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Rittblat M, Kotovich D, Tsur N, Beer Z, Radomislensky I, Gendler S, Almog O, Tsur AM, Avital G, Talmy T. Factors associated with failure of intraosseous access in prehospital trauma treatment by military medical personnel. BMJ Mil Health 2024:military-2024-002783. [PMID: 39384217 DOI: 10.1136/military-2024-002783] [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: 05/16/2024] [Accepted: 09/20/2024] [Indexed: 10/11/2024]
Abstract
INTRODUCTION Intraosseous devices have become an alternative to peripheral intravenous (PIV) access. Despite the established success of intraosseous devices in laboratory and simulator studies, there is a lack of data regarding their real-world utilisation in prehospital settings. Therefore, this study aims to evaluate the success rates of intraosseous access in a prehospital military context and identify factors associated with failure. METHODS Using the Israel Defense Forces (IDF) Trauma Registry, we retrospectively collected data from 2010 to 2023. The primary outcome was the first pass success rate of intraosseous access, and logistic regression models were applied to identify variables associated with first pass failure. RESULTS The study included 172 trauma patients who underwent attempted intraosseous access with 46.5% cases which were classified as military events. The median age was 22 years, and 17.3% were paediatric patients. First pass success was achieved in 67.4% of cases, with a cumulative success rate of 80.8% after multiple attempts. Moreover, significant differences were noted when examining the success rate of the three intraosseous devices used by the IDF teams, with the highest success rate being documented for the NIO Adult versus the EZ-IO or the BIG (81.4%; 76.7%; 62.4%). However, logistic regression analysis revealed that the number of PIV access attempts was the only variable significantly associated with decreased odds of achieving first pass intraosseous access. CONCLUSION These findings suggest that intraosseous devices are a viable alternative for establishing vascular access in prehospital military settings. However, success rates were slightly lower than previous reports, potentially due to the severity of injuries in the study cohort. Our analyses revealed a higher number of PIV access attempts correlated with reduced first pass intraosseous success, possibly stemming from caregiver proficiency in obtaining vascular access. Further research is needed to explore additional factors affecting intraosseous access success rates.
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Affiliation(s)
- Mor Rittblat
- Israeli Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel
- Department of Preventive Medicine and Epidemiology, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Military Medicine and 'Tzameret', Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Plastic and Reconstructive Surgery, Hadassah Hebrew University Medical Centre, Jerusalem, Israel
| | - D Kotovich
- Israeli Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel
- Department of Plastic and Reconstructive Surgery, Hadassah Hebrew University Medical Centre, Jerusalem, Israel
| | - N Tsur
- Israeli Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel
- Department of Plastic and Reconstructive Surgery, Hadassah Hebrew University Medical Centre, Jerusalem, Israel
| | - Z Beer
- Israeli Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel
- Department of Military Medicine and 'Tzameret', Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - I Radomislensky
- Israeli Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel
- The Israel National Center for Trauma & Emergency Medicine Research, Gertner Institute of Epidemiology and Health Policy Research, Tel Hashomer, Ramat Gan, Israel
| | - S Gendler
- Israeli Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel
| | - O Almog
- Israeli Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel
- Department of Military Medicine and 'Tzameret', Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - A M Tsur
- Israeli Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel
- Department of Otolaryngology-Head and Neck Surgery, Rabin Medical Center, Tel Aviv University, Petach Tiqva, Israel
| | - G Avital
- Israeli Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel
- Division of Anesthesia, Intensive Care & Pain Management, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - T Talmy
- Israeli Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel
- Department of Military Medicine and 'Tzameret', Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
- Division of Anesthesia, Intensive Care & Pain Management, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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Gehrz JA, Kay VC, Grady DW, Emerling AD, McGowan A, Reilly ER, Bebarta VS, Nassiri J, Viñals J, Zarow GJ, Auten JD. The relationship between intraosseous catheter tip placement, flow rates, and infusion pressures in a high bone density cadaveric swine ( Sus scrofa) model. J Am Coll Emerg Physicians Open 2024; 5:e13184. [PMID: 38966284 PMCID: PMC11223065 DOI: 10.1002/emp2.13184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 03/14/2024] [Accepted: 04/18/2024] [Indexed: 07/06/2024] Open
Abstract
Background Intraosseous (IO) infusion is a life-preserving technique when intravenous access is unobtainable. Successful IO infusion requires sufficiently high flow rates to preserve life but at low enough pressures to avoid complications. However, IO catheter tips are often misplaced, and the relative flow rates and pressures between IO catheter tips placed in medullary, trabecular, and cortical bone are not well described, which has important implications for clinical practice. Objectives We developed the Zone Theory of IO Catheter Tip Placement based on bone density and proximity to the venous central sinus and then tested the influence of catheter tip placement locations on flow rates and pressures in a cadaveric swine model. Methods Three cross-trained participants infused 500 mL of crystalloid fluid into cadaveric swine humerus and sternum (N = 210 trials total) using a push‒pull method with a 60 cm3 syringe. Computed tomography scans were scored by radiologists and categorized as zone 1 (medullary space), zone 2 (trabecular bone), or zone 3 (cortical bone) catheter tip placements. Differences between zones in flow rates, mean pressures, and peak pressures were assessed using analysis of variance and analysis of covariance to account for participant and site differences at the p < 0.05 threshold. Results Zone 1 and zone 2 placements were essentially identical in flow rates, mean pressures, and peak pressures (each p > 0.05). Zone 1 and zone 2 placements were significantly higher in flow rates and lower in pressures than zone 3 placements (each p < 0.05 or less). Conclusion Within the limitations of an unpressurized cadaveric swine model, the present findings suggest that IO catheter tip placements need not be perfect to acquire high flow rates at low pressures, only accurate enough to avoid the dense cortical bone of zone 3. Future research using in vivo animal and human models is needed to better define the clinical impact of IO catheter placement on infusion flow rates and pressures.
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Affiliation(s)
- Joseph A. Gehrz
- Combat Trauma Research GroupClinical Investigations DepartmentNaval Medical Center San DiegoSan DiegoCaliforniaUSA
- Department of Emergency MedicineNaval Medical Center San DiegoSan DiegoCaliforniaUSA
- Department of Military and Emergency MedicineUniformed Services University of the Health SciencesBethesdaMarylandUSA
| | - Victoria C. Kay
- Combat Trauma Research GroupClinical Investigations DepartmentNaval Medical Center San DiegoSan DiegoCaliforniaUSA
- Department of Emergency MedicineNaval Medical Center San DiegoSan DiegoCaliforniaUSA
| | - Derek W. Grady
- Department of RadiologyNaval Medical Center San DiegoSan DiegoCaliforniaUSA
| | - Alec D. Emerling
- Combat Trauma Research GroupClinical Investigations DepartmentNaval Medical Center San DiegoSan DiegoCaliforniaUSA
- Department of Emergency MedicineNaval Medical Center San DiegoSan DiegoCaliforniaUSA
- Department of Military and Emergency MedicineUniformed Services University of the Health SciencesBethesdaMarylandUSA
| | - Andrew McGowan
- Combat Trauma Research GroupClinical Investigations DepartmentNaval Medical Center San DiegoSan DiegoCaliforniaUSA
- Department of Emergency MedicineNaval Medical Center San DiegoSan DiegoCaliforniaUSA
- Department of Military and Emergency MedicineUniformed Services University of the Health SciencesBethesdaMarylandUSA
| | - Erin R. Reilly
- Combat Trauma Research GroupClinical Investigations DepartmentNaval Medical Center San DiegoSan DiegoCaliforniaUSA
- Department of Emergency MedicineNaval Medical Center San DiegoSan DiegoCaliforniaUSA
| | - Vikhyat S. Bebarta
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
- Department of Emergency MedicineCenter for COMBAT ResearchUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Joshua Nassiri
- Combat Trauma Research GroupClinical Investigations DepartmentNaval Medical Center San DiegoSan DiegoCaliforniaUSA
- Department of Military and Emergency MedicineUniformed Services University of the Health SciencesBethesdaMarylandUSA
- Department of RadiologyNaval Medical Center San DiegoSan DiegoCaliforniaUSA
| | - Jorge Viñals
- School of Physics and AstronomyUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Gregory J. Zarow
- Combat Trauma Research GroupClinical Investigations DepartmentNaval Medical Center San DiegoSan DiegoCaliforniaUSA
- The Emergency StatisticianIdyllwildCaliforniaUSA
| | - Jonathan D. Auten
- Combat Trauma Research GroupClinical Investigations DepartmentNaval Medical Center San DiegoSan DiegoCaliforniaUSA
- Department of Emergency MedicineNaval Medical Center San DiegoSan DiegoCaliforniaUSA
- Department of Military and Emergency MedicineUniformed Services University of the Health SciencesBethesdaMarylandUSA
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3
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Qasim ZA, Joseph B. Intraosseous access in the resuscitation of patients with trauma: the good, the bad, the future. Trauma Surg Acute Care Open 2024; 9:e001369. [PMID: 38646033 PMCID: PMC11029384 DOI: 10.1136/tsaco-2024-001369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 03/09/2024] [Indexed: 04/23/2024] Open
Abstract
The timely restoration of lost blood in hemorrhaging patients with trauma, especially those who are hemodynamically unstable, is of utmost importance. While intravenous access has traditionally been considered the primary method for vascular access, intraosseous (IO) access is gaining popularity as an alternative for patients with unsuccessful attempts. Previous studies have highlighted the higher success rate and easier training process associated with IO access compared with peripheral intravenous (PIV) and central intravenous access. However, the effectiveness of IO access in the early aggressive resuscitation of patients remains unclear. This review article aims to comprehensively discuss various aspects of IO access, including its advantages and disadvantages, and explore the existing literature on the clinical outcomes of patients with trauma undergoing resuscitation with IO versus intravenous access.
