Fat embolism with the use of intraosseous infusion during cardiopulmonary resuscitation

Fat intravasation, fat emboli and fat embolism syndrome in adult major trauma patients with intraosseous catheters: a systematic review

INTRODUCTION

Intraosseous (IO) administration of medication, fluids and blood products is accepted practice for critically injured patients in whom intravenous access is not immediately available. However, there are concerns that high intramedullary pressures resulting from IO infusion may cause bone marrow intravasation and subsequent fat embolisation. The aim of this systematic review is to synthesise the existing evidence describing fat intravasation, fat embolism and fat embolism syndrome (FES) following IO infusion.

METHODS

A systematic search of CINAHL, MEDLINE and Embase was undertaken using the search terms "intraosseous", "fat embolism", "fat intravasation" and "fat embolism syndrome". Two authors independently screened abstracts and full texts, against eligibility criteria and assessed risk of bias. A grey literature search (including references) was undertaken. Inclusion criteria were: all human and animal studies reporting novel data on IO-associated fat emboli. This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis.

RESULTS

22 papers were identified from the search, with a further 5 found from reference lists. N=7 full papers met inclusion criteria. These papers were all translational animal studies. The overall risk of bias was high. Studies demonstrated that fat intravasation and fat embolisation are near universal after IO infusion, but of uncertain clinical significance. The initial IO flush appears to cause the highest intramedullary pressure and highest chance of fat intravasation and embolisation. No conclusions could be drawn on FES.

CONCLUSIONS

IO catheters remain a useful intervention in the armamentarium of trauma clinicians. Although their use is widely accepted, there is a paucity of evidence investigating fat embolisation in IO infusions. Despite this, pulmonary fat emboli after IO infusion are very common. The existing data are of low quality with a high risk of bias. More research is needed to address this important subject.

PROSPERO REGISTRATION NUMBER

CRD42023399333.

Fat embolism after intraosseous catheters in pediatric forensic autopsies

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.

Intraosseous fluid resuscitation causes systemic fat emboli in a porcine hemorrhagic shock model

BACKGROUND

Intraosseous cannulation can be life-saving when intravenous access cannot be readily achieved. However, it has been shown that the procedure may cause fat emboli to the lungs and brain. Fat embolization may cause serious respiratory failure and fat embolism syndrome. We investigated whether intraosseous fluid resuscitation in pigs in hemorrhagic shock caused pulmonary or systemic embolization to the heart, brain, or kidneys and if this was enhanced by open chest conditions.

METHODS

We induced hemorrhagic shock in anesthetized pigs followed by fluid-resuscitation through bilaterally placed tibial (hind leg) intraosseous cannulas. The fluid-resuscitation was limited to intraosseous or i.v. fluid therapy, and did not involve cardiopulmonary resuscitation or other interventions. A subgroup underwent median sternotomy with pericardiectomy and pleurotomy before hemorrhagic shock was induced. We used invasive hemodynamic and respiratory monitoring including Swan Ganz pulmonary artery catheter and transesophageal echocardiography and obtained biopsies from the lungs, heart, brain, and left kidney postmortem.

RESULTS

All pigs exposed to intraosseous infusion had pulmonary fat emboli in postmortem biopsies. Additionally, seven of twenty-one pigs had coronary fat emboli. None of the pigs with open chest had fat emboli in postmortem lung, heart, or kidney biopsies. During intraosseous fluid-resuscitation, three pigs developed significant ST-elevations on ECG; all of these animals had coronary fat emboli on postmortem biopsies.

CONCLUSIONS

Systemic fat embolism occurred in the form of coronary fat emboli in a third of the animals who underwent intraosseous fluid resuscitation. Open chest conditions did not increase the incidence of systemic fat embolization.

Frequency and intensity of pulmonary bone marrow and fat embolism due to manual or automated chest compressions during cardiopulmonary resuscitation

Iatrogenic consequences of cardiopulmonary resuscitation (CPR) include sternal or rib fractures, pulmonary bone marrow embolisms (BME) and fat embolisms (FE). This report aimed to analyze the frequency and intensity of pulmonary BME and FE in fatal cases receiving final CPR efforts with the use of automated chest compression devices (ACCD) or manual chest compressions (mCC). The study cohort (all cardiac causes of death, no ante-mortem fractures) consisted of 15 cases for each group 'ACCD', 'mCC' and 'no CPR'. Lung tissue samples were retrieved and stained with hematoxylin eosin (n = 4 each) and Sudan III (n = 2 each). Evaluation was conducted microscopically for any existence of BME or FE, the frequency of BME-positive vessels, vessel size for BME and the graduation according to Falzi for FE. The data were compared statistically using non-parametric analyses. All groups were matched except for CPR duration (ACCD > mCC) but this time interval was linked to the existence of pulmonary BME (p = 0.031). Both entities occur in less than 25% of all cases following unsuccessful CPR. BME was only detectable in CPR cases, but was similar between ACCD and mCC cases for BME frequency (p = 0.666), BME intensity (p = 0.857) and the size of BME-affected pulmonary vessels (p = 0.075). If any, only mild pulmonary FE (grade I) was diagnosed without differences in the CPR method (p = 0.624). There was a significant correlation between existence of BME and FE (p = 0.043). Given the frequency, intensity and size of pulmonary BME and FE following CPR, these conditions may unlikely be considered as causative for death in case of initial survival but can be found in lower frequencies in autopsy histology.

