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
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.
Reference not yet available
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.
- 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)
- 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.
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.
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.
Evidence-to-Decision Table: NLS-616 IO vs IV
RCTs, cohort or case-control studies in children or neo