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Affiliation(s)
- Zaffer A Qasim
- Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Bellal Joseph
- Department of Surgery, The University of Arizona College of Medicine Tucson, Tucson, Arizona, USA
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Johnson D, Hensler JG, O'Sullivan J, Blouin D, de la Garza MA, Yauger Y. Effects of Endotracheal Epinephrine on Pharmacokinetics and Survival in a Swine Pediatric Cardiac Arrest Model. Pediatr Emerg Care 2024; 40:197-202. [PMID: 38416651 DOI: 10.1097/pec.0000000000003142] [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: 03/01/2024]
Abstract
OBJECTIVES The aim of this study was to compare the endotracheal tube (ET) and intravenous (IV) administration of epinephrine relative to concentration maximum, time to maximum concentration, mean concentration over time (MC), area under the curve, odds, and time to return of spontaneous circulation (ROSC) in a normovolemic pediatric cardiac arrest model. METHODS Male swine weighing 24-37 kg were assigned to 4 groups: ET (n = 8), IV (n = 7), cardiopulmonary resuscitation (CPR) + defibrillation (CPR + Defib) (n = 5), and CPR only (n = 3). Swine were placed arrest for 2 minutes, and then CPR was initiated for 2 minutes. Epinephrine (0.1 mg/kg) for the ET group or 0.01 mg/kg for the IV was administered every 4 minutes or until ROSC. Defibrillation started at 3 minutes and continued every 2 minutes for 30 minutes or until ROSC for all groups except the CPR-only group. Blood samples were collected over a period of 5 minutes. RESULTS The MC of plasma epinephrine for the IV group was significantly higher at the 30- and 60-second time points (P = 0.001). The ET group had a significantly higher MC of epinephrine at the 180- and 240-second time points (P < 0.05). The concentration maximum of plasma epinephrine was significantly lower for the ET group (195 ± 32 ng/mL) than for the IV group (428 ± 38 ng/mL) (P = 0.01). The time to maximum concentration was significantly longer for the ET group (145 ± 26 seconds) than for the IV group (42 ± 16 seconds) (P = 0.01). No significant difference existed in area under the curve between the 2 groups (P = 0.62). The odds of ROSC were 7.7 times greater for the ET versus IV group. Time to ROSC was not significantly different among the IV, ET, and CPR + Defib groups (P = 0.31). CONCLUSIONS Based on the results of this study, the ET route of administration should be considered a first-line intervention.
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Affiliation(s)
- Don Johnson
- From the US Army Graduate Program in Anesthesia Nursing, US Army Medical Center of Excellence, Fort Sam Houston, TX
| | - Julie G Hensler
- From the US Army Graduate Program in Anesthesia Nursing, US Army Medical Center of Excellence, Fort Sam Houston, TX
| | | | | | | | - Young Yauger
- TriService Nursing Research Program, Uniformed Services University, Bethesda, MD
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Miller C, Nardelli P, Hell T, Glodny B, Putzer G, Paal P. Sex differences in appropriate insertion depth for intraosseous access in adults: An exploratory radiologic single-center study. J Vasc Access 2024; 25:461-466. [PMID: 35922960 PMCID: PMC10938485 DOI: 10.1177/11297298221115412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 06/27/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Intraosseous access is a recommended alternative to venous access in emergencies. For its application, knowledge of the correct insertion depth is indispensable. We aimed to determine sex-specific differences on the appropriate insertion depth for intraosseous access in adults at the insertion sites most frequently used, namely the proximal and distal tibia and the proximal humerus. METHODS In this exploratory retrospective study, we measured thickness of soft tissue cover, cortex and cancellous bone along the puncture line on magnetic resonance images or computed tomography scans. Inclusion criteria were both sexes, 18-90 years of age and appropriate image quality. Primary outcome was the appropriate insertion depth to reach the cancellous bone for each sex. This was defined as the corridor between (i) the sum of the soft tissue cover and the cortex and (ii) the sum of (i) plus the diameter of the cancellous bone. Secondary outcomes were the differences in thickness of each layer between sexes. RESULTS In 179 females and males, the appropriate insertion depth was 32.5-45.5 mm and 20.5-42.0 mm in the proximal tibia, 14.5-30.5 mm and 16.5-34.5 mm in the distal tibia, and 27.5-52.5 mm and 26.0-56.5 mm in the proximal humerus. Although females had a thicker soft tissue cover (+6.8 mm [95% CI 3.7-10.1], p < 0.01) in the proximal tibia, extrapolation by correlation analysis showed no clinically relevant difference between the sexes. CONCLUSION In adults, there are no sex-specific differences in the appropriate insertion depth for intraosseous access in the proximal or distal tibia or in the proximal humerus.
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Affiliation(s)
- Clemens Miller
- Department of Anesthesiology, University Medical Centre Goettingen, Goettingen, Germany
| | - Paul Nardelli
- Department of Orthopedics and Traumatology, Medical University Innsbruck, Innsbruck, Austria
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Tobias Hell
- Department of Mathematics, Faculty of Mathematics, Computer Science and Physics, University of Innsbruck, Innsbruck, Austria
| | - Bernhard Glodny
- Department of Radiology, Medical University Innsbruck, Innsbruck, Austria
| | - Gabriel Putzer
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Peter Paal
- Department of Anesthesiology and Intensive Care Medicine, St. John of God Hospital, Paracelsus Medical University, Salzburg, Austria
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Kikodze N, Nemsadze K. Integration of Intraosseous Approach Method in Georgia. Pediatr Emerg Care 2024; 40:147-150. [PMID: 38221820 PMCID: PMC11444363 DOI: 10.1097/pec.0000000000003103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [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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Affiliation(s)
| | - Ketevan Nemsadze
- From the David Tvildiani Medical University
- Georgian National Academy of Sciences, Tbilisi, Georgia
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7
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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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Desai KK, Mann AJ, Azar F, Lottenberg L, Borrego R. Compartment Syndrome Resulting From Improper Intraosseous Cannulation: A Case Report. Cureus 2023; 15:e50248. [PMID: 38196424 PMCID: PMC10774495 DOI: 10.7759/cureus.50248] [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] [Accepted: 12/09/2023] [Indexed: 01/11/2024] Open
Abstract
Obtaining adequate vascular access is imperative for effective resuscitative, therapeutic, and diagnostic interventions. The intraosseous (IO) route is indicated when immediate vascular access is needed, and standard central or peripheral intravenous (IV) access is unattainable or would delay therapy in a critical patient. We present a rare case of improper IO line placement in the right proximal tibia of a 30-year-old female involved in a motor vehicle collision, resulting in extravasation of blood products into the surrounding tissue and development of acute compartment syndrome. Emergency Medical Services was unable to obtain IV access in a timely manner, thus a right proximal tibia 45mm IO line was placed, and a unit of whole blood was given with a high-pressure infusor in the field. At the trauma center, the patient's right lower extremity was severely tense and edematous with no palpable right lower extremity pulses and no Doppler signals. Computed tomography revealed the IO catheter extending through both the proximal and distal cortices of the right tibia. Medial and lateral fasciotomy of the right lower extremity was performed in which all four compartments of the right lower leg were released and a significant hematoma was evacuated from the superficial posterior compartment. This case highlights the importance of IO access as a life-saving intervention while also underscoring the need to educate and familiarize pre-hospital and hospital healthcare personnel in delivering IO access so as to mitigate risks and improve outcomes for critically ill patients.
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Affiliation(s)
- Kishan K Desai
- Department of Surgery, Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
- Department of Surgery, St. Mary's Medical Center, West Palm Beach, USA
| | - Adam J Mann
- Department of Surgery, Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
- Department of Surgery, St. Mary's Medical Center, West Palm Beach, USA
| | - Faris Azar
- Department of Surgery, Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
- Department of Surgery, St. Mary's Medical Center, West Palm Beach, USA
| | - Lawrence Lottenberg
- Department of Surgery, Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
- Department of Surgery, St. Mary's Medical Center, West Palm Beach, USA
| | - Robert Borrego
- Department of Surgery, Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
- Department of Surgery, St. Mary's Medical Center, West Palm Beach, USA
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Kyle AI, Auten JD, Zarow GJ, Natarajan R, Bianchi WD, Speicher MV, Palma J, Gaspary MJ. Determining Intraosseous Needle Placement Using Point-of-Care Ultrasound in a Swine (Sus scrofa) Model. Mil Med 2023; 188:2969-2974. [PMID: 35476019 DOI: 10.1093/milmed/usac108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/17/2022] [Accepted: 04/17/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Intraosseous (IO) access is critical in resuscitation, providing rapid access when peripheral vascular attempts fail. Unfortunately, misplacement commonly occurs, leading to possible fluid extravasation and tissue necrosis. Current research exploring the utility of bedside ultrasound in confirming IO line placement is limited by small sample sizes of skeletally immature subjects or geriatric cadaveric models. The objective of this study was to investigate the potential value of ultrasound confirming IO needle placement in a live tissue model with bone densities approximated to the young adult medical or trauma patient. MATERIALS AND METHODS In this randomized, blinded prospective study, IO devices were placed into the bilateral humeri of 36 sedated adult swine (N = 72) with bone densities approximating that of a 20-39-year-old adult. Of the 72 lines, 53 were randomized to the IO space ("correct") and 19 into the subcutaneous tissue ("incorrect"). Four emergency physicians with variable ultrasound experience and blinded to needle location independently assessed correct or incorrect needle placements based on the presence of an intramedullary "flare" on color power Doppler (CPD) during a saline flush. Participants adjusted the ultrasound beam trajectory and recorded assessments up to three times, totaling 204 separate observations. RESULTS Overall, sensitivity for placement confirmation was 72% (95% CI: 64%-79%). Specificity was 79% (95% CI: 66%-89%). First assessment and final assessment results were similar. More experienced sonographers demonstrated greater success in identifying inaccurate placements with a specificity of 86% (95% CI: 63%-96%). CONCLUSION Within the context of this study, point-of-care ultrasound with CPD did not reliably confirm IO line placement. However, more accurate assessments of functional and malpositioned catheters were noted in sonographers with greater than 4 years of experience. Future study into experienced sonographers' use of CPD to confirm IO catheter placement is needed.
