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Gipsman AI, Grant LMC, Piccione JC, Yehya N, Witmer C, Young LR, Wannes Daou A, Srinivasan A, Phinizy PA. Management of severe acute pulmonary haemorrhage in children. THE LANCET. CHILD & ADOLESCENT HEALTH 2025; 9:349-360. [PMID: 40246361 DOI: 10.1016/s2352-4642(25)00060-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2024] [Revised: 02/11/2025] [Accepted: 02/17/2025] [Indexed: 04/19/2025]
Abstract
Pulmonary haemorrhage is a potentially life-threatening condition with a variety of causes. Quality clinical trials are insufficient in children, restricting the evidence base to observational data and adult studies. The overall management strategy should address control of symptomatic bleeding, identification of the bleeding source, and treatment of the underlying cause. Flexible bronchoscopy is an important tool used to identify the cause and site of bleeding, do interventional procedures, and directly instil medications to affected areas. Medications to control bleeding include vasoconstrictors, antifibrinolytics, and recombinant factor VIIa. Definitive treatment often requires immunomodulatory medications, bronchial artery embolisation, or surgery. In this Review, we summarise the most recent evidence pertaining to medical, interventional, and surgical treatments of pulmonary haemorrhage in children.
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Affiliation(s)
- Alexander I Gipsman
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Lauren M C Grant
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joseph C Piccione
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Nadir Yehya
- Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Char Witmer
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lisa R Young
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Antoinette Wannes Daou
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Abhay Srinivasan
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Pelton A Phinizy
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Kalchiem-Dekel O, Tran BC, Glick DR, Ha NT, Iacono A, Pickering EM, Shah NG, Sperry MG, Sachdeva A, Reed RM. Prophylactic epinephrine attenuates severe bleeding in lung transplantation patients undergoing transbronchial lung biopsy: Results of the PROPHET randomized trial. J Heart Lung Transplant 2023; 42:1205-1213. [PMID: 37140517 DOI: 10.1016/j.healun.2023.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/03/2023] [Accepted: 03/08/2023] [Indexed: 03/15/2023] Open
Abstract
BACKGROUND Severe hemorrhage is an uncommon yet potentially life-threatening complication of transbronchial lung biopsy. Lung transplantation recipients undergo multiple bronchoscopies with biopsy and are considered to be at an increased risk for bleeding from transbronchial biopsy, independent of traditional risk factors. We aimed to evaluate the efficacy and safety of endobronchial administration of prophylactic topical epinephrine in attenuating transbronchial biopsy-related hemorrhage in lung transplant recipients. METHODS The Prophylactic Epinephrine for the Prevention of Transbronchial Lung Biopsy-related Bleeding in Lung Transplant Recipients study was a 2-center, randomized, double blind, placebo-controlled clinical trial. Participants undergoing transbronchial lung biopsy were randomized to receive 1:10,000-diluted topical epinephrine vs saline placebo administered prophylactically into the target segmental airway. Bleeding was graded based on a clinical severity scale. The primary efficacy outcome was incidence of severe or very severe hemorrhage. The primary safety outcome was a composite of 3-hours all-cause mortality and an acute cardiovascular event. RESULTS A total of 66 lung transplantation recipients underwent 100 bronchoscopies during the study period. The primary outcome of severe or very severe hemorrhage occurred in 4 cases (8%) in the prophylactic epinephrine group and in 13 cases (24%) in the control group (p = 0.04). The composite primary safety outcome did not occur in any of the study groups. CONCLUSIONS In lung transplantation recipients undergoing transbronchial lung biopsy, prophylactic administration of 1:10,000-diluted topical epinephrine into the target segmental airway before biopsy attenuates the incidence of significant endobronchial hemorrhage without conveying a significant cardiovascular risk. (ClinicalTrials.gov identifier: NCT03126968).
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Affiliation(s)
- Or Kalchiem-Dekel
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Bich-Chieu Tran
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Danielle R Glick
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ngoc-Tram Ha
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Aldo Iacono
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Edward M Pickering
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Nirav G Shah
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Mark G Sperry
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ashutosh Sachdeva
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Robert M Reed
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland.
