blunt hollow cannula of about 70 mm length instead (see for instance www.interlockmed.com and search for “Einmalknopfkanüle”) (should be available from other manufacturers in other countries as well); (3) the emergency procedure should never aim at an anatomically perfect placement with the tip of the cannula or catheter at the entrance to the right atrium, 2-3 cm below the abdominal wall is enough, most often blood can be aspirated. However, this preference for the umbilical route is in contrast to the only study on this issue, that I am aware of, comparing i.o. with umbilical access in a manikin (which might not be a good model) (Schwindt EM et al.. Pediatr Crit Care Med 2018; 19:468–76). We currently run a bench study with medical students to assess different umbilical access routes (lateral incision vs. cross section – UVC vs. cannula) on cut-off specimens of umbilical cords. Preliminary results are expected end of this year. Further literature for the cannula technique - both papers “unfortunately” in German: Hentschel R.; The emergency vascular access in the delivery room. DOI 10.3238/DIVI.2018.0014–0024 with 6 figures and short English abstract (available on request by email to the author) Hopfner RJ et al.; Erstversorgung und Reanimation von Frühgeborenen. DOI 10.1007/s10049-005-0750-6 Notfall + Rettungsmedizin 2005; 8: 334–41
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Luciane Berti cavalcanti (265 posts)
Não tenho experiência com intra óssea na reanimação.. mas acho interessante o treinamento e a abordagem..pois no momento da emergência todos nós temos que estar preparados para um plano B
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Chris Peterson (265 posts)
Our service is in agreement with use of Intraosseous needle in situations where umbilical venous cannulation is unsuccessful. UVC placement should be considered first as it is usually more rapid, and in our service appropriately trained staff are available. We agree with comments already made about prioritising practice and training in UVC technique to ensure familiarity. Intraosseous needles provide rapid access in the emergency department setting, and for general paediatricians, there is usually familiarity with their use. Study will remain difficult due to rarity of use.
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Luis Miranda (265 posts)
Considering that the umbilical vein catheterization in the delivery room is relatively safe and easy to teach, to learn and to practice, as opposed to the placement of an intraosseous line, I am convinced of the umbilical vein being, by far, the best choice
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GUEST
Ravi Agarwal, MD (265 posts)
As a practicing Neonatologist for 35 years and a NRP Lead instructor for last 30 years, the UVC access is fast and easy during the initial resuscitation of the neonate. One has remember you are inserting the catheter only 2-3 cm to gain emergency access for fluids and medications like epinephrine. Insertion of this low lying UVC is a very easy skill to learn. IO use Newborn Resuscitation should not be used at all.
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Shah Hossain (265 posts)
Umbilical venous access should be first line attempt, then attempt at IO access is a reasonable second option for Neonatal resuscitation.
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David Burchfield, MD (265 posts)
My only issue with the recommendation is that it is followed by the caveat "(weak recommendation, very low certainty of evidence). There are times that we should follow common sense. In adult resuscitation research, the closer to the heart that drugs are administered, the better the affect. Also, clearly, intraosseous is more traumatic. I would hope that this caveat can be edited so that people do not just choose IO as their preferred action because "the evidence is weak"/
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Jonathan Wyllie (265 posts)
Thank you for all the comments and input so far. Please keep them coming. The task force will assess all comments and derive themes or information to use to adjust the CoSTR where appropriate. Thank you everyone for engaging with this process. Vice Chair NLS Task Force
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Danielle Reed, MD (265 posts)
As a provider who has placed 5 IO's in code situations in the last few years and more emergent UVCs in the delivery room than I can count, I agree that the UVC should be the preferred access. The infants receiving IO's weights ranged from 2 to 4 kg and they all extravasated at some point in the resuscitation. Perhaps it was my technique but I would prefer a UVC whenever possible given the higher complication rate in my limited experience. That being said, if the IO was my only option, it seems reasonable.
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Carl D'Angio (265 posts)
IO access is not a well-established technique in newborns and most providers (at least in my practice settings) have little experience with it. UV should remain the overwhelmingly preferred route.