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Affiliation(s)
- Adrianna I Kyle
- Clinical Investigation Department, Combat Trauma Research Group, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - Jonathan D Auten
- Clinical Investigation Department, Combat Trauma Research Group, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | | | - Ramesh Natarajan
- Clinical Investigation Department, Combat Trauma Research Group, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - William D Bianchi
- Clinical Investigation Department, Combat Trauma Research Group, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - Matthew V Speicher
- Clinical Investigation Department, Combat Trauma Research Group, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - James Palma
- Clinical Investigation Department, Combat Trauma Research Group, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - Micah J Gaspary
- Clinical Investigation Department, Combat Trauma Research Group, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
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Arias Constanti V, Domingo Garau A, Rodríguez Marrodán B, Villalobos Pinto E, Riaza Gómez M, García Soto L, Hernández Borges Á, Madrid Rodríguez A. Do not do recommendations in different paediatric care settings. An Pediatr (Barc) 2023; 98:291-300. [PMID: 36941186 DOI: 10.1016/j.anpede.2023.02.019] [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: 01/10/2023] [Accepted: 02/03/2023] [Indexed: 03/23/2023] Open
Abstract
INTRODUCTION There are many initiatives aimed at eliminating health care interventions of limited utility in clinical practice. The Committee on Care Quality and Patient Safety of the Spanish Association of Pediatrics (AEP) has proposed the development of "DO NOT DO" recommendations (DNDRs) to establish a series of practices to be avoided in the care of paediatric patients in primary, emergency, inpatient and home-based care. MATERIAL AND METHODS The project was carried out in 2 phases: a first phase in which possible DNDRs were proposed, and a second in which the final recommendations were established by consensus using the Delphi method. Recommendations were proposed and evaluated by members of the professional groups and paediatrics societies invited to participate in the project under the coordination of members of the Committee on Care Quality and Patient Safety. RESULTS A total of 164 DNDRs were proposed by the Spanish Society of Neonatology, the Spanish Association of Primary Care Paediatrics, the Spanish Society of Paediatric Emergency Medicine, the Spanish Society of Internal Hospital Paediatrics and the Medicines Committee of the AEP and the Spanish Group of Paediatric Pharmacy of the Spanish Society of Hospital Pharmacy. The initial set was limited to 42 DNDRs, and the selection over successive rounds yielded a final set of 25 DNDRs, with 5 DNDRs for each paediatrics group or society. CONCLUSIONS This project allowed the selection and establishment by consensus of a series of recommendations to avoid unsafe, inefficient or low-value practices in different areas of paediatric care, which may contribute to improving the safety and quality of paediatric clinical practice.
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Affiliation(s)
- Vanessa Arias Constanti
- Comité de Calidad Asistencial y Seguridad del Paciente de la Asociación Española de Pediatría; Sociedad Española de Urgencias Pediátricas (SEUP)
| | - Araceli Domingo Garau
- Comité de Calidad Asistencial y Seguridad del Paciente de la Asociación Española de Pediatría; Sociedad Española de Urgencias Pediátricas (SEUP)
| | - Belén Rodríguez Marrodán
- Comité de Calidad Asistencial y Seguridad del Paciente de la Asociación Española de Pediatría; Comité de Medicamentos de la AEP (CM-AEP) y el Grupo Español de Farmacia Pediátrica de la Sociedad Española de Farmacia Hospitalaria (GEFP-SEFH)
| | - Enrique Villalobos Pinto
- Comité de Calidad Asistencial y Seguridad del Paciente de la Asociación Española de Pediatría; Sociedad Española de Pediatría Interna Hospitalaria (SEPIH)
| | | | | | - Ángel Hernández Borges
- Comité de Calidad Asistencial y Seguridad del Paciente de la Asociación Española de Pediatría; Sociedad Española de Cuidados Intensivos Pediátricos (SECIP)
| | - Aurora Madrid Rodríguez
- Comité de Calidad Asistencial y Seguridad del Paciente de la Asociación Española de Pediatría.
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Wang D, Deng L, Zhang R, Zhou Y, Zeng J, Jiang H. Efficacy of intraosseous access for trauma resuscitation: a systematic review and meta-analysis. World J Emerg Surg 2023; 18:17. [PMID: 36918947 PMCID: PMC10012735 DOI: 10.1186/s13017-023-00487-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 02/28/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND During medical emergencies, intraosseous (IO) access and intravenous (IV) access are methods of administering therapies and medications to patients. Treating patients in emergency medical situations is a highly time sensitive practice; however, research into the optimal access method is limited and existing systematic reviews have only considered out-of-hospital cardiac arrest (OHCA) patients. We focused on severe trauma patients and conducted a systematic review to evaluate the efficacy and efficiency of intraosseous (IO) access compared to intravenous (IV) access for trauma resuscitation in prehospital care. MATERIALS AND METHOD PubMed, Web of Science, Cochrane Library, EMBASE, ScienceDirect, banque de données en santé publique and CNKI databases were searched for articles published between January 1, 2000, and January 31, 2023. Adult trauma patients were included, regardless of race, nationality, and region. OHCA patients and other types of patients were excluded. The experimental and control groups received IO and IV access, respectively, in the pre-hospital and emergency departments for salvage. The primary outcome was success rate on first attempt, which was defined as secure needle position in the marrow cavity or a peripheral vein, with normal fluid flow. Secondary outcomes included mean time to resuscitation, mean procedure time, and complications. RESULTS Three reviewers independently screened the literature, extracted the data, and assessed the risk of bias in the included studies; meta-analyses were then performed using Review Manager (Version 5.4; Cochrane, Oxford, UK). The success rate on first attempt was significant higher for IO access than for IV access (RR = 1.46, 95% CI [1.16, 1.85], P = 0.001). The mean procedure time was significantly reduced (MD = - 5.67, 95% CI [- 9.26, - 2.07], P = 0.002). There was no significant difference in mean time to resuscitation (MD = - 1.00, 95% CI [- 3.18, 1.17], P = 0.37) and complications (RR = 1.22, 95% CI [0.14, 10.62], P = 0.86) between the IO and IV groups. CONCLUSION The success rate on first attempt of IO access was much higher than that of IV access for trauma patients, and the mean procedure time of IO access was significantly less when compared to IV access. Therefore, IO access should be suggested as an urgent vascular access for hypotensive trauma patients, especially those who are under severe shock.
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Affiliation(s)
- Dong Wang
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32, Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China.,Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, 610072, China
| | - Lei Deng
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32, Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China.,Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, 610072, China.,Sichuan Province Clinical Research Center for Emergency and Critical Care Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Ruipeng Zhang
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32, Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China.,Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, 610072, China
| | - Yiyue Zhou
- Department of Biology, Sorbonne University, 75005, Paris, France
| | - Jun Zeng
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32, Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China.,Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, 610072, China.,Sichuan Province Clinical Research Center for Emergency and Critical Care Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Hua Jiang
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32, Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China. .,Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, 610072, China. .,Sichuan Province Clinical Research Center for Emergency and Critical Care Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China.
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12
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Arias Constanti V, Domingo Garau A, Rodríguez Marrodán B, Villalobos Pinto E, Riaza Gómez M, García Soto L, Hernández Borges Á, Madrid Rodríguez A. Recomendaciones de no hacer en distintos ámbitos de la atención pediátrica. An Pediatr (Barc) 2023. [DOI: 10.1016/j.anpedi.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
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13
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Hernández Borges ÁA, Jiménez Sosa A, Pérez Hernández R, Ordóñez Sáez O, Aleo Luján E, Concha Torre A. Recomendaciones de «no hacer» en cuidados intensivos pediátricos en España: selección por método Delphi. An Pediatr (Barc) 2023. [DOI: 10.1016/j.anpedi.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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14
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Hernández Borges ÁA, Jiménez Sosa A, Pérez Hernández R, Ordóñez Sáez O, Aleo Luján E, Concha Torre A. Paediatric intensive care 'do not do' recommendations in Spain: Selection by Delphi method. An Pediatr (Barc) 2023; 98:28-40. [PMID: 36509646 DOI: 10.1016/j.anpede.2022.08.014] [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: 05/22/2022] [Accepted: 08/21/2022] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Health care is not free of ineffective, unsafe or inefficient diagnostic and therapeutic practices. To address this, different scientific societies and health authorities have proposed 'do not do' recommendations (DNDRs). Our goal was the selection by consensus of a set of DNDRs for paediatric intensive care in Spain. MATERIAL AND METHOD The research was carried out in 2 phases: first, gathering potential DNDRs; second, selecting the most important ones, using the Delphi method, based on the prevalence of the practice to be modified, the severity of its potential risks and the ease with which it could be modified. Proposals and evaluations were both made by members of working groups of the Sociedad Española de Cuidados Intensivos Pediátricos (SECIP, Spanish Society of Paediatric Intensive Care), coordinated by email. The initial set of DNDRs was reduced based on the coefficient of variation (<80%) of the corresponding evaluations. RESULTS A total of 182 DNDRs were proposed by 30 intensivists. The 14 Delphi evaluators managed to pare down the initial set to 85 DNDRs and, after a second round, to the final set of 26 DNDRs. The care quality dimensions most represented in the final set are clinical effectiveness and patient safety. CONCLUSIONS This study allowed the selection by consensus of a series of recommendations to avoid unsafe, inefficient or ineffective practices in paediatric intensive care in Spain, which could be useful for improving the quality of clinical care in our field.