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Revelo AE, Pastis NJ. Where Does Tranexamic Acid Fit in the Armamentarium for Bronchoscopic Bleeding? Chest 2023; 163:751-752. [PMID: 37031982 DOI: 10.1016/j.chest.2022.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 11/22/2022] [Indexed: 04/11/2023] Open
Affiliation(s)
- Alberto E Revelo
- Division of Pulmonary, Critical Care & Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH.
| | - Nicholas J Pastis
- Division of Pulmonary, Critical Care & Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
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QA project: Hemodynamic safety of endobronchial administration of phenylephrine for control of airway bleeding by bronchoscopy. Pulm Pharmacol Ther 2020; 64:101961. [PMID: 33035701 DOI: 10.1016/j.pupt.2020.101961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/09/2020] [Accepted: 09/30/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Phenylephrine has been administered endobronchially for airway bleeding during bronchoscopy as an alternative to epinephrine. Topical phenylephrine, often used in nasal surgery as a vasoconstrictor agent has been linked to cardiovascular morbidity. OBJECTIVE To evaluate the safety of bronchoscopic instillation of phenylephrine during bronchoscopy. METHODS We retrospectively reviewed patients who received endobronchial phenylephrine in our endoscopy suite. We compared the changes in blood pressure and heart rate before and after endobronchial phenylephrine administration. The safety of endobronchial phenylephrine was assessed with regards to the changes in hemodynamics and acute cardiovascular event, and 30-day mortality. Acute cardiovascular complications included acute coronary syndrome, aortic dissection, tachyarrhythmias, pulmonary edema and stroke. RESULTS We identified 30 patients who received endobronchial phenylephrine 100mcg/ml with a mean total volume of 6.5 ± 10.6 ml. They were given mainly for balloon dilation and cryobiopsy procedure (96.7%). On excluding patients who received concurrent IV pressor, there was a statistically significant increase of mean arterial pressure (MAP) by 12 ± 21 mmHg, p = 0.01 within 30 min of endobronchial phenylephrine compared to procedure day MAP baseline. There was 27% of patients with more than 20% increase in their MAP but none of the patients had MAP more than 140 nor the occurrence of acute cardiovascular event. There was no significant change in the patients' heart rate following endobronchial phenylephrine. CONCLUSION In our review, endobronchial phenylephrine with dose comparable to IV administration can cause significant raise in MAP but their absolute levels did not go beyond 180/120 mmHg nor resulted in acute cardiovascular complications.
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Huang R, Lin W, Fan H, Lu G, Yang D, Ma L, Lin J. Bronchoalveolar lavage with pediatric flexible fibreoptic bronchoscope in pediatric haematopoietic stem cell transplant patients: Nursing considerations for operative complications. J SPEC PEDIATR NURS 2019; 24:e12236. [PMID: 30821121 DOI: 10.1111/jspn.12236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 02/11/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE Bronchoalveolar lavage (BAL) with pediatric flexible fibreoptic bronchoscopy (FB) is used for diagnostic and therapeutic purposes in pediatric haematopoietic stem cell transplant (HSCT) patients with pulmonary complications. The aim of our study was to evaluate complications in pediatric HSCT patients undergoing BAL/FB and to explore the nursing emphases on complications. DESIGN AND METHODS We performed a retrospective, case-controlled study to evaluate perioperative complications of HSCT children. BAL/FB was conducted for 42 children with HSCT who experienced pulmonary complications between January 2017 and January 2018 within a tertiary hospital. Forty patients diagnosed with general pneumonia were randomly selected during the same period and served as the control group. We analyzed the signs and symptoms of all patients and compared the operative complications between the two groups. Furthermore, we presented the methods used to manage complications. RESULTS The presence of cough, lung rales, and imaging findings in the HSCT patients was significantly different from that of the control group (p < 0.0001). The complication rate was 66.67% (28/42) in the HSCT group and 22.5% (9/40) in the control group, and the difference was significant (p < 0.0001). Twelve out of 42 HSCT patients experienced airway mucosal bleeding (28.57%), and six had transient fever (14.29%). The topical use of epinephrine diluted saline (1:10,000) was highly effective for controlling airway mucosal bleeding without causing fluctuations in blood pressure. PRACTICE IMPLICATIONS There were more perioperative complications in the HSCT patients than in the general pneumonia patients who underwent BAL/FB. Airway mucosal bleeding was a key focus of perioperative nursing in HSCT patients undergoing bronchoscopy as main complication. BAL with the use of epinephrine diluted saline (1:10,000) effectively decreased airway mucosal bleeding.
