Intravenous Access Research Articles

EXTH-84. A DURABLE RECURRENT INTRACEREBROVENTRICULAR INFUSION METHOD IN MICE FOR PRECLINICAL ASSESSMENT OF CELLULAR THERAPEUTICS

Abstract BACKGROUND Significant advancement in cellular treatments for glioblastoma has been made in recent years. The administration route has shifted from intravenous access to local delivery, namely intracerebroventricular (ICV) delivery, in order to prevent the injected cellular products from becoming trapped in peripheral organs such as liver and spleen. There is currently no reliable preclinical system available to accurately examine new cellular treatments that involve long-term recurrent infusion into the cerebral ventricles. METHOD We optimized the surgical device and technique by modifying a commercially available ICV device with a predetermined needle length, eliminating the requirement for spacers hence relieving the tension of the surgical wounds. To avoid skin puncture, we substituted the tunneled catheter with a silicon catheter. The surgical incisions were secured with autoclips in replacement of sutures. We administered periodic infusions of engineered monocytes on a weekly basis using the tunneled catheter for a duration of 8 weeks. The rate of wound dehiscence was monitored. RESULTS The delivery of the engineered monocytes to the cerebral ventricle via the ICV device has been confirmed using a bioluminescence-based imaging. The device and the tunneled catheter demonstrate a long-lasting durability for a minimum of 8 weeks. The optimized device and method effectively reduce the occurrence of post-operative wound dehiscence. Using a silicon catheter minimizes skin punctures. CONCLUSION Our optimized ICV device, material, and surgical approach offer a dependable preclinical instrument for the long-term and recurrent delivery of cellular therapies that reflect patients’ clinical treatment schedules and provide a more accurate evaluation of their translational potential.

Delivery room dextrose gel for preterm hypoglycaemia (the GEHPPI study): a randomised placebo-controlled trial

ObjectiveEarly hypoglycaemia at the time of neonatal intensive care unit (NICU) admission is common in very/extreme preterm infants. This study aimed to determine whether buccal dextrose gel in the delivery...

Intraosseous and Intravenous Epinephrine Administration Routes in Out-of-Hospital Cardiac Arrest: Survival and Neurologic Outcomes.

The rate of survival after out-of-hospital cardiac arrest varies depending on the timeliness and effectiveness of prehospital interventions. This study was conducted to compare out-of-hospital cardiac arrest outcomes between intravenous and intraosseous routes and between upper and lower extremity routes for drug administration. We retrospectively analyzed data (collected using the Utstein template) from 1220 patients who had experienced out-of-hospital cardiac arrest in Taiwan's Taoyuan City between January 2021 and August 2023. The patients were stratified into intravenous and intraosseous groups by treatment approach and upper and lower extremity access groups by access site. The study outcomes were survival to discharge, favorable neurologic outcomes (Cerebral Performance Category score 1 or 2), and survival for >2 hours. The study groups were statistically compared before and after propensity score matching. Significant pre-propensity score matching differences were observed between intravenous and intraosseous groups, and the aforementioned study outcomes were better in the intravenous group than in the intraosseous group. However, the between-group differences became nonsignificant after propensity score matching. Furthermore, lower extremity access and delayed epinephrine administration were associated with worse outcomes. Survival rates fell below 12.6% when time to treatment exceeded 15 minutes, particularly in the cases of intraosseous access and lower extremity access. This study highlights the benefits of early intervention and upper extremity access for drug administration in patients with out-of-hospital cardiac arrest. Intraosseous access may serve as a viable alternative to intravenous access. Timely administration of essential drugs during resuscitation can improve clinical outcomes and thus has implications for emergency medical service training.

Intraosseous or Intravenous Vascular Access for Out-of-Hospital Cardiac Arrest.

