Comparison of Umbilical Venous and Intraosseous Access During Simulated Neonatal Resuscitation
Anand Rajani, M.D.Perinatal Medical Group, Inc.
Fresno, California
Previous affiliation:Fellow in Neonatal-Perinatal MedicineStanford University School of Medicine
Lucile Packard Children’s HospitalPalo Alto, California
Disclosure• I have nothing to disclose.
• This work was supported by the Young Investigator Award from the Neonatal Resuscitation Program.
Background• While 10% of newborns require some
assistance to begin breathing, only 1% require extensive resuscitative efforts
• Less than 2 in 1000 births require administration of intravenous epinephrine1
• Proficiency in rapid umbilical venous catheter (UVC) placement is difficult to maintain
1. Perlman JM, Risser R. Cardiopulmonary resuscitation in the delivery room. Arch Pediatr Adolesc Med 1995;149:20 – 5
Background• Establishing umbilical venous access is
frequently difficult • Catheter setup
• Thoracic compressions
• Moving sterile field
• Data indicate that intraosseous needle (IO) placement is a safe and effective alternative• Access times of 30-60 seconds in the pediatric setting2
• Pharmacokinetic data on IO epinephrine in newborn lambs suggest equal efficacy3
2. Zaritsky AL, Nadkarni UM, Hickey RW, et al. PALS provider manual. Dallas (TX)7 American Heart Association/American Academy of Pediatrics; 20023. Ellemunter H, Simma B, Trawoger R, et al. Intraosseous lines in preterm and full term neonates. Arch Dis Child Fetal Neonatal Ed 1990;80:F74-5.
Simulation
• Allows for the re-creation of high-risk, low frequency events in numbers that are useful for statistical analysis
• Can be video-recorded for further analysis
• No harm to real patients
Hypotheses• Primary Null Hypothesis:
• Ho: IO and UVC placement will be established in equal time
• Secondary Null Hypothesis:
• Ho: IO and UVC placement will be established with equal rates of error
• Observational Null Hypothesis:
• Ho: Perceived ease of use will be equal for UVC and IO
Methods• Recruited 40 healthcare practitioners
of varying training levels from Lucile Packard Children’s Hospital at Stanford
Training Level N (%)Resident in Pediatrics 16 (40)
Fellow in Neonatology 6 (15)
Neonatal Hospitalist 5 (12)
Neonatal Nurse Practitioner 5 (12)
Attending Neonatologist 8 (20)
Methods• Two standardized, videotaped simulated
resuscitation scenarios in which intravascular access was indicated
• A nurse and RT confederate performed CPR while the participant established access
• Indistinguishable kits containing UVCs or IOs were available at the bedside
• Simulation was stopped once access established
Methods: Study Design
• Prospective, blinded, randomized, 2x2 crossover design
• Randomized participants in separate blocks, by training level to perform either:
• UVC/IO or IO/UVC
• Prior to the simulations, participants watched a video reviewing the necessary steps involved in placement of a UVC and IO needle
Methods: Data Collection
• Using video recordings:• Placement Time
• Errors during placement• 4 error categories were used for each
modality:
1. Site preparation
2. Device Preparation
3. Location and depth
4. Confirmation of access
Methods: Data Collection
• Using questionnaire:
• Users perception of technical difficulty (Likert scale from 0-10)
• Preference for IO or UVC, if any
• asked for reasons behind preference
• space left for additional comments
Analyses for Primary
Hypothesis• Ho: IO and UVC will be established in equal time
• Test 1: t-test to evaluate for ‘period effect’
• Evaluate the difference in the two time periods of UVC/IO and IO/UVC
• There was no significant difference in placement times for UVC or IO relative to placement order
Analyses for Primary
Hypothesis• Test 2: Matched pairs t-test to evaluate
for any difference in placement time between UVC and IO
• For placement time, IO was significantly faster (p<0.0001)
• Using ANOVAs, resident group was significantly faster than all other groups
UVC and IO placement by
subgroupTraining Level (N)
UVC Time (sec) IO Time (sec) p value
All subjects (40) 105 59 <0.0001
Residents (16) 105 17 <0.0001
Fellows (6) 86 73 0.4431
Hospitalists (5) 104 86 0.4195
NNPs (5) 120 92 0.1238
Attendings (8) 111 94 <0.0326
Analyses for Secondary Hypotheses
• Ho: IO and UVC will be established with equal rates of error
• No significant difference was found
• 3 errors in the IO group (site prep)
• 1 error in the UVC group (site prep)
Analysis of Observational
Hypothesis•Ho: Perceived ease of use will be similar for
UVC and IO
•UVC and IO found to be equivalent • Residents (n=16) found IO to be easier to
place than UVC (p=0.003)• 25% (4) residents preferred IO; 2 had no preference
•22 participants preferred the UVC -- all cited familiarity as a reason for this preference• difference in experience: years vs.
minutes!
UVC and IO perceived ease of use by subgroupTraining Level (N)
UVC difficulty IO difficulty p value
All subjects (40) 4.6 4.3 0.6762
Residents (16) 6.5 4.75 0.0026
Fellows (6) 4.3 3.8 0.6462
Hospitalists (5) 4.4 6 0.2420
NNPs (5) 2.2 4.6 0.1856
Attendings (8) 1.8 2.5 0.1395
Discussion• Difference between mean IO and UVC
placement was 0.76 minutes (~46 seconds)
• Identifies differences in time to placement -- does not account for how components are packaged
• Implications for NRP / Possible practice changes
• perhaps IO should also be taught and recommended as a placement technique (not shown to be inferior)• UVCs could be recommended for use in tertiary care centers where
there is consistent experience; IOs may be more appropriate elsewhere
Conclusions• For the primary hypothesis: must reject Ho
• IO is faster than UVC
• For the secondary hypothesis: must accept Ho
• no difference in rates of error
• For the observational hypothesis: must accept Ho
• no difference in perceived ease of use
References1.Perlman JM, Risser R. Cardiopulmonary resuscitation
in the delivery room. Arch Pediatr Adolesc Med 1995;149:20-5.
2.Zaritsky AL, Nadkarni UM, Hickey RW, et al. PALS provider manual. Dallas (TX)7 American Heart Association/American Academy of Pediatrics; 2002
3.Ellemunter H, Simma B, Trawoger R, et al. Intraosseous lines in preterm and full term neonates. Arch Dis Child Fetal Neonatal Ed 1990;80:F74-5.
4.Sapien R, Stein H, Padbury JF, Thio S, Hodge D. Intraosseous versus intravenous epinephrine infusions in lambs: Pharmacokinetics and pharmacodynamics. Ped Emerg Care 1992;8:179-183.