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A simulation study of high-flow versus normal-flow three-way stopcock for rapid fluid administration in emergency situations: A randomised crossover design

  • Keishi Yamaguchi
    Correspondence
    Corresponding author. Tel.: +81 045 261 5656; fax: +81 045 231 1846.
    Affiliations
    Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 4-57 Urafunecho, Minamiku, Yokohama, Japan
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    c Tel.: +81 045 261 5656; fax: +81 045 231 1846.
    Tomoki Doi
    Footnotes
    c Tel.: +81 045 261 5656; fax: +81 045 231 1846.
    Affiliations
    Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 4-57 Urafunecho, Minamiku, Yokohama, Japan
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  • Author Footnotes
    c Tel.: +81 045 261 5656; fax: +81 045 231 1846.
    Takashi Muguruma
    Footnotes
    c Tel.: +81 045 261 5656; fax: +81 045 231 1846.
    Affiliations
    Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 4-57 Urafunecho, Minamiku, Yokohama, Japan
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    c Tel.: +81 045 261 5656; fax: +81 045 231 1846.
    Kento Nakajima
    Footnotes
    c Tel.: +81 045 261 5656; fax: +81 045 231 1846.
    Affiliations
    Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 4-57 Urafunecho, Minamiku, Yokohama, Japan
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    c Tel.: +81 045 261 5656; fax: +81 045 231 1846.
    Kyota Nakamura
    Footnotes
    c Tel.: +81 045 261 5656; fax: +81 045 231 1846.
    Affiliations
    Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 4-57 Urafunecho, Minamiku, Yokohama, Japan
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    c Tel.: +81 045 261 5656; fax: +81 045 231 1846.
    Takeru Abe
    Footnotes
    c Tel.: +81 045 261 5656; fax: +81 045 231 1846.
    Affiliations
    Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 4-57 Urafunecho, Minamiku, Yokohama, Japan
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    c Tel.: +81 045 261 5656; fax: +81 045 231 1846.
    Ichiro Takeuchi
    Footnotes
    c Tel.: +81 045 261 5656; fax: +81 045 231 1846.
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    Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 4-57 Urafunecho, Minamiku, Yokohama, Japan
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  • Author Footnotes
    c Tel.: +81 045 261 5656; fax: +81 045 231 1846.
    Naoto Morimura
    Footnotes
    c Tel.: +81 045 261 5656; fax: +81 045 231 1846.
    Affiliations
    Department of Acute Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo-ku, Tokyo 113-8655, Japan
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    c Tel.: +81 045 261 5656; fax: +81 045 231 1846.
Open AccessPublished:April 26, 2021DOI:https://doi.org/10.1016/j.aucc.2021.01.008

      Abstract

      Background

      Initial fluid resuscitation is presumed to be important for treating shock in the resuscitation phase. However, little is known how quickly and easily a physician could perform a rapid infusion with a syringe.

      Objectives

      We hypothesised that using a high-flow three-way stopcock (HTS) makes initial fluid resuscitation faster and easier than using a normal-flow three-way stopcock (NTS).

      Methods

      This was a simulation study with a prospective, nonblinded randomised crossover design. Twenty physicians were randomly assigned into two groups. Each participant used six peripheral intravenous infusion circuits, three with the HTS and the others with the NTS, and three cannulae, 22, 20, and 18 gauge (G). The first group started with the HTS first, while the other started with the NTS first. They were asked to inject the fluid as quick as possible. We compared the time until the participants finished rapid infusions of 500 ml of 0.9% saline and the practitioner's effort.

      Results

      In infusion circuits attached with the 22G cannula, the mean difference using the HTS and the NTS (95% confidence interval [CI]) was 16.30 ml/min (7.65–24.94) (p < 0.01). In those attached with the 20G cannula, the mean difference (95% CI) was 23.47 (12.43–34.51) (p < 0.01). In those attached with the 18G cannula, the mean difference (95% CI) was 42.53 (28.68–56.38) (p < 0.01).