Out-of-hospital cardiac arrest is a leading cause of death worldwide. Establishing vascular access is critical for administering guideline-recommended drugs during cardiopulmonary resuscitation. Both the intraosseous route and the intravenous route are used routinely, but their comparative effectiveness remains unclear. We conducted a randomized clinical trial to compare the effectiveness of initial attempts at intraosseous or intravenous vascular access in adults who had nontraumatic out-of-hospital cardiac arrest. The primary outcome was a sustained return of spontaneous circulation. Key secondary outcomes were survival at 30 days and survival at 30 days with a favorable neurologic outcome, defined by a score of 0 to 3 on the modified Rankin scale (scores range from 0 to 6, with higher scores indicating greater disability). Among 1506 patients who underwent randomization, 1479 were included in the primary analysis (731 in the intraosseous-access group and 748 in the intravenous-access group). The successful establishment of vascular access within two attempts occurred in 669 patients (92%) assigned to the intraosseous-access group and in 595 patients (80%) assigned to the intravenous-access group. Sustained return of spontaneous circulation occurred in 221 patients (30%) in the intraosseous-access group and in 214 patients (29%) in the intravenous-access group (risk ratio, 1.06; 95% confidence interval [CI], 0.90 to 1.24; P = 0.49). At 30 days, 85 patients (12%) in the intraosseous-access group and 75 patients (10%) in the intravenous-access group were alive (risk ratio, 1.16; 95% CI, 0.87 to 1.56); a favorable neurologic outcome at 30 days occurred in 67 patients (9%) and 59 patients (8%), respectively (risk ratio, 1.16; 95% CI, 0.83 to 1.62). Prespecified adverse events were uncommon. There was no significant difference in sustained return of spontaneous circulation between initial intraosseous and intravenous vascular access in adults who had out-of-hospital cardiac arrest. (Funded by the Novo Nordisk Foundation and others; IVIO EU Clinical Trials Register number, 2022-500744-38-00; ClinicalTrials.gov number, NCT05205031.).

Atypical posterior reversible encephalopathy syndrome following craniotomy for a metastatic lesion: illustrative case.

An 80-year-old male was found to have a metastatic lesion in his cerebrum. He underwent uncomplicated resection with prolonged inhalational anesthesia due to issues with intravenous access prior to surgery. Postoperatively, the patient had persistent altered mental status. Immediate postoperative head computed tomography and continuous electroencephalography were negative for possible causes. Standard brain magnetic resonance imaging (MRI) after metastatic resection demonstrated the development of edema in his pons and thalami, concerning for posterior reversible encephalopathy syndrome (PRES). Tight blood pressure control was initiated. His neurological examination returned to baseline. Follow-up MRI showed the resolution of edema. This is a report of PRES hypothesized to be attributable to prolonged inhalational anesthetic. PRES is a disorder in which patients present with altered mentation, seizures, visual impairment, or headache. PRES often occurs due to acute uncontrolled hypertension; however, other conditions, including autoimmune disease and cancer chemotherapy, have been linked. In severe cases, permanent brain damage and death have been reported. The authors present a case of PRES as the cause of severe neurological decline following craniotomy without severe or sustained hypertension. The authors hypothesize that PRES could be caused by blood pressure variability in the perioperative period and prolonged anesthesia. https://thejns.org/doi/10.3171/CASE24245.

Optimizing the anesthetic care of patients with aromatic l-amino acid decarboxylase deficiency.

Aromatic l-amino acid decarboxylase (AADC) deficiency is a rare autosomal recessive disorder that results in a lack of the monoamine neurotransmitters dopamine, serotonin, norepinephrine, and epinephrine. Patients present with a wide spectrum of symptoms, including motor and autonomic dysfunction, hypotonia, and developmental delay, often before the age of one. Until recently, treatment options were limited to symptom control, but the recent approval of the first gene therapy for AADC deficiency in Europe and the UK has provided an alternative to treating symptoms for this disease. Eladocagene exuparvovec is a one-time gene therapy, administered bilaterally to the putamen by magnetic resonance imaging-guided stereotactic neurosurgery. While administration of the gene therapy itself is minimally invasive, the anesthetic management of patients with AADC deficiency is challenging due to the absence of sympathetic regulation secondary to the lack of adrenergic neurotransmitters. Optimal anesthetic management requires an understanding of the complex and heterogeneous nature of the disease. Hemodynamic instability, temperature dysregulation, and hypoglycemia are of primary concern, but there are also challenges regarding intravenous access and airway management. A thorough preoperative assessment is essential and should be guided by the patient's history. Advanced planning is necessary regarding the timing of the procedure schedule and operative plan; meticulous preparation, simulation for the operating room, as well as communication with all perioperative staff members, are crucial. Intraoperatively, utmost care must be taken to protect the skin, maintain body temperature, and to prepare for inotropic and/or glycemic support as needed. Postoperative intensive care management is necessary for consideration of postoperative extubation and provision of supportive care. With careful planning, preparation, and vigilance, patients with AADC deficiency can safely undergo anesthesia.

