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Kay VC, Gehrz JA, Grady DW, Emerling AD, McGowan A, Reilly ER, Bebarta VS, Nassiri J, Vinals J, Schrader A, Zarow GJ, Auten JD. Application Times, Placement Accuracy, and User Ratings of Commercially Available Manual and Battery-Powered Intraosseous Catheters in a High Bone Density Cadaveric Swine Model. Mil Med 2024; 189:1960-1967. [PMID: 37897689 DOI: 10.1093/milmed/usad407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/21/2023] [Accepted: 10/07/2023] [Indexed: 10/30/2023] Open
Abstract
INTRODUCTION Intraosseous (IO) infusion, the pressurized injection of fluids into bone through a catheter, is a life-preserving resuscitative technique for treating trauma patients with severe hemorrhage. However, little is known regarding the application times, placement accuracy, and end-user ratings of battery-powered and manual IO access devices. This study was specifically designed to fill these knowledge gaps on six FDA-approved IO access devices. MATERIALS AND METHODS Three experienced U.S. Navy Emergency Medicine residents each placed commercially available 15-gauge IO catheters in cadaveric swine (Sus scrofa) proximal humeri and sternums in a randomized prospective experimental design. Devices included the battery-powered EZ-IO Rapid Infuser and the manual Jamshidi IO, PerSys NIO, SAM Manual IO, Tactical Advanced Lifesaving IO Needle (TALON), and PYNG First Access for Shock and Trauma 1 (30 trials per device, 10 per user, 210 total trials). Application times, placement accuracy in medullary (zone 1) and trabecular (zone 2) bone while avoiding cortical (zone 3) bone, and eight subjective user ratings were analyzed using ANOVA and nonparametric statistics at P < .05. RESULTS The EZ-IO demonstrated the fastest application times, high rates in avoiding zone 3, and the highest user ratings (P < .0001). The TALON conferred intermediate placement times, highest rates of avoiding zone 3, and second-highest user ratings. The SAM Manual IO and Jamshidi performed poorly, with mixed results for the PerSys NIO and PYNG First Access for Shock and Trauma 1. CONCLUSIONS The battery-powered EZ-IO performed best and remains the IO access device of choice. The present findings suggest that the TALON should be considered as a manual backup to the EZ-IO.
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Affiliation(s)
- Victoria C Kay
- Department of Emergency Medicine, Naval Medical Center San Diego, San Diego, CA 92134, USA
- Combat Trauma Research Group-West, Clinical Investigation Department, Naval Medical Center San Diego, San Diego, 92134, USA
| | - Joseph A Gehrz
- Department of Emergency Medicine, Naval Medical Center San Diego, San Diego, CA 92134, USA
- Combat Trauma Research Group-West, Clinical Investigation Department, Naval Medical Center San Diego, San Diego, 92134, USA
| | - Derek W Grady
- Combat Trauma Research Group-West, Clinical Investigation Department, Naval Medical Center San Diego, San Diego, 92134, USA
- Department of Radiology, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Alec D Emerling
- Department of Emergency Medicine, Naval Medical Center San Diego, San Diego, CA 92134, USA
- Combat Trauma Research Group-West, Clinical Investigation Department, Naval Medical Center San Diego, San Diego, 92134, USA
| | - Andrew McGowan
- Department of Emergency Medicine, Naval Medical Center San Diego, San Diego, CA 92134, USA
- Combat Trauma Research Group-West, Clinical Investigation Department, Naval Medical Center San Diego, San Diego, 92134, USA
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Erin R Reilly
- Department of Emergency Medicine, Naval Medical Center San Diego, San Diego, CA 92134, USA
- Combat Trauma Research Group-West, Clinical Investigation Department, Naval Medical Center San Diego, San Diego, 92134, USA
