492 - Direct Umbilical Vein Injection of Epinephrine with Cut Umbilical Cord Milking vs. Umbilical Venous Catheter Epinephrine at 0.01, 0.02, and 0.03mg/kg: A Randomized Study in an Ovine Model
Clinical Fellow University of California Davis University of California Davis Health System Sacramento, California, United States
Background: Background: In severely bradycardic or asystolic newborns, NRP recommends giving epinephrine (EPI) by the intravenous (IV) route as soon as venous access is established. Umbilical access with a low umbilical venous catheter (UVC) takes time and requires advanced skills and specialized materials. Endotracheal (ET) EPI has decreased bioavailability and lower rates of return of spontaneous circulation (ROSC) compared to IV. Direct umbilical vein (UV) injection with cut umbilical cord milking (DUV+UCM) may quicker alternative for intravascular EPI administration.
Objective: Objective: To determine if direct injection of EPI into the UV at the base of the umbilicus followed by cord milking leads to quicker ROSC as compared with UVC EPI administration at the full range of NRP recommended doses (0.01 mg/kg, 0.02 mg/kg, and 0.03 mg/kg).
Design/Methods:
Methods: Lambs were randomized to one of 6 groups (Fig 1). Lambs were exteriorized, intubated, and instrumented prior to cord occlusion. Asphyxia to cardiac arrest was induced by umbilical cord occlusion, then cut at the placental end to leave a long segment. Resuscitation followed NRP guidelines. Upon initiation of chest compressions, preparation to administer EPI began. In the DUV+UMC groups, EPI prepared in a 1mL syringe with a 23G needle was injected into the UV at the base of the umbilicus followed by 3 cord milkings to flush the dose. If subsequent doses of EPI were required, a UVC was placed. In the control arm, a low-lying UVC was placed and IV EPI was administered followed by a 3mL flush. Serum EPI concentrations were analyzed by liquid chromatography-mass spectrometry.
Results:
Results: 33 lambs were included in the analysis with ROSC success of 31/33. 5/18 lambs in the DUV+UCM groups required placement of a UVC and additional EPI. Time to first EPI dose was quicker in the DUV+UCM group, but time to ROSC was similar between groups (Figure 1). Higher EPI doses had higher peak EPI concentrations, but there was no difference in EPI concentrations between DUV+UCM vs. UVC EPI (Fig 2-4). Conclusion(s): Conclusion: DUV+UCM EPI had a 72% success of ROSC and similar EPI plasma concentrations to UVC EPI when successful. Our results suggest that this method has greater success of ROSC and achieves a quicker peak in plasma EPI compared to ET EPI. DUV+UCM should be considered as an alternate route of EPI administration while IV access is being established. Clinical studies are warranted.
Authors/Institutions: Peggy Chen, University of California Davis Health System, Sacramento, California, United States; Payam Vali, University of California Davis Health System, Sacramento, California, United States; Amy Lesneski, University of California Davis, Davis, California, United States; Morgan Hardie, University of California Davis, Davis, California, United States; Heather Knych, University of California Davis, Davis, California, United States; Deepika Sankaran, University of California Davis Health System, Sacramento, California, United States; Ziad Alhassen, University of California Davis Health System, Sacramento, California, United States; Houssam Joudi, University of California Davis, Davis, California, United States; Satyan Lakshminrusimha, University of California Davis Health System, Sacramento, California, United States
