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Comparison of intraosseous and intravenous epinephrine administration during resuscitation of asphyxiated newborn lambs
  1. Calum T Roberts1,2,3,
  2. Sarah Klink1,
  3. Georg M Schmölzer4,
  4. Douglas A Blank1,2,3,
  5. Shiraz Badurdeen1,5,
  6. Kelly J Crossley1,
  7. Karyn Rodgers1,
  8. Valerie Zahra1,
  9. Alison Moxham1,
  10. Charles Christoph Roehr6,7,8,
  11. Martin Kluckow9,
  12. Andrew William Gill10,
  13. Stuart B Hooper1,11,
  14. Graeme R Polglase1,11
  1. 1 The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
  2. 2 Department of Paediatrics, Monash University, Clayton, Victoria, Australia
  3. 3 Monash Newborn, Monash Health, Clayton, Victoria, Australia
  4. 4 Centre for the Studies of Asphyxia and Resuscitation, University of Alberta, Royal Alexandra Hospital, Edmonton, Alberta, Canada
  5. 5 Newborn Research Centre, Royal Women's Hospital, Parkville, Victoria, Australia
  6. 6 National Perinatal Epidemiology Unit, Nuffield Department of Population Health, Medical Sciences Division, University of Oxford, Oxford, UK
  7. 7 Newborn Care, Division of Women and Children, University of Bristol, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
  8. 8 Newborn Care, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
  9. 9 Department of Neonatology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
  10. 10 Centre for Neonatal Research and Education, University of Western Australia, Perth, Western Australia, Australia
  11. 11 Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
  1. Correspondence to Dr Calum T Roberts, The Ritchie Centre at Hudson Institute of Medical Research, Clayton, VIC 3168, Australia; calum.roberts{at}monash.edu

Abstract

Objective Intraosseous access is recommended as a reasonable alternative for vascular access during newborn resuscitation if umbilical access is unavailable, but there are minimal reported data in newborns. We compared intraosseous with intravenous epinephrine administration during resuscitation of severely asphyxiated lambs at birth.

Methods Near-term lambs (139 days’ gestation) were instrumented antenatally for measurement of carotid and pulmonary blood flow and systemic blood pressure. Intrapartum asphyxia was induced by umbilical cord clamping until asystole. Resuscitation commenced with positive pressure ventilation followed by chest compressions and the lambs received either intraosseous or central intravenous epinephrine (10 μg/kg); epinephrine administration was repeated every 3 min until return of spontaneous circulation (ROSC). The lambs were maintained for 30 min after ROSC. Plasma epinephrine levels were measured before cord clamping, at end asphyxia, and at 3 and 15 min post-ROSC.

Results ROSC was successful in 7 of 9 intraosseous epinephrine lambs and in 10 of 12 intravenous epinephrine lambs. The time and number of epinephrine doses required to achieve ROSC were similar between the groups, as were the achieved plasma epinephrine levels. Lambs in both groups displayed a similar marked overshoot in systemic blood pressure and carotid blood flow after ROSC. Blood gas parameters improved more quickly in the intraosseous lambs in the first 3 min, but were otherwise similar over the 30 min after ROSC.

Conclusions Intraosseous epinephrine administration results in similar outcomes to intravenous epinephrine during resuscitation of asphyxiated newborn lambs. These findings support the inclusion of intraosseous access as a route for epinephrine administration in current guidelines.

  • resuscitation
  • neonatology
  • emergency care

Data availability statement

Data are available upon reasonable request. Data are available to qualified researchers upon reasonable request to the authors.

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Data availability statement

Data are available upon reasonable request. Data are available to qualified researchers upon reasonable request to the authors.

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Footnotes

  • Twitter @calumtheroberts

  • Correction notice This article has been corrected since it first published. In figure 2, both lines in the graph are labeled “IV Epinephrine”. The black line has now been correctly labelled 'IO Epinephrine'.

  • Contributors CTR, GMS, DAB, SB, CCR, MK, AWG, SBH and GRP made substantial contributions to study conception and design, or analysis and interpretation of the data. SK, KJC, KR, VZ and AM contributed to data collection and analysis. CTR and GRP cowrote the first draft of the manuscript.

  • Funding This research was supported by the National Health and Medical Research Council (NHMRC) Project Grant APP1158494 and Fellowships (GRP: APP1173731; SBH: APP545921; CTR: APP1175634), a National Heart Foundation of Australia Vanguard Grant (103022), and the Victorian Government’s Operational Infrastructure Support Programme.

  • Disclaimer Teleflex Medical had no input in study design, conduct, or analysis or in manuscript preparation.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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