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Affiliation(s)
| | - Alejandro Jiménez Sosa
- Unidad de Investigación, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
| | - Rosalía Pérez Hernández
- UCIP, Servicio de Pediatría, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
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15
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Morosanu CO, Nita AR, Florian IS. Intra-osseous cerebrospinal fluid shunts-Overview of past and present clinical and experimental evidence. Neurochirurgie 2022; 68:e84-e96. [PMID: 36087694 DOI: 10.1016/j.neuchi.2022.08.003] [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: 03/14/2022] [Revised: 08/08/2022] [Accepted: 08/21/2022] [Indexed: 10/14/2022]
Abstract
In the history of hydrocephalus treatment, a variety of diversion sites have been explored to ensure an adequate alternative when the peritoneum was not a feasible option. An interesting choice was the elimination of excessive cerebrospinal fluid (CSF) in the skeletal system. The purpose of this review was to evaluate all shunting systems that have been implemented in bone structures and to determine their therapeutic potential. All articles pertaining to bone derivations were selected from PubMed, Medline, EBSCO and Scopus, using relevant search terms. The search revealed 6 types of osseous shunts that have been used throughout history: vertebral, diploic, ventriculomastoid, ventriculoiliac, ventriculosternal and ventriculohumeral. Some of them are purely of historical significance, but data from more recent clinical and experimental studies have rendered this type of receptacle a potential site for diverting CSF. Having knowledge of all the alternatives used in cases of refractory hydrocephalus is vital for choosing the appropriate surgical intervention.
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Affiliation(s)
- C O Morosanu
- Department of Neurosurgery, Royal Preston Hospital, Preston, UK; Human Anatomy Resource Centre, Faculty of Life and Health Sciences, University of Liverpool, Liverpool, UK.
| | - A R Nita
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - I S Florian
- Department of Neurosurgery, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
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16
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Little A, Jones DG, Alsbrooks K. A narrative review of historic and current approaches for patients with difficult venous access: considerations for the emergency department. Expert Rev Med Devices 2022; 19:441-449. [PMID: 35786122 DOI: 10.1080/17434440.2022.2095904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Timely placement of vascular access devices is critical during emergent clinical situations; however, challenges in peripheral access can be a common occurrence. Historically, emergency teams have used various approaches to gain peripheral vascular access in situations where traditional means were not feasible; these options have included peripheral venous cutdown, ultrasound-guided peripheral intravenous catheters (PIVs), longer PIVs, central catheters, and intraosseous devices. Each of these options have associated strengths and limitations depending on the clinical situation. AREAS COVERED This narrative review reports on the burden of difficult venous access situations and discusses the evidence, and strengths and limitations of vascular access options to help address this challenge. Although first puncture success rates can be high when using alternative methods, significant challenges can include increased procedure time and greater risk of complications. The Easy-Internal Jugular (Easy-IJ) technique is a newer alternative option for patients with difficult venous access that is demonstrated to be safe and effective in emergency care. EXPERT OPINION Moving forward, additional clinical studies are required to fully characterize the outcomes associated with the Easy-IJ technique and guidewire-assisted intravenous catheters, as well as to inform guideline development for more comprehensive recommendations on managing challenging or difficult peripheral access situations.
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Affiliation(s)
- Andrew Little
- Department of Emergency Medicine, AdventHealth Central Florida, Orlando, FL, USA
| | - Drew G Jones
- Department of Emergency Medicine, AdventHealth Central Florida, Orlando, FL, USA
| | - Kimberly Alsbrooks
- b Medical Affairs, Becton, Dickinson and Company (BD), Franklin Lakes, NJ, USA
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17
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Kristiansen S, Storm B, Dahle D, Domaas Josefsen T, Dybwik K, Nilsen BA, Waage-Nielsen E. Intraosseous fluid resuscitation causes systemic fat emboli in a porcine hemorrhagic shock model. Scand J Trauma Resusc Emerg Med 2021; 29:172. [PMID: 34930433 PMCID: PMC8686379 DOI: 10.1186/s13049-021-00986-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/09/2021] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Steinar Kristiansen
- Surgery and Intensive Care Unit, University Hospital of Northern Norway, Tromsø, Norway.
- Department of Surgery, Nordland Hospital Trust, Bodø, Norway.
- Department of Clinical Medicine, Faculty of Health Sciences, Arctic University of Norway, Tromsø, Norway.
| | - Benjamin Storm
- Department of Surgery, Nordland Hospital Trust, Bodø, Norway
- Department of Clinical Medicine, Faculty of Health Sciences, Arctic University of Norway, Tromsø, Norway
- Research Laboratory, Nordland Hospital Trust, Bodø, Norway
| | - Dalia Dahle
- Faculty of Biosciences and Aquaculture, Nord University, Bodø, Norway
| | | | - Knut Dybwik
- Department of Surgery, Nordland Hospital Trust, Bodø, Norway
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway
| | | | - Erik Waage-Nielsen
- Department of Surgery, Nordland Hospital Trust, Bodø, Norway
- Department of Clinical Medicine, Faculty of Health Sciences, Arctic University of Norway, Tromsø, Norway
- Research Laboratory, Nordland Hospital Trust, Bodø, Norway
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway
- Department of Immunology, Oslo University Hospital, University of Oslo, Oslo, Norway
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18
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Guo X, Popal AM, Zhu Z, Cai C, Lin J, Jiang H, Zheng Z, Zhang J, Shao A, Zhu J. Ventriculosternal Shunt for the Treatment of Idiopathic Normal Pressure Hydrocephalus: A Case Report. Front Surg 2021; 8:607417. [PMID: 34497825 PMCID: PMC8419424 DOI: 10.3389/fsurg.2021.607417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 07/27/2021] [Indexed: 01/15/2023] Open
Abstract
Background: Conventional corticospinal fluid (CSF) diversion surgery for idiopathic normal pressure hydrocephalus (iNPH) includes ventriculoperitoneal shunt and ventriculoatrial shunt. Ventriculosternal (VS) shunt may be considered if both the abdominal cavity and atrium are not feasible. Methods: A 76-year-old woman was admitted to our hospital with gait disturbance and urinary incontinence for 2 years, and the condition aggravated in the last 1 month. Based on clinical assessment and imaging findings, the patient was diagnosed with iNPH, with surgical indications. She was on peritoneal dialysis for chronic renal failure, and a cardiac Doppler echocardiogram showed enlargement of the left atrium and decreased diastolic function of the left ventricle. Due to these conditions, we chose the sternum as the vessel for CSF absorption and performed VS shunt. Results: No swelling, exudation, and effusion were found in the suprasternal fossa. Gait disturbance and urinary incontinence improved significantly immediately and 1 week after surgery, respectively. No shunt-related complication was reported at 16 months follow-up. Conclusion: This case demonstrated VS shunting as a feasible and alternative for the management of hydrocephalus.
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Affiliation(s)
- Xinxia Guo
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Abdul Malik Popal
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhoule Zhu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Chengwei Cai
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jingquan Lin
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Hongjie Jiang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhe Zheng
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jianmin Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Anwen Shao
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Junming Zhu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Banerjee S, Majors R, Luchian E, Chakrabarti A. Intraosseus route for thrombolysing acute stroke is safe and successful. QJM 2021; 114:324-325. [PMID: 33486524 DOI: 10.1093/qjmed/hcab008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- S Banerjee
- From the Department of Stroke Medicine, Norfolk and Norwich Hospital NHS Foundation Trust, Norwich, UK
| | - R Majors
- From the Department of Stroke Medicine, Norfolk and Norwich Hospital NHS Foundation Trust, Norwich, UK
| | - E Luchian
- From the Department of Stroke Medicine, Norfolk and Norwich Hospital NHS Foundation Trust, Norwich, UK
| | - A Chakrabarti
- From the Department of Stroke Medicine, Norfolk and Norwich Hospital NHS Foundation Trust, Norwich, UK
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20
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Bustamante S, Bajracharya GR, Cheruku S, Leung S, Mao G, Singh A, Mamoun N. Point-of-Care Ultrasound to Identify Landmarks of the Proximal Humerus: Potential Use for Intraosseous Vascular Access. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:725-730. [PMID: 32881005 DOI: 10.1002/jum.15442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 06/05/2020] [Accepted: 07/06/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES The inability to identify landmarks is an absolute contraindication for intraosseous access. The feasibility of landmark identification using ultrasound (US) has been demonstrated on human cadavers. We aimed to study the feasibility of point-of-care US in identifying proximal humerus landmarks in living human patients. METHODS This was a prospective cohort study conducted from May 3 to June 7, 2017, after approval from the Institutional Review Board at the Cleveland Clinic. Sixty upper extremities of 30 consenting participants across 3 distinct body mass index (BMI) groups (normal, obese, and morbidly obese) were alternately examined with a 12 L-RS linear US transducer (GE Healthcare, Chicago, IL) by 2 investigators. Six anatomic landmarks were identified: the humeral shaft, the surgical neck of the humerus, the lesser tubercle, the greater tubercle, the inter tubercular sulcus, and the target site for needle insertion on the greater tubercle. Rates of successful identification of all 6 landmarks as defined by independent agreement between the investigators were reported as estimated incidence rates with 95% bootstrap confidence interval (CI) sampling at the participant level. RESULTS Ultrasound had an overall success rate of 0.87 (95% CI, 0.78-0.95) in identifying all 6 landmarks with slight variability among various BMI groups. After excluding the surgical neck, the overall success rate improved to 0.93 (95% CI, 0.87-0.98), with minimum variability across BMI groups and no change in the ability to identify the target site. CONCLUSIONS Ultrasound is reliable in identifying proximal humerus intraosseous landmarks, with reasonable accuracy across various BMI groups.