      Conclusions

      This study revealed that the push-and-pull technique using the HTS was faster, easier, and less tiresome than using the NTS, with a statistically significant difference. In the resuscitation phase, initial and faster infusion is important. If only a single physician or other staff member such as a nurse is attending or does not have accessibility to any other devices in such an environment where medical resources are scarce, performing the push-and-pull technique using the HTS could help a physician to perform fluid resuscitation faster. By setting up the HTS instead of the NTS from the beginning, we would be able to begin fluid resuscitation immediately while preparing other devices.

      Keywords

      1. Introduction

      Serious haemorrhagic shock results in an insufficient supply of oxygen at the cellular level
      • Cannon J.W.
      Hemorrhagic shock.
      and organ dysfunction to death at the individual level if proper intervention is not provided.
      • Halmin M.
      • Chiesa F.
      • Vasan S.K.
      • Wikman A.
      • Norda R.
      • Rostgaard K.
      • et al.
      Epidemiology of massive transfusion: a binational study from Sweden and Denmark.
      ,
      • Bouglé A.
      • Harrois A.
      • Duranteau J.
      Resuscitative strategies in traumatic hemorrhagic shock.
      The number of deaths caused by haemorrhage is enormous and is a global problem.
      • Lozano R.
      • Naghavi M.
      • Foreman K.
      • Lim S.
      • Shibuya K.
      • Aboyans V.
      • et al.
      Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.
      Haemorrhagic shock caused by trauma, gastrointestinal haemorrhage, perioperative haemorrhage, rupture of an aneurysm, and maternal haemorrhage is not uncommon.
      • Christensen S.
      • Riis A.
      • Nørgaard M.
      • Sørensen H.T.
      • Thomsen R.W.
      Short-term mortality after perforated or bleeding peptic ulcer among elderly patients: a population-based cohort study.
      • Mannucci P.M.
      • Levi M.
      Prevention and treatment of major blood loss.
      • Anderson J.M.
      • Etches D.
      Prevention and management of postpartum hemorrhage.
      Treatments for haemorrhagic shock, in any case, require rapid fluid resuscitation and damage control for haemostasis to correct the insufficient supply of oxygen at the cellular level.
      • Kaur P.
      • Basu S.
      • Kaur G.
      • Kaur R.
      Transfusion protocol in trauma.
      Distributive shock caused by sepsis also requires initial fluid resuscitation. Initial fluid resuscitation and vasopressors are necessary to increase cardiac output, to improve organ perfusion, and to transport oxygen to cells.
      • Otero R.M.
      • Nguyen B.
      • Huang D.T.
      • Gaieski D.F.
      • Goyal M.
      • Gunnerson K.J.
      • et al.
      Early goal-directed therapy in severe sepsis and septic shock revisited: concepts, controversies, and contemporary findings.
      ,
      • Dellinger R.P.
      • Levy M.M.
      • Rhodes A.
      • Annane D.
      • Gerlach H.
      • Opal S.M.
      • et al.
      Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock, 2012.
      In the resuscitation phase, initial fluid resuscitation is presumed to be important. Most physicians try to perform the initial rapid infusion, using a large gauge of peripheral intravenous (IV) catheter or central line, setting a fluid bag high, using a pressure bag and auto device such as the Level 1® Fast Flow Fluid (Smiths Medical), or performing a push-and-pull technique using a syringe. Using a large gauge naturally makes the initial fusion faster because of the Hagen–Poiseuille equation. Based on the American College of Critical Care Medicine clinical practice parameters for resuscitation of paediatric patients with septic shock,
      • Brierley J.
      • Carcillo J.A.
      • Choong K.
      • Cornell T.
      • Decaen A.
      • Deymann A.
      • et al.
      Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine.
      using pressure bags or performing manual push-and-pull technique made fluid resuscitation faster and useful, compared with a gravity setting for children weighing less than 40 kg, with statistical differences.
      • Michael J.S.
      • Deborah G.G.
      • Daniel M.C.
      • Soledad A.F.
      • Mark W.H.
      Rapid fluid resuscitation in pediatrics: testing the American College of critical care medicine guideline.
      On the other hand, there is no consensus on whether a pressure bag, a manual push-and-pull technique, or a gravity setting would be effective for adult patients. The manual push-and-pull technique is a rapid infusion method using a three-way stopcock. Although it has not yet been established whether the three-way stopcock is the cause of catheter-related blood stream infection, three-way stopcocks can be an entry point for microbes into the peripheral IV catheter. In general, closed catheter access systems are associated with fewer catheter-related blood stream infections than open systems and should be used preferentially.
      • Niel-Weise B.S.
      • Daha T.J.
      • van den Broek P.J.
      Is there evidence for recommending needleless closed catheter access systems in guidelines? A systematic review of randomized controlled trials.
      • Rosenthal V.D.
      Clinical impact of needle-free connector design: a systematic review of literature [published online ahead of print, 2020 Feb 14].
      • Rosenthal V.D.
      • Udwadia F.E.
      • Kumar S.
      • Poojary A.
      • Sankar R.
      • Orellano P.W.
      • et al.
      Clinical impact and cost-effectiveness of split-septum and single-use prefilled flushing device vs 3-way stopcock on central line-associated bloodstream infection rates in India: a randomized clinical trial conducted by the International Nosocomial Infection Control Consortium (INICC).
      In clinical practice, however, physicians often try to make fluid resuscitation faster using the push–pull technique because the setup uses existing infusion lines and the technique is easy to perform, uses inexpensive consumables, and can replace circulatory volume quickly.
      • Michael J.S.
      • Deborah G.G.
      • Daniel M.C.
      • Soledad A.F.
      • Mark W.H.
      Rapid fluid resuscitation in pediatrics: testing the American College of critical care medicine guideline.
      Thus, we focused on the push–pull technique and examined how to perform it.
      The efficiency of the push-and-pull technique using the high-flow three-way stopcock (HTS) versus normal-flow three-way stopcock (NTS) was the focus of this study. There is no report on how fast the HTS performs compared with the NTS and whether the burden placed on the physician would be different in performing fluid resuscitation. The HTS has a larger diameter than the NTS, so we hypothesised that using the HTS makes initial fluid resuscitation faster and easier than using the NTS. If performing the push-and-pull technique using the HTS could help to perform fluid resuscitation faster and easier, the technique would be useful for a single physician attending or not having accessibility to any other devices.