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Andreas Mueller (265 posts)
In my opinion, umbilical cord venous access should be first line. IO access in neonates is associated with high rates of incorrect placement.
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Francesco Cardona (265 posts)
We irregularly (3-5 per annum) see IOs placed during neonatal resuscitation. This is especially done by hospitals that do not have a dedicated neonatal service. For non-neonatologists i.o. seems to be an attractive alternative, especially if they have not had adequate training in umbilical catherization or are from a background in emergency medicine. The io definitely needs to be better evaluated for efficacy and success rates. We have seen a few case were more than 1 attempt was needed for successful placement. Placement in preterm infants seems even more challenging. I believe it should remain in consideration when the UVC is not deemed a reasonable alternative.
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GUEST
David Kaufman (265 posts)
Since obtaining umbilical venous access is fast, safe and painless, it should always be the first method to obtain vascular access in a newborn. Peripheral intravenous access should also be part of this recommendation. The recommendation should be revised as suggested below: For Treatment Recommendations The treatment recommendations should be modified as follows: (quotation marks and capitals are used to indicate the changes): For the First statement: Umbilical venous catheterization IS the preferred vascular access "AND SHOULD BE ATTEMPTED FIRST TO OBTAIN VACULAR ACCESS" during newborn resuscitation. This should also be a Strong Recommendation. It may need different methodological science than used for other recommendations based on the unique vascular structures and physiology present in utero and at birth. I would liken it to the science used in recommending in a neonatal emergency translaryngeal intubation vs. a tracheostomy. And for the second statement: (Remove: "If umbilical venous access is not feasible".) AFTER FIRST ATTEMPTING TO OBTAIN VASCULAR ACCESS VIA THE UMBILICAL VEIN, PLACING A PERIPHERIAL INTRAVENOUS CATHETHER WOULD BE THE SECOND PREFERRED METHOD FOLLOWED BY the intraosseous route as vascular access during newborn resuscitation AS reasonable alternatives.
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GUEST
Beverly Walti (265 posts)
After 37 years in the NICU I have seen complications from IO placement .I believe UVC access is superior in our population. The neo performing this task are very adept at securing a line quickly and administration of medications is delivered in a timely manner
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Aurelio Villalba (265 posts)
Várias perspectivas devem ser consideradas. A mais importante, é nos investirmos totalmente, na RCP de alta performance , na tentativa real e humana de salvarmos o RN. Pois bem, o acesso I.O. PODE ser mais rapidamente obtido, em relação ao cateterismo umbilical ; já que durante as compressões torácicas coordenadas com ventilações, a visualização direta da veia umbilical, possa ser dificultada ,ou por extravasamento sanguíneo contínuo, ou mesmo por hipovolemia severa, que imporia uma condição de colabamento da veia umbilical. Quanto à velocidade de infusão de drogas e cristalóides, é possível uma distinção entre as duas vias de acesso vascular. Por serem técnicas distintas, merecem discernimento e ponderação, a respeito dos possíveis insucessos inerentes a tais procedimentos, sem contudo abrirmos mão dos benefícios de um acesso venoso de instalação rápida no ambiente da Reanimação Neonatal.
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Sara Berkelhamer (265 posts)
We are currently evaluating efficiency, success rates and confidence with drill-assisted versus manual IO placement in a size-appropriate newborn ovine asphyxial arrest model. Our preliminary data suggest more efficient placement, higher success rates and greater confidence with drill-assisted IO, supporting the use of a drill when this procedure is needed. In addition, we are evaluating pharmacokinetics and efficacy of IO as compared to UV epinephrine, with preliminary data suggesting comparable efficacy but differences in epinephrine peak and hemodynamics. These studies are supported by funding by the Neonatal Resuscitation Program and have been submitted for presentation at the Pediatric Academic Society Meetings.
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D P (265 posts)
So many people chiming in and saying UVC first when in fact the article itself says "We suggest umbilical venous catheterization as the preferred vascular access during newborn resuscitation". Read first people!
