Recent discussions
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Виктория Антонова
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 -
Виктория Антонова
Regarding the statement: We recommend against the use of a precordial thump for cardiac arrest (strong recommendation, very-low-certainty evidence). With monitored v-fib arrest, a precordial thump is unlikely to significantly delay defibrillation or cause deterioration of the rhythm (from course v-fib to fine v-fib). I do agree that there is evidence that there may be deterioration of V-tach to V-fib with R-on-T impulse; consider refining the statement to recommend avoiding precordial thump for monitored v-tach. -
Виктория Антонова
The knowledge gaps are especially important, as they highlight areas in which information/approach could be improved around the predominant technique of UVC access. -
Виктория Антонова
Great document! My only comment is that It is crucial to properly train dispatchers to recognize cardiac arrest as rapidly as possible. My recommendation would be to add this as a treatment recommendation. Without proper training, the other treatment recommendations lose their impact. -
Виктория Антонова
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. -
Виктория Антонова
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. -
Виктория Антонова
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. -
Виктория Антонова
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. -
Виктория Антонова
I would welcome a change in recommendation. My experience from many simulation-based trainings and emergency care of pediatric patients shows that the chest compressions are carried out much later when using ABC compared to CAB, since a ready-to-use bag for bag-mask ventilation is rarely directly available. In my opinion, changing the recommendations would not delay bag ventilation, but decrease the time to initiation of chest compressions. -
Виктория Антонова
Thank you for your comments. These are adult guidelines, but could probably have been marked more clearly. The BLS ILCOR treatment recommendation in 2015 was: "We suggest commencing CPR with compressions rather than ventilations (weak recommendation, very-low-quality evidence)."