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Schwindt EM, Häcker T, Stockenhuber R, Patsch JM, Mehany SN, Berger A, Schwindt JC. Finding the most suitable puncture site for intraosseous access in term and preterm neonates: an ultrasound-based anatomical pilot study. Eur J Pediatr 2023:10.1007/s00431-023-04972-8. [PMID: 37074459 DOI: 10.1007/s00431-023-04972-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 03/30/2023] [Accepted: 04/01/2023] [Indexed: 04/20/2023]
Abstract
The purpose of this prospective ultrasound-based pilot study was to identify the most suitable tibial puncture site for intraosseous (IO) access in term and preterm neonates, describe tibial dimensions at this site, and provide anatomical landmarks for rapid localization. We measured the tibial dimensions and distances to anatomical landmarks at puncture sites A (proximal: 10 mm distal to the tibial tuberosity; distal: 10 mm proximal to the malleolus medialis) and B (chosen by palpation of the pediatrician), in 40 newborns in four weight groups (< 1000 g; 1000-2000 g, 2000-3000 g, and 3000-4000 g). Sites were rejected if they fell short of the assumed safety distance to the tibial growth plate of 10 mm. If both A and B were rejected, puncture site C was determined sonographically at the maximum tibial diameter while maintaining the safety distance. Puncture site A violated the safety distance in 53% and 85% (proximally and distally, respectively) and puncture site B in 38% and 33%. In newborns weighing 3000-4000 g, at median (IQR), the most suitable puncture site at the proximal tibia was 13.0 mm (12.0-15.8) distal to the tuberosity and 6.0 mm (4.0-8.0) medial to the anterior rim of the tibia. The median (IQR) diameters at this site were 8.3 mm (7.9-9.1) (transverse) and 9.2 mm (8.9-9.8) (anterior-posterior). The diameters increased significantly with increasing weight. Conclusion: This study adds concise, practical information on the implementation of IO access in neonatal patients: the tibial dimensions in newborns in four different weight groups and initial data on anatomical landmarks to easily locate the IO puncture site. The results may help implement IO access in newborns more safely. What is Known: • Intraosseous access is a feasible option for emergency administration of vital drugs and fluids in newborns undergoing resuscitation when an umbilical venous catheter is impossible to place. • Severe complications of IO access due to malpositioned IO needles have been reported in neonates. What is New: • This study reports the most suitable tibial puncture sites for IO access and the tibial dimensions, in newborns of four weight groups. • The results can help to implement safe IO access in newborns.
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Affiliation(s)
- Eva M Schwindt
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University Vienna, Vienna, Austria.
- STAR-SIMCharacters Training and Research, Vienna, Austria.
| | - Theresa Häcker
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University Vienna, Vienna, Austria
| | | | - Janina M Patsch
- Division of General and Pediatric Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University Vienna, Vienna, Austria
- Vienna Bone and Growth Center, Vienna General Hospital and Medical University of Vienna, Vienna, Austria
| | - Sarah N Mehany
- Division of General and Pediatric Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University Vienna, Vienna, Austria
- Vienna Bone and Growth Center, Vienna General Hospital and Medical University of Vienna, Vienna, Austria
| | - Angelika Berger
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University Vienna, Vienna, Austria
| | - Jens C Schwindt
- STAR-SIMCharacters Training and Research, Vienna, Austria
- Neonatal Working Group, Austrian Resuscitation Council, Graz, Austria
