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Vianen NJ, Campfens JR, Brouwer-Bergsma M, Van Ditshuizen JC, Giannakopoulos GF, Hoogerwerf N, den Hartog D, Van Lieshout EMM, Maissan IM, Schober P, Venema L, Verhofstad MHJ, Van Vledder MG. Establishing Outcome Parameters for Helicopter Emergency Medical Services Research in the Netherlands: Results of a Mixed-Methods Delphi Consensus Study. PREHOSP EMERG CARE 2024:1-18. [PMID: 39378178 DOI: 10.1080/10903127.2024.2413038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 09/05/2024] [Accepted: 09/27/2024] [Indexed: 10/10/2024]
Abstract
OBJECTIVES Physician staffed Helicopter Emergency Medical Services (P-HEMS) care in the Netherlands has transitioned from predominantly trauma management to handling a variety of medical conditions. Relevant outcome parameters for Dutch P-HEMS research have not been previously defined. National consensus was sought to identify relevant long term patient outcome parameters, process outcome parameters and performance outcome parameters for Dutch P-HEMS care. METHODS This was a mixed methods Delphi consensus study. A list of potentially relevant outcome parameters was identified using a systematic literature review. These parameters were subsequently surveyed in a Delphi consensus study. Helicopter Emergency Medical Services physicians and relevant stakeholders were invited to participate in this Delphi survey, where they were allowed to suggest additional outcome parameters. Descriptive analysis was performed on all data sets. RESULTS Forty-nine potential outcome parameters for Dutch P-HEMS care were surveyed. Of 71 invited participants, 53 (75%), 40 (56%), and 20 (28%) participated in the first, second, and third round of the Delphi study, respectively. Consensus was reached on 25 (51%) of 49 outcome parameters as being important. These consisted of seven long term patient related outcome parameters, four short term patient related outcome parameters, five process outcome parameters and nine performance outcome parameters. CONCLUSIONS In conclusion, this study identified 25 outcome parameters relevant for Dutch physician staffed HEMS care. These parameters should be considered when designing future studies and should be routinely collected for each dispatch if possible.
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Affiliation(s)
- Niek J Vianen
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - J Reinout Campfens
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Margot Brouwer-Bergsma
- Department of Anesthesiology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Jan C Van Ditshuizen
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Trauma Centre Southwest Netherlands, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Georgios F Giannakopoulos
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Nico Hoogerwerf
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Dennis den Hartog
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Iscander M Maissan
- Department of Anesthesiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Patrick Schober
- Department of Anesthesiology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Lieneke Venema
- Department of Anesthesiology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Michael H J Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mark G Van Vledder
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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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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3
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Gehrz JA, Kay VC, Grady DW, Emerling AD, McGowan A, Reilly ER, Bebarta VS, Nassiri J, Viñals J, Zarow GJ, Auten JD. The relationship between intraosseous catheter tip placement, flow rates, and infusion pressures in a high bone density cadaveric swine ( Sus scrofa) model. J Am Coll Emerg Physicians Open 2024; 5:e13184. [PMID: 38966284 PMCID: PMC11223065 DOI: 10.1002/emp2.13184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 03/14/2024] [Accepted: 04/18/2024] [Indexed: 07/06/2024] Open
Abstract
Background Intraosseous (IO) infusion is a life-preserving technique when intravenous access is unobtainable. Successful IO infusion requires sufficiently high flow rates to preserve life but at low enough pressures to avoid complications. However, IO catheter tips are often misplaced, and the relative flow rates and pressures between IO catheter tips placed in medullary, trabecular, and cortical bone are not well described, which has important implications for clinical practice. Objectives We developed the Zone Theory of IO Catheter Tip Placement based on bone density and proximity to the venous central sinus and then tested the influence of catheter tip placement locations on flow rates and pressures in a cadaveric swine model. Methods Three cross-trained participants infused 500 mL of crystalloid fluid into cadaveric swine humerus and sternum (N = 210 trials total) using a push‒pull method with a 60 cm3 syringe. Computed tomography scans were scored by radiologists and categorized as zone 1 (medullary space), zone 2 (trabecular bone), or zone 3 (cortical bone) catheter tip placements. Differences between zones in flow rates, mean pressures, and peak pressures were assessed using analysis of variance and analysis of covariance to account for participant and site differences at the p < 0.05 threshold. Results Zone 1 and zone 2 placements were essentially identical in flow rates, mean pressures, and peak pressures (each p > 0.05). Zone 1 and zone 2 placements were significantly higher in flow rates and lower in pressures than zone 3 placements (each p < 0.05 or less). Conclusion Within the limitations of an unpressurized cadaveric swine model, the present findings suggest that IO catheter tip placements need not be perfect to acquire high flow rates at low pressures, only accurate enough to avoid the dense cortical bone of zone 3. Future research using in vivo animal and human models is needed to better define the clinical impact of IO catheter placement on infusion flow rates and pressures.
