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Chung J, Bundy J, Khan S, Hunt A, Carroll S, Ali A, Shafi N, Tesoro E. "Intraosseous Administration of Tenecteplase for Thrombolysis of an Acute Ischemic Stroke". J Stroke Cerebrovasc Dis 2024:107850. [PMID: 38971481 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107850] [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: 05/07/2024] [Revised: 06/28/2024] [Accepted: 07/03/2024] [Indexed: 07/08/2024] Open
Abstract
INTRO Current guidelines for acute ischemic stroke recommend timely administration of intravascular thrombolytic therapy to promote functional and neurologic outcomes. Tenecteplase is an emerging off-label therapy for this indication and being utilized by various institutions due to its simpler administration strategy. In emergent situations in which intravenous access cannot be obtained, intraosseous access is a viable option for medication administration. However, there has been minimal published cases to support the efficacy and safety of intraosseous administration of tenecteplase for acute ischemic stroke. CASE We describe the case of a 51-year-old woman who developed acute ischemic stroke within our institution. Due to difficulty achieving intravenous access and time-dependent efficacy of thrombolytic therapy, the decision was made to administer tenecteplase by the intraosseous route. Stroke symptoms improved within 48 hours following administration without complication. CONCLUSION Intraosseous administration of tenecteplase may be considered for treatment of acute ischemic stroke if intravenous access is unattainable.
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Affiliation(s)
- JinJoo Chung
- University of Illinois Hospital and Health Sciences System.
| | - Jonathan Bundy
- University of Illinois Hospital and Health Sciences System.
| | - Sameera Khan
- University of Illinois Hospital and Health Sciences System.
| | - Aaron Hunt
- University of Illinois Chicago College of Pharmacy.
| | - Seth Carroll
- University of Illinois Hospital and Health Sciences System.
| | - Aisha Ali
- University of Illinois Hospital and Health Sciences System.
| | - Neelofer Shafi
- University of Illinois Hospital and Health Sciences System.
| | - Eljim Tesoro
- University of Illinois Hospital and Health Sciences System.
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Wang Y, Zhou S, Wang L, Fang J, Zhang Y, Shi L, Lin G, Zhang M, Wang S. The Use of Intraosseous Infusion in the Early Resuscitation of Patients With Extremely Severe Burns. J Burn Care Res 2024; 45:520-524. [PMID: 38180502 DOI: 10.1093/jbcr/irad202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Indexed: 01/06/2024]
Abstract
According to research, shock, the most common complication of extremely severe burns, is also the leading cause of mortality among patients with such burns. The case fatality rate reaches 83.45% when the total burn area exceeds 90%. The American Heart Association in 2020 recommended the intraosseous (IO) access after the peripheral access and prior to the central venous access when venous cannulation is either difficult or delayed. The use and experience with intraosseous infusion in extremely severe burns are still limited. We report efficacy and safety results from 19 burn patients treated with IO infusion between June 2020 and December 2022. In these patients, the mean injury time of burns was 1.55 ± 1.10 hours, the mean burn surface area was 86.24% ± 11.33%, the mean catheterization time was 49.68 ± 10.11 seconds, and the mean emergency retention time was 2.75 ± 1.74 hours, the mean actual fluid supplement amount was 5,533.68 ± 3,077.19 mL, the mean hourly urine volume of the patient was 93.31 ± 60.94 mL, the mean emergency detention time was 4.16 ± 2.97 hours, and the mean duration of hospitalization was 34.50 ± 25.38 days. The results demonstrated a clinically meaningful improvement and higher response rate vs peripheral venous cannulation and an acceptable safety profile in those patients.
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Affiliation(s)
- Yuwei Wang
- Nursing Department, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, China
- Emergency Medicine, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, China
| | - Shuaishuai Zhou
- Nursing Department, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, China
- Emergency Medicine, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, China
| | - Lizhu Wang
- Nursing Department, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, China
| | - Jue Fang
- Nursing Department, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, China
- Emergency Medicine, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, China
| | - Yukun Zhang
- Nursing Department, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, China
- Emergency Medicine, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, China
| | - Lili Shi
- Nursing Department, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, China
- Emergency Medicine, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, China
| | - Gaoxing Lin
- Nursing Department, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, China
- Emergency Medicine, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, China
| | - Mangwei Zhang
- Nursing Department, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, China
- Emergency Medicine, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, China
| | - Sa Wang
- Nursing Department, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, China
- Emergency Medicine, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, China
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Kikodze N, Nemsadze K. Integration of Intraosseous Approach Method in Georgia. Pediatr Emerg Care 2024; 40:147-150. [PMID: 38221820 DOI: 10.1097/pec.0000000000003103] [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: 01/16/2024]
Abstract
OBJECTIVE In pediatric emergencies, as in case of shock, the use of intraosseous (IO) route is recommended to get rapid vascular access as soon as possible, as it revealed better outcome. Nevertheless, the IO approach is not used at all and/or is limited because of lack of demand and lack of training on the issue of medical staff. The aim of the study was to test applicable and/or demand of IO in clinics providing pediatric critical care services and assess the opportunities to integrate IO access use in emergency care in Georgia. METHODS A quasi-experimental study was conducted, following a training of medical staff to perform IO access procedure. Our study involved 140 children admitted to emergency department, 114 of whom underwent venous access and 26 underwent IO access. Several parameters were monitored and reported. Outcomes were compared between the 2 procedures. RESULTS Use of an IO catheter has significantly altered the clinical outcome of the patient's condition; 35% of the total number of patients needed to continue their treatment in the intensive care unit, whereas 65% of the patient's continued treatment in the various general wards (compared with 99% and 1%, respectively, in intravenous access patients). None of IO patients were transferred to other clinics because of the deterioration of their clinical condition. Complications in the form of local infection were not observed in any of the patients using the IO approach (which is interesting in terms of infection control). CONCLUSION With proper training and in certain indications, the internationally approved method can be safely used in pediatric emergency management in Georgian and similar country health system contexts. Several urgent conditions with high rates of requiring hospitalization could benefit from the IO approach.
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Kleinsmith RM, Kowalski H. Limb Length Discrepancy After Intraosseous Line Malpositioning: A Case Report. JBJS Case Connect 2024; 14:01709767-202403000-00046. [PMID: 38484087 DOI: 10.2106/jbjs.cc.23.00619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
CASE We will present the case of a 6-year-old girl who presented with a 3-cm limb length discrepancy after intraosseous line placement at age 14 months without other known history of trauma or infection to account for the growth arrest. Imaging revealed a left proximal tibial physeal bar amenable to surgical resection with autologous lipotransfer. At 10 months postoperatively, physical examination and imaging demonstrated a stable 3-cm leg length discrepancy with an interval increase in the length of the left tibia in proportion to the growth of the right side with an increase in valgus alignment that will continue to be monitored and addressed as indicated. CONCLUSION Pediatric intraosseous line placement presents unique challenges and can ultimately lead to physeal injury and growth arrest in the case of malpositioning.
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Affiliation(s)
- Rebekah M Kleinsmith
- Department of Orthopaedic Surgery, TRIA Orthopaedic Center, Bloomington, Minnesota
| | - Heather Kowalski
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa
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Márquez-Hernández VV, Gutiérrez-Puertas L, García-Viola A, Garrido-Molina JM, Gutiérrez-Puertas V, Aguilera-Manrique G, Rodríguez-García MC. Self-Efficacy in the Cannulation Technique for Intraosseous Access in Pediatric Cardiac Arrest: Egg Versus Bone. Pediatr Emerg Care 2023; 39:940-944. [PMID: 37079583 DOI: 10.1097/pec.0000000000002941] [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: 04/21/2023]
Abstract
OBJECTIVES The use of intraosseous (IO) access is recommended in cardiac arrest when peripheral venous access is not accessible. Various methodologies exist that are used for teaching and learning about cannulation of the IO route both in education and in research. The purpose of the present study was to compare self-efficacy in the cannulation technique for IO access through different techniques. METHODS A randomized comparative study was conducted. A total of 118 nursing students participated. The participants were randomly distributed into 2 intervention groups: chicken bone and egg. A checklist was used for data collection to evaluate the IO cannulation technique in nursing students and another to analyze self-efficacy. RESULTS The average total score of self-efficacy for all participants was 8.84 (standard deviation (SD) = 0.98). No statistically significant differences were found when comparing the total self-efficacy score and the intervention group ( U = 1604.500; z = -0.733; P = 0.463). No statistically significant differences were found between both groups for the average total score of the procedure ( U = 6916.500; z = -0.939; P = 0.348). The egg group carried out the IO cannulation procedure in a significantly less amount of time (M = 126.88, SD = 82.18) than the chicken bone group (M = 183.77, SD = 108.28), finding statistically significant differences ( U = 4983.500; z = -5.326; P < 0.001). CONCLUSIONS Using an egg to teach and learn about IO access could be considered a methodology that is equally effective as using a chicken bone, with the advantage of achieving IO access in a lesser amount of time.