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Affiliation(s)
- Rulin Huang
- Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, China
| | - Wenchun Lin
- Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, China
| | - Huifeng Fan
- Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, China
| | - Gen Lu
- Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, China
| | - Diyuan Yang
- Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, China
| | - Lan Ma
- Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, China
| | - Jiamian Lin
- Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, China
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Lin S, Callaway CW, Shah PS, Wagner JD, Beyene J, Ziegler CP, Morrison LJ. Adrenaline for out-of-hospital cardiac arrest resuscitation: A systematic review and meta-analysis of randomized controlled trials. Resuscitation 2014; 85:732-40. [DOI: 10.1016/j.resuscitation.2014.03.008] [Citation(s) in RCA: 114] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Revised: 02/20/2014] [Accepted: 03/10/2014] [Indexed: 01/01/2023]
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Khoo KL, Lee P, Mehta AC. Endobronchial epinephrine: confusion is in the air. Am J Respir Crit Care Med 2013; 187:1137-8. [PMID: 23675717 DOI: 10.1164/rccm.201209-1682le] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Rozanski EA, Rush JE, Buckley GJ, Fletcher DJ, Boller M. RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 4: Advanced life support. J Vet Emerg Crit Care (San Antonio) 2012; 22 Suppl 1:S44-64. [DOI: 10.1111/j.1476-4431.2012.00755.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | - John E. Rush
- Cummings School of Veterinary Medicine; Tufts University; North Grafton; MA
| | - Gareth J. Buckley
- College of Veterinary Medicine, University of Florida; Gainesville; FL
| | - Daniel J. Fletcher
- College of Veterinary Medicine, Department of Clinical Sciences; Cornell University; Ithaca; NY
| | - Manuel Boller
- Department of Clinical Studies, School of Veterinary Medicine and the Department of Emergency Medicine, School of Medicine; Center for Resuscitation Science University of Pennsylvania; Philadelphia; PA
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de Caen AR, Kleinman ME, Chameides L, Atkins DL, Berg RA, Berg MD, Bhanji F, Biarent D, Bingham R, Coovadia AH, Hazinski MF, Hickey RW, Nadkarni VM, Reis AG, Rodriguez-Nunez A, Tibballs J, Zaritsky AL, Zideman D. Part 10: Paediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2011; 81 Suppl 1:e213-59. [PMID: 20956041 DOI: 10.1016/j.resuscitation.2010.08.028] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Allan R de Caen
- Stollery Children's Hospital, University of Alberta, Canada.
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Kleinman ME, Chameides L, Schexnayder SM, Samson RA, Hazinski MF, Atkins DL, Berg MD, de Caen AR, Fink EL, Freid EB, Hickey RW, Marino BS, Nadkarni VM, Proctor LT, Qureshi FA, Sartorelli K, Topjian A, van der Jagt EW, Zaritsky AL. Part 14: Pediatric Advanced Life Support. Circulation 2010; 122:S876-908. [DOI: 10.1161/circulationaha.110.971101] [Citation(s) in RCA: 473] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Kleinman ME, de Caen AR, Chameides L, Atkins DL, Berg RA, Berg MD, Bhanji F, Biarent D, Bingham R, Coovadia AH, Hazinski MF, Hickey RW, Nadkarni VM, Reis AG, Rodriguez-Nunez A, Tibballs J, Zaritsky AL, Zideman D, Pediatric Basic and Advanced Life Support Chapter Collaborators. Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Pediatrics 2010; 126:e1261-318. [PMID: 20956433 PMCID: PMC3784274 DOI: 10.1542/peds.2010-2972a] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Collaborators] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Collaborators
Ian Adatia, Richard P Aickin, John Berger, Jeffrey M Berman, Desmond Bohn, Kate L Brown, Mark G Coulthard, Douglas S Diekema, Aaron Donoghue, Jonathan Duff, Jonathan R Egan, Christoph B Eich, Diana G Fendya, Ericka L Fink, Loh Tsee Foong, Eugene B Freid, Susan Fuchs, Anne-Marie Guerguerian, Bradford D Harris, George M Hoffman, James S Hutchison, Sharon B Kinney, Sasa Kurosawa, Jesús Lopez-Herce, Sharon E Mace, Ian Maconochie, Duncan Macrae, Mioara D Manole, Bradley S Marino, Felipe Martinez, Reylon A Meeks, Alfredo Misraji, Marilyn Morris, Akira Nishisaki, Masahiko Nitta, Gabrielle Nuthall, Sergio Pesutic Perez, Lester T Proctor, Faiqa A Qureshi, Sergio Rendich, Ricardo A Samson, Kennith Sartorelli, Stephen M Schexnayder, William Scott, Vijay Srinivasan, Robert M Sutton, Mark Terry, Shane Tibby, Alexis Topjian, Elise W van der Jagt, David Wessel,
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Kleinman ME, de Caen AR, Chameides L, Atkins DL, Berg RA, Berg MD, Bhanji F, Biarent D, Bingham R, Coovadia AH, Hazinski MF, Hickey RW, Nadkarni VM, Reis AG, Rodriguez-Nunez A, Tibballs J, Zaritsky AL, Zideman D, Pediatric Basic and Advanced Life Support Chapter Collaborators. Part 10: Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010; 122:S466-515. [PMID: 20956258 PMCID: PMC3748977 DOI: 10.1161/circulationaha.110.971093] [Citation(s) in RCA: 143] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Collaborators] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Note From the Writing Group: Throughout this article, the reader will notice combinations of superscripted letters and numbers (eg, “Family Presence During ResuscitationPeds-003”). These callouts are hyperlinked to evidence-based worksheets, which were used in the development of this article. An appendix of worksheets, applicable to this article, is located at the end of the text. The worksheets are available in PDF format and are open access.
