Pre-filled syringes with adrenaline during cardiopulmonary resuscitation in nonshockable rhythms. Pilot randomised crossover simulation study
, 23, 2, 24, 52, 23, 62, 2
Abstract
Background: Pre-filled syringes are increasingly popular in medicine, especially in emergency medicine, where fast intervention is crucial. Additionally, as indicated by numerous studies, the use of drugs in prefilled syringes reduces the risk of medical errors associated with inadequate preparation of the drug and reduces the risk of contamination as a result of tissue injury due to rupture of a standard ampoule with the drug. The aim of the study was to compare the use of pre-filled syringes with adrenaline and standard adrenalinę in ampoules during simulated CPR during simulated cardiopulmonary resuscitation in non-shockable rhythms performed by two-person teams.
Methods: The study was a randomised cross-over study and was based on medical simulation. The study involved 40 paramedics assigned randomly to 20 two-person rescue teams. These teams were to perform 10-minute cardiopulmonary resuscitation in three research scenarios: Scenario A — During CPR, access to the median basilic vein and preparation and administration of adrenaline infusions from generally available ampoules at concentration 1:1000 were required (Adrenaline WZF 0.1%; Polfa, Warsaw, Poland) with a standard syringe; Scenario B — During resuscitation, the median basilic vein was accessed and adrenalinę was to be administered from an adrenaline pre-filled syringe (Aguettant Santé, Lyon, France); Scenario C — During CPR, intraosseous tibial vascular access was obtained using a NIO Adult kit, and adrenaline was administered using a pre-filled syringe with adrenaline (Aguettant Santé, Lyon, France). Both the order of resuscitation and medication administration as well as the order of participants were random.
Results : The time to obtain vascular access in the examined scenarios varied and was 240 sec [IQR; 220–265] for Scenario A, 236 sec [IQR; 210–270] for Scenario B, and 165 sec [IQR; 90–180] for Scenario C; A vs. C, (p < 0.001), B vs. C (p < 0.001). In scenarios A, B, and C, the duration of adrenaline administration varied and was 55 sec [IQR; 50–85] vs. 20 sec [IQR; 18–35] vs. 20 sec [IQR; 20–30] (A vs. B, and A vs. C, p < 0.001).
Conclusion: A simulation study has shown that paramedics in two-person teams are unable to deliver
adrenaline at the time recommended by CPR guidelines. The delay of CPM adrenaline supply compared to PFS adrenaline is statistically significant. In the opinion of paramedics participating in the study, adrenalinę during resuscitation should be administered by means of pre-filled syringes, which eliminates the delays in rescue operations resulting from the time needed to prepare drugs as well as limited human resources in rescue teams.
Keywords: cardiopulmonary resuscitationmedical simulationpre-filled syringeepinephrineemergency medical service
References
- Chua SS, Chua HM, Omar A. Drug administration errors in paediatric wards: a direct observation approach. Eur J Pediatr. 2010; 169(5): 603–611.
- Board P. Reducing drug errors in anaesthesia. BMJ. 2011; 343: d6885.
- Berdot S, Sabatier B, Gillaizeau F, et al. Evaluation of drug administration errors in a teaching hospital. BMC Health Serv Res. 2012; 12: 60.
- Parshuram CS, To T, Seto W, et al. Systematic evaluation of errors occurring during the preparation of intravenous medication. CMAJ. 2008; 178(1): 42–48.
- Gokhman R, Seybert AL, Phrampus P, et al. Medication errors during medical emergencies in a large, tertiary care, academic medical center. Resuscitation. 2012; 83(4): 482–487.
- Hedlund N, Beer I, Hoppe-Tichy T, et al. Systematic evidence review of rates and burden of harm of intravenous admixture drug preparation errors in healthcare settings. BMJ Open. 2017; 7(12): e015912.
- Soar J, Nolan JP, Böttiger BW, et al. Adult advanced life support section Collaborators. European Resuscitation Council Guidelines for Resuscitation 2015: Section 3. Adult advanced life support. Resuscitation. 2015; 95: 100–147.
- Link MS, Berkow LC, Kudenchuk PJ, et al. Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015; 132(18 Suppl 2): S444–S464.
- Madziala M, Smereka J, Szarpak L. Pre-filled syringe as an option for drug delivery in emergency medicine. Disaster and Emergency Medicine Journal. 2017; 2(2): 98–99.
- Saliba P, Cuervo G, Hornero A, et al. The impact of flushing with pre-filled saline syringes on the incidence of peripheral venous catheter failure: A quasi-experimental study. J Vasc Access. 2019 [Epub ahead of print]: 1129729819888423.
- Jensen LS, Merry AF, Webster CS, et al. Evidence-based strategies for preventing drug administration errors during anaesthesia. Anaesthesia. 2004; 59(5): 493–504.
- Benhamou D, Piriou V, De Vaumas C, et al. Ready-to-use pre-filled syringes of atropine for anaesthesia care in French hospitals - a budget impact analysis. Anaesth Crit Care Pain Med. 2017; 36(2): 115–121.
- Larmené-Beld KHM, Spronk JT, Luttjeboer J, et al. A Cost Minimization Analysis of Ready-to-Administer Prefilled Sterilized Syringes in a Dutch Hospital. Clin Ther. 2019; 41(6): 1139–1150.
- Davidson LRR, Miller DR, Currie GP. How long does it take medical and nursing staff to assemble pre-filled emergency drug syringes? Resuscitation. 2009; 80(4): 499.
- Ewy GA, Bobrow BJ, Chikani V, et al. The time dependent association of adrenaline administration and survival from out-of-hospital cardiac arrest. Resuscitation. 2015; 96: 180–185.
- Baert V, Vilhelm C, Escutnaire J, et al. GR-RéAC. Intraosseous Versus Peripheral Intravenous Access During Out-of-Hospital Cardiac Arrest: a Comparison of 30-Day Survival and Neurological Outcome in the French National Registry. Cardiovasc Drugs Ther. 2020 [Epub ahead of print].
- Szarpak L, Truszewski Z, Smereka J, et al. A Randomized Cadaver Study Comparing First-Attempt Success Between Tibial and Humeral Intraosseous Insertions Using NIO Device by Paramedics: A Preliminary Investigation. Medicine (Baltimore). 2016; 95(20): e3724.
- Ross EM, Mapp J, Kharod C, et al. Time to epinephrine in out-of-hospital cardiac arrest: A retrospective analysis of intraosseous versus intravenous access. Am J Disaster Med. 2016; 11(2): 119–123.
- Szarpak L, Ladny JR, Dabrowski M, et al. Comparison of 4 Pediatric Intraosseous Access Devices: A Randomized Simulation Study. Pediatr Emerg Care. 2018 [Epub ahead of print].
- Smereka J, Madziała M, Szarpak L. Are firefighters able to perform intraosseous access and start fluid resuscitation in an anaphylactic patient? Am J Emerg Med. 2016; 34(8): 1707–1708.
- Bielski K, Szarpak L, Smereka J, et al. Comparison of four different intraosseous access devices during simulated pediatric resuscitation. A randomized crossover manikin trial. Eur J Pediatr. 2017; 176(7): 865–871.
- Holloway CM, Jurina CS, Orszag CJ, et al. Effects of humerus intraosseous versus intravenous amiodarone administration in a hypovolemic porcine model. Am J Disaster Med. 2016; 11(4): 261–269.