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Affiliation(s)
| | | | - Alba García-Viola
- Servicio de Urgencias de Atención Primaria de Distrito Sanitario Almería
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Mastrianni A, Sarcevic A, Hu A, Almengor L, Tempel P, Gao S, Burd RS. Transitioning Cognitive Aids into Decision Support Platforms: Requirements and Design Guidelines. ACM TRANSACTIONS ON COMPUTER-HUMAN INTERACTION : A PUBLICATION OF THE ASSOCIATION FOR COMPUTING MACHINERY 2023; 30:41. [PMID: 37694216 PMCID: PMC10489246 DOI: 10.1145/3582431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 12/16/2022] [Indexed: 09/12/2023]
Abstract
Digital cognitive aids have the potential to serve as clinical decision support platforms, triggering alerts about process delays and recommending interventions. In this mixed-methods study, we examined how a digital checklist for pediatric trauma resuscitation could trigger decision support alerts and recommendations. We identified two criteria that cognitive aids must satisfy to support these alerts: (1) context information must be entered in a timely, accurate, and standardized manner, and (2) task status must be accurately documented. Using co-design sessions and near-live simulations, we created two checklist features to satisfy these criteria: a form for entering the pre-hospital information and a progress slider for documenting the progression of a multi-step task. We evaluated these two features in the wild, contributing guidelines for designing these features on cognitive aids to support alerts and recommendations in time- and safety-critical scenarios.
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Affiliation(s)
- Angela Mastrianni
- College of Computing and Informatics, Drexel University, Philadelphia, USA
| | | | - Allison Hu
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, D.C., USA
| | - Lynn Almengor
- College of Computing and Informatics, Drexel University, Philadelphia, USA
| | - Peyton Tempel
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, D.C., USA
| | - Sarah Gao
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, D.C., USA
| | - Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, D.C., USA
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Intraosseous Tibial Resuscitation After a Total Knee Arthroplasty Leading to Osteonecrosis and Loosening of the Tibial Component. Arthroplast Today 2023; 19:101088. [PMID: 36691465 PMCID: PMC9860108 DOI: 10.1016/j.artd.2022.101088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 12/06/2022] [Accepted: 12/10/2022] [Indexed: 01/15/2023] Open
Abstract
A 51-year-old woman suffered cardiac arrest requiring emergent intraosseous access that abutted the tibial component of her total knee arthroplasty. She developed a wound at the site and knee pain which was concerning for deep infection. Subsequent imaging was consistent with osteonecrosis developing around the tibial component. The component eventually loosened, requiring a revision surgery. Her deep cultures remained negative throughout. Her findings are most consistent with osteonecrosis and aseptic loosening of her prosthesis. While intraosseous access may be beneficial during resuscitation, it has complications. This is the first reported case of osteonecrosis secondary to intraosseous access leading to prosthetic loosening necessitating a revision surgery.
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Hoskins M, Sefick S, Zurca AD, Walter V, Thomas NJ, Krawiec C. Current utilization of interosseous access in pediatrics: a population-based analysis using an EHR database, TriNetX. Int J Emerg Med 2022; 15:65. [PMID: 36447135 PMCID: PMC9706868 DOI: 10.1186/s12245-022-00467-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 11/10/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND When central or peripheral intravenous access cannot be achieved in a timely manner, intraosseous (IO) access is recommended as a safe and equally effective alternative for pediatric resuscitation. IO usage and its complications in the pediatric population have been primarily studied in the setting of cardiac arrest. However, population-based studies identifying noncardiac indications and complications associated with different age groups are sparse. RESULTS This was a retrospective observational cohort study utilizing the TriNetX® electronic health record data. Thirty-seven hospitals were included in the data set with 1012 patients where an IO procedure code was reported in the emergency department or inpatient setting. The cohort was split into two groups, pediatric subjects < 1 year of age and those ≥ 1 year of age. A total incidence of IO line placement of 18 per 100,000 pediatric encounters was reported. Total mortality was 31.8%, with a higher rate of mortality seen in subjects < 1 year of age (39.2% vs 29.0%; p = 0.0028). A diagnosis of cardiac arrest was more frequent in subjects < 1 year of age (51.5% vs 38.0%; p = 0.002), and a diagnosis of convulsions was more frequent in those ≥ 1 of age (28.0% vs 13.8%; p <0.01). Overall, 29 (2.9%) subjects had at least one complication. CONCLUSIONS More IOs were placed in subjects ≥ 1 year of age, and a higher rate of mortality was seen in subjects < 1 year of age. Lower frequencies of noncardiac diagnoses at the time of IO placement were found in both groups, highlighting IO may be underutilized in noncardiac settings such as convulsions, shock, and respiratory failure. Given the low rate of complications seen in both groups of our study, IO use should be considered early on for urgent vascular access, especially for children less than 1 year of age.
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Affiliation(s)
- Meloria Hoskins
- grid.240473.60000 0004 0543 9901Penn State College of Medicine, 500 University Drive, P.O. Box 859, Hershey, PA USA
| | - Samantha Sefick
- grid.240473.60000 0004 0543 9901Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Hershey Children’s Hospital, 500 University Drive, P.O. Box 850, Hershey, PA USA
| | - Adrian D. Zurca
- grid.240473.60000 0004 0543 9901Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Hershey Children’s Hospital, 500 University Drive, P.O. Box 850, Hershey, PA USA
| | - Vonn Walter
- grid.29857.310000 0001 2097 4281Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University College of Medicine, 500 University Drive, Hershey, PA USA
| | - Neal J. Thomas
- grid.29857.310000 0001 2097 4281Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University College of Medicine, 500 University Drive, Hershey, PA USA ,grid.29857.310000 0001 2097 4281Department of Public Health Sciences, Pennsylvania State University College of Medicine, 500 University Drive, Hershey, PA USA
| | - Conrad Krawiec
- grid.240473.60000 0004 0543 9901Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Hershey Children’s Hospital, 500 University Drive, P.O. Box 850, Hershey, PA USA
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Fat embolism after intraosseous catheters in pediatric forensic autopsies. Int J Legal Med 2022; 137:787-791. [PMID: 35771256 PMCID: PMC10085886 DOI: 10.1007/s00414-022-02848-4] [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: 04/12/2022] [Accepted: 05/27/2022] [Indexed: 10/17/2022]
Abstract
In our center, we performed the autopsy of a child who died from drowning and presented, at autopsy, a major pulmonary fat embolism (PFE). A cardiopulmonary resuscitation (CPR) was performed, including infusion by intraosseous catheter (IIC). No other traumatic lesions and diseases classically related to a risk of PFE were detected. According to some animal studies, we considered the IIC as the only possible cause for PFE. However, we could not find literature to confirm this hypothesis in humans, especially in a pediatric population. To verify the occurrence of PFE after IIC in a pediatric population, we retrospectively selected 20 cases of pediatric deaths autopsied in our center, in which a CPR was performed, without bone fractures or other possible causes of PFE: 13 cases with IIC (group A) and 7 cases without IIC (group B). Several exclusion criteria were considered. The histology slides of the pulmonary tissue were stained by Oil Red O. PFE was classified according to the Falzi scoring system. In group A, 8 cases showed PFE: 4 cases with a score 1 of Falzi and 4 cases with a score 2 of Falzi. In group B, no case showed PFE. The difference between the two groups was statistically significant. The results of our study seem to confirm that IIC can lead to PFE in a pediatric population and show that the PFE after IIC can be important (up to score 2 of Falzi). To the best of our knowledge, our study is the first specifically focused on the occurrence of PFE after IIC in a pediatric population by using autoptic data.
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Single Intraosseous Simvastatin Application Induces Endothelial Progenitor Cell Mobilization and Therapeutic Angiogenesis in a Diabetic Hindlimb Ischemia Rat Model. Plast Reconstr Surg 2021; 148:936e-945e. [PMID: 34644264 DOI: 10.1097/prs.0000000000008526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Endothelial progenitor cells have shown the ability to enhance neovascularization. In this study, the authors tested whether intraosseous delivery of simvastatin could mobilize endothelial progenitor cells and enhance recovery in a hindlimb ischemia model. METHODS There are eight groups of rats in this study: normal control; type 1 diabetes mellitus control group control without drug intervention; and type 1 diabetes mellitus rats that randomly received intraosseous simvastatin (0, 0.5, or 1 mg) or oral simvastatin administration (0, 20, or 400 mg). All type 1 diabetes mellitus rats had induced hindlimb ischemia. The number of endothelial progenitor cells in peripheral blood, and serum markers, were detected. The recovery of blood flow at 21 days after treatment was used as the main outcome. RESULTS The authors demonstrated that endothelial progenitor cell mobilization was increased in the simvastatin 0.5- and 1-mg groups compared with the type 1 diabetes mellitus control and simvastatin 0-mg groups at 1, 2, and 3 weeks. Serum vascular endothelial growth factor levels were significantly increased at 2 weeks in the simvastatin 0.5- and 1-mg groups, in addition to the increase of the blood flow and the gastrocnemius weight at 3 weeks. Similar increase can also been seen in simvastatin 400 mg orally but not in simvastatin 20 mg orally. CONCLUSION These findings demonstrate that a single intraosseous administration of simvastatin mobilized endothelial progenitor cells at a dose one-hundredth of the required daily oral dose in rats, and this potent mobilization of endothelial progenitor cells markedly improved diabetic limb ischemia by means of neovascularization.
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Song L, Koka R, Reese E, Mullins K, Murphy C. Intraosseous Specimens Submitted to the Laboratory: A Case Report and Review. Lab Med 2021; 51:e75-e77. [PMID: 32533694 DOI: 10.1093/labmed/lmaa029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Intraosseous (IO) devices are used for vascular access in settings where venous access is initially unobtainable, such as prehospital trauma care or cardiac arrest. While IO devices are effective for infusion of blood, fluids, and medications, there is limited data on the analytical equivalence of specimens taken out of IO devices and peripheral venous blood. Despite this, IO device manufacturers and clinical resources state that IO specimens can be submitted for laboratory analysis. As reported in this case, IO specimens may be drawn and labeled as 'peripheral blood'. IO specimens are not always caught by automated sample quality testing and may proceed through analysis without any warning signal to the laboratory. There are potential regulatory risks in accepting IO samples for analysis without validation. IO infusion is a valuable technique for vascular access in critically ill patients, but clinical laboratories will need to determine their own policies for identifying and handling IO specimens.