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Collaborators
Ian Adatia, Richard P Aickin, John Berger, Jeffrey M Berman, Desmond Bohn, Kate L Brown, Mark G Coulthard, Douglas S Diekema, Aaron Donoghue, Jonathan Duff, Jonathan R Egan, Christoph B Eich, Diana G Fendya, Ericka L Fink, Loh Tsee Foong, Eugene B Freid, Susan Fuchs, Anne-Marie Guerguerian, Bradford D Harris, George M Hoffman, James S Hutchison, Sharon B Kinney, Sasa Kurosawa, Jesus Lopez-Herce, Sharon E Mace, Ian Maconochie, Duncan Macrae, Mioara D Manole, Bradley S Marino, Felipe Martinez, Reylon A Meeks, Alfredo Misraji, Marilyn Morris, Akira Nishisaki, Masahiko Nitta, Gabrielle Nuthall, Sergio Pesutic Perez, Lester T Proctor, Faiqa A Qureshi, Sergio Rendich, Ricardo A Samson, Kennith Sartorelli, Stephen M Schexnayder, William Scott, Vijay Srinivasan, Robert M Sutton, Mark Terry, Shane Tibby, Alexis Topjian, Elise W van der Jagt, David Wessel,
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Abstract
If the endotracheal route is to be used for administration of epinephrine, the limited available evidence suggests that the currently recommended dose of 0.01 mg/kg is likely to be too low to be effective. Given the paucity of high-quality clinical data regarding endotracheal epinephrine, the intravenous route should be used as soon as venous access is established. Given the complete lack of clinical data in newborns, endotracheal administration of naloxone is not recommended.
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Affiliation(s)
- Myra H Wyckoff
- Department of Pediatrics, Division of Neonatal/Perinatal Medicine, University of Texas, Southwestern Medical Center, Dallas, TX 75290-9063, USA.
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Rehan VK, Garcia M, Kao J, Tucker CM, Patel SM. Epinephrine delivery during neonatal resuscitation: comparison of direct endotracheal tube vs catheter inserted into endotracheal tube administration. J Perinatol 2004; 24:686-90. [PMID: 15269703 DOI: 10.1038/sj.jp.7211172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVES The optimal method for epinephrine administration during neonatal resuscitation is not known. We hypothesized that epinephrine will be delivered more efficiently when administered via a feeding catheter inserted into the endotracheal tube (C-ETT) vs when administered directly into the ETT (D-ETT). Our objectives were to (1) compare the delivery of epinephrine to the distal end of the ETT when administered via D-ETT vs C-ETT; (2) measure the retention of epinephrine within the ETT vs the feeding catheter used for the drug delivery; and (3) compare the delivery of the drug with and without an air flush after administration via C-ETT. METHODS All experiments were performed in vitro, simulating epinephrine administration during neonatal resuscitation, according to the standard guidelines. Radiolabeled epinephrine, diluted to 1 microCi/ml, was used and experiments were repeated at least 4 times. Epinephrine administration via D-ETT was followed by one manual breath via a self-inflating bag attached to the ETT. Epinephrine delivery via C-ETT was followed by 1 ml saline flush, and in some experiments, this was also followed by a 1 cm(3) air flush. Epinephrine delivery and retention were assessed by measuring the radioactive content of the effluent fluid and that of the ETT or of the feeding catheter used for drug delivery. RESULTS Significantly higher dosage of the drug was delivered when administered via D-ETT vs C-ETT, if air flush following C-ETT method was not used. However, with an air flush following the saline flush after the drug instillation, there was no difference in the amount of epinephrine delivered between the two methods. Retention in the ETT wall or the catheter was <7.5% of the administered dose with either method. CONCLUSIONS Without an air flush following C-ETT method of epinephrine delivery, higher dosage of the drug is delivered via D-ETT vs C-ETT method. An air flush following the saline flush during C-ETT method improves drug delivery. Given that the C-ETT method is more cumbersome and time consuming, and does not improve drug delivery, D-ETT administration should be the method of choice for epinephrine delivery during neonatal resuscitation.