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Gustavo Pelligra (265 posts)
Agree that more research is needed but in the meantime and with the evidence (or lack of) available I think the authors recommendations are quite balanced and appropriate. For DR resuscitation where people are skilled/experienced with UVC placement I don't see the role for IO. However, in other settings (ie. ER, community hospitals) where practitioners have limited training/experience with UVCs, IO is a reasonable alternative (better than peripheral IV in my opinion). Thanks
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Evelise Pereira (265 posts)
Utilizo acesso umbilical para os procedimentos de reanimação na sala de parto. Mas seria interessante avaliar a possibilidade de uso da via intra-ossea nos recem-nascidos.
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Tim Collins (265 posts)
Conflicts of interest: Financial relationships
ILCOR Response (Newborn) 15th January 2020 Dear International Liaison Committee on Resuscitation, We are clinical & medical affairs directors writing on behalf of the Clinical & Medical Affairs (CMA) team employed by Teleflex Incorporated. Teleflex manufactures the Arrow ® EZ-IO® Intraosseous Vascular Access System. We read with interest your recent draft Intravenous vs. Intraosseous administration of drugs during cardiac arrest (NLS): Systematic Review: https://costr.ilcor.org/document/intravenous-vs-intraosseous-administration-of-drugs-during-cardiac-arrest-nls-task-force-systematic-review-costr Thank you for inviting public consultation to these systematic reviews which we agree enhance the science and practice behind resuscitation. Teleflex is a medical device company that produces a range of vascular access devices including intraosseous (IO), peripheral and central venous access devices. The Teleflex CMA team is a group of highly trained clinical and medical professionals representing multiple healthcare disciplines and is responsible for scientific discourse, research and clinical education, with the aim of improving patient clinical outcomes and patient safety. Regarding your draft recommendation for umbilical vein cannulation (UVC) as the preferred method of vascular access during newborn resuscitation we have the following comments: We agree with your population finding that newborn infants who require extended emergent support past basic airway interventions are in the 1% minority. It is well documented that newborn resuscitation primarily requires airway interventions with emergent vascular access being a low volume, high acuity procedure. In a recent 2018 study published in the European Journal of Pediatrics, Healthcote provided a retrospective review of extended newborn resuscitation timing at a large university hospital with an annual 6000 births where 91 births were initially identified and only 27 births met criteria for the study. It was found that intravenous access was frequently delayed with only 40% of newborns receiving their first dose of adrenaline at 10 minutes. (Heathcote, A.C., Jones, J. & Clarke, P. Eur J Pediatr (2018) 177: 1053.) This is consistent with data published by Sproat et. al. 2017. It is also noted in the Healthcote publication that intraosseous access may be a useful option when UVC is not successful. Multiple sources suggest intraosseous access may be used as a bridge to definitive vascular access. This is described in literature where authors concluded IO access "should be considered as a rapid, low risk, high yield aid to long-term IV access in both adults and children and is an important bridge to definitive access in resuscitation”. (Johnson M, Inaba K, Byerly S, et al. Intraosseous infusion as a bridge to definitive access. Am Surg 2016;82(10):876-80; Leidel BA, Kirchhoff C, Bogner V, Braunstein V, Biberthaler P, Kanz KG.) Comparison of intraosseous versus central venous vascular access in adults under resuscitation in the emergency department with inaccessible peripheral veins. (Resuscitation 2012;83(1):40-5. doi:10.1016/j.resuscitation.2011.08.017.) While umbilical vein cannulation is readily available in the hospital, newborn resuscitation is not limited to controlled operating or delivery room environments as noted in your evidence to decision table NLS-616 IO vs IV where population is documented as “Neonates in any setting (in-hospital or out-of-hospital)”. In and out of hospital settings can have wide variances of physical environment, access to medical equipment and availability of skilled clinicians. IO access outside of settings where clinicians skilled at UVC access are available has been supported in the literature as an effective alternative and skill obtainable by clinicians with a multitude of training levels. (Engle WA. Intraosseous