Early inotropic support in pediatric shock: evidence and challenges in prehospital setting and interfacility transport.

Intraosseous infusion using the bone injection gun in the prehospital setting

Objective Access of intraosseous (IO) compartments is a commonly used technique that is an invaluable asset in emergency resuscitation. Prehospital IO success rates using semi-automatic insertion devices vary between 70 and 100% of pediatric patients. There are limited data on time to insertion and duration of IO function in the prehospital setting. Recent studies limited to the pediatric emergency department (PED) setting have also suggested that IOs may be less successful in the infant population. We explored the use of IO access for pediatric resuscitation, encompassing the prehospital and pediatric emergency department (PED) settings. Methods This is a retrospective review of emergency medical services (EMS) patient care reports and PED data of patients aged 0–17 years old and transported by regional ground EMS agencies in Southwestern Ontario, Canada from 2012 to 2019. Mean and median time to first insertion and IO function (from insertion to IO failure, IV access, transfer to ICU, or death) were calculated. Results Successful prehospital IO access was achieved in 83.7% of patients. The median time required to achieve IO access was 4 min (IQR 3-7) and mean duration of IO function was 27.6 min (SD: 14.8). Patients less than 1 year old had fewer functional IOs (25.9% vs. 75.0%), more insertion attempts (2 vs. 1), and shorter duration of IO function (18.8 vs. 32.2 mins) than the older age group (p < 0.05). Conclusions This is the first study to provide time to IO access and IO duration in the prehospital setting, and the first prehospital evidence to suggest inferior IO function in infants <1 year old, compared to other ages. This highlights unique challenges for infants that have implications for the PED, interfacility transport, and critical care settings.

The use of the intraosseous (IO) route for drug administration has been widely reported in the prehospital and military trauma setting, for use in paediatric patients and for use in the cardiac arrest scenario for rapid access. We wish to highlight its use for rapid sequence induction (RSI) in the adult population in a case of difficult intravenous access. A patient presented to our hospital as a stand-by call to the Emergency Department resuscitation area. He was peri-arrest with cardiogenic shock. He was cyanosed with unrecordable oxygen saturations and blood pressure but was very combative. Intubation to facilitate oxygenation was required urgently due to his rapidly deteriorating condition. Multiple attempts at securing intravenous access had been unsuccessful. An EZ-IO (Prometheus Medical Ltd, Hereford, UK) Intraosseous Vascular Access System was inserted in his right proximal tibia. Rapid sequence induction was performed using fentanyl 200mg, ketamine 100mg and suxamethonium 100mg. No fasciculations were observed. We waited 30 s and attempted direct laryngoscopy, which obtained a Grade I Cormack-Lehane View. Intubation was secured at first attempt. The induction process felt very similar in nature and speed to a standard intravenous induction. Post intubation, rapid intravenous access was secured in the right external jugular and then a femoral central line sited. The intraosseous route for drug administration has been used for many years. Studies comparing the pharmacokinetic data of intraosseous versus central venous drug delivery have primarily been undertaken in animals. One study has compared intraosseous versus intravenous rocuronium in anaesthetised swine. They compared electromyographic data obtained following tibial intraosseous administration to that of peripheral intravenous administration and demonstrated no statistically significant difference in the onset time between the two groups. They also demonstrated that the duration of paralysis with the intraosseous route was longer than with the intravenous. They concluded that rocuronium could be administered via the intraosseous route in the same doses as when using the intravenous route. With regard to human studies, a prospective, randomised crossover study has compared the delivery of intraosseous to intravenous morphine in adults and demonstrated that there was no statistically significant difference in the majority of the pharmacokinetic data including the maximum plasma concentration, time to maximum concentration and area under plasma concentration time curve. The majority of reports of using intraosseous for RSI have come from military and trauma experience. A recent observational study has been published in the Emergency Medicine Journal looking at whether RSI via IO was comparable to the intravenous route in terms of grade of view and number of attempts at intubation. The study demonstrated that in the 34 patients who received RSI via IO for trauma they had a 97% first pass intubation rate and that 91% of patients had a Grade 1 Cormack-Lehane view. They were unable to compare this directly to RSI via the intravenous route, as intraosseous access is often the preferred route of access in a military trauma setting. A further military study retrospectively reviewed 830 adult trauma cases and found that 1014 IO devices were inserted over a 60-month period. They demonstrated that the devices were used to infuse anaesthetic induction drugs, analgesia, tranexamic acid, blood and blood products, and intravenous fluids. Of the 1205 times that the IO route was used to infuse drugs, anaesthetic induction agents were the most common drug given, being used for this purpose in 61.8% of cases. With regard to complications, there were no serious complications reported and 14 minor complications that included failure to correctly place IO device, failure to infuse drug, or fracture of needle. This is similar to a Danish study that looked at complications associated with intraosseous access. They showed that serious complications such as compartment syndrome or osetomyelitis are very rare and that problems such as difficulty penetrating periosteum, difficulty aspirating bone marrow and difficulties injecting or infusing fluids or drugs are more common. One of the concerns with the use of the intraosseous route in awake patients is the side effects of pain on insertion and pain on injection. Reports have