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Affiliation(s)
- Virender K Rehan
- Department of Pediatrics, Harbor-UCLA Research and Education Institute, Torrance, CA 90502, USA
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Cole SG, Otto CM, Hughes D. Cardiopulmonary cerebral resuscitation in small animals-A clinical practice review. Part II. J Vet Emerg Crit Care (San Antonio) 2003. [DOI: 10.1046/j.1435-6935.2003.00067.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Efrati O, Barak A, Ben-Abraham R, Modan-Moses D, Berkovitch M, Manisterski Y, Lotan D, Barzilay Z, Paret G. Should vasopressin replace adrenaline for endotracheal drug administration? Crit Care Med 2003; 31:572-6. [PMID: 12576968 DOI: 10.1097/01.ccm.0000050441.09207.16] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Arginine vasopressin was established recently as a drug of choice in the treatment of cardiac arrest and in retractable ventricular fibrillation; however, the hemodynamic effect of vasopressin following endotracheal drug administration has not been fully elucidated. We compared the effects of endotracheally administered vasopressin vs. adrenaline on hemodynamic variables in a canine model, and we investigated whether vasopressin produces the same deleterious immediate blood pressure decrease as did endotracheal adrenaline in the canine model. DESIGN Prospective controlled study. SETTING Animal laboratory in Tel-Aviv University, Israel. SUBJECTS Five adult mongrel dogs weighing 6.5-20 kg. INTERVENTIONS Dogs were anesthetized; each dog was intubated orally, and both femoral arteries were cannulated for the measurement of arterial pressure and for sampling blood gases. Each dog was studied four times, 1 wk apart, by using the same protocol for injection and anesthesia: endotracheal placebo (10 mL NaCl 0.9%,), endotracheal vasopressin (1 units/kg), endobronchial adrenaline (0.1 mg/kg), and endotracheal adrenaline (0.1 mg/kg). Following placebo, vasopressin, and adrenaline instillation, five forced manual ventilations were delivered with an Ambu bag. Each dog was its own control. MEASUREMENTS AND MAIN RESULTS Following placebo or drug administration, heart electrocardiography and arterial pressures were continuously monitored with a polygraph recorder for 1 hr. Endotracheal vasopressin produced an immediate increase of diastolic blood pressure (from 83 +/- 10 mm Hg [baseline] to 110 +/- 5 mm Hg at 1 min postinjection). This response lasted >1 hr. In contrast, both endotracheal and endobronchial administration of adrenaline produced an early and significant (p <.05) decrease in diastolic and mean blood pressures. The diastolic blood pressure increase from 85 +/- 10 mm Hg to 110 +/- 10 mm Hg took an ill-afforded 55 secs following endotracheal adrenaline. Diastolic blood pressure was significantly (p <.05) higher following vasopressin compared with adrenaline administration in both routes. CONCLUSIONS Vasopressin accomplishes its hemodynamic effect, particularly on diastolic blood pressure, more rapidly, vigorously, and protractedly and to a significant degree compared with both endotracheal and endobronchial adrenaline. Evaluation of the effects of endotracheal vasopressin in a closed chest cardiopulmonary resuscitation model is recommended.