      2. Methods

      2.1 Study design

      A prospective, randomised, nonblinded crossover study was conducted in the setting of a tertiary emergency medical centre belonging to an intensive care unit at Yokohama City University Medical Center in Kanagawa, Japan. Twenty emergency physicians were enrolled and divided into two groups. The participants were ensured that they could refuse participation in the study and could leave at any time during the study protocol if they wished. For ethical considerations, this study was conducted as per the principles expressed in the Declaration of Helsinki. The Institutional Review Board, IRB, waived the need for ethical review because this study used neither patients' clinical information nor staff's personal information. Participation in this study was regarded as consent. The initial design and protocol were presented at the 10th Asian Conference on Emergency Medicine in New Delhi on November 8, 2019.

      2.2 Device

      The focus was on the HTS, which was common in clinical haemodialysis.
      • Nakae H.
      • Omokawa S.
      • Asanuma Y.
      • Igarashi T.
      • Tajimi K.
      Study of safe usage of high-flow three-way stopcocks in a blood circuit.
      As described in Fig. 1A, the HTS had an inner diameter of 3 mm, which was 1.6 times the size of the NTS. The HTS was used safely in haemodialysis,
      • Nakae H.
      • Omokawa S.
      • Asanuma Y.
      • Igarashi T.
      • Tajimi K.
      Study of safe usage of high-flow three-way stopcocks in a blood circuit.
      but there was no report with regard to the use of the HTS in fluid resuscitation. In view of the larger inner diameter, the potential exists for the HTS to deliver fluid therapy at a greater speed than that delivered through a standard NTS.
      Fig. 1
      Fig. 1The HTS and the NTS (A) and scheme (B). Instruments have the HTS/NTS with the 22G/20G/18G IV catheter. HTS, high-flow three-way stopcock; NTS, normal-flow three-way stopcock; G, gauge; IV, intravenous.