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Affiliation(s)
- Joseph A. Gehrz
- Combat Trauma Research GroupClinical Investigations DepartmentNaval Medical Center San DiegoSan DiegoCaliforniaUSA
- Department of Emergency MedicineNaval Medical Center San DiegoSan DiegoCaliforniaUSA
- Department of Military and Emergency MedicineUniformed Services University of the Health SciencesBethesdaMarylandUSA
| | - Victoria C. Kay
- Combat Trauma Research GroupClinical Investigations DepartmentNaval Medical Center San DiegoSan DiegoCaliforniaUSA
- Department of Emergency MedicineNaval Medical Center San DiegoSan DiegoCaliforniaUSA
| | - Derek W. Grady
- Department of RadiologyNaval Medical Center San DiegoSan DiegoCaliforniaUSA
| | - Alec D. Emerling
- Combat Trauma Research GroupClinical Investigations DepartmentNaval Medical Center San DiegoSan DiegoCaliforniaUSA
- Department of Emergency MedicineNaval Medical Center San DiegoSan DiegoCaliforniaUSA
- Department of Military and Emergency MedicineUniformed Services University of the Health SciencesBethesdaMarylandUSA
| | - Andrew McGowan
- Combat Trauma Research GroupClinical Investigations DepartmentNaval Medical Center San DiegoSan DiegoCaliforniaUSA
- Department of Emergency MedicineNaval Medical Center San DiegoSan DiegoCaliforniaUSA
- Department of Military and Emergency MedicineUniformed Services University of the Health SciencesBethesdaMarylandUSA
| | - Erin R. Reilly
- Combat Trauma Research GroupClinical Investigations DepartmentNaval Medical Center San DiegoSan DiegoCaliforniaUSA
- Department of Emergency MedicineNaval Medical Center San DiegoSan DiegoCaliforniaUSA
| | - Vikhyat S. Bebarta
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
- Department of Emergency MedicineCenter for COMBAT ResearchUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Joshua Nassiri
- Combat Trauma Research GroupClinical Investigations DepartmentNaval Medical Center San DiegoSan DiegoCaliforniaUSA
- Department of Military and Emergency MedicineUniformed Services University of the Health SciencesBethesdaMarylandUSA
- Department of RadiologyNaval Medical Center San DiegoSan DiegoCaliforniaUSA
| | - Jorge Viñals
- School of Physics and AstronomyUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Gregory J. Zarow
- Combat Trauma Research GroupClinical Investigations DepartmentNaval Medical Center San DiegoSan DiegoCaliforniaUSA
- The Emergency StatisticianIdyllwildCaliforniaUSA
| | - Jonathan D. Auten
- Combat Trauma Research GroupClinical Investigations DepartmentNaval Medical Center San DiegoSan DiegoCaliforniaUSA
- Department of Emergency MedicineNaval Medical Center San DiegoSan DiegoCaliforniaUSA
- Department of Military and Emergency MedicineUniformed Services University of the Health SciencesBethesdaMarylandUSA
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Qasim ZA, Joseph B. Intraosseous access in the resuscitation of patients with trauma: the good, the bad, the future. Trauma Surg Acute Care Open 2024; 9:e001369. [PMID: 38646033 PMCID: PMC11029384 DOI: 10.1136/tsaco-2024-001369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 03/09/2024] [Indexed: 04/23/2024] Open
Abstract
The timely restoration of lost blood in hemorrhaging patients with trauma, especially those who are hemodynamically unstable, is of utmost importance. While intravenous access has traditionally been considered the primary method for vascular access, intraosseous (IO) access is gaining popularity as an alternative for patients with unsuccessful attempts. Previous studies have highlighted the higher success rate and easier training process associated with IO access compared with peripheral intravenous (PIV) and central intravenous access. However, the effectiveness of IO access in the early aggressive resuscitation of patients remains unclear. This review article aims to comprehensively discuss various aspects of IO access, including its advantages and disadvantages, and explore the existing literature on the clinical outcomes of patients with trauma undergoing resuscitation with IO versus intravenous access.
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Affiliation(s)
- Zaffer A Qasim
- Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Bellal Joseph
- Department of Surgery, The University of Arizona College of Medicine Tucson, Tucson, Arizona, USA
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Joerck C, Wilkinson R, Angiti RR, Lutz T, Scerri L, Carmo KB. Use of Intraosseous Access in Neonatal and Pediatric Retrieval-Neonatal and Pediatric Emergency Transfer Service, New South Wales. Pediatr Emerg Care 2023; 39:853-857. [PMID: 37391199 DOI: 10.1097/pec.0000000000003005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
OBJECTIVES Pediatric patients who are critically unwell require rapid access to central vasculature for administration of life-saving medications and fluids. The intraosseous (IO) route is a well-described method of accessing the central circulation. There is a paucity of data surrounding the use of IO in neonatal and pediatric retrieval. The aim of this study was to review the frequency, complications, and efficacy of IO insertion in neonatal and pediatric patients in retrieval. METHODS A retrospective review of cases referred to neonatal and pediatric emergency transfer service, New South Wales over the epoch 2006 to 2020. Medical records documenting IO use were audited for patient demographic data, diagnosis, treatment details, IO insertion and complication statistics, and mortality data. RESULTS Intraosseous access was used in 467 patients (102 neonatal/365 pediatric). The most common indications were sepsis, respiratory distress, cardiac arrest, and encephalopathy. The main treatments were fluid bolus, antibiotics, maintenance fluids, and resuscitation drugs. Return of spontaneous circulation after resuscitation drugs occurred in 52.9%; perfusion improved with fluid bolus in 73.1%; blood pressure improved with inotropes in 63.2%; seizures terminated with anticonvulsants in 88.7%. Prostaglandin E1 was given to eight patients without effect. Intraosseous access-related injury occurred in 14.2% of pediatric and 10.8% of neonatal patients. Neonatal and pediatric mortality rates were 18.6% and 19.2%, respectively. CONCLUSIONS Survival in retrieved neonatal and pediatric patients who required IO is higher than previously described in pediatric and adult cohorts. Early insertion of an IO facilitates early volume expansion, delivery of critical drugs, and allows time for retrieval teams to gain more definitive venous access. In this study, prostaglandin E1 delivered via a distal limb IO had no success in reopening the ductus arteriosus.