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Affiliation(s)
- Linda Song
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD
| | - Rima Koka
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD
| | - Erika Reese
- Division of Transfusion Medicine, University of Maryland Medical Center, Baltimore, MD
| | - Kristin Mullins
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD
| | - Colin Murphy
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD
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Arakawa J, Woelber E, Working Z, Meeker J, Friess D. Complications of Intraosseous Access: Two Case Reports From a Single Center. JBJS Case Connect 2021; 11:01709767-202106000-00038. [PMID: 33979829 DOI: 10.2106/jbjs.cc.19.00382] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASES Intraosseous (IO) access is an effective surrogate for intravascular access in critically ill patients. We present 2 cases of IO complications. The first patient is a 44-year-old man with deep peroneal nerve sensorimotor dysfunction due to possible missed acute compartment syndrome from improper placement of a tibial IO needle. The second patient is an immunosuppressed 69-year-old man with idiopathic factor VIII deficiency who required amputation 7 months after right tibia IO access. CONCLUSION These adverse events of IO access are limited in the literature. We make recommendations to reduce these outcomes.
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Affiliation(s)
- Jordan Arakawa
- Department of Orthopaedics & Rehabilitation, Oregon Health and Science University, Portland, Oregon
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Laney JA, Friedman J, Fisher AD. Sternal Intraosseous Devices: Review of the Literature. West J Emerg Med 2021; 22:690-695. [PMID: 34125048 PMCID: PMC8202990 DOI: 10.5811/westjem.2020.12.48939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 12/06/2020] [Indexed: 11/22/2022] Open
Abstract
Introduction The intraosseous (IO) route is one of the primary means of vascular access in critically ill and injured patients. The most common sites used are the proximal humerus, proximal tibia, and sternum. Sternal IO placement remains an often-overlooked option in emergency and prehospital medicine. Due to the conflicts in Afghanistan and Iraq the use of sternal IOs have increased. Methods The authors conducted a limited review, searching PubMed and Google Scholar databases for “sternal IO,” “sternal intraosseous,” and “intraosseous” without specific date limitations. A total of 47 articles were included in this review. Results Sternal IOs are currently FDA approved for ages 12 and older. Sternal IO access offers several anatomical, pharmacokinetic, hemodynamic, and logistical advantages over peripheral intravenous and other IO points of access. Sternal IO use carries many of the same risks and limitations as the humeral and tibial sites. Sternal IO gravity flow rates are sufficient for transfusing blood and resuscitation. In addition, studies demonstrated they are safe during active CPR. Conclusion The sternal IO route remains underutilized in civilian settings. When considering IO vascular access in adults or older children, medical providers should consider the sternum as the recommended IO access, particularly if the user is a novice with IO devices, increased flow rates are required, the patient has extremity trauma, or administration of a lipid soluble drug is anticipated.
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Affiliation(s)
- Jared A Laney
- Texas A&M University College of Medicine, Bryan, Texas
| | | | - Andrew D Fisher
- Medical Command, Texas Army National Guard, Austin, Texas.,University of New Mexico School of Medicine, Department of Surgery, Albuquerque, New Mexico
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Mansfeld A, Radafshar M, Thorgeirsson H, Höijer CJ, Segerlantz M. Palliative Sedation via Intraosseous Vascular Access: A Safe and Feasible Way to Obtain a Vascular Access End of Life. J Palliat Med 2020; 22:109-111. [PMID: 30633698 DOI: 10.1089/jpm.2018.0398] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Intraosseous (IO) access is normally reserved for emergencies and critical care conditions when venous cannulation is not possible. Nonetheless, we present a case of IO insertion to a 56-year-old man, tetraplegic for many years due to progressive spinal muscular atrophy and with refractory suffering. The IO access was used for palliative sedation with propofol in a home care setting. The patient died after 11 days of palliative care, of which the last 4 days were with palliative sedation using an IO cannula as a vascular access. No complications were noted from this route of administration. We advocate the use of IO access in the palliative care of terminal ill patients when a venous cannulation is not possible.
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Affiliation(s)
- Annica Mansfeld
- 1 Department of Palliative Care and Advanced Home Health Care, Primary Health Care Skåne, Lund, Sweden
| | - Mohammadhossein Radafshar
- 1 Department of Palliative Care and Advanced Home Health Care, Primary Health Care Skåne, Lund, Sweden
| | - Hlin Thorgeirsson
- 1 Department of Palliative Care and Advanced Home Health Care, Primary Health Care Skåne, Lund, Sweden
| | - Carl Johan Höijer
- 1 Department of Palliative Care and Advanced Home Health Care, Primary Health Care Skåne, Lund, Sweden
| | - Mikael Segerlantz
- 1 Department of Palliative Care and Advanced Home Health Care, Primary Health Care Skåne, Lund, Sweden.,2 Department of Clinical Sciences Lund, Faculty of Medicine, Institute for Palliative Care, Lund University, Lund, Sweden
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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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Determination of the Pretibial Soft Tissue Thickness in Children: Are Intraosseous Infusion Needles Long Enough? Pediatr Emerg Care 2020; 36:39-42. [PMID: 31851078 DOI: 10.1097/pec.0000000000002019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The EZ-IO intraosseous (IO) needle is available in 2 needle sizes for children based on the patient weight. To date, there is no published evidence validating the use of weight-based scaling in children. We hypothesized that pretibial subcutaneous tissue thickness (PSTT) does not correspond with patient weight but rather with age and body mass index (BMI). Our objective was to describe the relationship of a patient's PSTT to their weight, age, and BMI in children less than 40 kg. METHOD One hundred patients who weighed less than 40 kg were recruited prospectively from October 2013 to April 2015 at a tertiary care pediatric emergency department. All sonographic assessments were performed by 1 of 2 emergency physicians certified in point-of-care ultrasound. A single sonographic image was taken over the proximal tibia corresponding to the site of IO insertion. In patients where both sonographers performed independent measurements, a Pearson correlation coefficient was determined. Univariate linear regression was performed to determine the relationship between age, weight, and BMI with PSTT. RESULTS One hundred participants were recruited and ranged in age from 10 days to 14 years (mean [SD], 5.01 [3.14] years). Fifty-seven percent of participants were male. Patients' weights ranged from 3.5 to 39.3 kg (mean [SD], 21.42 [9.12] kg), and BMI ranged from 12.1 to 45.0 kg/m (mean [SD], 17.31 [4.00]). The mean (SD) PSTT across participants was 0.68 (0.2) cm. The intraclass correlation coefficient for agreement between the 2 sonographers was moderate (intraclass correlation coefficient, 0.602 [confidence interval, 0.385-0.757]). There were significant positive correlations between BMI and PSTT (r = 0.562, P = <0.001) as well as weight and PSTT (r = 0.293, P < 0.003). There was a weak correlation between age and PSTT (0.065, P = 0.521). CONCLUSIONS Pretibial subcutaneous tissue thickness correlates most strongly with BMI, followed by weight, and weakly with age. Our findings suggest that current IO needle length recommendations should be based on BMI rather than weight. This would suggest that clinicians need to be aware that young patients in particular with large BMIs may pose problems with current weight-based needle length recommendations.
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Wasserman P, Kurra C, Taylor K, Fields JR, Caldwell M. Intramuscular hemorrhage and fluid extravasation into the anterior compartment secondary to intraosseous resuscitation, the "Nicked-Cortex" sign. Radiol Case Rep 2019; 14:1452-1457. [PMID: 31695835 PMCID: PMC6823788 DOI: 10.1016/j.radcr.2019.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 09/07/2019] [Accepted: 09/07/2019] [Indexed: 11/24/2022] Open
Abstract
Intraosseous needle access is a reliable method of vascular access used for rapid fluid resuscitation and delivery of medications in certain emergent settings. Fluid extravasation is a possible complication of intraosseous needle access that can lead to compartment syndrome. To our knowledge, imaging findings resulting from this complication have not been described. In this case report, we demonstrate conventional radiograph, computed tomography, and magnetic resonance image findings due to extravasation of resuscitation fluids following the aberrant insertion of an intraosseous needle in an unstable adult trauma patient. We also describe a new radiographic sign associated with this iatrogenic complication, the "Nicked-Cortex" sign.