access for administration of medications in neonates. (Clin Perinatol 2006;33(1):161-8; Ellemunter H, Simma B, Trawoger R, Maurer H. Intraosseous lines in preterm and full-term neonates. Arch Dis Child Fetal Neonatal Ed 1999; 80: F74-5.) Both umbilical and intraosseous access require a trained clinician, however intraosseous access offers multiple newborn insertion sites and is considered peripheral access that may be provided by a wider range of clinicians using aseptic technique. (Fiorito BA, Farrukh M, Doran TM, et al. Intraosseous access in the setting of pediatric critical transport. Pediatr Crit Care Med 2005;6:50–3.) Studies regarding training of IO vs UVC technique have been done in simulation settings and show IO access to be faster but one study showed no difference in perceived ease of procedure. (Abe KK, Blum GT, Yamamoto LG. Intraosseous is faster and easier than umbilical venous catheterization in newborn emergency vascular access models. (Am J Emerg Med 2000;18(2):126-9; Rajani AK, Chitkara R, Oehlert J, Halamek LP. Comparison of umbilical venous and intraosseous access during simulated neonatal resuscitation. Pediatrics 2011;128(4):e954-8.doi:10.1542/peds.2011-0657.) Definitive umbilical vascular access requires sterile technique provided by a select group of clinicians with radiologic confirmation. This emergent bridge device requires replacement or repositioning in the singular umbilical vein for definitive vascular needs. We note your considerations for the absence of data comparing vascular access in neonates. The recent 2019 publication by Scrivens documents there have been no clinical randomized trials comparing IO access in neonates with other forms of access. There have been several case studies including children under 1 year of age, but only one looking specifically at neonatal patients. (Scrivens, A., Reynolds, P. R., Emery, F. E., Roberts, C. T., Polglase, G. R., Hooper, S. B., & Roehr, C. C. (2019).) Use of Intraosseous Needles in Neonates: A Systematic Review. Neonatology, 116(4), 305-314.) It should also be noted that mention of intraosseous access in the newborn population is typically in the proximal tibia and not the more recently approved femur. This comprehensive review of data and devices concludes that “IO access should be available on neonatal units and considered for early use in neonates where other access routes have failed.” This is especially important in rural settings where access to skilled practitioners may be limited. The article goes on to state “If IO devices provide a faster method of delivering adrenaline effectively than UVC, this may lead to changes in neonatal resuscitation practice.” We agree that the absence of literature suggests a weak recommendation and very low certainty of evidence and suggest it would be beneficial to support research in this area prior to presenting new recommendations. Kind regards, Dr. Chris Davlantes, MD, FACEP Medical Director – Clinical & Medical Affairs Teleflex Incorporated Clinical Assistant Professor - Department of Emergency Medicine University of Kansas Health System Dr. Tim Collins, EdD, MSc, PGCLT, BSc, RN, Resuscitation Council Instructor Director – Clinical & Medical Affairs Europe, Middle East & Africa Teleflex Medical Europe
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Tim Collins (1 posts)
Conflicts of interest: Financial relationships
ILCOR Response (Newborn) 15th January 2020 Dear International Liaison Committee on Resuscitation, We are clinical and medical affairs directors writing on behalf of the Clinical & Medical Affairs (CMA) team employed by Teleflex Incorporated. Teleflex manufactures the Arrow ® EZ-IO® Intraosseous Vascular Access System. We read with interest your recent draft Intravenous vs. Intraosseous administration of drugs during cardiac arrest (NLS): Systematic Review: https://costr.ilcor.org/document/intravenous-vs-intraosseous-administration-of-drugs-during-cardiac-arrest-nls-task-force-systematic-review-costr Thank you for inviting public consultation to these systematic reviews which we agree enhance the science and practice behind resuscitation. Teleflex is a medical device company that produces a range of vascular access devices including intraosseous (IO), peripheral and central venous access devices. The Teleflex CMA team is a group of highly trained clinical and medical professionals representing multiple healthcare disciplines and is responsible for scientific discourse, research and clinical education, with the aim of improving patient clinical outcomes and patient safety. Regarding your draft recommendation for umbilical vein cannulation (UVC) as the preferred method of vascular access during newborn resuscitation we have the following comments: We agree with your