456 - Epinephrine Through Advanced Airway During Neonatal Resuscitation - A Simulation and Translational Model Study

Publication Number: 1438.456

TIEN T.M. PHAN, Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, Buffalo, NY, United States; Sylvia F. Gugino, SUNY at Buffalo, Buffalo, NY, United States; Justin Helman, Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, Buffalo, NY, United States; Nicole Bradley, Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, Buffalo, NY, United States; Lori nielsen, SUNY Buffalo, Buffalo, NY, United States; Neel D. Mittal, Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, Bufffalo, NY, United States; Rupashree R. Mandala, Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, Depew, NY, United States; Saptadweepa Sanghamitra, Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, Buffalo, NY, United States; Srinivasan Mani, Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, Buffalo, NY, United States; Mausma Bawa, University at Buffalo, Buffalo, NY, United States; Munmun Rawat, University at Buffalo, Buffalo, NY, United States; Praveen Chandrasekharan, Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, Buffalo, NY, United States

Background: Most recent neonatal resuscitation guidelines recommend the use of an endotracheal tube (ETT) or a laryngeal mask (LMA) for airway management. Epinephrine (EPI) is administered via ETT until an umbilical access is placed, when chest compressions do not improve heart rate. Using a catheter to deliver EPI could improve drug delivery while preventing drug retention in the airway.

Objective: To evaluate if delivering EPI via a catheter with an airway (ETT/LMA) improves drug delivery.

Design/Methods: We used two methods to validate the findings:
1. Simulation: ETT and LMA were tested with and without a catheter (n =10 each group). Catheter length: 31 cm; 0.4 ml of normal saline (NS) was retained after delivery, with a total of 1 ml of NS used.
2. Translational study: After IACUC approval, twenty-four near-term lambs underwent cardiac arrest by umbilical cord occlusion until a sustained heart rate of 0 for 5 minutes. Randomization was 2:2. Study group: a) ETT with catheter, b) LMA with catheter, versus Control group: c) ETT without a catheter, d) LMA without a catheter. The primary outcome was EPI in the airway. The secondary outcome was gas exchange and hemodynamics. We performed an analysis of the EPI remaining in the airway using an ELISA kit. Data was analyzed by Chi-square, ANOVA post hoc, and Kruskal-Wallis tests. Significance was p < 0.05 with a power of 0.80.

Results: 1. Simulation: Administration of EPI with the push of air in a catheter showed significantly less residual in the ETT and LMA (p < 0.0001) as shown in Figure 1a,b,c,d.
2. Translational study: Baseline characteristics are shown in Fig. 2a. Gas exchange in LMA without a catheter showed a higher PaCO2, as shown in Fig. 2b. Carotid blood flows were significantly lower with LMA (Fig. 2c). Use of advanced airways with and without a catheter showed no difference in residual EPI ( Fig. 3).

Conclusion(s): While simulation suggested catheter use affects fluid delivery, translational ovine studies indicate that catheter-assisted EPI administration does not improve delivery or outcomes in a fluid-filled airway model. Larger translational and clinical trials are needed to confirm these findings in human neonates.

Figure 1
Figure 1 shows the simulation method. Figure 1a and 1b demonstrate the use of the catheter in a controlled manner with air push. The bar graphs represent the administration of epinephrine through the endotracheal tube and laryngeal mask airway. The asterisk bar graph (represented as average and standard deviation) represents significance.

Figure 2
Figure 2a - Baseline characteristcs. Fib2b - Gas exchange. Fig 2c Hemodynamics.

Figure 3
Residual EPI left in the airway represented as box and whiskers plot.