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Affiliation(s)
- Paul Wasserman
- Department of Radiology, College of Medicine, University of Florida, 655 West 8th Street C90, Jacksonville, FL 32209, USA
| | - Chandana Kurra
- Department of Radiology, College of Medicine, University of Florida, 655 West 8th Street C90, Jacksonville, FL 32209, USA
| | - Kristin Taylor
- Department of Radiology, College of Medicine, University of Florida, 655 West 8th Street C90, Jacksonville, FL 32209, USA
| | - Jaime R. Fields
- College of Medicine, University of Florida, Gainesville, FL, USA
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Sørgjerd R, Sunde GA, Heltne JK. Comparison of two different intraosseous access methods in a physician-staffed helicopter emergency medical service - a quality assurance study. Scand J Trauma Resusc Emerg Med 2019; 27:15. [PMID: 30760297 PMCID: PMC6373167 DOI: 10.1186/s13049-019-0594-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 01/30/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intravenous access in critically ill and injured patients can be difficult or impossible in the field. Intraosseous access is a well-established alternative to achieve access to a noncollapsible vascular network. We wanted to compare the use of a sternal and tibial/humeral intraosseous device in a physician-staffed helicopter emergency medical service. METHODS The helicopter emergency medical service in Bergen, Norway, is equipped with two different intraosseous devices, the EZ-IO and FAST-Responder. We compared insertion time, insertion sites, flow, indication for intraosseous access, and complications between the tibial/humeral and sternal techniques. RESULTS In 49 patients, 53 intraosseous insertions were made. The overall intraosseous rate was 1.5% (53 insertions in 3600 patients treated). The main patient categories were cardiac arrest and trauma. Overall, 93.9% of the insertions were successful on the first attempt. The median insertion time using EZ-IO was 15 s compared to 20 s using FAST-Responder. Insertion complications registered using the EZ-IO included extravasation, aspiration failure and insertion time > 30 s. Using FAST-Responder, there were reported complications such as user failure (12.5%) and insertion time > 30 s (12.5%). Regarding the flow, we found that 35.1% of the EZ-IO insertions experienced poor flow and needed a pressure bag. With FAST-Responder, the flow was reported as very good or good in 85.7%, and no insertions had poor flow. CONCLUSION Intraosseous access seems to be a reliable rescue technique in our helicopter emergency medical service, with high insertion success rates. EZ-IO was a more rapid method in gaining vascular access compared to FAST-Responder. However, FAST-Responder may be a better method when high-flow infusion is needed. Few complications were registered with both techniques in our service.
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Affiliation(s)
- Renate Sørgjerd
- Department of Anesthesia and Intensive Care, Haukeland University Hospital, Jonas Lies vei 65, 5021, Bergen, Norway.
| | - Geir Arne Sunde
- Department of Anesthesia and Intensive Care, Haukeland University Hospital, Jonas Lies vei 65, 5021, Bergen, Norway
| | - Jon-Kenneth Heltne
- Department of Anesthesia and Intensive Care, Haukeland University Hospital, Jonas Lies vei 65, 5021, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Chalopin T, Lemaignen A, Guillon A, Geffray A, Derot G, Bahuaud O, Agout C, Rosset P, Castellier C, De Pinieux G, Valentin AS, Bernard L, Bastides F. Acute Tibial osteomyelitis caused by intraosseous access during initial resuscitation: a case report and literature review. BMC Infect Dis 2018; 18:665. [PMID: 30558553 PMCID: PMC6296120 DOI: 10.1186/s12879-018-3577-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 12/03/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intra-osseous (IO) access is recommended in cases of pre-hospital emergency or resuscitation when intravascular (IV) route is difficult or impossible. Despite recent improvement in IO devices and increasing indications, it remains rarely used in practice. Various complications have been reported but are uncommon. CASE PRESENTATION We report a case of massive acute tibial osteomyelitis in an adult male three months after an IO catheter insertion for emergency drug infusion. We review the literature on association between IO access and acute osteomyelitis in children and adults. CONCLUSIONS Emergency-care givers and radiologists should be informed about this infrequent complication in order to make early diagnosis and initiate adequate antibiotic therapy.
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Affiliation(s)
- Thomas Chalopin
- Department of Internal Medicine and Infectious Diseases, University Hospital of Tours, Hospital Bretonneau, Tours, France
- François Rabelais University, Tours, France
| | - Adrien Lemaignen
- Department of Internal Medicine and Infectious Diseases, University Hospital of Tours, Hospital Bretonneau, Tours, France
- François Rabelais University, Tours, France
| | - Antoine Guillon
- Department of Intensive Care Unit, University Hospital of Tours, Tours, France
| | - Arnaud Geffray
- Department of Medical Imaging, University Hospital of Tours, Tours, France
| | - Gaelle Derot
- Department of Medical Imaging, University Hospital of Tours, Tours, France
| | - Olivier Bahuaud
- Department of Internal Medicine and Infectious Diseases, University Hospital of Tours, Hospital Bretonneau, Tours, France
- François Rabelais University, Tours, France
| | - Charles Agout
- Department of Orthopedic Surgery, University Hospital of Tours, Tours, France
| | - Philippe Rosset
- Department of Orthopedic Surgery, University Hospital of Tours, Tours, France
| | - Claire Castellier
- Department of Anatomopathology, University Hospital of Tours, Tours, France
| | | | | | - Louis Bernard
- Department of Internal Medicine and Infectious Diseases, University Hospital of Tours, Hospital Bretonneau, Tours, France
- François Rabelais University, Tours, France
| | - Frederic Bastides
- Department of Internal Medicine and Infectious Diseases, University Hospital of Tours, Hospital Bretonneau, Tours, France
- François Rabelais University, Tours, France
- 2 boulevard Tonnellé, 37044 Tours, Cedex 9 France
| | - Centre De Référence Des Infections Ostéo-Articulaires Du Grand-Ouest (CRIOGO) Study Team
- Department of Internal Medicine and Infectious Diseases, University Hospital of Tours, Hospital Bretonneau, Tours, France
- François Rabelais University, Tours, France
- Department of Intensive Care Unit, University Hospital of Tours, Tours, France
- Department of Medical Imaging, University Hospital of Tours, Tours, France
- Department of Orthopedic Surgery, University Hospital of Tours, Tours, France
- Department of Anatomopathology, University Hospital of Tours, Tours, France
- Bacteriological Laboratory, University Hospital of Tours, Tours, France
- 2 boulevard Tonnellé, 37044 Tours, Cedex 9 France
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Intra-osseous-access-associated lower limb compartment syndrome in a critically injured paediatric patient. Eur J Anaesthesiol 2018; 35:981-983. [PMID: 30376489 DOI: 10.1097/eja.0000000000000873] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Symonds T, Parkinson B, Hazratwala K, McEwen P, Wilkinson M, Grant A. Use of regional administration of prophylactic antibiotics in total knee arthroplasty. ANZ J Surg 2018; 88:848-853. [PMID: 30151929 DOI: 10.1111/ans.14816] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 05/26/2018] [Accepted: 06/06/2018] [Indexed: 11/28/2022]
Abstract
Prosthetic joint infection after total knee arthroplasty is an infrequent, yet serious complication. Antimicrobial prophylaxis plays an important role in reducing the rate of surgical site infections. To be effective as an antimicrobial prophylaxis, the serum, tissue and bone concentrations of the antibiotic must be greater than the target organism's minimum inhibitory concentration. As antibiotic resistance increases current intravenous prophylactic dosing has been shown to be subtherapeutic for some patients. Intravenous regional administration and intraosseous regional administration of prophylactic antibiotics are novel methods used to increase the antibiotic tissue concentrations, which may enhance the efficacy of prophylactic antibiotics in total knee arthroplasty. Currently, literature has shown both intravenous regional administration and intraosseous regional administration to be safe and effective techniques. However, there is no clinical evidence to show that it results in a reduction of prosthetic joint infection rates. This study summarizes the current knowledge base on the use of regional administration of prophylactic antibiotics in total knee arthroplasty.
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Affiliation(s)
- Tristan Symonds
- Orthopaedics Department, Orthopaedic Research Institute of Queensland, Townsville, Queensland, Australia
| | - Ben Parkinson
- Orthopaedics Department, Orthopaedic Research Institute of Queensland, Townsville, Queensland, Australia
| | - Kaushik Hazratwala
- Orthopaedics Department, Orthopaedic Research Institute of Queensland, Townsville, Queensland, Australia
| | - Peter McEwen
- Orthopaedics Department, Orthopaedic Research Institute of Queensland, Townsville, Queensland, Australia
| | - Matthew Wilkinson
- Orthopaedics Department, Orthopaedic Research Institute of Queensland, Townsville, Queensland, Australia
| | - Andrea Grant
- Orthopaedics Department, Orthopaedic Research Institute of Queensland, Townsville, Queensland, Australia
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Intraosseous access in children. New applications of an ancient technique. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2018. [DOI: 10.1016/j.tacc.2018.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Slocum AH, Reinitz SD, Jariwala SH, Van Citters DW. Design, Development, and Validation of an Intra-Osseous Needle Placement Guide. J Med Device 2017. [DOI: 10.1115/1.4037442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Intra-osseous (IO) needles are an easy and reliable alternative to intravenous (IV) access in the prehospital and emergency settings for treating patients in shock. The advantage of utilizing an IO is that secure, noncollapsible peripheral venous access can be obtained rapidly in critically ill patients. Placement of IO needles in the proximal tibia, humerus, or sternum, however, requires knowledge of human anatomy and the requisite skill to position, align, and place the device. In the developing world, this is not always available, and in the chaos of an in-hospital code, prehospital trauma, or a mass-casualty incident, even trained providers can have trouble correctly placing IV or IO needles. The Tib-Finder is an intuitive drill guide that significantly improves efficiency with which IO can be placed in the proximal tibia. Here, we present the conceptualization, design, and creation of an alpha-prototype Tib-Finder drill guide in less than 90 days; initial validation was achieved through analysis of anthropometric measurements of human skeletons, and usability studies were performed using untrained volunteers and mannequins. The Tib-Finder is intended to provide first responders and medical personnel, in the first world and the developing world, a way to accurately and repeatably locate the proximal tibia and achieve safe, rapid intravascular access in critically ill patients. Further, it eliminates the need for direct contact between patients and caregivers and improves the ease-of-use of IO devices by first responders and healthcare providers.