      2.3 Instruments

      Fig. 1B shows that six peripheral infusion circuits were used. Each of the three infusion circuits had an HTS, and the others had an NTS. We attached 22 gauge (G), 20G, and 18G peripheral IV catheters to three infusion circuits with the HTS, respectively. Similarly, we attached 22G, 20G, and 18G IV catheters to three peripheral infusion circuits with the NTS, respectively. All catheters were placed in a collection bag, 8.5-L bucket, made by YAZAKI KAKO Corporation (Shizuoka, Japan). Based on the facility's equipment, all infusion bags were set at a height of 200 cm, and the collection bags were set at a height of 80 cm from the floor.

      2.4 Protocol

      First, we compared a push-and-pull technique between the HTS and NTS. The participants were randomly assigned to two groups, group A and group B, based on a random number table (Fig. 2). All participants watched an instruction video about how to perform rapid infusion with a syringe using a three-way stopcock. They were asked to inject the fluid as quick as possible. All participants were given numbers in a consecutive order and divided into two random groups, odd numbers in group A and even numbers in group B.
      Fig. 2
      Fig. 2Study protocol. Twenty physicians were recruited, and all of them first watched a video about how to perform a rapid infusion with a syringe using a three-way stopcock. After that, they were randomly assigned into two groups based on a random number table, and each physician performed rapid infusion with a syringe six times. Then, they answered questionnaires.
      All participants used the push-and-pull technique to infuse 500 ml of 0.9% saline on three occasions, initially through a 22G cannula and subsequently through a 20G and an 18G cannula. Measured using a manual stopwatch, time for fluid infusion and the practitioner's effort was compared using a standard stopcock and a high-flow stopcock.
      For each gauge, group A used the HTS first and then the NTS without a break. Group B used the NTS first and then the HTS without a break. A 5-min break was taken between each stopcock. The participants performed rapid infusions with a syringe six times in total, and the time until the participants finished rapid infusions with a syringe of 500 ml of 0.9% saline was measured.
      Once all participants had performed the procedure, the cohort of physicians was requested to complete a six-point Likert scale questionnaire. These questions were as follows: (i) How was the usability of the HTS? (ii) How was the usability of the NTS? (iii) How was the fatigue using the HTS? and (iv) How was the fatigue using the NTS? The participants chose the most appropriate degree of usability of the HTS and the NTS from a six-point Likert scale: (i) very low, (ii) low, (iii) slightly low, (iv) slightly high, (v) high, and (vi) very high. Regarding the degree of fatigue on rapid infusion with a syringe, similarly, a six-point Likert scale was used as well. This scale was anchored from “never fatigued” (a score of 1) to “very fatigued” (a score of 6). All participants were asked to choose the most appropriate degree of fatigue on rapid infusion with each gauge.
      Finally, we added two more settings to verify the effectiveness of the push-and-pull technique. One of them was a natural gravity setting. We measured twice the time that 500 ml of 0.9% saline was infused in the natural gravity setting using each of the six circuits. The other setting placed a 500-ml bag of 0.9% saline within a pressure bag, and the fluid bag was pressurised to 300 mmHg.

      2.5 Sample size and statistical analysis

      A sample size for a crossover study design was calculated. There was no previous study evaluating a difference in speed between the HTS and the NTS. Based on our clinical experiences, we estimated that the difference of 30 s between the HTS and the NTS might be significant to distinguish the speed. In this equivalence of means using two-sided tests on data from the two-period crossover design, a total sample size of 19 achieved 81% power at a 5% significance level when the true difference between the mean was 30, the standard deviation of the paired differences was 50.0, and the equivalence limits were −60.0 and 60.0. Thus, a total of 20 physicians were recruited for this study.
      Data were expressed as mean and standard deviations. Univariate analysis was carried out in all experiments using the Mann–Whitney U test for continuous variables to compare between the NTS and HTS. All statistical tests were two sided, and p values less than 0.05 were considered statistically significant. We used IBM-SPSS Statistics for Windows, Version 23, (IBM Corp; Armonk, NY) for all analyses.