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Affiliation(s)
- Ori Efrati
- Pediatric Intensive Care Unit, The Chaim Sheba Medical Center, Tel-Hashomer, Israel
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Manisterski Y, Vaknin Z, Ben-Abraham R, Efrati O, Lotan D, Berkovitch M, Barak A, Barzilay Z, Paret G. Endotracheal Epinephrine: A Call for Larger Doses. Anesth Analg 2002. [DOI: 10.1213/00000539-200210000-00045] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Manisterski Y, Vaknin Z, Ben-Abraham R, Efrati O, Lotan D, Berkovitch M, Barak A, Barzilay Z, Paret G. Endotracheal epinephrine: a call for larger doses. Anesth Analg 2002; 95:1037-41, table of contents. [PMID: 12351290 DOI: 10.1097/00000539-200210000-00045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED Endotracheal administration of epinephrine 0.02 mg/kg (twice the IV dose) is recommended when IV access is unavailable during cardiopulmonary resuscitation. The standard IV dose has been considered too small for the endotracheal route by causing a detrimental decrease of arterial blood pressure (BP), presumably mediated by the beta-adrenergic receptor unopposed by alpha adrenergic vasoconstriction. We conducted a prospective, randomized, laboratory comparison of increasing doses of endotracheal epinephrine to ascertain the yet undetermined optimal dose of endotracheal epinephrine that would increase BP. After injecting normal saline (control), saline-diluted epinephrine (0.02, 0.035, 0.1, 0.2, and 0.3 mg/kg) was injected into the endotracheal tube of five anesthetized dogs at least 1 wk apart. Arterial blood samples for blood gases were collected before and at 14 time points up to 60 min after the drug administration. Heart rate and arterial BP were continuously monitored with a polygraph recorder. Only the 0.3 mg/kg dose successfully caused an increase in BP, observed 2 min after administration, and lasting for 10 min. An early decrease in BP was obviated only at a dose equivalent to 10-fold the currently recommended one. IMPLICATIONS We conducted a prospective, randomized, laboratory comparison of increasing doses of endotracheal epinephrine to ascertain the yet undetermined optimal dose of endotracheal epinephrine that would increase arterial blood pressure (BP). A decrease in BP was obviated only at a dose equivalent to 10-fold the currently recommended one. Clinical studies using larger doses of endotracheal epinephrine and their use as first-line therapy in cardiac arrest are warranted.
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Affiliation(s)
- Yossi Manisterski
- Department of Pediatric Intensive Care, The Chaim Sheba Medical Center, Tel Hashomer and the Sackler Faculty of Medicine, Tel Aviv University, Israel
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Efrati O, Barak A, Ben-Abraham R, Weinbroum AA, Lotan D, Manistersky Y, Yahav J, Barzilay Z, Paret G. Hemodynamic effects of tracheal administration of vasopressin in dogs. Resuscitation 2001; 50:227-32. [PMID: 11719151 DOI: 10.1016/s0300-9572(01)00338-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Intravenous administration of vasopressin during cardiopulmonary resuscitation (CPR) has been shown to be more effective than optimal doses of epinephrine. Earlier studies had been performed on a porcine model, but pigs produce lysine vasopressin hormone, while humans and dogs do not. This study was designed to compare the effects of tracheal vasopressin with those of NaCl 0.9% (placebo) on haemodynamic variables in a dog model. METHODS Five dogs were allocated to receive either vasopressin 1.2 U/kg or placebo (10 ml of NaCl 0.9%) via the tracheal route after being anesthetized and ventilated. Haemodynamic variables were determined and arterial blood gases were measured. RESULTS All animals of the vasopressin group demonstrated a significant increase of the systolic (from 135+/-7 to 165+/-6 mmHg, P<0.05), diastolic (from 85+/-10 to 110+/-10 mmHg, P<0.05) and mean blood pressure (from 98.5+/-3 to 142.2+/-5, P<0.05). Blood pressure rose rapidly and lasted for more than an hour (plateau effect). Heart rate decreased significantly following vasopressin (from 54+/-9 to 40+/-5 beats per min, P<0.05) but not in the placebo group. These changes were not demonstrated with placebo injection. CONCLUSION Tracheal administration of vasopressin was followed by significantly higher diastolic, systolic and mean blood pressures in the vasopressin group compared with the placebo group. Blood gases remained unchanged in both groups. Vasopressin administered via the trachea may be an acceptable alternative for vasopressor administration during CPR, when intravenous access is delayed or not available, however, further investigation is necessary.