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Affiliation(s)
- Sergio Bustamante
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
- Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gausan Ratna Bajracharya
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
- Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shravan Cheruku
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Steve Leung
- Department of Radiology, Metro Health, Cleveland, Ohio, USA
| | - Guangmai Mao
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
- Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Quantitative Health Sciences Cleveland Clinic, Cleveland, Ohio, USA
| | - Asha Singh
- Department of Anesthesiology and Perioperative Medicine, University Hospitals, Cleveland Medical Center, Cleveland, Ohio, USA
| | - Negmeldeen Mamoun
- Division of Cardiothoracic Anesthesia, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
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21
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Krähling H, Masthoff M, Schwindt W, Stracke CP, Schindler P. Intraosseous contrast administration for emergency stroke CT. Neuroradiology 2021; 63:967-970. [PMID: 33462626 PMCID: PMC8128809 DOI: 10.1007/s00234-021-02642-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 01/07/2021] [Indexed: 05/30/2023]
Abstract
Computed tomography (CT) imaging in acute stroke is an established and fairly widespread approach, but there is no data on applicability of intraosseous (IO) contrast administration in the case of failed intravenous (IV) cannula placement. Here, we present the first case of IO contrast administration for CT imaging in suspected acute stroke providing a dedicated CT examination protocol and analysis of achieved image quality as well as a review of available literature.
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Affiliation(s)
- Hermann Krähling
- Clinic for Radiology, University Hospital Muenster, Muenster, Germany
| | - Max Masthoff
- Clinic for Radiology, University Hospital Muenster, Muenster, Germany
| | - Wolfram Schwindt
- Clinic for Radiology, University Hospital Muenster, Muenster, Germany.,Division of Interventional Neuroradiology, University Hospital Muenster, Muenster, Germany
| | - Christian Paul Stracke
- Clinic for Radiology, University Hospital Muenster, Muenster, Germany.,Division of Interventional Neuroradiology, University Hospital Muenster, Muenster, Germany
| | - Philipp Schindler
- Clinic for Radiology, University Hospital Muenster, Muenster, Germany.
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22
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Der-Nigoghossian C, Tesoro EP, Strein M, Brophy GM. Principles of Pharmacotherapy of Seizures and Status Epilepticus. Semin Neurol 2020; 40:681-695. [PMID: 33176370 DOI: 10.1055/s-0040-1718721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Status epilepticus is a neurological emergency with an outcome that is highly associated with the initial pharmacotherapy management that must be administered in a timely fashion. Beyond first-line therapy of status epilepticus, treatment is not guided by robust evidence. Optimal pharmacotherapy selection for individual patients is essential in the management of seizures and status epilepticus with careful evaluation of pharmacokinetic and pharmacodynamic factors. With the addition of newer antiseizure agents to the market, understanding their role in the management of status epilepticus is critical. Etiology-guided therapy should be considered in certain patients with drug-induced seizures, alcohol withdrawal, or autoimmune encephalitis. Some patient populations warrant special consideration, such as pediatric, pregnant, elderly, and the critically ill. Seizure prophylaxis is indicated in select patients with acute neurological injury and should be limited to the acute postinjury period.
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Affiliation(s)
- Caroline Der-Nigoghossian
- Department of Pharmacy, Neurosciences Intensive Care Unit, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Eljim P Tesoro
- Department of Pharmacy Practice (MC 886), College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Micheal Strein
- Pharmacotherapy and Outcomes Science and Neurosurgery, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, Virginia
| | - Gretchen M Brophy
- Pharmacotherapy and Outcomes Science and Neurosurgery, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, Virginia
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23
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Iatrogenic humeral anatomic neck fracture after intraosseous vascular access. Skeletal Radiol 2020; 49:1481-1485. [PMID: 32424705 DOI: 10.1007/s00256-020-03462-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 04/19/2020] [Accepted: 05/04/2020] [Indexed: 02/02/2023]
Abstract
Intraosseous infusion has become a key tool in the resuscitation of critically ill or injured patients, both in pre-hospital settings and in emergency departments. Intraosseous access is obtained through the percutaneous placement of a needle into the medullary space of a bone, thereby allowing access into the systemic venous circulation via the medullary space, which is essential to treat patients in shock, cardiac arrest, airway compromise, or major trauma. This becomes critically important when obtaining conventional intravenous access is difficult or impossible. Few cases of iatrogenic fracture have been reported for intraosseous access in the tibia and no case to-date has been reported of iatrogenic fracture secondary to humeral access. We report a case of a 55-year-old patient being resuscitated emergently with proximal humeral intraosseous infusion for cardiac and respiratory arrest secondary to status epilepticus. After successful resuscitation and removal of the intraosseous cannula, the patient noted new-onset shoulder pain. The patient was ultimately diagnosed with an iatrogenic fracture of the anatomic neck of the humerus through the intraosseous needle tract when the appropriate history was obtained in conjunction with cross-sectional imaging. As the use of intraosseous access expands, such fractures may well be seen more frequently. Intraosseous access is limited to the period of resuscitation and the cannula is often not present at the time of imaging. It is important for radiologists to recognize the findings related to intraosseous access as well as this complication with its characteristic locations and morphology.
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Banchev A, Stoyanova D, Avramova B, Mladenov B, Moutafchieva P, Konstantinov D. Successful intraosseous factor VIII application in a haemophilic emergency. J Clin Pharm Ther 2020; 46:212-214. [PMID: 32860636 DOI: 10.1111/jcpt.13252] [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: 04/26/2020] [Revised: 08/03/2020] [Accepted: 08/03/2020] [Indexed: 11/30/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVES Intravenous (IV) replacement therapy with plasma derived or recombinant factor VIII (FVIII) and factor IX concentrates is the mainstay for treatment of patients with haemophilia A and B. Therefore, the current therapy is particularly dependent on the presence of a secure IV access especially in case of emergency. CASE DESCRIPTION A life-threatening bleeding event in an 8-month-old boy is managed by intraosseous (IO) infusion of recombinant FVIII concentrate. No adverse events have been observed 6 months after the application, and complete heeling has been reported. WHAT IS NEW AND CONCLUSION Venous application of factor concentrate remains inevitable in any haemophilic emergency. In case IV access is lacking, an IO institution of factor might be considered. To our knowledge, this represents the first reported case of IO application of recombinant FVIII concentrate in a patient with haemophilia.
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Affiliation(s)
- Atanas Banchev
- Department of Paediatric Haematology and Oncology, University Hospital "Tzaritza Giovanna - ISUL", Sofia, Bulgaria
| | - Denka Stoyanova
- Department of Paediatric Haematology and Oncology, University Hospital "Tzaritza Giovanna - ISUL", Sofia, Bulgaria
| | - Boryana Avramova
- Department of Paediatric Haematology and Oncology, University Hospital "Tzaritza Giovanna - ISUL", Sofia, Bulgaria
| | - Bogdan Mladenov
- Paediatric Intensive Care Unit, University Hospital "Pirogov", Sofia, Bulgaria
| | - Petya Moutafchieva
- Department of Paediatric Surgery, University Hospital "Pirogov", Sofia, Bulgaria
| | - Dobrin Konstantinov
- Department of Paediatric Haematology and Oncology, University Hospital "Tzaritza Giovanna - ISUL", Sofia, Bulgaria
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Abstract
Successful emergency transfusions require early recognition and activation of resources to minimize treatment delays. The initial goals should focus on replacement of blood in a balanced fashion. There is an ongoing debate regarding the best approach to transfusions, with some advocating for resuscitation with a fixed ratio of blood products and others preferring to use viscoelastic assays to guide transfusions. Whole-blood transfusion also is a debated strategy. Despite these different approaches, it generally is accepted that transfusions should be started early and crystalloid infusions limited. As hemodynamic stability is restored, endpoints of resuscitation should be used to guide the resuscitation.
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Affiliation(s)
- Michael S Farrell
- Department of Surgery, University of California San Francisco, 1001 Potrero Avenue, Ward 3A, San Francisco, CA 94110, USA; Zuckerberg San Francisco General Hospital, San Francisco, CA, USA. https://twitter.com/mfarrellmd
| | - Woon Cho Kim
- Department of Surgery, University of California San Francisco, 1001 Potrero Avenue, Ward 3A, San Francisco, CA 94110, USA; Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Deborah M Stein
- Department of Surgery, University of California San Francisco, 1001 Potrero Avenue, Ward 3A, San Francisco, CA 94110, USA; Zuckerberg San Francisco General Hospital, San Francisco, CA, USA.