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Affiliation(s)
- Alexander H. Slocum
- Mem. ASME Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115; Department of Plastic and Reconstructive Surgery, Medical College of Wisconsin, 1155 N. Mayfair Road, Wauwatosa, WI 53226 e-mail:
| | - Steven D. Reinitz
- Thayer School of Engineering, Dartmouth College, 14 Engineering Drive, Hanover, NH 03755
| | - Shailly H. Jariwala
- Thayer School of Engineering, Dartmouth College, 14 Engineering Drive, Hanover, NH 03755 e-mail:
| | - Douglas W. Van Citters
- Mem. ASME Thayer School of Engineering, Dartmouth College, 14 Engineering Drive, Hanover, NH 03755
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Wijesuriya JD, Keogh S. Integrated major haemorrhage management in the retrieval setting: Damage control resuscitation from referral to receiving facility. Emerg Med Australas 2017; 29:470-475. [DOI: 10.1111/1742-6723.12742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 10/19/2016] [Accepted: 12/14/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Julian D Wijesuriya
- Central London School of Anaesthesia and Intensive Care Medicine; Royal Free Hospital; London UK
| | - Sean Keogh
- Faculty of Science, Health, Education and Engineering, University of the Sunshine Coast; Maroochydore Queensland Australia
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Singh S, Aggarwal P, Lodha R, Agarwal R, Gupta AK, Dhingra R, Karve JS, Jaggu SK, Bhargava B. Feasibility study of a novel intraosseous device in adult human cadavers. Indian J Med Res 2017; 143:275-80. [PMID: 27241639 PMCID: PMC4892072 DOI: 10.4103/0971-5916.182616] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background & objectives: Intraosseous (IO) access is an alternative to difficult intravenous (iv) access during emergency clinical situations. Existing IO solutions are expensive, require power supply and trained manpower; limiting their use in resource constrained settings. To address these limitations, a novel IO device has been developed. The objectives of this study were to evaluate functionality and safety of this device in adult human cadavers. Methods: The ability of the IO device to penetrate the proximal and/or distal tibia was evaluated in three adult cadavers. Subjective parameters of loss of resistance, stable needle hold, easy needle withdrawal and any damage to the device were evaluated during the study. The insertion time was the objective parameter measured. Four sets of radiographs per insertion confirmed the position of the needle and identified complications. Results: A single physician performed 12 IO access procedures using the same device. Penetration of proximal and/or distal tibia was achieved in all instances. It was successful in the first attempt in eight (66.7%) and during second attempt in the remaining. The mean time to insertion was 4.1 ± 3.1 sec. Appropriate insertion of needle in the intra-medullary space of bone was confirmed with radiological examination in 10 (83.3%) insertions. In two occasions after penetrating the cortical layer of bone, the device overshot the intra-medullary space, as detected by radiological examination. Device got bent during insertion in one instance. There was no evidence of needle breakage or bone fracture. The needle could be withdrawn effortlessly in all instances. Interpretation & conclusions: The novel IO device could successfully penetrate the adult cadaver bones in most cases. Further studies are needed to confirm these results on a large sample.
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Affiliation(s)
- Sandeep Singh
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Praveen Aggarwal
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Lodha
- Department of Paediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Ramesh Agarwal
- Department of Paediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Arun Kr Gupta
- Department of Radio-Diagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Renu Dhingra
- Department of Anatomy, All India Institute of Medical Sciences, New Delhi, India
| | - Jayant Sitaram Karve
- Stanford-India Biodesign Programme, All India Institute of Medical Sciences, New Delhi, India
| | - Srinivas Kiran Jaggu
- Stanford-India Biodesign Programme, All India Institute of Medical Sciences, New Delhi, India
| | - Balram Bhargava
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
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Hodgetts JM, Johnston A, Kendrew J. Long-term follow-up of two patients with retained intraosseous sternal needles. J ROY ARMY MED CORPS 2017; 163:221-222. [PMID: 28249956 DOI: 10.1136/jramc-2016-000699] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 11/03/2016] [Accepted: 11/06/2016] [Indexed: 11/04/2022]
Abstract
Sternal intraosseous devices are widely used in both civilian and military trauma when vascular access is difficult to establish. We discuss a rare complication of intraosseous needle insertion in two patients where the needle tip remained in the sternum after the device had been removed. Neither patient had evidence of any complication of the retained intraosseous needle tip after >6 years of follow-up.
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Affiliation(s)
- James M Hodgetts
- Department of Trauma and Orthopaedics, Royal Centre for Defence Medicine, Queen Elizabeth Hospital Birmingham, UK
| | - A Johnston
- Intensive Care, Royal Centre for Defence Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - J Kendrew
- Department of Trauma and Orthopaedics, Royal Centre for Defence Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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Blueprint for Implementing New Processes in Acute Care: Rescuing Adult Patients With Intraosseous Access. J Trauma Nurs 2017; 22:266-73. [PMID: 26352658 DOI: 10.1097/jtn.0000000000000152] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The intraosseous (IO) access initiative at an urban university adult level 1 trauma center began from the need for a more expeditious vascular access route to rescue patients in extremis. The goal of this project was a multidisciplinary approach to problem solving to increase access of IO catheters to rescue patients in all care areas. The initiative became a collaborative effort between nursing, physicians, and pharmacy to embark on an acute care endeavor to standardize IO access. This is a descriptive analysis of processes to effectively develop collaborative strategies to navigate hospital systems and successfully implement multilayered initiatives. Administration should empower nurse to advance their practice to include IO for patient rescue. Intraosseous access may expedite resuscitative efforts in patients in extremis who lack venous access or where additional venous access is required for life-saving therapies. Limiting IO dwell time may facilitate timely definitive venous access. Continued education and training by offering IO skill laboratory refreshers and annual e-learning didactic is optimal for maintaining proficiency and knowledge. More research opportunities exist to determine medication safety and efficacy in adult patients in the acute care setting.
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Bielski K, Szarpak L, Smereka J, Ladny JR, Leung S, Ruetzler K. Comparison of four different intraosseous access devices during simulated pediatric resuscitation. A randomized crossover manikin trial. Eur J Pediatr 2017; 176:865-871. [PMID: 28500463 PMCID: PMC5486567 DOI: 10.1007/s00431-017-2922-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 04/24/2017] [Accepted: 04/28/2017] [Indexed: 02/06/2023]
Abstract
UNLABELLED The aim of the study was to compare the success rate, procedure time, and user satisfaction of pediatric NIO™ compared to Pediatric BIG®, EZ-IO®, and Jamshidi intraosseous access devices. This was a randomized, crossover manikin trial with 87 paramedics. The correct location of intraosseous access when using NIO, BIG, EZ-IO, and Jamshidi was varied and was respectively 100, 90, 90, and 90%. The time required to obtain intravascular access (time T1) in the case of NIO, BIG, EZ-IO, and Jamshidi was varied and amounted to 9 s [IQR, 8-12] for NIO, 12 s [IQR, 9-16] for BIG, 13.5 s [IQR, 11-17] for the EZ-IO, and 15 s [IQR, 13-19] for Jamshidi. The paramedics evaluated each device on the subjective ease with which they performed the procedures. The intraosseous device, which proved the easiest to use was NIO, which in the case of CPR received a median rating of 1.5 (IQR, 0.5-1.5) points. CONCLUSION Our study found that NIO® is superior to BIG®, EZ-IO®, and Jamshidi. NIO® achieved the highest first attempt success rate. NIO® also required the least time to insert and easiest to operate even by novice users. Further study is needed to test our findings in cadavers or human subjects. Based on our findings, NIO® is a promising intraosseous device for use in pediatric resuscitation. What is Known: • Venous access in acutely ill pediatric patients, such as those undergoing cardiopulmonary resuscitation, is needed for prompt administration of drugs and fluids. • Intraosseous access is recommended by American Heart Association and European Resuscitation council if vascular access is not readily obtainable to prevent delay in treatment. What is New: • This simulated pediatric resuscitation compared performance of four commercially available pediatric intraosseous devices in a manikin model. • NIO® outperformed BIG®, EZ-IO®, and Jamshidi in first attempt success rates and time of procedure among novice users.
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Affiliation(s)
- Karol Bielski
- MEDITRANS The Voivodship Emergency Medical Service and Sanitary Transport, Warsaw, Poland
| | - Lukasz Szarpak
- Department of Emergency Medicine, Medical University of Warsaw, Lindleya 4 Street, 02-005, Warsaw, Poland.
| | - Jacek Smereka
- Department of Emergency Medical Service, Wroclaw Medical University, Wroclaw, Poland
| | - Jerzy R. Ladny
- Department of Emergency Medicine and Disaster, Medical University Bialystok, Bialystok, Poland
| | - Steve Leung
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH USA
| | - Kurt Ruetzler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH USA ,Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH USA
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Abstract
Obtaining reliable enteral and vascular access constitutes a significant fraction of a pediatric surgeon׳s job. Multiple approaches are available. Given the complicated nature of this patient population multiple complications can also occur. This article discusses the various techniques and potential complications associated with short- and long-term enteral and vascular access.
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Affiliation(s)
- James S Farrelly
- Division of Pediatric General and Thoracic Surgery, Yale Children's Hospital, Yale University School of Medicine, PO Box 208062, New Haven, Connecticut 06520-8062
| | - David H Stitelman
- Division of Pediatric General and Thoracic Surgery, Yale Children's Hospital, Yale University School of Medicine, PO Box 208062, New Haven, Connecticut 06520-8062.
