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.