| | - Vikhyat S Bebarta
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
- Center for COMBAT Research, Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Joshua Nassiri
- Combat Trauma Research Group-West, Clinical Investigation Department, Naval Medical Center San Diego, San Diego, 92134, USA
- Department of Radiology, Naval Medical Center San Diego, San Diego, CA 92134, USA
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Jorge Vinals
- School of Physics and Astronomy, University of Minnesota, Minneapolis, MN 55455, USA
| | - Andrew Schrader
- Division of Animal Resources, NMCSD San Diego, San Diego, CA 92134, USA
| | - Gregory J Zarow
- Combat Trauma Research Group-West, Clinical Investigation Department, Naval Medical Center San Diego, San Diego, 92134, USA
- The Emergency Statistician, Idyllwild, CA 92549, USA
| | - Jonathan D Auten
- Combat Trauma Research Group-West, Clinical Investigation Department, Naval Medical Center San Diego, San Diego, 92134, USA
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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Lee KJ, McGuire MM, Harvey WC, Bianchi WD, Emerling AD, Reilly ER, Bebarta VS, Lopez JJ, Zarow GJ, Auten JD. Performance comparison of intraosseous devices and setups for infusion of whole blood in a cadaveric swine bone model. Am J Emerg Med 2022; 54:58-64. [DOI: 10.1016/j.ajem.2022.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 01/09/2022] [Accepted: 01/16/2022] [Indexed: 10/19/2022] Open
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Sulava E, Bianchi W, McEvoy CS, Roszko PJ, Zarow GJ, Gaspary MJ, Natarajan R, Auten JD. Single Versus Double Anatomic Site Intraosseous Blood Transfusion in a Swine Model of Hemorrhagic Shock. J Surg Res 2021; 267:172-181. [PMID: 34153560 DOI: 10.1016/j.jss.2021.04.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 04/05/2021] [Accepted: 04/10/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Blood transfusion via single site intraosseous access is a critical modality when caring for a trauma victim that lacks intravascular access. Flow rates and potential clinical complications when utilizing two sites of intraosseous access are not well known. MATERIALS AND METHODS Anesthetized adult female Yorkshire swine (Sus scrofa; n = 48; 76.7 ± 1.75kg; range 66-90kg) were cannulated and then bled approximately 30% total blood volume. Swine were randomly assigned to treatment groups: single sited humerus, single sited sternum, dual sited humerus or dual sited humerus and sternum. Flow rates, hemolysis, physiologic measurements, biochemical variables, and pulmonary histologic inflammation and occlusion were contrasted between groups. RESULTS Dual sited intraosseous transfusion flow rates (128ml/min, 95% CI 123-132) were double the flow rates of single sites (65ml/min, 95% CI 60-70), P < .0001.Single sited humeral flow rates were greater than sternal flow rates, with respective averages of 74ml/min and 55ml/min, though not reaching statistical significance (P < 0.17). There was no significant elevation of plasma free hemoglobin in any group after transfusion as compared to baseline (P = 0.7). Groups did not significantly differ in vitals or biochemical variables. Most pulmonary specimens had some intraparenchymal fat embolism, however no animals had evidence of occlusive intra-arterial fat embolism. CONCLUSIONS Dual anatomic site, pressure bag driven, intraosseous blood transfusion approximately doubles flow rates without evidence of clinical complications or hemolysis. Further research using a survivability model is needed to characterize long-term complications from pressurized IO transfusions.
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Affiliation(s)
- Eric Sulava
- Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia; Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia.