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Affiliation(s)
- O Efrati
- Pediatric ICU, The Chaim Sheba Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, 52621 Tel-Hashomer, Tel Aviv, Israel
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20
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Mielke LL, Lanzinger MJ, Aschke C, Entholzner EK, Wilhelm MG, Henke J, Hargasser SR, Erhardt W, Hipp RF. Plasma epinephrine levels after epinephrine administration using different tracheal administration techniques in an adult CPR porcine model. Resuscitation 2001; 50:103-8. [PMID: 11719136 DOI: 10.1016/s0300-9572(01)00327-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The aim of the study was to compare arterial plasma epinephrine levels after tracheal epinephrine application using three different tracheal instillation techniques at different tracheal levels in a porcine adult cardiopulmonary resuscitation model. In the prospective, randomized study, electrically-induced cardiopulmonary arrest was applied to 32 anaesthetized and paralyzed domestic pigs. After 3 min of cardiopulmonary arrest and 2 min of external chest compressions using a pneumatic compression device and mechanical ventilation, epinephrine was administered intravenously (20 microg/kg) or tracheally (50 microg/kg): using either direct injection into the upper end of the tracheal tube, via a catheter placed into the bronchial system and using a special tracheal application tube. In each group, there were eight pigs. Arterial blood samples were taken before and up to 10 min after epinephrine administration. Regression analysis was performed of the correlated data. The values of mean arterial blood pressure and end-tidal CO(2) during the time of observation did not differ between groups. Total plasma epinephrine concentrations showed a significant increase in all groups, but with no difference between the tracheal groups. However, peak epinephrine levels in the intravenous group were significantly higher than in tracheal groups. We conclude that administration using three different tracheal instillation levels result in similar onset and peak plasma epinephrine levels in this setting and therefore the preferred method of tracheal epinephrine application for cardiopulmonary resuscitation may be selected by other criteria.
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Affiliation(s)
- L L Mielke
- Arbeitsgruppe Notfallmedizin, Technische Universität München, Innere-Wiener-Str.30, D-81667 Munich, Germany
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21
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Vaknin Z, Manisterski Y, Ben-Abraham R, Efrati O, Lotan D, Barzilay Z, Paret G. Is endotracheal adrenaline deleterious because of the beta adrenergic effect? Anesth Analg 2001; 92:1408-12. [PMID: 11375813 DOI: 10.1097/00000539-200106000-00009] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
IV adrenaline increases coronary and cerebral perfusion pressures during cardiopulmonary resuscitation. We recently showed that endotracheal adrenaline can decrease blood pressure (BP), a detrimental effect presumably mediated by the beta 2-adrenergic receptor unopposed by alpha-adrenergic vasoconstriction. This prospective, randomized, laboratory comparison of endotracheal adrenaline (0.05 mg/kg diluted with normal saline to 10 mL total volume) with or without nonselective beta-blocker (propranolol) pretreatment was conducted in an attempt to clarify the mechanism of this BP decrease. Five mongrel dogs were given 0.05 mg/kg endotracheal adrenaline (diluted) or 0.05 mg/kg endotracheal adrenaline followed by an IV propranolol (0.1 mg/kg) pretreatment. Each dog served as its own control (10 mL of normal saline administered endotracheally) and received each regimen at least one week apart. Endotracheal adrenaline given after the propranolol pretreatment produced an increase in systolic, diastolic, and mean arterial BPs, from 165/110 mm Hg (mean 128 mm Hg) to 177.5/125 mm Hg (mean 142.5 mm Hg), respectively, as opposed to the hypotensive effect of isolated endotracheal adrenaline (P < 0.03). Thus, endotracheal adrenaline was associated with predominantly beta-adrenergic-mediated effects, causing hypotension via peripheral vasodilatation unopposed by alpha-adrenergic vasoconstriction. The search for the optimal dose of endotracheal adrenaline should be aimed at achieving the higher alpha-adrenergic vasoconstrictive threshold.
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Affiliation(s)
- Z Vaknin
- Department of Pediatric Intensive Care, The Chaim Sheba Medical Center, Tel Hashomer, Israel
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22
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Naganobu K, Hasebe Y, Uchiyama Y, Hagio M, Ogawa H. A Comparison of Distilled Water and Normal Saline as Diluents for Endobronchial Administration of Epinephrine in the Dog. Anesth Analg 2000. [DOI: 10.1213/00000539-200008000-00016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Naganobu K, Hasebe Y, Uchiyama Y, Hagio M, Ogawa H. A comparison of distilled water and normal saline as diluents for endobronchial administration of epinephrine in the dog. Anesth Analg 2000; 91:317-21. [PMID: 10910841 DOI: 10.1097/00000539-200008000-00016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED We compared the effects of distilled water and normal saline as diluents for the endobronchial administration of epinephrine in anesthetized dogs by using a cross-over design. Six dogs received 2 mL of either normal saline or distilled water into the bronchus, and the other solution was administered 1 wk later. Eight dogs received 0.02 mg/kg epinephrine diluted in either distilled water (E + water) or normal saline (E + saline) to a total volume of 2 mL into the bronchus, and the other solution was administered 1 wk later. Normal saline or distilled water without epinephrine did not affect the plasma epinephrine concentration, mean arterial pressure (MAP), and PaO(2). The peak plasma epinephrine concentration was significantly larger after treatment with E + water (26.5 +/- 7.9 ng/mL) than after E + saline (2.1 +/- 0.7 ng/mL). E + water caused an increase in MAP of 91 +/- 24 mm Hg, whereas E + saline did not affect MAP. The maximal decrease in PaO(2) after the administration of E + water (14 +/- 5 mm Hg) was significantly greater than after E + saline (7 +/- 2 mm Hg). In conclusion, distilled water as the diluent for endobronchially administered epinephrine to a total volume of 2 mL allowed better absorption of epinephrine compared with normal saline without a serious detrimental effect on PaO(2). IMPLICATIONS Using a small volume of distilled water as the diluent for endobronchial epinephrine administration significantly increased epinephrine absorption and arterial pressure in comparison with normal saline, without having a serious detrimental effect on PaO(2), in an anesthetized, noncardiopulmonary, resuscitation dog model.