Use of intra-osseous access in adults: a systematic review

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.

Fat Intravasation from Intraosseous Flush and Infusion Procedures

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.

Intraosseous line use, complications, and outcomes among a population-based cohort of children presenting to California hospitals

OBJECTIVES

Intraosseous line (IO) use has been described in prehospital settings, with some studies in the emergency department (ED). However, population-based studies describing IO line use across diverse ED and hospital settings are sparse, and the true incidence of complications remains unknown.

METHODS

This was a retrospective cohort study using administrative data from 450 California hospitals and EDs. We included all children aged 0 to 18 years with ED or inpatient visits from 2005 through 2007. CPT (Current Procedural Terminology) and ICD-9 (International Classification of Diseases, Ninth Revision) codes were used to identify IO line use. ICD-9 diagnosis codes were searched for potential complications related to IO line use including compartment syndrome, fracture, and osteomyelitis. Descriptive statistics were used to calculate incidence of use, outcomes, and hospital setting with IO line use.

RESULTS

Two hundred ninety-one children had IO lines placed in 90 hospitals, including 239 in the ED and 52 inpatient. There were 6,660,564 pediatric ED visits and 2,276,231 pediatric admissions, resulting in an incidence of IO line placement of 0.04 per 1000 ED visits and 0.02 per 1000 admissions. Mortality was 37% among patients with IO line placement. The most common diagnoses included cardiac arrest (34%), trauma (19%), and respiratory failure (6%). Types of hospital in which IO lines were placed included children's hospitals 14%, general hospitals 86%, and rural hospitals 7.9%. No complications were identified.

CONCLUSIONS

The overall incidence of IO line use in the ED and hospital setting is low, but IO line access is used in a variety of different hospital and ED settings for high-acuity conditions. No IO line complications were identified.

Evaluation of the bone injection gun as a method for intraosseous cannula placement for fluid therapy in adult dogs

OBJECTIVE

To evaluate the Bone Injection Gun (BIG) for placement of intraosseous cannulas through impact penetration and compare it with a standard Jamshidi bone marrow needle (JBMN) and to compare fluid delivery dynamics through each device.

STUDY DESIGN

Randomized in vivo study.

ANIMALS

Forty-eight mature dogs.

METHODS

During surgical laboratories, dogs were randomly assigned to 2 groups (n = 24), and intraosseous access in the proximal tibial metaphysis was obtained using a BIG or JBMN. Variables measured during placement included insertion success, time required for placement, and alterations in respiratory rate (RR), heart rate (HR), and systolic blood pressure. After placement, maintenance fluids were administered to 6 dogs from each group, and fluids were administered under pressure to 6 dogs from each group to compare rates of delivery through each device. After euthanasia, the tibiae were harvested to evaluate and compare the morphologic consequences of needle and cannula placement.

RESULTS

Successful placement occurred in 20 (83%) dogs for the BIG and 23 (96%) dogs for the JBMN, which was not significantly different (P =.3475). Time required for placement was significantly less (P =.0024) for the BIG (mean, 22.4 +/- 8.2 seconds) compared with the JBMN (mean, 42.0 +/- 28.1 seconds). Significant increases in RR occurred in both groups and in the HR for the BIG group, but significant differences were not noted between groups. Mean rate of pressurized fluid administration was similar for both groups. Two distinct patterns of cortical bone damage occurred, but the clinical significance of this observation is uncertain.

CONCLUSIONS

The BIG provides more rapid access to the intraosseous space for fluid administration than the JBMN.

CLINICAL RELEVANCE

The BIG is an effective alternative for obtaining rapid access to the intraosseous space for emergency fluid and drug administration.

Excretory urography by intraosseous injection of contrast media in a rabbit model

There are many indications for an intravenous excretory urogram. However, where intravenous access is not available, the intraosseous route to the circulation may be an alternative. We found that safe and diagnostic excretory urograms could be obtained in rabbits following the injection of different contrast media via the intraosseous route. In fact, these excretory urograms were indistinguishable from ones obtained by the conventional intravenous route. While the rabbits did not develop any abnormal clinical signs following the procedure, there were postmortem histologic lesions of osteochondrosis in 5 of 22 (22.7%) tibias receiving an intraosseous needle, but in none of the 14 tibias that did not receive an intraosseous needle. Further, the use of diatrizoate was associated with the development of osteochondrosis while the use of iopamidol was not.