      3. Results

      All of the twenty emergency physicians completed the study protocol (Fig. 2). The participants performed rapid infusion with a syringe six times. The participants' characteristics are summarised in Table 1. All of the twenty emergency physicians are senior staff members in Japan with an experience of more than 6 years. The group consisted of nine residents and 11 teaching staff members. Group A had eight men, with a median career duration of 6.5 years. Group B had five men, with a median career duration of 7 years. There were no significant differences between group A and group B with regard to demographic characteristics.
      Table 1Characteristics of the participants.
      VariablesGroup A (n = 10)Group B (n = 10)p-value
      Male, frequency (%)8 (80)5 (50)0.16
      Career (years), median (interquartile range)6.5 (5–11.25)7 (5.5–9.75)0.69
      Fig. 3 shows the comparison of flow rates between the HTS and NTS. In infusion circuits attached with the 22G cannula, the mean flow rate of using the HTS was 108 ml/min. On the other hand, the mean flow rate of using the NTS was 94.0 ml/min, with which the mean difference (95% confidence interval [CI]) was 16.30 (7.65–24.94) (p < 0.01). In infusion circuits attached with the 20G cannula, the mean flow rate of using the HTS and the NTS was 129 ml/min and 106 ml/min, respectively, with which the mean difference (95% CI) was 23.47 (12.43–34.51) (p < 0.01). In infusion circuits attached with the 18G cannula, the mean flow rate of using the HTS and the NTS was 165 ml/min and 133 ml/min, respectively, with which the mean difference (95% CI) was 42.53 (28.68–56.38) (p < 0.01).
      Fig. 3
      Fig. 3Results of the flow rate: 22G (A), 20G (B), and 18G (C). HTS, high-flow three-way stopcock; NTS, normal-flow three-way stopcock; G, gauge.
      We show the results of the four questionnaires using the Likert scale on the degree of usability and fatigue using the HTS and the NTS (Fig. 4). Regarding the degree of usability, the participants indicated that rapid infusion with a syringe using the HTS was “high”. On the other hand, they indicated that rapid infusion with a syringe using the NTS is between “low” and “slightly low” (p < 0.01). Regarding the degree of fatigue on rapid infusion with a syringe, the participants gave a score of 5 for use of the HTS and also a score of 5 for the use of the NTS (p < 0.01).
      Fig. 4
      Fig. 4Results of the four questions using the Likert scale about the degree of usability (A) and fatigue (B) of the HTS and the NTS. HTS, high-flow three-way stopcock; NTS, normal-flow three-way stopcock; G, gauge.
      Fig. 5, Fig. 6, Fig. 7 show comparison among a natural gravity setting, a pressure bag setting, and a push–pull technique by each gauge size of 18G, 20G, and 22G, respectively. In the natural gravity setting and the pressure bag setting maintained at 300 mmHg, there was no flow rate difference between the HTS or NTS (in the gravity setting, p = 0.429 for 18G, 0.201 for 20G, and 0.445 for 22G; in the pressure bag, p = 0.100 for 18G, 0.565 for 20G, and 0.698 for 22G). Regardless of the HTS or NTS, rapid infusion speed was determined only by the gauge.
      Fig. 5
      Fig. 5Results of three comparisons: gravity set, pressure bag, and push-and-pull technique, 22G. HTS, high-flow three-way stopcock; NTS, normal-flow three-way stopcock; G, gauge.
      Fig. 6
      Fig. 6Results of three comparisons: gravity set, pressure bag, and push-and-pull technique, 20G. HTS, high-flow three-way stopcock; NTS, normal-flow three-way stopcock; G, gauge.
      Fig. 7
      Fig. 7Results of three comparisons: gravity set, pressure bag, and push-and-pull technique, 18G. HTS, high-flow three-way stopcock; NTS, normal-flow three-way stopcock; G, gauge.