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Johnson M, Inaba K, Byerly S, Falsgraf E, Lam L, Benjamin E, Strumwasser A, David JS, Demetriades D. Intraosseous Infusion as a Bridge to Definitive Access. Am Surg 2016. [DOI: 10.1177/000313481608201003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Intraosseous (IO) needle placement is an alternative for patients with difficult venous access. The purpose of this retrospective study was to examine indications and outcomes associated with IO use at a Level 1 trauma center (January 2008–May 2015). Data points included demographics, time to insertion, intravenous (IV) access points, indications, infusions, hospital and intensive care unit length of stay, and mortality. Of 68 patients with IO insertion analyzed (63.2% blunt trauma, 29.4% penetrating trauma, and 7.4% medical), 56 per cent were hypotensive on arrival and 38.2 per cent asystolic. The most common indications for IO infusion were difficult IV access (69%) and rapid sequence intubation (20.6%). The median time to IO access was three minutes. IV access was gained after IO in 72.1 per cent of patients. Through IO access, 30.9 per cent patients received crystalloid, 29.4 per cent received Advanced Care Life Support (ACLS) medications, 25 per cent rapid sequence intubation medications, 20.6 per cent blood products, and 2.9 per cent seizure medications. Overall, 80.9 per cent were intubated in the Emergency Department (ED), 26.5 per cent had ED thoracotomy, and 20.6 per cent had a laparotomy. Median crystalloid infused through IO was 180 cc in pediatric patients and 1 L in adults, respectively. Extravasation, the most common complication, was experienced by 7.4 per cent of patients. Inhospital mortality was 72.9 per cent. IO access should be considered when there is a need for rapid intervention requiring vascular access.
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Affiliation(s)
- Megan Johnson
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Kenji Inaba
- Division of Trauma Surgery and Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, California; and
| | - Saskya Byerly
- Division of Trauma Surgery and Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, California; and
| | - Erika Falsgraf
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | - Elizabeth Benjamin
- Division of Trauma Surgery and Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, California; and
| | - Aaron Strumwasser
- Division of Trauma Surgery and Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, California; and
| | - Jean-Stephane David
- Department of Anesthesia and Intensive Care, Lyon Sud University Hospital, Hospices Civils de Lyon, Pierre Benite and Lyon Sud School of Medicine, Claude Bernard Lyon 1 University, Oullins, France
| | - Demetrios Demetriades
- Division of Trauma Surgery and Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, California; and
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Wolfson DL, Tandoh MA, Jindal M, Forgione PM, Harder VS. Adult Intraosseous Access by Advanced EMTs: A Statewide Non-Inferiority Study. PREHOSP EMERG CARE 2016; 21:7-13. [DOI: 10.1080/10903127.2016.1209262] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Celık T, Ozturk C, Balta S, Demırkol S, Iyısoy A. A new route to life in patients with circulatory shock: intraosseous route. Am J Emerg Med 2016; 34:922-3. [DOI: 10.1016/j.ajem.2016.02.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 02/09/2016] [Indexed: 11/30/2022] Open
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Assessment of trauma patients. Int J Orthop Trauma Nurs 2016; 21:21-30. [DOI: 10.1016/j.ijotn.2015.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 10/06/2015] [Accepted: 10/12/2015] [Indexed: 11/17/2022]
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Petitpas F, Guenezan J, Vendeuvre T, Scepi M, Oriot D, Mimoz O. Use of intra-osseous access in adults: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:102. [PMID: 27075364 PMCID: PMC4831096 DOI: 10.1186/s13054-016-1277-6] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 03/31/2016] [Indexed: 11/10/2022]
Abstract
Background Indications for intra-osseous (IO) infusion are increasing in adults requiring administration of fluids and medications during initial resuscitation. However, this route is rarely used nowadays due to a lack of knowlegde and training. We reviewed the current evidence for its use in adults requiring resuscitative procedures, the contraindications of the technique, and modalities for catheter implementation and skill acquisition. Methods A PubMed search for all articles published up to December 2015 was performed by using the terms “Intra-osseous” AND “Adult”. Additional articles were included by using the “related citations” feature of PubMed or checking references of selected articles. Editorials, comments and case reports were excluded. Abstracts of all the articles that the search yielded were independently screened for eligibility by two authors and included in the analysis after mutual consensus. In total, 84 full-text articles were reviewed and 49 of these were useful for answering the following question “when, how, and for which population should an IO infusion be used in adults” were selected to prepare independent drafts. Once this step had been completed, all authors met, reviewed the drafts together, resolved disagreements by consensus with all the authors, and decided on the final version. Results IO infusion should be implemented in all critical situations when peripheral venous access is not easily obtainable. Contraindications are few and complications are uncommon, most of the time bound to prolonged use. The IO infusion allows for blood sampling and administration of virtually all types of fluids and medications including vasopressors, with a bioavailability close to the intravenous route. Unfortunately, IO infusion remains underused in adults even though learning the technique is rapid and easy. Conclusions Indications for IO infusion use in adults requiring urgent parenteral access and having difficult intravenous access are increasing. Physicians working in emergency departments or intensive care units should learn the procedures for catheter insertion and maintenance, the contraindications of the technique, and the possibilities this access offers. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1277-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- F Petitpas
- Department of Anesthesiology and Intensive Care, University Hospital of Poitiers, 86021 Poitiers, France.,Laboratory of Anatomy, Biomechanics and Simulation, University Hospital of Poitiers, 86021, Poitiers, France
| | - J Guenezan
- Emergency Department, University Hospital of Poitiers, 86021 Poitiers, France.
| | - T Vendeuvre
- Orthopedic Surgical Department, University Hospital of Poitiers, 86021, Poitiers, France
| | - M Scepi
- Laboratory of Anatomy, Biomechanics and Simulation, University Hospital of Poitiers, 86021, Poitiers, France.,Emergency Department, University Hospital of Poitiers, 86021 Poitiers, France
| | - D Oriot
- Laboratory of Anatomy, Biomechanics and Simulation, University Hospital of Poitiers, 86021, Poitiers, France.,Pediatric Emergency Department, University Hospital of Poitiers, 86021, Poitiers, France
| | - O Mimoz
- Department of Anesthesiology and Intensive Care, University Hospital of Poitiers, 86021 Poitiers, France.,Emergency Department, University Hospital of Poitiers, 86021 Poitiers, France
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Lieberman P, Nicklas RA, Randolph C, Oppenheimer J, Bernstein D, Bernstein J, Ellis A, Golden DBK, Greenberger P, Kemp S, Khan D, Ledford D, Lieberman J, Metcalfe D, Nowak-Wegrzyn A, Sicherer S, Wallace D, Blessing-Moore J, Lang D, Portnoy JM, Schuller D, Spector S, Tilles SA. Anaphylaxis--a practice parameter update 2015. Ann Allergy Asthma Immunol 2016; 115:341-84. [PMID: 26505932 DOI: 10.1016/j.anai.2015.07.019] [Citation(s) in RCA: 299] [Impact Index Per Article: 37.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 07/12/2015] [Indexed: 12/12/2022]
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Comparison of the Fluid Resuscitation Rate with and without External Pressure Using Two Intraosseous Infusion Systems for Adult Emergencies, the CITRIN (Comparison of InTRaosseous infusion systems in emergency medicINe)-Study. PLoS One 2015; 10:e0143726. [PMID: 26630579 PMCID: PMC4668027 DOI: 10.1371/journal.pone.0143726] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 11/08/2015] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Intraosseous infusion is recommended if peripheral venous access fails for cardiopulmonary resuscitation or other medical emergencies. The aim of this study, using body donors, was to compare a semi-automatic (EZ-IO®) device at two insertion sites and a sternal intraosseous infusion device (FASTR™). METHODS Twenty-seven medical students being inexperienced first-time users were randomized into three groups using EZ-IO and FASTR. The following data were evaluated: attempts required for successful placement, insertion time and flow rates with and without external pressure to the infusion. RESULTS The first-pass insertion success of the EZ-IO tibia, EZ-IO humerus and FASTR was 91%, 77%, and 95%, respectively. Insertion times (MW ± SD) did not show significant differences with 17 ± 7 (EZ-IO tibia) vs. 29 ± 42 (EZ-IO humerus) vs. 33 ± 21 (FASTR), respectively. One-minute flow rates using external pressures between 0 mmHg and 300 mmHg ranged between 27 ± 5 to 69 ± 54 ml/min (EZ-IO tibia), 16 ± 3 to 60 ± 44 ml/min (EZ-IO humerus) and 53 ± 2 to 112 ± 47 ml/min (FASTR), respectively. Concerning pressure-related increases in flow rates, negligible correlations were found for the EZ-IO tibia in all time frames (c = 0.107-0.366; p ≤ 0.013), moderate positive correlations were found for the EZ-IO humerus after 5 minutes (c = 0.489; p = 0.021) and strong positive correlations were found for the FASTR in all time frames (c = 0.63-0.80; p ≤ 0.007). Post-hoc statistical power was 0.62 with the given sample size. CONCLUSIONS The experiments with first-time users applying EZ-IO and FASTR in body donors indicate that both devices may be effective intraosseous infusion devices, likely suitable for fluid resuscitation using a pressure bag. Variations in flow rate may limit their reliability. Larger sample sizes will prospectively be required to substantiate our findings.
