Intraosseous is faster and easier than umbilical venous catheterization in newborn emergency vascular access models

Vascular access and drug therapy in pediatric resuscitation

Using the evidence brought together through the 2005 International Liaison Committee on Resuscitation evidence evaluation process and the subsequent 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, the role for specific drug therapy in pediatric cardiac arrest is outlined. The drugs discussed include epinephrine, vasopressin, calcium, sodium bicarbonate, atropine, magnesium, and glucose. The literature addressing how best to deliver these drugs to the critically ill child is also presented, specifically looking at the use of intraosseous and endotracheal drug therapy.

Infant intraosseous infusion

Neonatal health care providers are fortunate that the umbilical cord generally provides easy intravenous (IV) access for newborn patients. Outside of the immediate newborn period, however, it may be impossible to obtain peripheral or umbilical IV access in critically ill newborns. Intraosseous (IO) infusion is not widely used in the neonatal population, but is a viable option when IV access cannot be established quickly. This article examines IO infusion devices and placement sites and addresses assessment and care of the infant receiving IO fluids and medications.

Intraosseous access for administration of medications in neonates

Intraosseous administration of resuscitation medications and fluids in preterm and term neonates is an alternative when intravascular access is not possible with intravenous catheters or needles. Intraosseous access is rarely needed in neonates because of the availability of clinicians with expert technical skills for placement of intravenous catheters in neonatal ICUs, the presence of the umbilical vein during the first days after birth when most resuscitations occur, and the predominance of resuscitations being responsive to positive-pressure ventilation alone. Intraosseous access is most likely to be needed in out-of-hospital settings and in hospitalized infants without intravenous access who have vascular collapse secondary to shock or when clinicians responsible for vascular access during resuscitations are more skilled in intraosseous access than intravenous access.

The utilisation of intraosseous infusion in the resuscitation of paediatric major trauma patients

Intraosseous lines are a reliable and rapid tool for obtaining vascular access in emergency situations, particularly in children. Their use is recommended when intravenous access cannot be easily secured and there is a need for fluid or pharmacological resuscitation. Training in this technique is included in the Advanced Trauma Life Support (ATLS) and Advanced Paediatric Life Support course (APLS) provider courses. The objective of this study is to analyse the national use of intraosseous lines in paediatric trauma in England and Wales. Data has been collected from the Trauma Audit and Research Network (TARN) group longitudinally over 14 years from 1988 to 2002. From 23,489 paediatric trauma cases, intraosseous lines were used in only 129 patients. Compared with the remainder of the paediatric data, we found that these were the younger (1-6 years), more severely injured patients (higher ISS, lower GCS, higher head, thorax, and abdominal AIS). The mortality of these patients was high at 64% compared with 4% overall. IO line use was greater in general than in Paediatric hospitals, perhaps due to good intravenous access skills in paediatric centres. We recommend that intraosseous line use should be a skill available to everybody involved in paediatric trauma resuscitation, particularly those who may not have refined paediatric intravenous cannulation skills.

[Vascular access in emergency paediatric anaesthesia]

There is very little literature to guide the young practitioner in caring for a child that needs emergency surgery and has difficult venous access. Questionnaires were sent to 89 members of the Swiss Paediatric Anaesthesia Society and to the heads of Anaesthesia Departments of Swiss teaching hospitals. Two typical case records were presented, both of which were characterised by the fact that 2-3 peripheral venous cannulation attempts were unsuccessful. Case A: a young child with a fracture of the radius and case B an infant with upper gastrointestinal ileus. The anaesthetists were then questioned regarding their preferences for optimal treatment. The majority would proceed with further attempts and, if these still failed, intramuscular or inhalational induction of anaesthesia was suggested as a reasonable choice for case A. However, for case B, a femoral venous or intraosseous access to the venous system was judged to be the safest method. On the basis of our inquiry and a literature search, a priority list was developed to suggest the best possible techniques for vascular access and alternative anaesthesia induction techniques for emergency paediatric procedures.

Intraosseous access in the setting of pediatric critical care transport

OBJECTIVE

To demonstrate safety and efficacy of intraosseous needle placement among health care provider groups in the setting of pediatric critical care transport.

DESIGN

Retrospective chart review.

SETTING

Pediatric critical care transports to a pediatric intensive care unit.

PATIENTS

Children undergoing pediatric critical care transport between January 1, 2000, and March 31, 2002, requiring intraosseous access before arrival to the pediatric intensive care unit.

INTERVENTIONS

Intraosseous access placed for emergent vascular access.

MEASUREMENTS AND MAIN RESULTS

During the study period, the transport team performed 1,792 transports and identified 47 patients requiring 58 intraosseous placements. These were placed by emergency medical technician-paramedics (18%), referring emergency medicine physicians (42%), and the transport team members (40%). The intraosseous needles were placed with a mean of 1.2 attempts per placement and a first attempt success rate of 78%. Main site of placement was the proximal anterior tibia (95%). Access was maintained for a mean of 5.2 hrs. The intraosseous needle was used for fluids, medications, and laboratory studies. Admitting diagnoses included respiratory distress (28%), cardiopulmonary arrest (26%), neurologic insults (17%), dehydration (15%), sepsis (11%), and other (3%). Ages ranged from 3 wks to 14 yrs (mean 2.2 yrs) and weights from 2.1 to 60 kg (mean 12.3 kg). Complications were noted in seven of 58 (12%), all limited to local edema or infiltration.