An [illustrative] update on pediatric emergency ultrasound: part 3 - cerebral, musculoskeletal and other applications.

Point-of-care ultrasound (POCUS) plays an essential role in pediatric emergency medicine by improving diagnostics and procedural safety. The role of POCUS in the care of pediatric patients in the emergency department has expanded considerably in recent years. Cranial and musculoskeletal imaging has significant potential, yet POCUS has also become a vital tool for common procedures, such as central and difficult peripheral intravenous access. The purpose of this article is to provide an overview of pediatric POCUS applications for cranial, small parts (head, eyes, nose, throat, and soft tissue), musculoskeletal, and common procedural applications, forming the third part of the series.

Autologous platelet concentrates in root coverage procedures.

Gingival recessions are vastly prevalent among the general population. With regards to their treatment, recent advancements in periodontal and microsurgical procedures, focusing on minimal invasiveness and patient-centered therapies, have propelled a shift in their contemporary treatment, highlighting the field of biologics and bioactive mediators. Among different classes and types of biologics, autologous platelet concentrates (APCs), also referred to as autologous blood-derived products, are commonly used and preferred among many clinicians. These are essentially obtained via venipuncture (intravenous access) followed by centrifugation, for which numerous protocols and preparation methods have been used, leading to varieties of blood-derived products. In this review, via a systematic search, we explored the efficacy of the different utilized preparation methods and centrifugation protocols of APCs (e.g., platelet-rich plasma (PRP), platelet-rich fibrin (PRF), leucocyte-PRF, advanced-PRF, concentrated growth factor (CGF), etc.) for the treatment of type 1 gingival recessions (RT1, without interproximal attachment loss or noticeable tooth displacement), as well as their effectiveness relative to a common control (treatment with flap advancement alone without any additional material). Based on the available literature from randomized trials found in our systematic search, we observed that utilization of PRF can significantly enhance treatment outcomes when performing a coronally advanced flap, in terms of the amount of root coverage. The improvement in root coverage was further enhanced in the presence of baseline keratinized tissue width, and with an increasing relative magnitude (the more the baseline keratinized tissue width, the better the root coverage outcomes when using PRF). The efficacy of these products needs to be further explored with different graft substitutes and matrices, as well as relative to other commonly applied biologics, through well-conducted and adequately-powered randomized clinical trials.

Effectiveness of intraosseous access during resuscitation: a retrospective cohort study

PurposeDuring resuscitation in emergency situations, establishing intravascular access is crucial for promptly initiating delivery of fluids, blood, blood products, and medications. In cases of emergency, when intravenous (IV) access proves unsuccessful, intraosseous (IO) access serves as a viable alternative. However, there is a notable lack of information concerning the frequency and efficacy of IO access in acute care settings. This study aims to assess the efficacy of intraosseous (IO) access in acute care settings, especially focusing on children in a level 1 trauma center.MethodsThis retrospective study included patients with IO access presented in a level 1 trauma center emergency department (ED) between January 2015 and April 2020. Data regarding medication and fluid infusion was documented, and the clinical success rate was calculated.ResultsOf the 109,548 patients that were admitted to the ED, 25,686 IV lines were inserted. Documentation of 188 patients of which 73 (38.8%) children was complete and used for analysis. In these 188 patients, a total of 232 IO accesses were placed. Overall, 182 patients had a functional IO access (204 needles) (88%). In children (age < 18 years) success rate was lower as compared to adults, 71–84% as compared to 94%. However, univariate regression showed no association between the percentage of functional IO access and gender, age, weight, health care location (prehospital and in hospital), anatomical position (tibia as compared to humerus) or type of injury.ConclusionIntraosseous access demonstrates a high success rate for infusion, independent of gender, age, weight, anatomical positioning, or healthcare setting, with minimal complication rates. Caution is especially warranted for children under the age of six months, since success rate was lower.