population finding that newborn infants who require extended emergent support past basic airway interventions are in the 1% minority. It is well documented that newborn resuscitation primarily requires airway interventions with emergent vascular access being a low volume, high acuity procedure. In a recent 2018 study published in the European Journal of Pediatrics, Healthcote provided a retrospective review of extended newborn resuscitation timing at a large university hospital with an annual 6000 births where 91 births were initially identified and only 27 births met criteria for the study. It was found that intravenous access was frequently delayed with only 40% of newborns receiving their first dose of adrenaline at 10 minutes. (Heathcote, A.C., Jones, J. & Clarke, P. Eur J Pediatr (2018) 177: 1053.) This is consistent with data published by Sproat et. al. 2017. It is also noted in the Healthcote publication that intraosseous access may be a useful option when UVC is not successful. Multiple sources suggest intraosseous access may be used as a bridge to definitive vascular access. This is described in literature where authors concluded IO access "should be considered as a rapid, low risk, high yield aid to long-term IV access in both adults and children and is an important bridge to definitive access in resuscitation”. (Johnson M, Inaba K, Byerly S, et al. Intraosseous infusion as a bridge to definitive access. Am Surg 2016;82(10):876-80; Leidel BA, Kirchhoff C, Bogner V, Braunstein V, Biberthaler P, Kanz KG.) Comparison of intraosseous versus central venous vascular access in adults under resuscitation in the emergency department with inaccessible peripheral veins. (Resuscitation 2012;83(1):40-5. doi:10.1016/j.resuscitation.2011.08.017.) While umbilical vein cannulation is readily available in the hospital, newborn resuscitation is not limited to controlled operating or delivery room environments as noted in your evidence to decision table NLS-616 IO vs IV where population is documented as “Neonates in any setting (in-hospital or out-of-hospital)”. In and out of hospital settings can have wide variances of physical environment, access to medical equipment and availability of skilled clinicians. IO access outside of settings where clinicians skilled at UVC access are available has been supported in the literature as an effective alternative and skill obtainable by clinicians with a multitude of training levels. (Engle WA. Intraosseous access for administration of medications in neonates. (Clin Perinatol 2006;33(1):161-8; Ellemunter H, Simma B, Trawoger R, Maurer H. Intraosseous lines in preterm and full-term neonates. Arch Dis Child Fetal Neonatal Ed 1999; 80: F74-5.) Both umbilical and intraosseous access require a trained clinician, however intraosseous access offers multiple newborn insertion sites and is considered peripheral access that may be provided by a wider range of clinicians using aseptic technique. (Fiorito BA, Farrukh M, Doran TM, et al. Intraosseous access in the setting of pediatric critical transport. Pediatr Crit Care Med 2005;6:50–3.) Studies regarding training of IO vs UVC technique have been done in simulation settings and show IO access to be faster but one study showed no difference in perceived ease of procedure. (Abe KK, Blum GT, Yamamoto LG. Intraosseous is faster and easier than umbilical venous catheterization in newborn emergency vascular access models. (Am J Emerg Med 2000;18(2):126-9; Rajani AK, Chitkara R, Oehlert J, Halamek LP. Comparison of umbilical venous and intraosseous access during simulated neonatal resuscitation. Pediatrics 2011;128(4):e954-8.doi:10.1542/peds.2011-0657.) Definitive umbilical vascular access requires sterile technique provided by a select group of clinicians with radiologic confirmation. This emergent bridge device requires replacement or repositioning in the singular umbilical vein for definitive vascular needs. We note your considerations for the absence of data comparing vascular access in neonates. The recent 2019 publication by Scrivens documents there have been no clinical randomized trials comparing IO access in neonates with other forms of access. There have been several case studies including children under 1 year of age, but only one looking specifically at neonatal patients. (Scrivens, A., Reynolds, P. R., Emery, F. E., Roberts, C. T., Polglase, G. R., Hooper, S. B., & Roehr, C. C. (2019).) Use of Intraosseous Needles in Neonates: A Systematic Review. Neonatology, 116(4), 305-314.) It should also be noted that mention of intraosseous access in the newborn population is typically in the proximal tibia and not the more recently approved femur. This comprehensive review of data and devices concludes that “IO access should be available on neonatal