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Keller A, Boukai A, Feldman O, Diamand R, Shavit I. Comparison of three intraosseous access devices for resuscitation of term neonates: a randomised simulation study. Arch Dis Child Fetal Neonatal Ed 2022; 107:289-292. [PMID: 34340986 DOI: 10.1136/archdischild-2021-321988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 07/19/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To compare the success rates and ease of use of three intraosseous (IO) access devices used in term neonates. DESIGN A three-arm randomised controlled simulation study was conducted. SETTING A simulation laboratory. PARTICIPANTS Seventy-two paediatric residents completing their emergency department rotation as part of their residency training, and 20 paediatric specialists. INTERVENTION Using an animal bone model, the one-attempt success rate of the EZ-IO drill, the NIO-I needle and the Jamshidi needle was compared. Uncooked Cornish Hen bones were used because of their similarity in length and diameter to the bones of neonates. Participants were asked to record the perceived ease of use of their assigned device using a 5-point Likert Scale. MAIN OUTCOME MEASURE The main outcome was the visualisation of flow emerging from the distal end of the bone, and perceived ease of use of the three IO devices. RESULTS The EZ-IO, NIO-I and Jamshidi groups included 30, 31 and 31 participants, respectively, with median (IQR) years of experience of 3 (2-5), 3 (2-6) and 4 (3-5) years. Participants had significantly lower one-attempt success rates with the EZ-IO drill than with the NIO-I and the Jamshidi needles (14 of 30 (46.7%) vs 24 of 31 (77.4%); p=0.016, and 14 of 30 (46.7%) vs 25 of 31 (80.7%); p=0.007, respectively). The median (IQR) ease-of-use score of the EZ-IO drill was higher than that of the NIO-I and Jamshidi needles (5 (4-5) vs 4 (4-5); p=0.008, and 5 (4-5) vs 4 (3-4); p=0.0004, respectively). CONCLUSIONS Although easier to use, the EZ-IO drill demonstrated lower success rates than the IO needles in establishing IO access on a neonatal bone model.
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Affiliation(s)
- Alon Keller
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Amit Boukai
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Oren Feldman
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Paediatric Emergency Department, Rambam Health Care Campus, Haifa, Israel
| | - Raz Diamand
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Paediatric Emergency Department, Rambam Health Care Campus, Haifa, Israel
| | - Itai Shavit
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel .,Paediatric Emergency Department, Rambam Health Care Campus, Haifa, Israel
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Eifinger F, Scaal M, Wehrle L, Maushake S, Fuchs Z, Koerber F. Finding alternative sites for intraosseous infusions in newborns. Resuscitation 2021; 163:57-63. [PMID: 33862177 DOI: 10.1016/j.resuscitation.2021.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/17/2021] [Accepted: 04/01/2021] [Indexed: 02/04/2023]
Abstract
AIM Intraosseous (IO)-access plays an alternative route during resuscitation. Our study in preterm and term stillborns was performed to find alternative IO puncture sites beside the recommended proximal tibia. METHODS The cadavers used were legal donations. 20 stillborns (mean: 29.2weeks, IQR 27.1-39.6) were investigated. Spectral-CT were analysed to calculate the diameter and circumferences of: i) proximal humerus ii) distal femur iii) proximal tibia iv) diaphyseal tibial. Contrast medium was applied under video documentation to investigate the drainage into the vascular system. RESULTS In term newborns, diameter of the cortex of the proximal humeral head is 12.1 ± 1.8 mm, distal end of the femur 11.9 ± 3.4 mm and the proximal tibial bone 12.0 ± 2.4 mm with cross-sectional diameter of 113.5 ± 19.7 mm2, 120.6 ± 28.2 mm2 and 111.6 ± 29.5 mm2, respectively. Regarding the preterm groups, there is a strong age-related growth in diameter and cross -sectional size. The diaphyseal area is the smallest in all measured bones with an age-dependent increase and is about half of that of metaphyseal diameters (proximal and distal) and about one third of that of metaphyseal cross sectional areas. The proximal femoral head region has the largest diameter of all measured bones with an egg-shaped formation with an extensive joint capsula. All investigated metaphyseal areas lack a clearly enclosed bone marrow cavity. Infusion of contrast medium into the distal femoral end and the proximal humerus head demonstrate the drainage of contrast medium into the central venous system within seconds. CONCLUSION Proximal humeral head and distal femoral end might be alternative IO areas which may lead to further IO puncture sites in neonates.