Epinephrine administration in adults with out-of-hospital cardiac arrest: A comparison between intraosseous and intravenous route

BackgroundThe effectiveness of acetated Ringer’s solution in pediatric shock has received little attention. This study aimed to assess the clinical outcomes of using compound sodium acetate Ringer’s solution (AR) for fluid resuscitation in children with septic shock.MethodsWe retrospectively analyzed the clinical data of children with septic shock admitted to the pediatric intensive care unit of the Affiliated Hospital of Southwest Medical University from December 2019 to January 2023. Based on the resuscitation fluid administered, the participants were categorized into the compound AR and normal saline (NS) groups. We compared blood circulation conditions, internal environment parameters (arterial blood pH, lactic acid, serum sodium, chloride, calcium, magnesium, potassium, and blood glucose), and 28-day clinical outcomes between the two groups.ResultsThis study included 40 children, with 13 and 27 in the compound AR and NS groups, respectively. The two groups showed no significant differences in sex, age, body weight, body mass index, primary inflammation level, or Pediatric Sequential Organ Failure Assessment on admission. Similarly, no significant difference was observed in resuscitation fluid volume administered during the first hour (compound AR group: 250.00 mL [100.00, 390.00]; NS group: 250.00 mL [100.00, 500.00]). The total amount of crystalloid and colloid fluids administered within 24 h, vasoactive drug use, and blood pressure recovery post-resuscitation did not significantly differ between the groups. However, at 6 h post-resuscitation, the compound AR had considerably lower lactate level than the NS group (1.12 vs. 2.20 mmol/L). There were no significant differences in arterial blood pH, serum sodium, chloride, calcium, magnesium, potassium, and blood glucose levels between the groups. After treatment, in the compound AR group, 3 patients died, 2 improved, and 8 were cured. In the NS group, 7 patients died, 8 improved, and 12 were cured. The 28-day treatment outcomes (mortality rate, improvement rate, cure rate, or side effects) showed no significant differences between the groups.ConclusionsCompound AR was as effective as NS as a resuscitation fluid in pediatric septic shock, demonstrating similar intravascular volume restoration and hemodynamic stability maintenance. However, it caused a faster decline in arterial lactate levels without obvious side effects.

In traumatically injured or medically unstable pediatric patients requiring resuscitation, gaining intravenous access often is frustrating for the physician and agonizing for the patient. Even when cardiopulmonary resuscitation is performed by trained professionals, cardiac arrests in children in the prehospital setting have a mortality of 79% to 100%. Immediate vascular access such as that obtained by intraosseous infusion improves survival. The intraosseous infusion technique uses the medullary cavity in the tibia as a "noncollapsible vein" for parenteral infusion. It is indicated in a child in shock or cardiac arrest when two attempts to access peripheral vasculature have failed or when more than 2 minutes have elapsed in the attempt to gain access. Epinephrine, bicarbonate, calcium, lidocaine, and volume expanders can be infused via the intraosseous route. Complications rarely occur. The technique described here is gaining acceptance in both prehospital and emergency department settings.

Damage control resuscitation, avoidance of dilutional coagulopathy, and increased blood component therapy reduce mortality after major trauma hemorrhage. Improved outcomes seen in recent warfare have placed whole blood as the preferred product for resuscitation of severe traumatic hemorrhage. As of 2018, flight physicians of the Israeli Airborne Combat Search and Rescue Unit (ACSRU) treat these patients with low titer cold-stored O-positive whole blood (LTCSO+ WB). Intraosseous (IO) is the preferred route if intravenous access is not available. To date, no study has described the administration of LTCSO+ WB via the IO route in the prehospital setting. We present a case of whole blood transfusion via the IO route in a 30-year-old car accident patient who suffered major injuries and developed severe hemorrhagic shock. Intravenous access could not be obtained at the scene. En route, two units of LTCSO+ WB were administered, using an IO hand drill, and the patient's hemodynamic status improved. The patient survived the injury with a good outcome. This is the first report of whole blood infusion via the IO route in traumatic hemorrhagic shock in the prehospital setting. Our positive experience suggests that this approach may have a role in hemorrhagic trauma patients when intravenous access cannot be obtained.

