Use of Intraosseous Access in Neonatal and Pediatric Retrieval-Neonatal and Pediatric Emergency Transfer Service, New South Wales.

OBJECTIVES: Pediatric patients who are critically unwell require rapid access to central vasculature for administration of life-saving medications and fluids. The intraosseous (IO) route is a well-described method of accessing the central circulation. There is a paucity of data surrounding the use of IO in neonatal and pediatric retrieval. The aim of this study was to review the frequency, complications, and efficacy of IO insertion in neonatal and pediatric patients in retrieval. METHODS: A retrospective review of cases referred to neonatal and pediatric emergency transfer service, New South Wales over the epoch 2006 to 2020. Medical records documenting IO use were audited for patient demographic data, diagnosis, treatment details, IO insertion and complication statistics, and mortality data. RESULTS: Intraosseous access was used in 467 patients (102 neonatal/365 pediatric). The most common indications were sepsis, respiratory distress, cardiac arrest, and encephalopathy. The main treatments were fluid bolus, antibiotics, maintenance fluids, and resuscitation drugs. Return of spontaneous circulation after resuscitation drugs occurred in 52.9%; perfusion improved with fluid bolus in 73.1%; blood pressure improved with inotropes in 63.2%; seizures terminated with anticonvulsants in 88.7%. Prostaglandin E1 was given to eight patients without effect. Intraosseous access-related injury occurred in 14.2% of pediatric and 10.8% of neonatal patients. Neonatal and pediatric mortality rates were 18.6% and 19.2%, respectively. CONCLUSIONS: Survival in retrieved neonatal and pediatric patients who required IO is higher than previously described in pediatric and adult cohorts. Early insertion of an IO facilitates early volume expansion, delivery of critical drugs, and allows time for retrieval teams to gain more definitive venous access. In this study, prostaglandin E1 delivered via a distal limb IO had no success in reopening the ductus arteriosus.

Unsuccessful alloplastic esophageal replacement with porcine small intestinal submucosa.

In general, there is no perfect method for esophageal replacement under consideration of the numerous associated risks and complications. The aim of this study was to examine a new material--small intestinal submucosa (SIS)--in alloplastic esophageal replacement. We implanted tubular SIS prosthesis about 4 cm in length in the cervical esophagus of 14 piglets (weight 9-13 kg). For the first 10 days, the animals were fed parenterally, supplemented by free given water, followed by an oral feeding phase. Four weeks after surgery, the animals were sacrificed. Only 1 of the 14 animals survived the study period of 4 weeks. The other piglets had to be sacrificed prematurely because of severe esophageal stenosis. On postmortem exploration, the prosthesis could not be found either macroscopically or histologically. Sutures between the prosthesis and the cervical muscles did not improve the results. Until now, the use of alloplastic materials in esophageal replacement has failed irrespective of the kind of material. As well as in our experiments, severe stenosis had been reported in several animal studies. The reasons for this unacceptable high rate of stenosis after alloplastic esophageal replacement seem to be multifactorial. Possible solutions could be transanastomotic splints, less inert materials, the decrease of anastomotic tension by stay sutures, the use of adult stem cells, and tissue engineering.