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Affiliation(s)
- K Naganobu
- Department of Veterinary Science, Faculty of Agriculture, Miyazaki University, Japan.
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Mielke LL, Lanzinger MJ, Entholzner EK, Hargasser SR, Hipp RF. The time required to perform different methods for endotracheal drug administration during CPR. Resuscitation 1999; 40:165-9. [PMID: 10395399 DOI: 10.1016/s0300-9572(99)00005-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We compared the times necessary to perform different endotracheal drug application techniques during CPR. In a simulated CPR situation with a mannequin 28 paramedics and seven emergency physicians performed different drug instillation techniques in a randomized manner: direct injection into the upper end of the endotracheal tube (group tube), via a suction catheter placed into the bronchial system (group suction catheter), via a flexible venous catheter placed into the bronchial system (group venous catheter), using an EDGAR tube (an endotracheal tube with an injection channel within the wall of the tube (group EDGAR). We measured the time necessary to prepare the drug solution and compared the time necessary to prepare and perform each instillation method and the time the ventilation was interrupted. Comparison between groups was performed by the Kruskal-Wallis test. It took significantly longer to perform the more complicated techniques using suction catheters (26; 18 54 s) and venous catheters (30; 22-50 s) compared to the other two groups (median; min-max) (p < 0.05). No differences concerning the application time were found between the group tube (7; 5 14 s) and group EDGAR (8; 5-13 s). The time of interruption of chest compression's and ventilation: group suction tube (11; 5-19 s) and group catheter (12; 6-18 s) was significant longer than in group tube (5; 2-9 s) (p < 0.05). In group EDGAR the connection ventilator-tube remained intact due to its concept of drug application. The use of special devices such as suction catheters or venous catheters for endotracheal instillation during CPR results in significantly longer preparation and instillation times with a longer interruption of the oxygen supply and chest compression's.
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Affiliation(s)
- L L Mielke
- Arbeitsgruppe Notfallmedizin, Technische Universität München, Klinikum rechts der Isar, Germany
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25
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Mielke LL, Frank C, Lanzinger MJ, Wilhelm MG, Entholzner EK, Hargasser SR, Hipp RF. Plasma catecholamine levels following tracheal and intravenous epinephrine administration in swine. Resuscitation 1998; 36:187-92. [PMID: 9627070 DOI: 10.1016/s0300-9572(98)00007-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We compared plasma epinephrine levels after three different tracheal epinephrine application techniques and intravenous injection in male and female anesthetized and paralyzed domestic pigs. Epinephrine was administered intravenously (10 microg/kg) (group i.v.) or tracheally (100 microg/kg) either by direct injection into the upper end of the tracheal tube (group Tube), via a suction tube placed into the bronchial system (group Catheter) or using an EDGAR tube (group EDGAR), each group: n = 8. Arterial plasma samples were drawn before and 0.5, 1, 1.5, 2, 2.5, 3, 4, 5, 6, 7 and 10 min after epinephrine administration. Plasma concentrations of epinephrine were measured with high pressure liquid chromatography using electrochemical detection. Analysis was performed by regression analysis for correlated data. Total plasma epinephrine concentrations showed a significant increase within 0.5 min in all groups. However, peak plasma epinephrine levels in group i.v. were significantly higher than in tracheal groups, while no differences between tracheal groups over the time were found. We conclude that in swine with spontaneous circulation tracheal instillation techniques using special devices such as suction tubes or EDGAR tubes result in onset and peak plasma epinephrine levels equivalent to those after direct injection into the upper end of the tracheal tube.
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Affiliation(s)
- L L Mielke
- Arbeitsgruppe Notfallmedizin, Technische Universität München, Klinikum rechts der Isar, Germany
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