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Khan MNH, Jamal AB, Anjum SN. Complications of interosseous infusion resulting in a diagnostic dilemma. Trauma Case Rep 2020; 26:100289. [PMID: 32195310 PMCID: PMC7076247 DOI: 10.1016/j.tcr.2020.100289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2020] [Indexed: 11/26/2022] Open
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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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Neill MJ, Burgert JM, Blouin D, Tigges B, Rodden K, Roberts R, Anderson P, Hallquist T, Navarro J, O'Sullivan J, Johnson D. Effects of humeral intraosseous epinephrine in a pediatric hypovolemic cardiac arrest porcine model. Trauma Surg Acute Care Open 2020; 5:e000372. [PMID: 32154374 PMCID: PMC7046964 DOI: 10.1136/tsaco-2019-000372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 12/04/2019] [Accepted: 12/10/2019] [Indexed: 11/25/2022] Open
Abstract
Background Aims of the study were to determine the effects of humerus intraosseous (HIO) versus intravenous (IV) administration of epinephrine in a hypovolemic, pediatric pig model. We compared concentration maximum (Cmax), time to maximum concentration (Tmax), mean concentration (MC) over time and return of spontaneous circulation (ROSC). Methods Pediatric pig were randomly assigned to each group (HIO (n=7); IV (n=7); cardiopulmonary resuscitation (CPR)+defibrillation (defib) (n=7) and CPR-only group (n=5)). The pig were anesthetized; 35% of the blood volume was exsanguinated. pigs were in arrest for 2 min, and then CPR was performed for 2 min. Epinephrine 0.01 mg/kg was administered 4 min postarrest by either route. Samples were collected over 5 min. After sample collection, epinephrine was administered every 4 min or until ROSC. The Cmax and MC were analyzed using high-performance liquid chromatography. Defibrillation began at 3 min postarrest and administered every 2 min or until ROSC or endpoint at 20 min after initiation of CPR. Results Analysis indicated that the Cmax was significantly higher in the IV versus HIO group (p=0.001). Tmax was shorter in the IV group but was not significantly different (p=0.789). The MC was significantly greater in the IV versus HIO groups at 90 and 120 s (p<0.05). The IV versus HIO had a significantly higher MC (p=0.001). χ2 indicated the IV group (5 out of 7) had significantly higher rate of ROSC than the HIO group (1 out of 7) (p=0.031). One subject in the CPR+defib and no subjects in the CPR-only groups achieved ROSC. Discussion Based on the results of our study, the IV route is more effective than the HIO route.
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Affiliation(s)
- Michael James Neill
- US Army Graduate Program in Anesthesia Nursing, US Army Medical Department, Fort Sam Houston, Texas, USA
| | - James M Burgert
- Department of Continuing EducationEvidence-based Healthcare Program, University of Oxford Kellogg College, Oxford, Oxfordshire, UK
| | | | - Benjamin Tigges
- US Army Graduate Program in Anesthesia Nursing, US Army Medical Department, Fort Sam Houston, Texas, USA
| | - Kari Rodden
- US Army Graduate Program in Anesthesia Nursing, US Army Medical Department, Fort Sam Houston, Texas, USA
| | - Rachel Roberts
- US Army Graduate Program in Anesthesia Nursing, US Army Medical Department, Fort Sam Houston, Texas, USA
| | - Phillip Anderson
- US Army Graduate Program in Anesthesia Nursing, US Army Medical Department, Fort Sam Houston, Texas, USA
| | - Travis Hallquist
- US Army Graduate Program in Anesthesia Nursing, US Army Medical Department, Fort Sam Houston, Texas, USA
| | - John Navarro
- US Army Graduate Program in Anesthesia Nursing, US Army Medical Department, Fort Sam Houston, Texas, USA
| | - Joseph O'Sullivan
- US Army Graduate Program in Anesthesia Nursing, US Army Medical Department, Fort Sam Houston, Texas, USA
| | - Don Johnson
- US Army Graduate Program in Anesthesia Nursing, US Army Medical Department, Fort Sam Houston, Texas, USA
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Peyko V, Shams D, Urbanski R, Noga J. 4-Factor Prothrombin Complex Concentrate Administration via Intraosseous Access for Urgent Reversal of Warfarin. J Emerg Med 2019; 57:82-84. [DOI: 10.1016/j.jemermed.2019.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 02/01/2019] [Accepted: 03/04/2019] [Indexed: 11/30/2022]
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Abstract
Intraosseous (IO) access is used widely as an optional vascular route for critically ill patients. It is still unclear whether the IO access can be used as a source for emergency blood samples. The aim of this study was to systematically review the existing literature on the usability of IO blood samples for analysing the parameters relevant to emergency care. We performed a data search from the Medline and Embase databases, the Cochrane Library and the Clinical trials registry. Animal studies and studies with healthy and ill adults and children were included in the search. The data were collected and reported following the PRISMA guidelines. The PROSPERO database registration number of this review is CRD42017064194. We found 27 studies comparing the blood samples from the IO space with arterial or venous samples, but only three of them followed the recommended guidelines for method comparison studies. The study populations were heterogeneous, and the sample sizes were relatively small (14, 17 and 20 individuals) in the three studies. The results of specific laboratory parameters were scarce and discordant. The evidence on the agreement between IO and arterial and venous samples is still weak. Existing studies with healthy volunteers and animal models provide important insight into the analyses of IO samples, but more evidence, especially from haemodynamically unstable patients, is needed for wider implementation of IO blood sampling in critically ill patients.
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The intraosseous have it: A prospective observational study of vascular access success rates in patients in extremis using video review. J Trauma Acute Care Surg 2019; 84:558-563. [PMID: 29300281 DOI: 10.1097/ta.0000000000001795] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Quick and successful vascular access in injured patients arriving in extremis is crucial to enable early resuscitation and rapid OR transport for definitive repair. We hypothesized that intraosseous (IO) access would be faster and have higher success rates than peripheral intravenous (PIV) or central venous catheters (CVCs). METHODS High-definition video recordings of resuscitations for all patients undergoing emergency department thoracotomy from April 2016 to July 2017 were reviewed as part of a quality improvement initiative. Demographics, mechanism of injury, access type, access location, start and stop time, and success of each vascular access attempt were recorded. Times to completion for access types (PIV, IO, CVC) were compared using Kruskal-Wallis test adjusted for multiple comparisons, while categorical outcomes, such as success rates by access type, were compared using χ test or Fisher's exact test. RESULTS Study patients had a median age of 30 years (interquartile range [IQR], 25-38 years), 92% were male, 92% were African American, and 93% sustained penetrating trauma. A total of 145 access attempts in 38 patients occurred (median, 3.8; SD, 1.4 attempts per patient). There was no difference between duration of PIV and IO attempts (0.63; IQR, 0.35-0.96 vs. 0.39 IQR, 0.13-0.65 minutes, adjusted p = 0.03), but both PIV and IO were faster than CVC attempts (3.2; IQR, 1.72-5.23 minutes; adjusted p < 0.001 for both comparisons). Intraosseous lines had higher success rates than PIVs or CVCs (95% vs. 42% vs. 46%, p < 0.001). CONCLUSION Access attempts using IO are as fast as PIV attempts but are more than twice as likely to be successful. Attempts at CVC access in patients in extremis have high rates of failure and take a median of over 3 minutes. While IO access may not completely supplant PIVs and CVCs, IO access should be considered as a first-line therapy for trauma patients in extremis. LEVEL OF EVIDENCE Therapeutic, level III.
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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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Morosanu CO, Filip GA, Nicolae L, Florian IS. From the heart to the bladder-particularities of ventricular shunt topography and the current status of cerebrospinal fluid diversion sites. Neurosurg Rev 2018; 43:847-860. [PMID: 30338415 DOI: 10.1007/s10143-018-1033-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 08/28/2018] [Accepted: 09/17/2018] [Indexed: 12/01/2022]
Abstract
Hydrocephalus represents the pathological elevation of cerebrospinal fluid (CSF) levels as a consequence of various embryological or acquired defects. Although the classic method of treatment is by means of diverting the CSF from the ventricular system towards the peritoneum, there are other sites of diversion that have proven their efficiency through time, in the context of complications related to the more common option of intraperitoneal insertion. The aim of the review is to assess and organize a database of all the types of shunt locations from the oldest shunt attempts until present, using Pubmed and Medline and to underline the particularities related to technique, indications, complications and associated epidemiological background. Current literature reveals up to 36 sites of diversion of CSF with a diverse topography varying from cephalic regions such as venous sinuses or mastoid bone, thoracic elements such as the heart or the pleura and abdominopelvic segments such as the peritoneum or the urinary bladder. Several atypical locations were studied such as the fallopian and intestinal shunts. Although ventriculoperitoneal and ventriculoatrial shunts are the most commonly used shunts today, there are some systems such as the ventriculosinusal and ventriculolymphatic shunts that prove to be equally as efficient. The successful treatment of hydrocephalus requires a complete comprehension of the indications and therapeutic options and a reliable evaluation of the risks and possible complications. The profile of cerebral ventricular shunts is highly dynamic and the spectrum of cerebrospinal fluid diversion offers multiple solutions in the benefit of the patient.
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Affiliation(s)
- Cezar Octavian Morosanu
- Department of Neurosurgery, North Bristol NHS Trust, Southmead Hospital, Southmead Rd, Westbury-on-Trym, Bristol, United Kingdom.
| | - Gabriela Adriana Filip
- Department of Physiology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Liviu Nicolae
- Department of Neurosurgery, North Bristol NHS Trust, Southmead Hospital, Southmead Rd, Westbury-on-Trym, Bristol, United Kingdom
| | - Ioan Stefan Florian
- Department of Neurosurgery, Cluj County Emergency Hospital, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
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Fukuda T, Ohashi-Fukuda N, Kondo Y, Hayashida K, Kukita I. Association of Prehospital Advanced Life Support by Physician With Survival After Out-of-Hospital Cardiac Arrest With Blunt Trauma Following Traffic Collisions: Japanese Registry-Based Study. JAMA Surg 2018; 153:e180674. [PMID: 29710068 DOI: 10.1001/jamasurg.2018.0674] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance Controversy remains as to whether advanced life support (ALS) or basic life support (BLS) is superior for critically ill and injured patients, including out-of-hospital cardiac arrest (OHCA) and major trauma, in the prehospital setting. Objective To assess whether prehospital ALS should be provided for traumatic OHCA and who should perform it. Design, Setting, and Participants Japanese government-managed nationwide population-based registry data of patients with OHCA transported to an emergency hospital were analyzed. Patients who experienced traumatic OHCA following a traffic collision from 2013 to 2014 were included. Patients provided prehospital ALS by a physician were compared with both patients provided ALS by emergency medical service (EMS) personnel and patients with only BLS. The data were analyzed on May 1, 2017. Exposures Advanced life support by physician, ALS by EMS personnel, or BLS only. Main Outcomes and Measures The primary outcome was 1-month survival. The secondary outcomes were prehospital return of spontaneous circulation and favorable neurologic outcomes with the Glasgow-Pittsburgh cerebral performance category score of 1 or 2. Results A total of 4382 patients were included (mean [SD] age, 57.5 [22.2] years; 67.9% male); 828 (18.9%) received prehospital ALS by physician, 1591 (36.3%) received prehospital ALS by EMS personnel, and 1963 (44.8%) received BLS only. Among these patients, 96 (2.2%) survived 1 month after OHCA, including 26 of 828 (3.1%) for ALS by physician, 25 of 1591 (1.6%) for ALS by EMS personnel, and 45 of 1963 (2.3%) for BLS. After adjusting for potential confounders using multivariable logistic regression, ALS by physician was significantly associated with higher odds for 1-month survival compared with both ALS by EMS personnel and BLS (adjusted OR, 2.13; 95% CI, 1.20-3.78; and adjusted OR, 1.94; 95% CI, 1.14-3.25; respectively), whereas there was no significant difference between ALS by EMS personnel and BLS (adjusted OR, 0.91; 95% CI, 0.54-1.51). A propensity score-matched analysis in the ALS cohort showed that ALS by physician was associated with increased chance of 1-month survival compared with ALS by EMS personnel (risk ratio, 2.00; 95% CI, 1.01-3.97; P = .04). This association was consistent across a variety of sensitivity analyses. Conclusions and Relevance In traumatic OHCA, ALS by physician was associated with increased chance of 1-month survival compared with both ALS by EMS personnel and BLS.