Review on Acute Reactions while Administration of Intravenous Medications

The most common invasive procedure that patients admitted to hospital wards likely undergo is intravenous (IV) access. Medications through IV fluid injection is administered to up to 80% of hospital patients. Certain medications, such as phenytoin, vancomycin, ampicillin/sulbactam combinations, steroids, and cefotaxime, might result in abrupt responses when intravenous fluids are administered. antibiotics such as mitomycin, daunorubicin, dactinomycin, and doxorubicin. Antineoplastic drugs such as methotrexate, cyclophosphamide, etoposide, vinorelbine, carboplatin, oxaliplatin, paclitaxel, and epirubicin. Dopamine, noradrenaline, amiodarone, adrenaline, and pituitrin are examples of inotropic substances. Bevacizumab, Cisplatin, Heparin, Glucocorticoids, Tamoxifen, Testosterone, and Antidepressants. When administering IV medication, Clinical Pharmacist are crucial in identifying and reporting drugs that cause acute responses. Clinical Pharmacist can be involved because they can be crucial in ensuring safe pharmaceutical use in hospitals.

Postmortem Identification of a Foreign Body in the Heart: A Case Report.

The presence of a foreign body in the heart have been reported, mostly in adults. Deaths and injuries can result from the breakage or rupture of angiography catheters. We present a case in which an angiocath tip was identified in the right ventricle of a pediatric patient, and the patient died as a result thereof. As no similar cases have been reported, we would like to draw attention to this subject. A 4.5-month-old female patient who was hospitalized 3 times during her life had a history of peripheral venous access establishment in the extremities with angiocatheters. During these hospital admissions, a central catheter was not inserted, and no additional problems were identified. Emergency personnel responded and found the patient at home, experiencing bradycardia and arrhythmia. She was resuscitated and taken to the hospital, where she died. The autopsy revealed, the tip of a 1.5cm long, 1mm wide lumen catheter had penetrated the right ventricular wall (Fig.1) (Fig.2), thus her death was attributed to complications that developed as a result of the peripheral vascular access catheter tip breaking and migrating to the right ventricle. Although the patient did not have an ECG, physical examination by the emergency ambulance personnel revealed an irregular and bradycardic heartbeat, suggesting that the child may have developed arrhythmia and atrioventricular conduction block. Health care professionals must check upon removal of peripheral intravenous access, and record whether the integrity of the peripheral catheter tip was compromised to prevent similar events in future. Fig.1 Angiocath tip piercing the right ventricular wall and exiting the heart Fig.2 a A 1.5cm long, b 1mm wide lumen catheter tip penetrating the right ventricular wall.

Factors associated with failure of intraosseous access in prehospital trauma treatment by military medical personnel

IntroductionIntraosseous devices have become an alternative to peripheral intravenous (PIV) access. Despite the established success of intraosseous devices in laboratory and simulator studies, there is a lack of data regarding...

Ergonomics Risk Assessment of Musculoskeletal Disorder During Ultrasound-Guided Internal Jugular Venous Cannulation.

Acutely sick patients can receive emergency intravenous access through central venous cannulation to administer fluids and medicines, perform haemodynamic monitoring and extracorporeal therapies, including plasmapheresis or haemodialysis. Using the Seldinger procedure, access is gained by percutaneous puncture, frequently guided by ultrasonography into the femoral, subclavian or internal jugular veins. This study aimed to identify ergonomic risk factors for musculoskeletal disorders (MSDs) in operators performing ultrasonography-guided internal jugular vein (IJV) cannulation at various table heights and probe orientations. Sixty emergency medicine residents participated in a cross-sectional study conducted by the Emergency and Trauma Department of Hospital Universiti Sains Malaysia, Kelantan. Participants were instructed to perform the cannulation at two distinct table heights and with two distinct probe orientations. To compute the ergonomic risk score, the Rapid Entire Body Assessment (REBA) method was used. The table height of 0.5 elbow factor with varied probe resulted in a median REBA score of 5.0, whereas the table height of 0.7 elbow factor with varied probe had a median REBA score of 4.0. All four positions exhibited medium risk for MSDs. This study showed that the table height of 0.7 elbow factor is more ergonomically favourable while still imposed medium risk for MSDs.

