Recent discussions
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Виктория Антонова
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. -
Виктория Антонова
I agree with the treatment recommendations. -
Виктория Антонова
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 -
Виктория Антонова
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. -
Виктория Антонова
Thank you for this review. We welcome the positive acknowledgement of efficiency that stroke recognition tools can have for the lay public and positive outcomes. The discussion in your justification narrative rightly defers to those providing local guidelines for responders regarding the use of glucose which, from an educational perspective is perhaps better suited to the trained first responder. Perhaps an additional gap in existing knowledge is the ability of a lay responder to make the decision to take the test, their ability to do so, and the pathway for decision-making beyond the test. -
Виктория Антонова
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 -
Виктория Антонова
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. -
Виктория Антонова
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. -
Виктория Антонова
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 -
Виктория Антонова
Re: Highly Malignant EEG - does not make sense to make a recommendation to use this to predict outcome when the definitions vary so broadly and the time-points at which they are evaluated also vary broadly. Other EEG patterns may have inconsistency in definitions, but they were still ultimately evaluating roughly the same thing. "Malignant EEG" patterns are all different here - thus this is not even appropriate to lump together in a single SR since there is such a major degree of inconsistency. How can a TR be based on different EEG findings evaluated at different time points post-arrest ?