      4. Discussion

      Our study revealed that the push-and-pull technique using the HTS was faster than that using the NTS, with a statistically significant difference (p < 0.01). We also revealed that the superiority of the HTS did not change regardless of the catheter gauge (p < 0.01). Moreover, questionnaires also revealed that it was easier and less fatiguing to perform the push-and-pull technique using the HTS rather than using the NTS, with a statistically significant difference (p < 0.01). There was no previous report that the HTS was used for fluid resuscitation. These findings indicate that the push-and-pull technique using the HTS could make fluid resuscitation faster and that physicians who perform the push-and-pull technique could be less fatigued. In other words, physicians would be able to perform the push-and-pull technique continuously. Thus, we recommend that the HTS should be kept in the resuscitation phase in case it is needed. In fluid dynamics, the Hagen–Poiseuille equation defines the flow velocity. Therefore, on the distal side of a syringe, there is no significant difference in infusion speed using either the HTS or the NTS. Thus, from these results, using the HTS makes fluid resuscitation faster because of the low resistance when filling the syringe.
      The findings from this study comparing the effectiveness of using a pressure bag and push-and-pull technique are consistent with those from another study.
      • Michael J.S.
      • Deborah G.G.
      • Daniel M.C.
      • Soledad A.F.
      • Mark W.H.
      Rapid fluid resuscitation in pediatrics: testing the American College of critical care medicine guideline.
      Comparing the use of push-and-pull technique and the use of pressure bags, our study revealed that the use of a pressure bag resulted in a slightly faster infusion speed than the push-and-pull technique because of a continuous pressure applied. In addition, a disconnect–reconnect technique resulted in a faster rate of fluid resuscitation than the push-and-pull technique.
      • Cole E.T.
      • Harvey G.
      • Urbanski S.
      • Foster G.
      • Thabane L.
      • Parker M.J.
      Rapid paediatric fluid resuscitation: a randomised controlled trial comparing the efficiency of two provider-endorsed manual paediatric fluid resuscitation techniques in a simulated setting.
      Using a novel infusion device (LifeFlow® Rapid Infuser) made initial fluid resuscitation faster than the push-and-pull technique, with statistical differences.
      • Gillis H.C.
      • Walia H.
      • Tumin D.
      • Bhalla T.
      • Tobias J.D.
      Rapid fluid administration: an evaluation of two techniques.
      These methods reported in the aforementioned studies required equipment or some staff members. Thus, if only a single physician is attending or does not have accessibility to any other devices in such an environment where medical resources are scarce, performing the push-and-pull technique using the HTS could help a physician to perform fluid resuscitation faster. By setting up the HTS instead of the NTS from the beginning, we would be able to begin fluid resuscitation immediately while preparing other devices.
      We should keep in mind that higher frequency and volume of flushing has been observed to have more peripheral IV complications, such as vessel damage, infection, and thrombosis.
      • Hawthorn A.
      • Bulmer A.C.
      • Mosawy S.
      • Keogh S.
      Implications for maintaining vascular access device patency and performance: application of science to practice.
      ,
      • Keogh S.
      • Flynn J.
      • Marsh N.
      • Mihala G.
      • Davies K.
      • Rickard C.
      Varied flushing frequency and volume to prevent peripheral intravenous catheter failure: a pilot, factorial randomised controlled trial in adult medical-surgical hospital patients.
      High-pressure and high-volume injections should only be undertaken in emergency situations where there is no other alternative.
      This study focused on the HTS because of its potential to make initial infusion faster. Our study showed that rapid infusion with a syringe using the HTS was faster, easier, and less fatiguing than using the NTS, with a statistically significant difference. There was a statistically significant difference in the fluid rate, but its clinical significance might be unclear, and a further investigation may be needed.
      There are some caveats and limitations in this study. This study was conducted in a single centre, and only staff physicians were enrolled. In Japan, fluid resuscitation is often delivered by doctors, as in this study. On the other hand, in many countries, fluid resuscitation is delivered by nurses, so generalisability of our study findings might be limited. Further research enrolling nurses, as well as measuring physical characteristics among participants, is needed to overcome this limitation. IV pressure was not a consideration. As the IV pressure becomes resistant, the speed of rapid infusion with a syringe may slow down, and the results of this study may be likely to be affected. We performed this study using only 0.9% saline, and it is unclear whether the results would hold good for either colloid or blood infusion. There is a report that the push-and-pull technique may increase the risk of contamination compared with other devices.
      • Spangler H.
      • Piehl M.
      • Lane A.
      • Robertson G.
      Improving aseptic technique during the treatment of pediatric septic shock.
      It is necessary to consider the possibility of contamination caused by using the HTS. Although there is no statistically significant difference in the number of women between the two groups, differences in numbers may have affected the results. Our assessment tools could be subjective measures and might lack a validity and reliability to measure effort and fatigue by participants. Developing such a scale should be considered in future studies. We found nonsignificance but differences in proportions between male and female patients among the participants. This might limit the generalisability of our study findings. The other limitation was that this study was performed using only a 20-ml syringe. We usually use a 20-ml syringe in fluid resuscitation, so we chose a 20-ml syringe in this study. However, another report shows that using a 10-ml syringe was most effective than using syringes of other sizes.
      • Gibbs N.
      • Murphy T.
      • Campbell R.
      Maximum transfusion rates in neonates and infants.