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Affiliation(s)
- Tatsuma Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan.,Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Naoko Ohashi-Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan.,Division of Acute Care Surgery, Trauma, and Surgical Critical Care, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Kei Hayashida
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan.,Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ichiro Kukita
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
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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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37
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Engels PT, Erdogan M, Widder SL, Butler MB, Kureshi N, Martin K, Green RS. Use of intraosseous devices in trauma: a survey of trauma practitioners in Canada, Australia and New Zealand. Can J Surg 2016; 59:374-382. [PMID: 27669404 PMCID: PMC5125919 DOI: 10.1503/cjs.011215] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Accepted: 06/20/2016] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Although used primarily in the pediatric population for decades, the use of intraosseous (IO) devices in the resuscitation of severely injured adult trauma patients has recently become more commonplace. The objective of this study was to determine the experience level, beliefs and attitudes of trauma practitioners in Canada, Australia and New Zealand regarding the use of IO devices in adult trauma patients. METHODS We administered a web-based survey to all members of 4 national trauma and emergency medicine organizations in Canada, Australia and New Zealand. Survey responses were analyzed using descriptive statistics, univariate comparisons and a proportional odds model. RESULTS Overall, 425 of 1771 members completed the survey, with 375 being trauma practitioners. IO devices were available to 97% (353 of 363), with EZ-IO being the most common. Nearly all physicians (98%, 357 of 366) had previous training with IO devices, and 85% (223 of 261) had previously used an IO device in adult trauma patients. Most respondents (79%, 285 of 361) were very comfortable placing an IO catheter in the proximal tibia. Most physicians would always or often use an IO catheter in a patient without intravenous access undergoing CPR for traumatic cardiac arrest (84%, 274 of 326) or in a hypotensive patient (without peripheral intravenous access) after 2 attempts or 90 s of trying to establish vascular access (81%, 264 of 326). CONCLUSION Intraosseous devices are readily available to trauma practitioners in Canada, Australia and New Zealand, and most physicians are trained in device placement. Most physicians surveyed felt comfortable using an IO device in resuscitation of adult trauma patients and would do so for indications broader than current guidelines.
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Affiliation(s)
- Paul T. Engels
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Engels); Trauma Nova Scotia, Halifax, NS (Erdogan, Green); the Department of Surgery, University of Alberta, Edmonton, Alta. (Widder); the Department of Critical Care Medicine, Dalhousie University, Halifax, NS (Butler, Kureshi, Green); and the Alfred Hospital, Melbourne, Australia (Martin)
| | - Mete Erdogan
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Engels); Trauma Nova Scotia, Halifax, NS (Erdogan, Green); the Department of Surgery, University of Alberta, Edmonton, Alta. (Widder); the Department of Critical Care Medicine, Dalhousie University, Halifax, NS (Butler, Kureshi, Green); and the Alfred Hospital, Melbourne, Australia (Martin)
| | - Sandy L. Widder
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Engels); Trauma Nova Scotia, Halifax, NS (Erdogan, Green); the Department of Surgery, University of Alberta, Edmonton, Alta. (Widder); the Department of Critical Care Medicine, Dalhousie University, Halifax, NS (Butler, Kureshi, Green); and the Alfred Hospital, Melbourne, Australia (Martin)
| | - Michael B. Butler
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Engels); Trauma Nova Scotia, Halifax, NS (Erdogan, Green); the Department of Surgery, University of Alberta, Edmonton, Alta. (Widder); the Department of Critical Care Medicine, Dalhousie University, Halifax, NS (Butler, Kureshi, Green); and the Alfred Hospital, Melbourne, Australia (Martin)
| | - Nelofar Kureshi
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Engels); Trauma Nova Scotia, Halifax, NS (Erdogan, Green); the Department of Surgery, University of Alberta, Edmonton, Alta. (Widder); the Department of Critical Care Medicine, Dalhousie University, Halifax, NS (Butler, Kureshi, Green); and the Alfred Hospital, Melbourne, Australia (Martin)
| | - Kate Martin
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Engels); Trauma Nova Scotia, Halifax, NS (Erdogan, Green); the Department of Surgery, University of Alberta, Edmonton, Alta. (Widder); the Department of Critical Care Medicine, Dalhousie University, Halifax, NS (Butler, Kureshi, Green); and the Alfred Hospital, Melbourne, Australia (Martin)
| | - Robert S. Green
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Engels); Trauma Nova Scotia, Halifax, NS (Erdogan, Green); the Department of Surgery, University of Alberta, Edmonton, Alta. (Widder); the Department of Critical Care Medicine, Dalhousie University, Halifax, NS (Butler, Kureshi, Green); and the Alfred Hospital, Melbourne, Australia (Martin)
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Wille T, Neumaier K, Koller M, Ehinger C, Aggarwal N, Ashani Y, Goldsmith M, Sussman JL, Tawfik DS, Thiermann H, Worek F. Single treatment of VX poisoned guinea pigs with the phosphotriesterase mutant C23AL: Intraosseous versus intravenous injection. Toxicol Lett 2016; 258:198-206. [DOI: 10.1016/j.toxlet.2016.07.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 06/27/2016] [Accepted: 07/06/2016] [Indexed: 02/09/2023]
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Kehrl T, Becker BA, Simmons DE, Broderick EK, Jones RA. Intraosseous access in the obese patient: assessing the need for extended needle length. Am J Emerg Med 2016; 34:1831-4. [DOI: 10.1016/j.ajem.2016.06.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 05/21/2016] [Accepted: 06/12/2016] [Indexed: 10/21/2022] Open
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Smereka A, Stawicka I, Czyzewski L. Nurses' knowledge and attitudes toward intraosseous access: preliminary data. Am J Emerg Med 2016; 34:1724. [PMID: 27318743 DOI: 10.1016/j.ajem.2016.06.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 06/04/2016] [Indexed: 11/24/2022] Open
Affiliation(s)
- Adam Smereka
- Department and Clinic of Gastroenterology and Hepatology, Wroclaw Medical University, Wroclaw, Poland
| | | | - Lukasz Czyzewski
- Department of Nephrologic Nursing, Medical University of Warsaw, Warsaw, Poland.
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A Comparison of the Effects of Intraosseous and Intravenous 5% Albumin on Infusion Time and Hemodynamic Measures in a Swine Model of Hemorrhagic Shock. Prehosp Disaster Med 2016; 31:436-42. [PMID: 27210025 DOI: 10.1017/s1049023x16000509] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
UNLABELLED Introduction Obtaining intravenous (IV) access in patients in hemorrhagic shock is often difficult and prolonged. Failed IV attempts delay life-saving treatment. Intraosseous (IO) access may often be obtained faster than IV access. Albumin (5%) is an option for prehospital volume expansion because of the absence of interference with coagulation and platelet function. Hypothesis/Problem There are limited data comparing the performance of IO and IV administered 5% albumin. The aims of this study were to compare the effects of tibial IO (TIO) and IV administration of 500 mL of 5% albumin on infusion time and hemodynamic measurements of heart rate (HR), mean arterial pressure (MAP), cardiac output (CO), and stroke volume (SV) in a swine model of hemorrhagic shock. METHODS Sixteen male swine were divided into two groups: TIO and IV. All subjects were anesthetized and a Class III hemorrhage was achieved by exsanguination of 31% of estimated blood volume (EBV) from a femoral artery catheter. Following exsanguination, 500 mL of 5% albumin was administered under pressurized infusion (300 mmHg) by the TIO or IV route and infusion time was recorded. Hemodynamic measurements of HR, MAP, CO, and SV were collected before and after exsanguination and every 20 seconds for 180 seconds during 5% albumin infusion. RESULTS An independent t-test determined that IV 5% albumin infusion was significantly faster compared to IO (P=.01). Mean infusion time for TIO was seven minutes 35 seconds (SD=two minutes 44 seconds) compared to four minutes 32 seconds (SD=one minute 08 seconds) in the IV group. Multivariate Analysis of Variance was performed on hemodynamic data collected during the 5% albumin infusion. Analyses indicated there were no significant differences between the TIO and IV groups relative to MAP, CO, HR, or SV (P>.05). CONCLUSION While significantly longer to infuse 5% albumin by the TIO route, the longer TIO infusion time may be negated as IO devices can be placed more quickly compared to repeated IV attempts. The lack of significant difference between the TIO and IV routes relative to hemodynamic measures indicate the TIO route is a viable route for the infusion of 5% albumin in a swine model of Class III hemorrhage. Muir SL , Sheppard LB , Maika-Wilson A , Burgert JM , Garcia-Blanco J , Johnson AD , Coyner JL . A comparison of the effects of intraosseous and intravenous 5% albumin on infusion time and hemodynamic measures in a swine model of hemorrhagic shock. Prehosp Disaster Med. 2016;31(4):436-442.