Adherence to Intravenous Access Recommendations for Cesarean Delivery.

Adherence to Intravenous Access Recommendations for Cesarean Delivery.

7291 From Vaginal Bleeding to Genetic Complexity: McCune Albright Syndrome in a Toddler; Emphasizing Atypical Manifestations, Diagnostic Challenges, and Comprehensive Management

Abstract Disclosure: A.G. Martinez Sanchez: None. N. Fernandez: None. C.L. Bustamante Escobar: None. Background: McCune Albright Syndrome (MAS) is a rare genetic disorder characterized by a triad of peripheral precocious puberty, irregular café-au-lait spots, and bone fibrous dysplasia. It is often caused by post-zygotic somatic mutations in the GNAS1 gene. We present a case of a patient initially presenting with precocious puberty, whose diagnostic journey revealed MAS with atypical manifestations. Presentation: A 23-month-old girl was brought to the emergency department after her mother noticed vaginal bleeding during a diaper change; denied any trauma, fever, rash, or dysuria. Patient developed accelerated growth about six months earlier, followed by pubic hair three months prior and bilateral thelarche two weeks before presentation. The patient had no exposure to endocrine disruptors. The physical examination revealed a well-developed child, in the 92nd percentile for weight and 97th for height. Additionally, breast buds, fine hair on the labia, and minimal blood at the vaginal introitus, with no apparent signs of trauma. Initial laboratory findings showed prepubertal LH and FSH levels, elevated estradiol 120 pg/ml (prepubertal range &amp;lt;10) and advanced bone age (4.2 years). Normal levels of testosterone, 17-hydroxyprogesterone, and DHEA sulfate. Pelvic ultrasound demonstrated an enlarged uterus (5.6 x 1.8 x 2.4 cm) and a large cystic lesion (4.4 cm) on the right ovary. During a follow-up at the endocrinology department one week later, a meticulous examination identified an irregular café-au-lait spot measuring about 2cm over the occipital right side of her scalp. Further tests, including GnRH stimulation test, tumor markers (LDH, b-HCG, CEA, and Ca19-9), brain MRI and bone scan, yielded normal findings. Given the presentation consistent with Peripheral precocious puberty, Letrozole was initiated at 1.25 mg daily. Three months later, her growth velocity remained accelerated. However, there was a decrease in both breast tissue and uterus size (4.2 x 1.2 x 1.7 cm), and the ovarian cyst was resolved. Genetic testing in blood indicated no mutations. To conduct a thorough assessment, the insulin-like growth factor (IGF-1) level was measured and found to be 200 ng/mL (normal range 56-144 ng/mL). Unfortunately, obtaining prolactin levels was challenging due to difficult intravenous (IV) access. Conclusion: This case reveals the complexity of MAS in precocious puberty, emphasizing atypical features that add complexity to the diagnosis. Identifying an irregular café-au-lait spot served as a diagnostic indicator, revealing the diverse clinical presentations. The challenges of relying solely on genetic testing for diagnosis are evident due to the mosaic nature and tissue-specific distribution of the mutation, as highlighted by the absence of mutations in this patient. Long-term management requires ongoing monitoring and a multidisciplinary approach for optimal patient outcomes. Presentation: 6/1/2024

When to choose intraosseous access in prehospital trauma care: A registry-based study from the Israel Defense Forces