      5. Conclusions

      This study is the first report to reveal that a push-and-pull technique using the HTS was faster, easier, and less tiresome than that using the NTS, with a statistically significant difference. In the resuscitation phase, initial and faster infusion of IV fluid is important to ensure adequate circulatory volume is maintained. This study focused on the use of the HTS to increase the speed of fluid resuscitation, showing there was a statistically significant difference in speed of fluid delivery when compared with a standard NTS. If only a single physician or other staff member such as a nurse is attending or does not have accessibility to any other devices in such an environment wherein medical resources are scarce, performing the push-and-pull technique using the HTS could help a physician to perform fluid resuscitation faster. By setting up the HTS instead of the NTS from the beginning, we would be able to begin fluid resuscitation immediately while preparing other devices.

      Funding

      This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

      Conflict of Interest

      None.

      CRediT authorship contribution statement

      K.Y., T.D., T.M., K.N., T.A., and N.M. made substantial contributions to the study conception and design as well as the acquisition of data. K.Y., T.D., T.M., K.N., T.A, I.T., and N.M. made substantial contributions to the analysis and interpretation of the data. All authors were involved in drafting the manuscript and critically revising it, and all gave approval to the final version.

      Acknowledgements

      The authors thank all participants for attending and working through the study protocol.

      Appendix A. Supplementary data

      The following is the Supplementary data to this article:

      References

        • Cannon J.W.
        Hemorrhagic shock.
        N Engl J Med. 2018; 378: 370-379
        • Halmin M.
        • Chiesa F.
        • Vasan S.K.
        • Wikman A.
        • Norda R.
        • Rostgaard K.
        • et al.
        Epidemiology of massive transfusion: a binational study from Sweden and Denmark.
        Crit Care Med. 2016; 44: 468-477
        • Bouglé A.
        • Harrois A.
        • Duranteau J.
        Resuscitative strategies in traumatic hemorrhagic shock.
        Ann Intensive Care. 2013; 3: 1
        • Lozano R.
        • Naghavi M.
        • Foreman K.
        • Lim S.
        • Shibuya K.
        • Aboyans V.
        • et al.
        Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.
        Lancet. 2012; 380: 2095-2128
        • Christensen S.
        • Riis A.
        • Nørgaard M.
        • Sørensen H.T.
        • Thomsen R.W.
        Short-term mortality after perforated or bleeding peptic ulcer among elderly patients: a population-based cohort study.
        BMC Geriatr. 2007; 7: 1-8
        • Mannucci P.M.
        • Levi M.
        Prevention and treatment of major blood loss.
        N Engl J Med. 2007; 356: 2301-2311
        • Anderson J.M.
        • Etches D.
        Prevention and management of postpartum hemorrhage.
        Am Fam Physician. 2007; 75: 875-882
        • Kaur P.
        • Basu S.
        • Kaur G.
        • Kaur R.
        Transfusion protocol in trauma.
        J Emergencies, Trauma, Shock. 2011; 4: 103-108
        • Otero R.M.
        • Nguyen B.
        • Huang D.T.
        • Gaieski D.F.
        • Goyal M.
        • Gunnerson K.J.
        • et al.
        Early goal-directed therapy in severe sepsis and septic shock revisited: concepts, controversies, and contemporary findings.
        Chest. 2006; 130: 1579-1595
        • Dellinger R.P.
        • Levy M.M.
        • Rhodes A.
        • Annane D.
        • Gerlach H.
        • Opal S.M.
        • et al.
        Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock, 2012.
        Intensive Care Med. 2013; 39: 165-228
        • Brierley J.
        • Carcillo J.A.
        • Choong K.
        • Cornell T.
        • Decaen A.
        • Deymann A.
        • et al.
        Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine.
        Crit Care Med. 2009; 37: 666-688
        • Michael J.S.
        • Deborah G.G.
        • Daniel M.C.
        • Soledad A.F.
        • Mark W.H.
        Rapid fluid resuscitation in pediatrics: testing the American College of critical care medicine guideline.
        Ann Emerg Med. 2007; 50: 601-607
        • Niel-Weise B.S.
        • Daha T.J.
        • van den Broek P.J.
        Is there evidence for recommending needleless closed catheter access systems in guidelines? A systematic review of randomized controlled trials.
        J Hosp Infect. 2006; 62: 406-413
        • Rosenthal V.D.
        Clinical impact of needle-free connector design: a systematic review of literature [published online ahead of print, 2020 Feb 14].
        J Vasc Access. 2020; 1129729820904904
        • Rosenthal V.D.
        • Udwadia F.E.
        • Kumar S.
        • Poojary A.
        • Sankar R.
        • Orellano P.W.
        • et al.
        Clinical impact and cost-effectiveness of split-septum and single-use prefilled flushing device vs 3-way stopcock on central line-associated bloodstream infection rates in India: a randomized clinical trial conducted by the International Nosocomial Infection Control Consortium (INICC).
        Am J Infect Contr. 2015; 43: 1040-1045
        • Nakae H.
        • Omokawa S.
        • Asanuma Y.
        • Igarashi T.
        • Tajimi K.
        Study of safe usage of high-flow three-way stopcocks in a blood circuit.
        Ther Apher Dial. 2006; 10: 436-440
        • Cole E.T.
        • Harvey G.
        • Urbanski S.
        • Foster G.
        • Thabane L.
        • Parker M.J.
        Rapid paediatric fluid resuscitation: a randomised controlled trial comparing the efficiency of two provider-endorsed manual paediatric fluid resuscitation techniques in a simulated setting.
        BMJ Open. 2014; 4e005028https://doi.org/10.1136/bmjopen-2014-005028
        • Gillis H.C.
        • Walia H.
        • Tumin D.
        • Bhalla T.
        • Tobias J.D.
        Rapid fluid administration: an evaluation of two techniques.
        Med Dev (Auckl). 2018; 11: 331-336
        • Hawthorn A.
        • Bulmer A.C.
        • Mosawy S.
        • Keogh S.
        Implications for maintaining vascular access device patency and performance: application of science to practice.
        J Vasc Access. 2019; 20: 461-470
        • Keogh S.
        • Flynn J.
        • Marsh N.
        • Mihala G.
        • Davies K.
        • Rickard C.
        Varied flushing frequency and volume to prevent peripheral intravenous catheter failure: a pilot, factorial randomised controlled trial in adult medical-surgical hospital patients.
        Trials. 2016; 17: 348
        • Spangler H.
        • Piehl M.
        • Lane A.
        • Robertson G.
        Improving aseptic technique during the treatment of pediatric septic shock.
        J Infusion Nurs. 2019; 42: 23-28
        • Gibbs N.
        • Murphy T.
        • Campbell R.
        Maximum transfusion rates in neonates and infants.
        Anaesth Intensive Care. 1986; 14: 347-349