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Research paper
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, MD
a
,
*
Tomoki Doi, MD
a
,
c
Takashi Muguruma, MD, Ph.D
a
,
c
Kento Nakajima, MD
a
,
c
Kyota Nakamura, MD, Ph.D
a
,
c
Takeru Abe, Ph.D
a
,
c
Ichiro Takeuchi, MD, Ph.D
a
,
c
Naoto Morimura, MD, Ph.D
b
,
c
a
Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 4-57 Urafunecho, Minamiku, Yokohama, Japan
b
Department of Acute Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo-ku, Tokyo 113-8655, Japan
article information
Article history:
Received 25 November 2019
Received in revised form
21 January 2021
Accepted 23 January 2021
Keywords:
Infusion with a syringe
Initial infusion
Haemorrhagic shock
Hypovolemic shock
Shock
Trauma
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 (7.65e24.94) (p<0.01). In those attached with the
20G cannula, the mean difference (95% CI) was 23.47 (12.43e34.51) (p<0.01). In those attached with the
18G cannula, the mean difference (95% CI) was 42.53 (28.68e56.38) (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.
©2021 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction
Serious haemorrhagic shock results in an insufficient supply of
oxygen at the cellular level
1
and organ dysfunction to death at the
*Corresponding author. Tel.: þ81 045 261 5656; fax: þ81 045 231 1846.
E-mail addresses: yamakei0218@yahoo.co.jp (K. Yamaguchi), tm-matrix@nifty.
com (T. Doi), mgrmtks@gmail.com (T. Muguruma), nakajimak.812@gmail.com
(K. Nakajima), nakamuk@yokohama-cu.ac.jp (K. Nakamura), abet@yokohama-cu.
ac.jp (T. Abe), itake@myad.jp (I. Takeuchi), molimula@r6.dion.ne.jp (N. Morimura).
c
Tel.: þ81 045 261 5656; fax: þ81 045 231 1846.
Contents lists available at ScienceDirect
Australian Critical Care
journal homepage: www.elsevier.com/locate/aucc
https://doi.org/10.1016/j.aucc.2021.01.008
1036-7314/©2021 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
Australian Critical Care xxx (xxxx) xxx
Please cite this article as: Yamaguchi K et al., A simulation study of high-flow versus normal-flow three-way stopcock for rapid fluid
administration in emergency situations: A randomised crossover design, Australian Critical Care, https://doi.org/10.1016/j.aucc.2021.01.008
individual level if proper intervention is not provided.
2,3
The
number of deaths caused by haemorrhage is enormous and is a
global problem.
4
Haemorrhagic shock caused by trauma, gastro-
intestinal haemorrhage, perioperative haemorrhage, rupture of an
aneurysm, and maternal haemorrhage is not uncommon.
5e7
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.
8
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.
9,10
In the resuscitation phase,
initial fluid resuscitation is presumed to be important. Most phy-
sicians 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 HagenePoiseuille equation.
Based on the American College of Critical Care Medicine clinical
practice parameters for resuscitation of paediatric patients with
septic shock,
11
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.
12
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 estab-
lished 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.
13e15
In clinical practice, however, physicians often
try to make fluid resuscitation faster using the pushepull technique
because the setup uses existing infusion lines and the technique is
easy to perform, uses inexpensive consumables, and can replace
circulatory volume quickly.
12
Thus, we focused on the pushepull
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 physi-
cian 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 prin-
ciples 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.
16
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,
16
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.
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 20 0 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.
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
K. Yamaguchi et al. / Australian Critical Care xxx (xxxx) xxx2
Please cite this article as: Yamaguchi K et al., A simulation study of high-flow versus normal-flow three-way stopcock for rapid fluid
administration in emergency situations: A randomised crossover design, Australian Critical Care, https://doi.org/10.1016/j.aucc.2021.01.008
“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% sig-
nificance 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 physi-
cians were recruited for this study.
Data were expressed as mean and standard deviations. Uni-
variate analysis was carried out in all experiments using the
ManneWhitney U test for continuous variables to compare be-
tween 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.
Fig. 1. The 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.
Fig. 2. Study 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.
K. Yamaguchi et al. / Australian Critical Care xxx (xxxx) xxx 3
Please cite this article as: Yamaguchi K et al., A simulation study of high-flow versus normal-flow three-way stopcock for rapid fluid
administration in emergency situations: A randomised crossover design, Australian Critical Care, https://doi.org/10.1016/j.aucc.2021.01.008
There were no significant differences between group A and group B
with regard to demographic characteristics.
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
(7.65e24.94) (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 (12.43e34.51) (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 (28.68e56.38)
(p<0.01).
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).
Figs. 5e7show comparison among a natural gravity setting, a
pressure bag setting, and a pushepull technique by each gauge size
of 18G, 20G, and 22G, respectively. In the natural gravitysetting and
the pressure bag setting maintained at 300 mmHg, there was no
flow rate difference between the HTS or NTS (in the gravity setting,
p¼0.429 for 18G, 0.201 for 20G, and 0.445 for 22G; in the pressure
bag, p ¼0.100 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.
4. Discussion
Our study revealed that the push-and-pull technique using the
HTS was faster than that using the NTS, with a statistically signifi-
cant 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 HagenePoiseuille 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.
12
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 disconnectereconnect technique resulted in
a faster rate of fluid resuscitation than the push-and-pull tech-
nique.