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Affiliation(s)
- Frank Eifinger
- Department of Pediatric Critical Care Medicine and Neonatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str.62, 50937 Cologne, Germany.
| | - Martin Scaal
- Institute of Anatomy II, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str.62, 50937 Cologne, Germany
| | - Lukas Wehrle
- Department of Pediatric Critical Care Medicine and Neonatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str.62, 50937 Cologne, Germany
| | - Stien Maushake
- Department of Pediatric Critical Care Medicine and Neonatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str.62, 50937 Cologne, Germany
| | - Zeynep Fuchs
- Department of Pediatric Critical Care Medicine and Neonatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str.62, 50937 Cologne, Germany
| | - Friederike Koerber
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str.62, 50937 Cologne, Germany
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Bruckner M, Lista G, Saugstad OD, Schmölzer GM. Delivery Room Management of Asphyxiated Term and Near-Term Infants. Neonatology 2021; 118:487-499. [PMID: 34023837 DOI: 10.1159/000516429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/09/2021] [Indexed: 11/19/2022]
Abstract
Approximately 800,000 newborns die annually due to birth asphyxia. The resuscitation of asphyxiated term newly born infants often occurs unexpected and is challenging for healthcare providers as it demands experience and knowledge in neonatal resuscitation. Current neonatal resuscitation guidelines often focus on resuscitation of extremely and/or very preterm infants; however, the recommendations for asphyxiated term newborn infants differ in some aspects to those for preterm infants (i.e., respiratory support, supplemental oxygen, and temperature management). Since the update of the neonatal resuscitation guidelines in 2015, several studies examining various resuscitation approaches to improve the outcome of asphyxiated infants have been published. In this review, we discuss current recommendations and recent findings and provide an overview of delivery room management of asphyxiated term newborn infants.
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Affiliation(s)
- Marlies Bruckner
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada.,Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Gianluca Lista
- Division of Neonatology, Department of Pediatric, "V. Buzzi" Ospedale Dei Bambini, Milan, Italy
| | - Ola D Saugstad
- Department of Pediatric Research, Oslo University Hospital Rikshospitalet, University of Oslo, Oslo, Norway.,Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada.,Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
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Capobianco S, Weiss M, Schraner T, Stimec J, Neuhaus K, Neuhaus D. Checking the basis of intraosseous access-Radiological study on tibial dimensions in the pediatric population. Paediatr Anaesth 2020; 30:1116-1123. [PMID: 32720412 DOI: 10.1111/pan.13979] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 07/13/2020] [Accepted: 07/20/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Malposition of intraosseous needles in pediatric patients is frequently reported. Incorrect needle length and penetration depth related to the puncture site and level are possible causes. AIMS Aim of this study was to analyze anatomic dimensions of the proximal tibia in the pediatric population with respect to intraosseous needle placement and needle tip position. METHODS Plain lower leg radiographs of children aged from birth to 16 years of age were analyzed. Pretibial tissue layer, cortical bone thickness, and the diameter of the medullary cavity were measured at two different puncture levels. Data were analyzed as descriptive statistics and by polynomial regression plots and set in context to commonly used EZ-IO® needle lengths of 15 and 25 mm. RESULTS Radiographs from 190 patients (104 boys/86 girls) were included. When fully inserted to skin level, up to 10.5% of needles do not reach medullary cavity at one and 18.5% at two patient's fingerbreadths distal to tibial tuberosity. The opposite cortical wall is touched or penetrated in 16% and 25%, respectively. Up to 96% of too deep needle tip positions occur in children younger than 24 months, as do too superficial tip positions in 59%. CONCLUSIONS Puncture level and needle length have a great influence on potential needle tip positions. Infants and toddlers are at highest risk for malpositioning. Due to relevant growth-related differences in tibial anatomy, an age-related and well-reflected approach is crucial to successfully establish intraosseous access.