PurposePrompt vascular access is crucial for resuscitating bleeding trauma casualties in prehospital settings but achieving peripheral intravenous (PIV) access can be challenging during hemorrhagic shock due to peripheral vessel collapse. Early intraosseous (IO) device use is suggested as an alternative. This study examines injury characteristics and factors linked to IO access requirements. MethodsA registry-based cohort study from the Israel Defense Forces Trauma Registry (2010 – 2023) included trauma casualties receiving PIV or IO access prehospital. Casualties who had at least one documented PIV or IO access attempt were included, while those without vascular access were excluded. Casualties requiring both PIV and IO were classified in the IO group. Univariable logistic regression assessed the factors associated with IO access. Results were reported as odds ratios (OR) with 95% confidence intervals (CI), and significant difference was set at p < 0.05. ResultsOf 3462 casualties (86.3% male, the median age: 22 years), 3287 (94.9%) received PIV access and 175 (5.1%) had IO access attempts. In the IO group, 30.3% received freeze-dried plasma and 23.4% received low titer group O whole blood, significantly higher than that in the PIV group. Prehospital mortality was 35.0% in the IO group. Univariable analysis showed significant associations with IO access for increased PIV attempts (OR = 1.69; 95% CI: 1.34 – 2.13) and signs of profound shock (OR = 11.0; 95% CI: 5.5 – 23.3). ConclusionProfound shock signs are strongly linked to the need for IO access in prehospital settings with each successive PIV attempt increasing the likelihood of requiring IO conversion. IO access often accompanies low titer group O whole blood or freeze-dried plasma administration and higher prehospital mortality, indicating its use in emergent resuscitation situations. Early IO consideration is advised for trauma casualties with profound shock.

Vein Visualisation Technology for Peripheral Intravenous Access in Paediatric Patients: A Clinical Decision-Making Tool.

The aim of this study is to develop a clinical decision-making tool to guide utilisation of vein visualisation technologies and enhance chances of successful peripheral intravenous catheter (PIVC) insertion, using data collected from a vascular access team in a large paediatric medical centre in the United States. Quantitative two-phase, cluster analysis design. The study consisted of the following two phases: (1) a quantitative retrospective chart review to evaluate clinician utilisation and preference for vein visualisation technologies and (2) a quantitative prospective design, including a post-discharge retrospective chart review, to confirm utilisation of vein visualisation technologies and factors influencing clinician decision-making. A total of 16 groups were created based on the cluster analysis and expert clinician input. The results of first-attempt success analyses identified optimal device recommendations for each of the 16 patient groups. For patients older than 2 years old, the NIR device was more likely to result in first-attempt success regardless of BMI or access site and the NIR device was most optimal for almost all categories of paediatric patients regardless of BMI or access site. The transilluminator was found to be the most optimal device to use with younger patients (< 2 years old) who are underweight. Vein visualisation technology is recommended by professional nursing organisations to improve PIV access. Yet, adoption of this useful technology to aid selection of an optimal vein for insertion and visualisation during insertion is limited. This is the first study to develop a clinical decision-making tool for vein visualisation technology in PIVC insertion. Vein visualisation technology allows for a rapid, thorough assessment of patients' vasculature to determine an optimal site for PIVC placement beyond what is visible to the naked eye or achievable using traditional methods. The tool was designed to guide healthcare professionals towards successful first attempt PIVC insertions, thereby improving patient outcomes and efficiency of care. None.

Development of a Cost-Effective and High-Fidelity Gel Model for Peripheral Ultrasound-Guided Intravenous Access Training.