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The Use of Intraosseous Fluid Resuscitation in a Pediatric Patient with Ebola Virus Disease. J Emerg Med 2015; 49:962-4. [DOI: 10.1016/j.jemermed.2015.06.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 06/01/2015] [Indexed: 11/19/2022]
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Suominen PK, Nurmi E, Lauerma K. Intraosseous access in neonates and infants: risk of severe complications - a case report. Acta Anaesthesiol Scand 2015; 59:1389-93. [PMID: 26300243 DOI: 10.1111/aas.12602] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Revised: 07/20/2015] [Accepted: 08/02/2015] [Indexed: 11/29/2022]
Abstract
Gaining vascular access in a neonate during cardiopulmonary resuscitation is crucial and challenging. Intraosseous (IO) access can offer a fast and reliable method for achieving emergency access for fluids and drugs when venous access fails in a critically ill child. IO access can however result in rare, but serious adverse events including compartment syndrome and amputation. We describe a case resulting in leg amputation due to IO infusion in a neonate after resuscitation and therapeutic hypothermia. We compared 10 tibia X-rays in three age groups. The mean medullary diameter of the proximal tibia at the recommended site for IO access was 7 mm in neonate, 10 mm in 1- to 12-month-old infants, and 12 mm in 3- to 4-year-old children. This provides a narrow margin of safety for the correct positioning and the avoidance of dislodgement of the IO needle. The correct position of the IO needle should be confirmed by bone marrow aspiration and fluid bolus. Unnecessary touching of the IO needle after fixing it in place should be avoided by inserting a luer-lock catheter with a three-way stop-cock for IO drug and fluid administration. Regular observation of the circulation and possible swelling of the leg should be performed. The IO administration of inotropic infusions should also be avoided after the initial resuscitation phase. When treating with therapeutic hypothermia, it may be wise to remove the IO needle much earlier than the currently recommended 24 h because of the problems in peripheral circulation and its monitoring.
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Affiliation(s)
- P. K. Suominen
- Department of Anaesthesia and Intensive Care; Children's Hospital, University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - E. Nurmi
- Department of Anaesthesia and Intensive Care; Children's Hospital, University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - K. Lauerma
- HUS Medical Imaging Center, Radiology; Children's Hospital, University of Helsinki and Helsinki University Hospital; Helsinki Finland
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Sá RARD, Melo CL, Dantas RB, Delfim LVV. Vascular access through the intraosseous route in pediatric emergencies. Rev Bras Ter Intensiva 2015; 24:407-14. [PMID: 23917941 PMCID: PMC4031810 DOI: 10.1590/s0103-507x2012000400019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Accepted: 11/27/2012] [Indexed: 11/21/2022] Open
Abstract
Obtaining venous access in critically ill children is an essential procedure to
restore blood volume and administer drugs during pediatric emergencies. The first
option for vascular access is through a peripheral vein puncture. If this route
cannot be used or if a prolonged period of access is necessary, then the intraosseous
route is an effective option for rapid and safe venous access. The present work is a
descriptive and exploratory literature review. The study's aim was to describe the
techniques, professional responsibilities, and care related to obtaining venous
access via the intraosseous route in pediatric emergencies. We selected 22 articles
(published between 2000 and 2011) that were available in the Latin American and
Caribbean Health Sciences (LILACS) and MEDLINE databases and the SciELO electronic
library, in addition to the current protocol of cardiopulmonary resuscitation from
the American Heart Association (2010). After the literature search, data were pooled
and grouped into the following categories of analysis: historical aspects and
physiological principles; indications, benefits, and contraindications; professional
assignments; technical principles; care during the access; and possible
complications. The results of the present study revealed that the intraosseous route
is considered the main secondary option for vascular access during the emergency
response because the technique is quick and easily executed, presents several
non-collapsible puncture sites, and enables the rapid and effective administration of
drugs and fluid replacement.
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Overbey JK, Kon AA. Dermal Abrasion Experienced as an Adverse Effect of the EZ-IO(®). J Emerg Med 2015; 50:e7-10. [PMID: 26603361 DOI: 10.1016/j.jemermed.2015.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 08/26/2015] [Accepted: 09/04/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND In 2007, an update was released to the pediatric and neonatal septic shock guidelines, which emphasized early use of therapies, specifically, first-hour fluid resuscitation and inotrope therapy. This has led to increased use of intraosseous (IO) access as a source of vascular access. Previously, IO access could be obtained only via a manual IO placement. New semi-automatic devices, such as EZ-IO(®) (Vidacare, Shavano Park, TX), allow for safer and quicker IO access. Data support the use of semi-automatic devices during the acute resuscitation period. CASE REPORT The patient was a 7-month old girl with VACTERL association (Vertebral defects, Anal atresia, Cardiac defects, Tracheo-Esophageal fistula, Renal anomalies, Limb abnormalities) and complex past medical history. The patient experienced a "choking episode," which led to subsequent apnea and cyanosis. The patient presented in shock to a local pediatric emergency department. After multiple unsuccessful intravenous line attempts, IO access was obtained using the EZ-IO(®). Once in the pediatric intensive care unit with venous access, the IO device was removed and the site had "red bulls-eye target shape" damage to the skin, which appeared consistent with the EZ-IO(®) flange. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: IO device use is increasing due to the most recent pediatric and neonatal septic shock guidelines, which emphasize first-hour fluid resuscitation and inotrope therapy. It is vital that emergency physicians be aware of the adverse effects of semi-automatic IO devices, including dermal abrasion, which has not been reported previously. With proper training and familiarity, it is possible to avoid dermal abrasion as an adverse effect of the semi-automatic IO device.
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Affiliation(s)
- Jamie K Overbey
- Department of Pediatrics, Naval Medical Center San Diego, San Diego, California
| | - Alexander A Kon
- Department of Pediatrics, Naval Medical Center San Diego, San Diego, California; Department of Pediatrics, University of California San Diego, San Diego, California
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Benson G. Intraosseous access to the circulatory system: An under-appreciated option for rapid access. J Perioper Pract 2015; 25:140-143. [PMID: 26312264 DOI: 10.1177/1750458915025007-805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
In many emergency situations rapid vascular access is a priority, particularly in cases involving haemodynamic compromise. Traditional vascular access through the use of an intravenous cannula, although the preferred first line method, can in certain circumstances have a high rate of failure. A study by Minville et al (2006) showed that the success rate of first attempt venous cannulation can be as low as 76%. Repeated attempts at venous cannulation in patients with difficult vascular access wastes valuable time which in some situations could prove fatal.
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Joanne G, Stephen P, Susan S. Intraosseous vascular access in critically ill adults-a review of the literature. Nurs Crit Care 2015; 21:167-77. [PMID: 25688586 DOI: 10.1111/nicc.12163] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Revised: 12/04/2014] [Accepted: 01/07/2015] [Indexed: 12/01/2022]
Affiliation(s)
- Garside Joanne
- Division of acute care; University of Huddersfield; Queensgate, Huddersfield, West Yorkshire UK
| | - Prescott Stephen
- Division of acute care; University of Huddersfield; Queensgate, Huddersfield, West Yorkshire UK
| | - Shaw Susan
- Calderdale and Huddersfield NHS Foundation Trust; Halifax UK
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Helm M, Haunstein B, Schlechtriemen T, Ruppert M, Lampl L, Gäßler M. EZ-IO(®) intraosseous device implementation in German Helicopter Emergency Medical Service. Resuscitation 2014; 88:43-7. [PMID: 25553609 DOI: 10.1016/j.resuscitation.2014.12.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 12/10/2014] [Accepted: 12/20/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Intraosseous access (IO) is a rapid and safe alternative when peripheral venous access is difficult. Our aim was to summarize the first three years experience with the use of a semi-automatic IO device (EZ-IO(®)) in German Helicopter Emergency Medical Service (HEMS). METHODS Included were all patients during study period (January 2009-December 2011) requiring an IO access performed by HEMS team. Outcome variables were IO rate, IO insertion success rates, site of IO access, type of EZ-IO(®) needle set used, strategy of vascular access, procedure related problems and operator's satisfaction. RESULTS IO rate was 0.3% (348/120.923). Overall success rate was 99.6% with a first attempt success rate of 85.9%; there was only one failure (0.4%). There were three insertion sites: proximal tibia (87.2%), distal tibia (7.5%) and proximal humerus (5.3%). Within total study group IO was predominantly the second-line strategy (39% vs. 61%, p<0.001), but in children<7 years, in trauma cases and in cardiac arrest IO was more often first-line strategy (64% vs. 28%, p<0.001; 48% vs. 34%, p<0.032; 50% vs. 29%, p<0.002 respectively). Patients with IO access were significantly younger (41.7±28.7 vs. 56.5±24.4 years; p<0.001), more often male (63.2% vs. 57.7%; p=0.037), included more trauma cases (37.3% vs. 30.0%; p=0.003) and more often patients with a NACA-Score≥5 rating (77.0% vs. 18.6%; p<0.001). Patients who required IO access generally presented with more severely compromised vital signs associated with the need for more invasive resuscitation actions such as intubation, chest drains, CPR and defibrillation. In 93% EZ-IO(®) needle set handling was rated "good". Problems were reported in 1.6% (needle dislocation 0.8%, needle bending 0.4% and parafusion 0.4%). CONCLUSIONS The IO route was generally used in the most critically ill of patients. Our relatively low rate of usage would indicate that this would be compatible with the recommendations of established guidelines. The EZ-IO(®) intraosseous device proved feasible with a high success rate in adult and pediatric emergency patients in HEMS.