units and considered for early use in neonates where other access routes have failed.” This is especially important in rural settings where access to skilled practitioners may be limited. The article goes on to state “If IO devices provide a faster method of delivering adrenaline effectively than UVC, this may lead to changes in neonatal resuscitation practice.” We agree that the absence of literature suggests a weak recommendation and very low certainty of evidence and suggest it would be beneficial to support research in this area prior to presenting new recommendations. Kind regards, Dr. Chris Davlantes, MD, FACEP Medical Director – Clinical & Medical Affairs Teleflex Incorporated Clinical Assistant Professor - Department of Emergency Medicine University of Kansas Health System Dr. Tim Collins, EdD, MSc, PGCLT, BSc, RN, Resuscitation Council Instructor Director – Clinical & Medical Affairs Europe, Middle East & Africa Teleflex Medical Europe
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T C (265 posts)
Would agree with DP and adding in David Kaufmen suggestions a hierarchy needs consideration if UV access is impeded and further with Roland Hentschel re training to gain UVC access - 'using real cords in training' and interestingly an emergency catheter - that's cost effective easy to prime and for use in all setting's: 'Tertiary, non - Tertiary and Low resource. We do similar training using real cords but with low cost feeding tubes to gain the 'feel' at the work stations but with SIM training we use actual equipment for the rigour but with silicone cords. We work on having the smallest catheter available (in Tertiary and Non Tertiary settings) i.e fg3.5 to allow access for the smallest 23-24weeker upwards. This allows minimisation of equipment - storage issues, cost effectiveness - damaging packaging and expense of actual UV catheters (where in he past we kept a variety of sizes on hand -most would expire by there 'Use by date'). As Resus cots have changed over the years and storage space reduced - emergency equipment - numbers needed to be considered. If a catheter is not available we had supported in the past a 'feeding tube' now that unique intravenous and enteral systems are in place i.e.. 'that is no longer compatible' a back up to this is 'Butter fly - needle set' where needle is cut off and this tubing now has a luer lock connector for 3-way Tap to be added for delivery of fluid bolus and medications. Importantly the training not only in access to UV but set up of delivery system and administration - technique needs considering. Like UVC and for IO access those that have perfected the skill should continue with what they know well. We do not stock IO equipment in our NICU this equipment if needed would be through an escalation process to gain access and personal from PICU team, as yet this has not been required
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Simone Caldeira Siva (265 posts)
Acho o cateterismo umbilical mais seguro para acesso vascular no momento da reanimação neonatal O acesso IO requer prática e principalmente material próprio para evitar complicações óssea no RN
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Peter Antevy (265 posts)
As mentioned by Scott DeBoer in an earlier comment, there are few if any EMS agencies in the U.S. that perform UVC. The recommendation language should be worded differently for pre-hospital vs. in-hospital personnel. This recommendation will be disregarded by most of us in EMS based on the current wording mainly due to impracticality. Furthermore, we have moved to the distal femur for IO placement in pediatric arrest with good success. We do agree that the proximal tibia IO site is fraught with difficulties and complications.
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Michelle Kompare (265 posts)
I agree with the treatment recommendations.
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Charles Sheppard (265 posts)
In the prehospital ED adult cardiac arrest the IO is faster with better flow than a peripheral IV (if humeral) and is not "traumatic" as someone above said. I would hate to see people pushing IV with often significant delays with multiple attempts at a peripheral IV.
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Renato Lima (265 posts)
I am conducting an intervention study related to neonatal resuscitation in one of the poorest regions of Brazil. In this region, there are no doctors specializing in neonatology, the structure is very precarious and about 7000 newborns are born per year. I believe that IO training for this population would be more feasible given the difficulty of a practitioner with poor CUV practice succeeding in advanced resuscitation.
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