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Affiliation(s)
- Stéphanie Capobianco
- Department of Anesthesia, University Children's Hospital, Zurich, Switzerland.,Children's Research Centre (CRC), University Children's Hospital Zurich, Zurich, Switzerland
| | - Markus Weiss
- Department of Anesthesia, University Children's Hospital, Zurich, Switzerland.,Children's Research Centre (CRC), University Children's Hospital Zurich, Zurich, Switzerland
| | - Thomas Schraner
- Children's Research Centre (CRC), University Children's Hospital Zurich, Zurich, Switzerland.,Department of Diagnostic Imaging, University Children's Hospital, Zurich, Switzerland
| | - Jennifer Stimec
- Division of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada
| | - Kathrin Neuhaus
- Children's Research Centre (CRC), University Children's Hospital Zurich, Zurich, Switzerland.,Division of Plastic and Reconstructive Surgery, Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Diego Neuhaus
- Department of Anesthesia, University Children's Hospital, Zurich, Switzerland.,Children's Research Centre (CRC), University Children's Hospital Zurich, Zurich, Switzerland
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Feld K, Bonni M, Körber F, Eifinger F, Banaschak S. Post-mortem estimation of gestational age and maturation of new-borns by CT examination of clavicle length, femoral length and femoral bone nuclei. Forensic Sci Int 2020; 314:110391. [DOI: 10.1016/j.forsciint.2020.110391] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 06/19/2020] [Accepted: 06/23/2020] [Indexed: 12/11/2022]
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Haase B, Springer L, Poets CF. Evaluating practioners' preferences regarding vascular emergency access in newborn infants in the delivery room: a national survey. BMC Pediatr 2020; 20:405. [PMID: 32854665 PMCID: PMC7450589 DOI: 10.1186/s12887-020-02294-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 08/12/2020] [Indexed: 02/06/2023] Open
Abstract
Background Venous access during neonatal emergencies in the delivery room (DR) can be accomplished through an umbilical venous catheter (UVC) or an intraosseous (IO) access. Preference of one over the other is unclear. We wanted to evaluate practioners’ views. Methods An anonymous online questionnaire was circulated to healthcare professionals with different background and experience, all working in neonatal intensive care units in Germany. The web-based survey consisted of 13 questions and data collection was performed using an online tool. Results We received 502 completed questionnaires, 152 (30%) were from neonatologists, the remainder from residents, fellows and neonatal nurses. For resuscitation of term newborns in the DR 61% of neonatologists vs. 53% of non-neonatologists were in favour of UVC instead of an IO as an emergency access. UVC placement was rated (very) difficult to impossible by 60% of neonatologists and 90% of non-neonatologists (p < 0.05). All respondents cited lack of experience as the main reason for feeling reluctant to place an UVC or IO access, the latter only being taken into consideration in term infants. Conclusions UVC placement in the DR is rated more often difficult to use by non-neonatologists than by neonatologists, apparently related to lack of experience. IO access was only considered for resuscitating term infants due to lacking practice and missing approval for birth weights < 3000 g. Frequent training might improve these clinical skills.
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Affiliation(s)
- Bianca Haase
- Department of Neonatology, University Children's Hospital Tuebingen, Calwerstraße 7, 72076 , Tuebingen, Germany.