| | - William Bianchi
- Department of Emergency Medicine, Naval Medical Center San Diego, San Diego, California; Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia
| | - Christian S McEvoy
- Department of General Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia; Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia
| | - Paul J Roszko
- Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia; Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia
| | - Gregory J Zarow
- Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia
| | - Micah J Gaspary
- Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia; Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia
| | - Ramesh Natarajan
- Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia; Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia
| | - Jonathan D Auten
- Department of Emergency Medicine, Naval Medical Center San Diego, San Diego, California; Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia
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Capobianco S, Weiss M, Schraner T, Stimec J, Neuhaus K, Neuhaus D. Checking the basis of intraosseous access-Radiological study on tibial dimensions in the pediatric population. Paediatr Anaesth 2020; 30:1116-1123. [PMID: 32720412 DOI: 10.1111/pan.13979] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 07/13/2020] [Accepted: 07/20/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Malposition of intraosseous needles in pediatric patients is frequently reported. Incorrect needle length and penetration depth related to the puncture site and level are possible causes. AIMS Aim of this study was to analyze anatomic dimensions of the proximal tibia in the pediatric population with respect to intraosseous needle placement and needle tip position. METHODS Plain lower leg radiographs of children aged from birth to 16 years of age were analyzed. Pretibial tissue layer, cortical bone thickness, and the diameter of the medullary cavity were measured at two different puncture levels. Data were analyzed as descriptive statistics and by polynomial regression plots and set in context to commonly used EZ-IO® needle lengths of 15 and 25 mm. RESULTS Radiographs from 190 patients (104 boys/86 girls) were included. When fully inserted to skin level, up to 10.5% of needles do not reach medullary cavity at one and 18.5% at two patient's fingerbreadths distal to tibial tuberosity. The opposite cortical wall is touched or penetrated in 16% and 25%, respectively. Up to 96% of too deep needle tip positions occur in children younger than 24 months, as do too superficial tip positions in 59%. CONCLUSIONS Puncture level and needle length have a great influence on potential needle tip positions. Infants and toddlers are at highest risk for malpositioning. Due to relevant growth-related differences in tibial anatomy, an age-related and well-reflected approach is crucial to successfully establish intraosseous access.
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Affiliation(s)
- Stéphanie Capobianco
- Department of Anesthesia, University Children's Hospital, Zurich, Switzerland.,Children's Research Centre (CRC), University Children's Hospital Zurich, Zurich, Switzerland
| | - Markus Weiss
- Department of Anesthesia, University Children's Hospital, Zurich, Switzerland.,Children's Research Centre (CRC), University Children's Hospital Zurich, Zurich, Switzerland
| | - Thomas Schraner
- Children's Research Centre (CRC), University Children's Hospital Zurich, Zurich, Switzerland.,Department of Diagnostic Imaging, University Children's Hospital, Zurich, Switzerland
| | - Jennifer Stimec
- Division of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada
| | - Kathrin Neuhaus
- Children's Research Centre (CRC), University Children's Hospital Zurich, Zurich, Switzerland.,Division of Plastic and Reconstructive Surgery, Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Diego Neuhaus
- Department of Anesthesia, University Children's Hospital, Zurich, Switzerland.,Children's Research Centre (CRC), University Children's Hospital Zurich, Zurich, Switzerland
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Petrucci E, Cofini V, Pizzi B, Di Carlo S, Necozione S, Fusco P, Marinangeli F. Ultrasound-guidance for intraosseous access could improve resuscitation maneuvers. A retrospective data report on Italian earthquake victims. Minerva Anestesiol 2019; 86:357-358. [PMID: 31818088 DOI: 10.23736/s0375-9393.19.14072-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Emiliano Petrucci
- Department of Anesthesia and Intensive Care Unit, San Salvatore Academic Hospital, L'Aquila, Italy -
| | - Vincenza Cofini
- Biostatistics and Epidemiology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Barbara Pizzi
- Department of Anesthesia and Intensive Care Unit, SS . Filippo and Nicola Hospital of Avezzano, L'Aquila, Italy
| | - Stefano Di Carlo
- Department of Anesthesia, Resuscitation, Intensive and Pain Care, Gabriele D'Annunzio University, Chieti, Italy
| | - Stefano Necozione
- Biostatistics and Epidemiology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Pierfrancesco Fusco
- Department of Anesthesia and Intensive Care Unit, San Salvatore Academic Hospital, L'Aquila, Italy
| | - Franco Marinangeli
- Unit of Anesthesia, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
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