Can early warning scores identify deteriorating patients in pre-hospital settings? A systematic review

Objective: To analyze the clinical characteristics and risk factors of periventricular-intraventricular hemorrhage (PIVH) in extremely low birth weight infants (ELBWI). Methods: From January 2019 to January 2022, the clinical data of 238 ELBWI admitted to the intensive care unit of Henan Provincial Children's Hospital within 1 week after birth and regular head color ultrasound examination were retrospective reviewed. The infants were divided into PIVH group and non-PIVH group according to whether PIVH occurred. The incidence and time of PIVH were described, and the differences in basic clinical features, perinatal conditions, postnatal treatment and complications between the two groups were compared. The risk factors of PIVH in ELBWI were further explored by multivariate binary logistic regression analysis. Results: Among 238 ELBWI (146 males and 92 females), 82 cases (34.5%) developed PIVH, including 28 cases (11.8%) of severe PIVH and 54 cases (22.7%) of mild PIVH. Among the 82 cases of PIVH, 68 cases occurred within 3 days after birth. Gestational age [(27.4±1.5) weeks vs (27.8±1.5) weeks, P=0.012], gestational diabetes mellitus [0 vs 9.0%(14/156), P=0.005], fibrinogen (FIB) [(1.8±0.5) g/L vs (2.7±0.9) g/L, P=0.012] were lower in PIVH group than in non-PIVH group. However, intrauterine distress [46.3%(38/82) vs 11.5%(18/156), P<0.001], birth asphyxia [85.4%(70/82) vs 62.8%(98/156), P<0.001], patent ductus arteriosus (PDA) [65.9%(54/82) vs 51.3%(80/156）, P=0.017], failure to withdraw invasive ventilator within 1 week [82.9%(14/82) vs 67.3%(105/156), P=0.010], use of vasoactive drugs within 1 week [28.0%(23/82) vs 15.4%(24/156), P=0.020], acidosis [28.0%(23/82) vs 12.2%(19/156), P=0.002], and hemorrhagic disease [18.3%(15/82) vs 7.1%(11/156), P=0.008] were higher in PIVH group than in non-PIVH group. Multivariate binary logistic regression analysis found that the risk factors for PIVH in ELBWI were acidosis (OR=2.257, 95%CI: 1.104-4.614, P=0.026), use of vasoactive drugs within 1 week (OR=2.274, 95%CI: 1.148-4.504, P=0.018), bleeding disorders (OR=2.583, 95%CI: 1.075-6.206, P=0.034) use of vasoactive drugs within 1 week (OR=2.301, 95%CI: 1.153-4.591, P<0.001). Conclusions: The incidence of PIVH in ELBWI is high, which mostly occurs within 3 days after birth. Acidosis, hemorrhagic disease, use of vasoactive agents within 1 week and failure to evacuate invasive ventilators within 1 week may increase the risk of PIVH in ELBWI.

Sepsis is a leading cause of morbidity and mortality in the United States. This chapter reviews the diagnostic and treatment challenges of pediatric sepsis. It also offers differential diagnoses as well as treatment algorithms including triage screening tools, an escalation plan for difficult intravenous access, and empiric antibiotic treatment. Timely fluid and antibiotic administration are the mainstay of pediatric sepsis treatment. This chapter highlights the distinction between warm and cold shock as it reflects the pathophysiologic differences of pediatric and adult patients, and the appropriate use of vasoactive agents in pediatric shock is discussed. The chapter also discusses complications and mortality associated with pediatric sepsis.

Hemoglobin-based Oxygen Carriers

Risks of intravenous administration of hypotonic fluids for pediatric patients in ED and prehospital settings: Let's remove the handle from the pump

Perioperative use of vasoactive drugs on postoperative outcomes after major abdominal surgery. Response to Br J Anaesth 2020; 125: e353–4

The IO route is an established method of obtaining vascular access in children in acute and emergency situations and is now increasingly being used in adults as an alternative to intravenous access, yet a paucity of evidence exists regarding its use, effectiveness and implementation. The aim of this literature review is to present a detailed investigation critiquing contemporary practices of intraosseous (IO) vascular access in adult patients. Specific objectives identified led to the exploration of clinical contexts, IO device/s and anatomical sites; education and training requirements; implications and recommendations for emergency health care practice and any requirements for further research. An exploratory literature review was undertaken in acknowledgement of the broad and complex nature of the project aim. Five electronic search engines were examined iteratively from June 2013 to February 2014. The search terms were 'intraosseous' and 'adult' which were purposely limited because of the exploratory nature of the review. Studies that met the inclusion criteria of primary research articles with an adult focus were included. Research with a paediatric focus was excluded. Secondary research, reviews, case reports, editorials and opinion papers were excluded. IO vascular access is considered an alternative intravascular access route although debate considering the preferred anatomical site is ongoing. Documented practices are only established in pre-hospital and specialist emergency department settings; however, variety exists in policy and actual practice. Achieving insertion competence is relatively uncomplicated following minimal preparation although ongoing skill maintenance is less clear. IO vascular access is associated with minimal complications although pain is a significant issue for the conscious patient especially during fluid administration. The IO route is clearly a valuable alternative to problematic intravascular access. However, further research, including cost effectiveness reviews, is required to gain clarity of whole acute care approaches.

Deep vein thrombosis associated with central venous catheters – a review