Introduction Simulation tools are crucial in medical educationbut current commercial models for ultrasound-guided intravenous (IV) access lack complexity and can be prohibitively expensive. This article proposes a cost-effective gel model system that replicates realistic vein and artery interactions, addressing the limitations of traditional models. An advanced gelatin model was constructed that incorporates intricate vein and artery configurations and enhances medical training by providing a more authentic experience. Patient testing will further validate its efficacy, promising improved accessibility for skill refinement in resource-constrained environments. Methods In a controlled study at theKirk Kerkorian School of Medicine at the University of Nevada, Las Vegas, 12 medical students with limited ultrasound experience participated in a workshop using novel and Blue Phantom™ models for ultrasound-guided IV catheter placement. The advanced gelatin model, created with Ziplock™ Tupperware®, ultrasonography gel-filled balloons, and gelatin, proved more effective, as assessed by participants' post-training comfort levels. The comparison of participants' pre- and post-training comfort levels with the models was the primary study objective. Participants were asked to complete a confidence survey based on a five-point Likert scale, and after using both models, this survey was re-administered to assess the participant's level of comfort after model use. The statistical analysis comparison of post-training survey data to the pre-training survey data was accomplished using SPSS version 29 (IBM Corp, Armonk, NY), where a paired t-test was set at a significance threshold of p <0.05. Results Analysis of data from both commercially made and advanced ultrasound-guided IV models using a paired t-test revealed a significant advantage for the advanced model. Participants, despite limited ultrasound experience, reported feeling over 4 points higher in skill confidence (p = 0.004) with the advanced model. Its popularity stems from diverse vasculature modeling, proving effective for both experienced practitioners and inexperienced individuals, maintaining value as user skill levels increase. Conclusion This study proposes an advanced model for ultrasound-guided peripheral IV access training, demonstrating a statistically significant increase in confidence levels. Despite limitations such as small sample size and single-site participation, the advanced model's adaptability and cost-effectiveness make it a strong contender for replacing current commercial models, potentially enhancing proficiency and confidence while reducing costs.

Re-evaluating intra-cardiac arrest adjunctive medications and routes of drug administration.

This narrative review summarizes the evidence for the most commonly used intra-cardiac arrest adjunctive medications and routes of administration and discusses promising new therapies from preclinical animal models. Large trials on the administration of calcium as well as the combination of vasopressin and glucocorticoids during cardiac arrest have been published. Calcium administration during cardiopulmonary resuscitation does not improve outcomes and might cause harm. Vasopressin and glucocorticoid administration during cardiopulmonary resuscitation improve the chance of return of spontaneous circulation but has uncertain effects on survival. We identified a total of seven ongoing clinical trials investigating the potential role of bicarbonate, of vasopressin and glucocorticoids, and of intravenous versus intraosseous vascular access. Several medications such as levosimendan and inhaled nitric oxide show promise in preclinical studies, and clinical trials are either planned or actively recruiting. Large trials on intra-cardiac arrest administration of calcium and vasopressin with glucocorticoids have been performed. Several trials are ongoing that will provide valuable insights into the potential benefit of other intra-cardiac arrest medications such as bicarbonate as well as the potential benefit of intravenous or intraosseous vascular access.

EP552 - Colonoscope Incarceration in an Inguinal Hernia: A Case Report

Abstract Aim We report a rare case of incarceration of a colonoscope within left inguinal hernia, highlighting the unusual circumstances and challenges faced by colonoscopists. Case presentation An 83-year-old male patient with a known left inguinal hernia underwent an urgent colonoscopy for positive quantitative faecal immunochemical test, anaemia, weight loss and fatigue. The patient had declined any form of analgesia/sedation for colonoscopy. Scope guide was used during the procedure. Initially, a proximal sigmoid loop was negotiated successfully. The colonoscope reached the mid transverse colon but the procedure became uncomfortable for the patient. There was an obvious loop on the scope guide which could not be reduced despite various manoeuvres. An attempt to apply external pressure to allow progression revealed a large left inguinal hernia containing a loop of the colonoscope. Thus, it was decided to discontinue the procedure, however, unexpectedly, during withdrawal, the colonoscope became lodged. Attempts to manually reduce this were very uncomfortable for the patient, therefore, intravenous access was gained to administer sedation &amp; analgesia. Another colleague was summoned to assist with manual reduction while simultaneously withdrawing the colonoscope allowing for reduction of the hernia and removal of the colonoscope. The patient was kept overnight for observations and was discharged home the following day. Subsequently CT colonography confirmed large left inguinal hernia containing sigmoid colon. Conclusion This case delves into the intricate details of the incident, exploring the contributing factors, such as the patient's medical history and the nature of the hernia. We discuss ways to avoid this complication in the future as well as suggest a technique for resolution of the complication.