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Bodenham Chair A, Babu S, Bennett J, Binks R, Fee P, Fox B, Johnston AJ, Klein AA, Langton JA, Mclure H, Tighe SQM. Association of Anaesthetists of Great Britain and Ireland: Safe vascular access 2016. Anaesthesia 2016; 71:573-85. [PMID: 26888253 PMCID: PMC5067617 DOI: 10.1111/anae.13360] [Citation(s) in RCA: 178] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2015] [Indexed: 12/13/2022]
Abstract
Safe vascular access is integral to anaesthetic and critical care practice, but procedures are a frequent source of patient adverse events. Ensuring safe and effective approaches to vascular catheter insertion should be a priority for all practitioners. New technology such as ultrasound and other imaging has increased the number of tools available. This guidance was created using review of current practice and literature, as well as expert opinion. The result is a consensus document which provides practical advice on the safe insertion and removal of vascular access devices.
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Affiliation(s)
- A Bodenham Chair
- Anaesthesia and Intensive Care, Leeds Teaching Hospitals, Leeds, UK
| | - S Babu
- Anaesthesia, North Manchester General Hospital, Manchester, UK
| | - J Bennett
- Anaesthesia, Birmingham Children's Hospital, Birminham, UK
| | - R Binks
- Airedale Hospital and Faculty of Intensive Care Medicine, West Yorkshire, UK
| | - P Fee
- Anaesthesia, Belfast Health and Social Care Trust, Belfast, UK
| | - B Fox
- Anaesthesia, East Anglia, and Group of Anaesthetists in Training, AAGBI, London, UK
| | - A J Johnston
- Anaesthesia and Intensive Care, Addenbrooke's Hospital, Cambridge, UK
| | - A A Klein
- Anaesthesia, Papworth Hospital, Cambridge, UK
| | - J A Langton
- Anaesthesia, Plymouth Hospitals, Plymouth, and Royal College of Anaesthetists, UK
| | - H Mclure
- Anaesthesia, Leeds Teaching Hospitals, Leeds, UK
| | - S Q M Tighe
- Anaesthesia and Intensive Care, Countess of Chester Hospital and AAGBI Council, Chester, UK
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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: 97] [Impact Index Per Article: 12.1] [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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Ming Woo PY, Hung Pang PK, Chan KY, Ching Kwok JK. Ventriculosternal Shunting for the Management of Hydrocephalus: Case Report of A Novel Technique. Neurosurgery 2016; 11 Suppl 3:371-5; discussion 375. [PMID: 26114598 PMCID: PMC4892763 DOI: 10.1227/neu.0000000000000861] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Conventional cerebrospinal fluid diversion such as ventriculoperitoneal or ventriculoatrial shunting for the management of hydrocephalus is one of the commonest neurosurgical procedures. However, in selected patients, surgical options are limited when relative contraindications for these operations exist. A patient who underwent ventriculosternal shunting, a novel procedure, is presented with durable and successful outcomes. OBJECTIVE To demonstrate the feasibility, durability, and safety of ventriculosternal shunting for the management of hydrocephalus. METHODS A patient with end-stage renal failure and heart failure with recurrent pleural effusion suffered from post-subarachnoid hemorrhage communicating hydrocephalus. Because of the need for continuous ambulatory peritoneal dialysis and the risk of introducing excessive cardiac preloading, conventional shunting was relatively contraindicated. Ventriculosternal shunting was performed by adopting the cancellous matrix of the sternum as the anatomic receptacle for intraosseous cerebrospinal fluid absorption. After placement of the ventricular catheter in the usual manner, the distal end was inserted into the sternum. RESULTS There was demonstrable clinical and radiological improvement in hydrocephalus by ventriculosternal shunting. Cerebrospinal fluid intraosseous absorption by this novel procedure translated into both physical and cognitive recovery. The procedure was tolerable, effective, and durable, with the patient suffering no complications 3 years after the procedure. CONCLUSION Ventriculosternal shunting for the management of hydrocephalus is a feasible, safe, and durable surgical treatment option for selected patients when conventional procedures are contraindicated.
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Fulkerson J, Lowe R, Anderson T, Moore H, Craig W, Johnson D. Effects of Intraosseous Tibial vs. Intravenous Vasopressin in a Hypovolemic Cardiac Arrest Model. West J Emerg Med 2016; 17:222-8. [PMID: 26973756 PMCID: PMC4786250 DOI: 10.5811/westjem.2015.12.28825] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 12/10/2015] [Indexed: 11/21/2022] Open
Abstract
Introduction This study compared the effects of vasopressin via tibial intraosseous (IO) and intravenous (IV) routes on maximum plasma concentration (Cmax), the time to maximum concentration (Tmax), return of spontaneous circulation (ROSC), and time to ROSC in a hypovolemic cardiac arrest model. Methods This study was a randomized prospective, between-subjects experimental design. A computer program randomly assigned 28 Yorkshire swine to one of four groups: IV (n=7), IO tibia (n=7), cardiopulmonary resuscitation (CPR) + defibrillation (n=7), and a control group that received just CPR (n=7). Ventricular fibrillation was induced, and subjects remained in arrest for two minutes. CPR was initiated and 40 units of vasopressin were administered via IO or IV routes. Blood samples were collected at 0.5, 1, 1.5, 2, 2.5, 3, and 4 minutes. CPR and defibrillation were initiated for 20 minutes or until ROSC was achieved. We measured vasopressin concentrations using high-performance liquid chromatography. Results There was no significant difference between the IO and IV groups relative to achieving ROSC (p=1.0) but a significant difference between the IV compared to the CPR+ defibrillation group (p=0.031) and IV compared to the CPR-only group (p=0.001). There was a significant difference between the IO group compared to the CPR+ defibrillation group (p=0.031) and IO compared to the CPR-only group (p=0.001). There was no significant difference between the CPR + defibrillation group and the CPR group (p=0.127). There was no significant difference in Cmax between the IO and IV groups (p=0.079). The mean ± standard deviation of Cmax of the IO group was 58,709±25, 463pg/mL compared to the IV group, which was 106,198±62, 135pg/mL. There was no significant difference in mean Tmax between the groups (p=0.084). There were no significant differences in odds of ROSC between the tibial IO and IV groups. Conclusion Prompt access to the vascular system using the IO route can circumvent the interruption in treatment observed with attempting conventional IV access. The IO route is an effective modality for the treatment of hypovolemic cardiac arrest and may be considered first line for rapid vascular access.
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Affiliation(s)
- Justin Fulkerson
- U.S. Army Graduate Program in Anesthesia, Fort Sam Houston, Texas
| | - Robert Lowe
- U.S. Army Graduate Program in Anesthesia, Fort Sam Houston, Texas
| | - Tristan Anderson
- U.S. Army Graduate Program in Anesthesia, Fort Sam Houston, Texas
| | - Heather Moore
- U.S. Army Graduate Program in Anesthesia, Fort Sam Houston, Texas
| | - William Craig
- U.S. Army Graduate Program in Anesthesia, Fort Sam Houston, Texas
| | - Don Johnson
- U.S. Army Graduate Program in Anesthesia, Fort Sam Houston, Texas
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Jawad N, Brown K, Sebire N, Arthurs O. Accuracy of paediatric intraosseous needle placement from post mortem imaging. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.jofri.2015.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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G-CSF Administration after the Intraosseous Infusion of Hypertonic Hydroxyethyl Starches Accelerating Wound Healing Combined with Hemorrhagic Shock. BIOMED RESEARCH INTERNATIONAL 2016; 2016:5317630. [PMID: 26989687 PMCID: PMC4773547 DOI: 10.1155/2016/5317630] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 01/13/2016] [Accepted: 01/21/2016] [Indexed: 12/04/2022]
Abstract
Objective. To evaluate the therapeutic effects of G-CSF administration after intraosseous (IO) resuscitation in hemorrhagic shock (HS) combined with cutaneous injury rats. Methods. The rats were randomly divided into four groups: (1) HS with resuscitation (blank), (2) HS with resuscitation + G-CSF (G-CSF, 200 μg/kg body weight, subcutaneous injection), (3) HS with resuscitation + normal saline solution injection (normal saline), and (4) HS + G-CSF injection without resuscitation (Unres/G-CSF). To estimate the treatment effects, the vital signs of alteration were first evaluated, and then wound closure rates and homing of MSCs and EPCs to the wound skins and vasculogenesis were measured. Besides, inflammation and vasculogenesis related mRNA expressions were also examined. Results. IO infusion hypertonic hydroxyethyl starch (HHES) exhibited beneficial volume expansion roles and G-CSF administration accelerated wound healing 3 days ahead of other groups under hemorrhagic shock. Circulating and the homing of MSCs and EPCs at wound skins were significantly elevated at 6 h after G-CSF treatment. Inflammation was declined since 3 d while angiogenesis was more obvious in G-CSF treated group on day 9. Conclusions. These results suggested that the synergistical application of HHES and G-CSF has life-saving effects and is beneficial for improving wound healing in HS combined with cutaneous injury rats.
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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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Monsieurs K, Nolan J, Bossaert L, Greif R, Maconochie I, Nikolaou N, Perkins G, Soar J, Truhlář A, Wyllie J, Zideman D. Kurzdarstellung. Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0097-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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