Recent discussions
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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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Thank you for this review. From an educational perspective we welcome use of clingfilm for storage and oral hydrating solutions as possible alternatives to those options listed. This presents another opportunity for educators to reassure learners and lay responders of regular household items that can be used for first aid application. -
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Thank you for this review. We support the recommendation's focus on direct pressure rather than adjuncts, and with the steer away from the use of pressure points. As identified in the gaps, expecting the first aider to be able to identify the pressure point would require extra educational instruction and safeguarding challenges. -
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Re: GWR - not clinically helpful to sub-divide in to so many different regions for purposes of this review and may be more helpful to group the analysis as simply saying multiple ROIs were evaluated. Also unclear why this SR divided cardiac and non-cardiac etiologies when others did not (even when it was reported for the individual studies). Continue to have concerns about how ILCOR is making TRs based on parameters that lack a standard definition and are basically a hodge-podge of different things lumped together in a SR (ie for the DWI section, cannot make generalizations about "positive DWI findings" - this could be a small clinically insignificant DWI lesion vs diffuse cortical necrosis, and the current recommendation does not differentiate) References missing some of the articles - Greer, others. Perhaps just not listed on this cover page? Re: DWI and ADC work - consider the following studies from our group as well (not sure if they fit the inclusion criteria for the SR but if they do they are relevant) - Hirsch et al, J Neuroimaging - Prognostic value of a qualitative brain MRI scoring system after cardiac arrest, 2015. Hirsch et al, Neurocritical Care - Multi-Center Study of Diffusion-Weighted Imaging in Coma After Cardiac Arrest, 2016. -
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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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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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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 -
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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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The term "epileptiform" should not used any more to describe discharges, because it is unclear whether the discharges are actually epileptiform and the term epileptiform has clinical connotations. There are some discharges that are more benign and would not be considered epileptiform. This is outlined in a previous ACNS statement that is cited in the ETD table (Hirsch 2013 J Clin Neurophys) and the correct terminology should be used. It perpetuates the problems with this research (ie lack of standard definitions) when we use outdated terminology. Suggest removing the term "epileptiform" and simply saying "discharges" in order to be consistent with critical care EEG definitions. -
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Lifevac has provided 44 clinical files of effective use , no adverse effects in the exact format requested by ILCOR . As we are all aware in field emergency with approx 8 min to implement this is a substantial accumulation . As it has been used by laypeople as well as professionals , on people from 7 weeks to 90 plus years of age what else would be needed. Thank you