CONCLUSIONS

Intraosseous placement is frequently needed in the care of critically ill pediatric patients before they reach the pediatric intensive care unit. We have demonstrated that intraosseous needles can be placed safely with similar rates of success when comparing different provider groups. Emergency medical technician-paramedics, emergency medicine physicians, and pediatric critical care transport teams should be familiar with intraosseous placement.

Invasive Techniken in der Notfallmedizin

Based on written surveys conducted during the series of workshops entitled "Invasive emergency techniques (INTECH)" the aim of this study was to characterize defined qualifications of emergency physicians and to discuss by examples whether strictly practice-oriented workshops represent a suitable means of closing the apparent gaps in training. Our data show clearly that even experienced emergency physicians indicated that they lack training in carrying out preclinical invasive emergency procedures such as chest tube, cricothyrotomy and intraosseous access. Furthermore, they are only very seldom confronted with emergency situations in which these procedures could decidedly affect the survival of a patient and which, at the same time, put them under extremely high emotional pressure. Thus, the didactic concept of continuing education workshops that are strictly practice-oriented and that focus in particular on problem areas in emergency medicine, can contribute significantly to help close the gaps in training and ensure that emergency physicians are highly qualified.

Clinical review: vascular access for fluid infusion in children

The current literature on venous access in infants and children for acute intravascular access in the routine situation and in emergency or intensive care settings is reviewed. The various techniques for facilitating venous cannulation, such as application of local warmth, transillumination techniques and epidermal nitroglycerine, are described. Preferred sites for central venous access in infants and children are the external and internal jugular veins, the subclavian and axillary veins, and the femoral vein. The femoral venous cannulation appears to be the most safe and reliable technique in children of all ages, with a high success and low complication rates. Evidence from the reviewed literature strongly supports the use of real-time ultrasound techniques for venous cannulation in infants and children. Additionally, in emergency situations the intraosseous access has almost completly replaced saphenous cutdown procedures in children and has decreased the need for immediate central venous access.

Which IO model best simulates the real thing?

OBJECTIVE

To determine which model best simulates the actual IO procedure in children.

METHODS

Forty emergency and critical care physicians with significant IO experience (6 or more IO procedures) in real children were recruited at 4 academic centers. Study subjects were provided with a kit containing 15 gauge IO needles and 5 IO models; a plastic IO doll leg (PL), a turkey femur/thigh (TT), a turkey tibia/drumstick (TD), a chicken femur/thigh (CT), and a pork rib (PR). Study participants scored the similarity of the bone model to that of placing an IO in a child (0 = no experience, 1 = perfect simulation, 2 = excellent, but not perfect, 3 = good, 4 = moderate, 5 = poor) and the hardness of the bone (H = too hard, J = just right, S = too soft) for each age group (preterm, newborn, 1-4 months, 5-12 months, 12-36 months, 3-6 years, 6-12 years, and >12 years old) of whom they had previous experience. Mean scores were calculated and compared to determine which model provided the best simulation.

RESULTS

After excluding zero scores, overall mean scores for the CT, TD, TT, PL, and PR models were 3.2, 3.3, 3.3, 3.3, and 4.4 (P < 0.001), respectively. The pork rib had the worst score in all age groups, while the other 4 models had roughly similar scores. All models had substantial percentages of the models classified as too hard or too soft, except for the pork rib, which was predominantly too hard.

CONCLUSIONS

For IO research and teaching purposes, bone models should be age appropriate. This study suggests that there is great variability in preference with the chicken, turkey, and plastic models.

Comparison of a new screw-tipped intraosseous needle versus a standard bone marrow aspiration needle for infusion

The purpose of this study is to compare the speed and ease of establishing intraosseous infusion using a standard bone marrow needle (SBMN; $8) and a new screw-tipped intraosseous needle (Sur-Fast; $42). The study is an experimental design. A total of 42 medical students, without prior IO experience, were recruited as study subjects. Subjects were randomized to perform the IO procedures in one of two models: (1) turkey femur or (2) pork ribs. Each subject performed an initial trial using both IO needles without practice (inexperienced) and a second trial using both IO needles after practice (experienced attempt), such that in total, each subject completed four attempts (two with each needle type). IO placement times were measured, and placement difficulty scores were measured using a 10 cm visual analog scale (VAS). The averaged elapsed time to successful IO completion was significantly shorter for the SBMN in the initial "inexperienced" attempt (33 versus 54 seconds, P = .019), but there was no significant difference in the postpractice "experienced" attempt. VAS difficulty scores were lower (easier) for the SBMN for both inexperienced and experienced trials. Success rates were significantly higher for the Sur-Fast needle during the experienced attempt (95% versus 79%, P < .05), but there was no significant difference in success rates during the inexperienced attempt. The Sur-Fast screw-tipped intraosseous needle does not show superiority over the SBMN in this intraosseous model, therefore its higher cost is difficult to justify based on this study.