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Affiliation(s)
- Matthias Helm
- Department of Anaesthesiology & Intensive Care Medicine - Section Emergency Medicine/HEMS "Christoph 22", Armed Forces Medical Centre Ulm, Germany.
| | - Benedikt Haunstein
- Department of Anaesthesiology & Intensive Care Medicine - Section Emergency Medicine/HEMS "Christoph 22", Armed Forces Medical Centre Ulm, Germany
| | - Thomas Schlechtriemen
- Medical Quality Management - ADAC Luftrettung (Subsidiary of the German Automobile Association), Munich, Germany
| | - Matthias Ruppert
- Department of Medicine - ADAC Luftrettung (Subsidiary of the German Automobile Association), Munich, Germany
| | - Lorenz Lampl
- Department of Anaesthesiology & Intensive Care Medicine - Section Emergency Medicine/HEMS "Christoph 22", Armed Forces Medical Centre Ulm, Germany
| | - Michael Gäßler
- Department of Medicine - ADAC Luftrettung (Subsidiary of the German Automobile Association), Munich, Germany
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Rubal BJ, Meyers BL, Kramer SA, Hanson MA, Andrews JM, DeLorenzo RA. Fat Intravasation from Intraosseous Flush and Infusion Procedures. PREHOSP EMERG CARE 2014; 19:376-90. [PMID: 25495011 DOI: 10.3109/10903127.2014.980475] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY HYPOTHESIS The primary study objective was to delineate the procedural aspects of intraosseous (IO) infusions responsible for fat intravasation by testing the hypothesis that the fat content of effluent blood increases during IO infusions. METHODS IO cannulas were inserted into the proximal tibiae of 35 anesthetized swine (Sus scrofa, 50.1 ± 3.5 kg) and intravasated fat was assessed using a lipophilic fluoroprobe (Nile red) and by vascular ultrasound imaging. Effluent blood bone marrow fat was assessed at baseline, during flush, and with regimens of controlled infusion pressures (73-300 mmHg) and infusion flow rates (0.3-3.0 mL per second). Fat intravasation was also assessed with IO infusions at different tibial cannulation sites and in the distal femur. In 7 animals, the lipid uptake of alveolar macrophages and lung tissue assessed for fat embolic burden using oil red O stain 24 hours post infusion. Additionally, bone marrow shear-strain was assessed radiographically with IO infusions. RESULTS Fat intravasation was observed during all IO infusion regimens, with subclinical pulmonary fat emboli persisting 24 hours post infusion. It was noted that initial flush was a significant factor in fat intravasation, low levels of intravasation occurred with infusions ≤300 mmHg, fat intravasation and bone marrow shear-strain increased with IO infusion rates, and intravasation was influenced by cannula insertion site. Ultrasound findings suggest that echogenic particles consistent with fat emboli are carried in fast and slow venous blood flow fields. Echo reflective densities were observed to rise to the nondependent endovascular margins and coalesce in accordance with Stoke's law. In addition, ultrasound findings suggested that intravasated bone marrow fat was thrombogenic. CONCLUSION Results suggest that in swine the intravasation of bone marrow fat is a common consequence of IO infusion procedures and that its magnitude is influenced by the site of cannulation and infusion forces. Although the efficacy and benefits of IO infusions for emergent care are well established, emergency care providers also should be cognizant that infusion procedures affect bone marrow fat intravasation.
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Faminu F. Intraosseous vascular access: Boning up on the basics. Nursing 2014; 44:60-64. [PMID: 25025256 DOI: 10.1097/01.nurse.0000451529.25093.4b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Femi Faminu
- Femi Faminu is a BLS and ACLS training center coordinator for the Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, Calif. The author has disclosed that she has no financial relationships related to this article
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Abstract
Abstract
Intraosseous vascular access is a time-tested procedure which has been incorporated into the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation. Intravenous access is often difficult to achieve in shock patients, and central line placement can be time consuming. Intraosseous vascular access, however, can be achieved quickly with minimal disruption of chest compressions. Newer insertion devices are easy to use, making the intraosseous route an attractive alternative for venous access during a resuscitation event. It is critical that anesthesiologists, who are often at the forefront of patient resuscitation, understand how to properly use this potentially life-saving procedure.
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Abbal B, Perbet S, Pereira B, Colomb S, Ehrmann S, Bazin JE, Constantin JM. [Use of the intraosseous access in adult patients in France in 2012]. ACTA ACUST UNITED AC 2014; 33:221-6. [PMID: 24631005 DOI: 10.1016/j.annfar.2014.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 02/04/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate theoretical and practical knowledges of intraosseous (IO) access in adults patients in France in 2012. STUDY DESIGN National observational descriptive transversal study as survey of opinion and practices. MATERIALS AND METHODS An email, with an URL to online computerized quiz, was sent to residents and medical doctors who were working, in France, in anesthesiologist units, intensive care units or emergency units. Several questions were asked about theoretical and practical knowledges concerning IO access. RESULTS After 1359 responses, 396 (29%) practitioners have used an IO kit mainly in case of cardiopulmonary arrest in adults (68%). The insurance of operators in this technique and the rate of physicians who has even put an IO catheter increased with the years of experience of physicians. The reasons given for not using an IO access were no trouble placing a peripheral vein (77%) and unfamiliarity with the equipment and technology (32%). Most of practitioners (753 [55%]) have been trained and 90% (n=265) of untrained doctors believe that training was necessary. The powered system was the most used (71%). CONCLUSION Only 29% of practitioners have ever used an IO kit. With the new IO kits, a theoretical and practical training is needed to ensure IO kit used.
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Affiliation(s)
- B Abbal
- Département d'anesthésie-réanimation, réanimation adultes & USC, CHU de Clermont-Ferrand, CHU Estaing, 1, place Lucie-et-Raymond-Aubrac, 63003 Clermont-Ferrand cedex, France; Département d'anesthésie-réanimation, hôpital Lapeyronie, CHU de Montpellier, 34295 Montpellier cedex 5, France
| | - S Perbet
- Département d'anesthésie-réanimation, réanimation adultes & USC, CHU de Clermont-Ferrand, CHU Estaing, 1, place Lucie-et-Raymond-Aubrac, 63003 Clermont-Ferrand cedex, France; Faculté de médecine, R2D2, EA 7281, université d'Auvergne, 63001 Clermont-Ferrand, France; Faculté de médecine, université d'Auvergne, centre de simulation CAUMSSI, 63001 Clermont-Ferrand, France.
| | - B Pereira
- Direction de la recherche clinique et de l'innovation, biostatistiques, CHU de Clermont-Ferrand, CHU Gabriel-Montpied, 63003 Clermont-Ferrand, France
| | - S Colomb
- Faculté de médecine, université d'Auvergne, centre de simulation CAUMSSI, 63001 Clermont-Ferrand, France; Département d'anesthésie-réanimation, réanimation médico-chirurgicale, CHU de Clermont-Ferrand, CHU Gabriel-Montpied, 63003 Clermont-Ferrand, France
| | - S Ehrmann
- Réanimation médicale, CHU de Tours, 37000 Tours, France
| | - J-E Bazin
- Département d'anesthésie-réanimation, réanimation adultes & USC, CHU de Clermont-Ferrand, CHU Estaing, 1, place Lucie-et-Raymond-Aubrac, 63003 Clermont-Ferrand cedex, France; Faculté de médecine, université d'Auvergne, centre de simulation CAUMSSI, 63001 Clermont-Ferrand, France
| | - J-M Constantin
- Département d'anesthésie-réanimation, réanimation adultes & USC, CHU de Clermont-Ferrand, CHU Estaing, 1, place Lucie-et-Raymond-Aubrac, 63003 Clermont-Ferrand cedex, France; Faculté de médecine, R2D2, EA 7281, université d'Auvergne, 63001 Clermont-Ferrand, France; Faculté de médecine, université d'Auvergne, centre de simulation CAUMSSI, 63001 Clermont-Ferrand, France
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Hallas P, Brabrand M, Folkestad L. Complication with intraosseous access: scandinavian users' experience. West J Emerg Med 2013; 14:440-3. [PMID: 24106537 PMCID: PMC3789903 DOI: 10.5811/westjem.2013.1.12000] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2012] [Revised: 12/11/2012] [Accepted: 01/29/2013] [Indexed: 11/16/2022] Open
Abstract
Introduction: Intraosseous access (IO) is indicated if vascular access cannot be quickly established during resuscitation. Complication rates are estimated to be low, based on small patient series, model or cadaver studies, and case reports. However, user experience with IO use in real-life emergency situations might differ from the results in the controlled environment of model studies and small patient series. We performed a survey of IO use in real-life emergency situations to assess users’ experiences of complications. Methods: An online questionnaire was sent to Scandinavian emergency physicians, anesthesiologists and pediatricians. Results: 1,802 clinical cases of IO use was reported by n=386 responders. Commonly reported complications with establishing IO access were patient discomfort/pain (7.1%), difficulties with penetration of periosteum with IO needle (10.3%), difficulties with aspiration of bone marrow (12.3%), and bended/broken needle (4.0%). When using an established IO access the reported complications were difficulties with injection fluid and drugs after IO insertion (7.4%), slow infusion (despite use of pressure bag) (8.8%), displacement after insertion (8.5%), and extravasation (3.7%). Compartment syndrome and osteomyelitis occurred in 0.6% and 0.4% of cases respectively. Conclusion: In users’ recollection of real-life IO use, perceived complications were more frequent than usually reported from model studies. The perceived difficulties with using IO could affect the willingness of medical staff to use IO. Therefore, user experience should be addressed both in education of how to use, and research and development of IOs.
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Affiliation(s)
- Peter Hallas
- Copenhagen University Hospital, Department of Pediatric Anesthesia, Rigshospitalet, Denmark
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