17
Using a novel infusion device (LifeFlow®Rapid Infuser)
made initial fluid resuscitation faster than the push-and-pull
technique, with statistical differences.
18
These methods reported in
the aforementioned studies required equipment or some staff
Table 1
Characteristics of the participants.
Variables Group A (n¼10) Group B (n¼10) p-value
Male, frequency (%) 8 (80) 5 (50) 0.16
Career (years), median (interquartile range) 6.5 (5e11.25) 7 (5.5e9.75) 0.69
Fig. 3. Results 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.
K. Yamaguchi et al. / Australian Critical Care xxx (xxxx) xxx4
Please cite this article as: Yamaguchi K et al., A simulation study of high-flow versus normal-flow three-way stopcock for rapid fluid
administration in emergency situations: A randomised crossover design, Australian Critical Care, https://doi.org/10.1016/j.aucc.2021.01.008
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 complica-
tions, such as vessel damage, infection, and thrombosis.
19,20
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.
21
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 reli-
ability 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
Fig. 4. Results 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. Results 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. Results 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.
K. Yamaguchi et al. / Australian Critical Care xxx (xxxx) xxx 5
Please cite this article as: Yamaguchi K et al., A simulation study of high-flow versus normal-flow three-way stopcock for rapid fluid
administration in emergency situations: A randomised crossover design, Australian Critical Care, https://doi.org/10.1016/j.aucc.2021.01.008
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.
22
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 impor-
tant 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 differ-
ence 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, per-
forming 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 contribu-
tions 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
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.aucc.2021.01.008.
References
[1] Cannon JW. Hemorrhagic shock. N Engl J Med 2018;378:370e9.
[2] Halmin M, Chiesa F, Vasan SK, Wikman A, Norda R, Rostgaard K, et al.
Epidemiology of massive transfusion: a binational study from Sweden and
Denmark. Crit Care Med 2016;44(3):468e77.
[3] Bougl
e A, Harrois A, Duranteau J. Resuscitative strategies in traumatic hem-
orrhagic shock. Ann Intensive Care 2013;3(1):1.
[4] 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(9859):2095e128.
[5] Christensen S, Riis A, Nørgaard M, Sørensen HT, Thomsen RW. Short-term
mortality after perforated or bleeding peptic ulcer among elderly patients: a
population-based cohort study. BMC Geriatr 2007;7:1e8.
[6] Mannucci PM, Levi M. Prevention and treatment of major blood loss. N Engl J
Med 2007;356(22):2301e11.
[7] Anderson JM, Etches D. Prevention and management of postpartum hemor-
rhage. Am Fam Physician 2007;75(6):875e82.
[8] Kaur P, Basu S, Kaur G, Kaur R. Transfusion protocol in trauma. J Emergencies,
Trauma, Shock 2011;4(1):103e8.
[9] Otero RM, Nguyen B, Huang DT, Gaieski DF, Goyal M, Gunnerson KJ, et al.
Early goal-directed therapy in severe sepsis and septic shock revisited: con-
cepts, controversies, and contemporary findings. Chest 2006;130(5):
1579e95.
[10] Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al.
Surviving sepsis campaign: international guidelines for management of
severe sepsi s and septic shock, 201 2. Intensive Care Me d 2013;39(2):
165e228.
[11] Brierley J, Carcillo JA, 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 Medi-
cine. Crit Care Med 2009;37(2):666e88.
[12] Michael JS, Deborah GG, Daniel MC, Soledad AF, Mark WH. Rapid fluid
resuscitation in pediatrics: testing the American College of critical care
medicine guideline. Ann Emerg Med 2007;50(5):601e7.
[13] Niel-Weise BS, Daha TJ, van den Broek PJ. Is there evidence for recommending
needleless closed catheter access systems in guidelines? A systematic review
of randomized controlled trials. J Hosp Infect 2006;62(4):406e13.
[14] Rosenthal VD. 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.
[15] Rosenthal VD, Udwadia FE, Kumar S, Poojary A, Sankar R, Orellano PW, 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 Inter-
national Nosocomial Infection Control Consortium (INICC). Am J Infect Contr
2015;43(10):1040e5.
[16] 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(5):
436e40.
[17] Cole ET, Harvey G, Urbanski S, Foster G, Thabane L, Parker MJ. 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;4:e005028. https://doi.org/10.1136/
bmjopen-2014-005028.
[18] Gillis HC, Walia H, Tumin D, Bhalla T, Tobias JD. Rapid fluid administration: an
evaluation of two techniques. Med Dev (Auckl) 2018;11:331e6.
[19] Hawthorn A, Bulmer AC, Mosawy S, Keogh S. Implications for maintaining
vascular access device patency and performance: application of science to
practice. J Vasc Access 2019;20(5):461e70.
[20] 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(1):348.
[21] Spangler H, Piehl M, Lane A, Robertson G. Improving aseptic technique
during the treatment of pediatric septic shock. J Infusion Nurs 2019;42(1):
23e8.
[22] Gibbs N, Murphy T, Campbell R. Maximum transfusion rates in neonates and
infants. Anaesth Intensive Care 1986;14(4):347e9.
Fig. 7. Results 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.
K. Yamaguchi et al. / Australian Critical Care xxx (xxxx) xxx6
Please cite this article as: Yamaguchi K et al., A simulation study of high-flow versus normal-flow three-way stopcock for rapid fluid
administration in emergency situations: A randomised crossover design, Australian Critical Care, https://doi.org/10.1016/j.aucc.2021.01.008