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Affiliation(s)
| | | | | | | | - Laura Scerri
- From the Newborn and Pediatric Emergency Transport Service (NETS NSW)
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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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Intraosseous access in the resuscitation of trauma patients: a literature review. Eur J Trauma Emerg Surg 2020; 47:47-55. [PMID: 32078703 DOI: 10.1007/s00068-020-01327-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 02/11/2020] [Indexed: 01/21/2023]
Abstract
PURPOSE Intraosseous (IO) catheters continue to be recommended in trauma resuscitation. Their utility has recently been debated due to concerns regarding inadequate flow rates during blood transfusion, and the potential for haemolysis. The objective of this review was to examine the evidence for intraosseous catheters in trauma resuscitation, and to highlight areas for future research. METHODS A PubMed and Embase search for articles published from January 1990 to August 2018 using the terms ("intra-osseous access" or "intraosseous access" or "IO access") AND trauma was performed. Original articles describing the use of an IO catheter in the resuscitation of one or more trauma patients were eligible. Animal, cadaveric studies and those involving healthy volunteers were excluded. RESULTS Nine studies, comprising of 1218 trauma patients and 1432 device insertions, were included. The insertion success rate was 95% and the incidence of complications 0.9%. Flow-rate data and evidence of haemolysis were poorly reported. CONCLUSION Intraosseous catheters have high insertion success rates and a low incidence of complications in trauma patients. Existing evidence suggests that IO transfusion is not associated with haemolysis, however, further studies in humans are needed. There is a paucity of flow rate data for blood transfusion via IO catheters in this population, although much anecdotal evidence advocating their use exists.
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Auten JD, McEvoy CS, Roszko PJ, Polk TM, Kachur RE, Kemp JD, Natarajan R, Zarow GJ. Safety of Pressurized Intraosseous Blood Infusion Strategies in a Swine Model of Hemorrhagic Shock. J Surg Res 2019; 246:190-199. [PMID: 31600648 DOI: 10.1016/j.jss.2019.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 08/09/2019] [Accepted: 09/11/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Current guidelines support intraosseous access for trauma resuscitation when intravenous access is not readily available. However, safety of intraosseous blood transfusions with varying degrees of infusion pressure has not been previously characterized. MATERIALS AND METHODS Adult female Yorkshire swine (Sus scrofa; n = 36; mean (M): 80 kg, 95% CI: 78-82 kg) were cannulated and then bled approximately 30% total blood volume. Swine were randomly assigned to proximal humerus intraosseous blood infusion with either Rapid Infuser, or Pressure Bag, or Push-Pull methods (n = 12 each). Flow rates, infusion pressures, vitals, biochemical variables, and pulmonary and renal tissue pathology were contrasted between groups. RESULTS Flow rates were greater for the Push-Pull strategy than Pressure Bag (96.5 mL/min versus 72.6 mL/min, P = 0.02) or Rapid Infuser (96.5 mL/min versus 60 mL/min, P = 0.002) strategies. The pressures generated during the Push-Pull transfusion (3058 mmHg) were greater than the other strategies (≤360 mmHg). After the observation period, plasma-free hemoglobin levels were higher in the Push-Pull strategy than in the Rapid Infuser (40 mg/dL versus 12 mg/dL, P = 0.02) or Pressure Bag (40 mg/dL versus 12 mg/dL, P = 0.01). Groups did not significantly differ in vitals, biochemical variables, or tissue pathology. CONCLUSIONS Push-Pull conferred the highest flow rates, but with higher infusion pressures and evidence of intravascular hemolysis. Rapid Infuser and Pressure Bag infusions had no increase from baseline in plasma-free hemoglobin. Pressure Bag infusion was noted to confer an advantage in flow rates over Rapid Infuser. Intraosseous blood transfusion with pressure bags can safely bridge toward central access in the early phases of trauma resuscitation.
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Affiliation(s)
- Jonathan D Auten
- Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia; 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
| | - Travis M Polk
- Department of General Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia; Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia
| | - Ryan E Kachur
- Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia; Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia
| | - Jean D Kemp
- Department of Pathology, Naval Medical Center Portsmouth, 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
| | - Greg J Zarow
- Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia
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