| | - Laila Springer
- Department of Neonatology, University Children's Hospital Tuebingen, Calwerstraße 7, 72076 , Tuebingen, Germany
| | - Christian Friedrich Poets
- Department of Neonatology, University Children's Hospital Tuebingen, Calwerstraße 7, 72076 , Tuebingen, Germany
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Mileder LP, Urlesberger B, Schwaberger B. Use of Intraosseous Vascular Access During Neonatal Resuscitation at a Tertiary Center. Front Pediatr 2020; 8:571285. [PMID: 33042930 PMCID: PMC7530188 DOI: 10.3389/fped.2020.571285] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/14/2020] [Indexed: 12/02/2022] Open
Abstract
Introduction: Emergency vascular access is rarely required during neonatal resuscitation. We aimed to analyze frequency of use, success, and complication rates of intraosseous (IO) vascular access in neonates at a single tertiary neonatal intensive care unit. Method: We performed a questionnaire-based survey among pediatric residents, pediatricians, and neonatologists, asking for the use of IO access in neonates between April 1st, 2015, and April 30th, 2020. We then reviewed electronic patient charts of all identified neonates for demographic data as well as indications and complications of IO puncture. Results: All 41 questionnaires were answered. Nine physicians had attempted IO access 15 times in a total of 12 neonates. Among them were eight term neonates, three preterm neonates, and one former extreme preterm neonate at a post-menstrual age of 42 weeks (m:f = 6:6). The overall success rate was 75%. IO access was attempted primarily during post-natal resuscitation (11/12 neonates, 91.7%) and after unsuccessful peripheral venous puncture (8/12 neonates, 66.7%). It was used to administer adrenaline, fluid and/or blood, and emergency sedation after intubation. Minor short-term complications were reported in three of nine successful IO punctures (33.3%). Discussion: Over the study period of 61 months, IO access was rarely attempted during neonatal resuscitation. Our success rate was lower than reported elsewhere, suggesting that IO puncture may be more challenging in neonates than in older infants and children. No severe short-term complications occurred.
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Affiliation(s)
- Lukas P Mileder
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Berndt Urlesberger
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Bernhard Schwaberger
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
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Intraosseous devices in small children: The need for a clearly defined strategy. Resuscitation 2019; 146:281-282. [PMID: 31812663 DOI: 10.1016/j.resuscitation.2019.11.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 11/06/2019] [Indexed: 11/20/2022]
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Scrivens A, Reynolds PR, Emery FE, Roberts CT, Polglase GR, Hooper SB, Roehr CC. Use of Intraosseous Needles in Neonates: A Systematic Review. Neonatology 2019; 116:305-314. [PMID: 31658465 DOI: 10.1159/000502212] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 07/17/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND The use of intraosseous (IO) access during resuscitation is widely accepted and promoted in paediatric medicine but features less prominently in neonatal training. Whilst umbilical venous catheterization (UVC) is a reliable method of delivering emergency drugs and fluids, it is not always achievable in a timely manner. IO access warrants exploration as an alternative. AIM Conduct a systematic review of existing literature to examine the evidence for efficacy and safety of IO devices in neonatal patients, from birth to discharge. METHOD A search of PubMed, Ovid, Medline, and Embase was carried out. Abstracts were screened for relevance to focus on neonatal-specific literature and studies which carried out separate analyses for neonates (infants <28 days of age or resident on a neonatal unit). RESULTS One case series and 12 case reports describe IO device insertion into 41 neonates, delivering a variety of drugs, including adrenaline (epinephrine) and volume resuscitation. Complications range from none to severe. Cadaveric studies show that despite a small margin for error, IO devices can be correctly sited in neonates. Simulation studies suggest that IO devices may be faster and easier to site than UVC, even in experienced hands. CONCLUSION IO access should be available on neonatal units and considered for early use in neonates where other access routes have failed. Appropriate training should be available to staff in addition to existing life support and UVC training. Further studies are required to assess the optimal device, position, and whether medication can be delivered IO as effectively as by UVC. If IO devices provide a faster method of delivering adrenaline effectively than UVC, this may lead to changes in neonatal resuscitation practice.
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Affiliation(s)
- Alexandra Scrivens
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom,
| | - Peter R Reynolds
- Neonatal Intensive Care Unit, St. Peter's Hospital, Ashford & St. Peter's Hospitals NHS Foundation Trust, Chertsey, United Kingdom
| | - Faith E Emery
- Neonatal Intensive Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | - Calum T Roberts
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia.,Monash Newborn, Monash University Hospital, Melbourne, Victoria, Australia
| | - Graeme R Polglase
- Hudson Institute, The Ritchie Centre, Melbourne, Victoria, Australia
| | - Stuart B Hooper
- Hudson Institute, The Ritchie Centre, Melbourne, Victoria, Australia
| | - Charles Christoph Roehr
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom.,University Department of Paediatrics, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
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