Intraosseous infusion: a review of methods and novel devices

The Use of Intraosseous Infusion in the Early Resuscitation of Patients With Extremely Severe Burns

According to research, shock, the most common complication of extremely severe burns, is also the leading cause of mortality among patients with such burns. The case fatality rate reaches 83.45% when the total burn area exceeds 90%. The American Heart Association in 2020 recommended the intraosseous (IO) access after the peripheral access and prior to the central venous access when venous cannulation is either difficult or delayed. The use and experience with intraosseous infusion in extremely severe burns are still limited. We report efficacy and safety results from 19 burn patients treated with IO infusion between June 2020 and December 2022. In these patients, the mean injury time of burns was 1.55 ± 1.10 hours, the mean burn surface area was 86.24% ± 11.33%, the mean catheterization time was 49.68 ± 10.11 seconds, and the mean emergency retention time was 2.75 ± 1.74 hours, the mean actual fluid supplement amount was 5,533.68 ± 3,077.19 mL, the mean hourly urine volume of the patient was 93.31 ± 60.94 mL, the mean emergency detention time was 4.16 ± 2.97 hours, and the mean duration of hospitalization was 34.50 ± 25.38 days. The results demonstrated a clinically meaningful improvement and higher response rate vs peripheral venous cannulation and an acceptable safety profile in those patients.

Limb Length Discrepancy After Intraosseous Line Malpositioning: A Case Report

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.

POCUS Confirmation of Intraosseous Line Placement: Visualization of Agitated Saline within the Right Heart in a Critically Ill Infant

Intraosseous (IO) line placement can be a life-saving procedure in the management of critically ill patients. Confirmation of correct IO line placement can be difficult. Prior studies have examined the use of point of care ultrasound (POCUS) to confirm IO line placement by using power Doppler over bone to detect flow within the intraosseous space. This case illustrates a novel use of POCUS in which agitated saline is visualized within the right heart as a means of confirming correct IO placement.

A Case of Compartment Syndrome Due to Out-of-Hospital Intraosseous Misplacement During Cardiopulmonary Resuscitation

Resuscitation relies heavily on gaining access to the circulatory system. During cardiopulmonary resuscitation (CPR), the biggest, most readily accessible vein that does not impede resuscitation is desired. Intraosseous (IO) access is designated for life-threatening emergencies and is a relatively safe procedure with fewer complications. We describe an intriguing and uncommon consequence of out-of-hospital IO placement: compartment syndrome resulting from the displacement of the IO needle by emergency medical services (EMS) workers in a diabetic woman with hypoglycemia. A few hours later, the patient had swelling, discomfort, and loss of motor and sensory sensations at the IO site, necessitating further examinations. The IO needle had traversed both the anterior and posterior cortices of the tibia and was located in the soft tissues along the posterior portion of the tibia as shown by imaging of the afflicted area. Immediate decompression fasciotomy was performed to preserve the patient's limb.

Development and Evaluation of a Three-Dimensional-Printed Pediatric Intraosseous Infusion Simulator To Enhance Medical Training

Vascular access is an essential and rate-limiting step during pediatric resuscitation efforts. Intraosseous (IO) access, an effective resuscitative strategy, remains underutilized in emergency departments. Many medical graduates report never performing the procedure before graduation, and it has been recommended that continuing education and in-servicing programs be implemented to increase the use and familiarity of IO access. The goal of this technical report is to describe the development and evaluation of a three-dimensional (3D)-printed Pediatric IO Infusion Model for simulation-based medical education. The simulator was designed by combining open-source models of a human skeleton and a lower leg surface scan in Blender (Blender Foundation, Amsterdam, Netherlands; www.blender.org), scaled to a pediatric size, and manipulated further using a JavaScript program. Polylactic acid was used to simulate bone while silicone molds were used as skin and soft tissue. Two trainers were produced and evaluated by seven emergency medicine physicians, two family medicine residents, and three medical students.

Overall, the simulator was positively received with all participants indicating they would recommend it to assist in the training of others. Suggestions focused on enhancing the anatomical representations of both the skin and bones to enhance the learner experience. The content and outcomes of this report support the use of this simulator as part of simulation-based medical education.

Tibial Osteomyelitis Following Prehospital Intraosseous Access

Intraosseous (IO) access is a lifesaving alternative to peripheral or central venous access in emergency care. However, emergency physicians and prehospital care providers must be aware of the potential for infectious complications associated with this intervention. We describe the case of a HIV-negative, otherwise immunocompetent adult patient who underwent prehospital insertion of a tibial IO device. Following successful resuscitation, the patient developed tibial osteomyelitis requiring multiple operative debridements, soft tissue coverage, and several courses of prolonged antimicrobial therapy. Skin antisepsis prior to device insertion followed by early device removal are important strategies for reducing the risk of infection associated with IO access.

Comparison of four different intraosseous access devices during simulated pediatric resuscitation. A randomized crossover manikin trial

The aim of the study was to compare the success rate, procedure time, and user satisfaction of pediatric NIO™ compared to Pediatric BIG®, EZ-IO®, and Jamshidi intraosseous access devices. This was a randomized, crossover manikin trial with 87 paramedics. The correct location of intraosseous access when using NIO, BIG, EZ-IO, and Jamshidi was varied and was respectively 100, 90, 90, and 90%. The time required to obtain intravascular access (time T1) in the case of NIO, BIG, EZ-IO, and Jamshidi was varied and amounted to 9 s [IQR, 8-12] for NIO, 12 s [IQR, 9-16] for BIG, 13.5 s [IQR, 11-17] for the EZ-IO, and 15 s [IQR, 13-19] for Jamshidi. The paramedics evaluated each device on the subjective ease with which they performed the procedures. The intraosseous device, which proved the easiest to use was NIO, which in the case of CPR received a median rating of 1.5 (IQR, 0.5-1.5) points.

CONCLUSION

Our study found that NIO® is superior to BIG®, EZ-IO®, and Jamshidi. NIO® achieved the highest first attempt success rate. NIO® also required the least time to insert and easiest to operate even by novice users. Further study is needed to test our findings in cadavers or human subjects. Based on our findings, NIO® is a promising intraosseous device for use in pediatric resuscitation. What is Known: • Venous access in acutely ill pediatric patients, such as those undergoing cardiopulmonary resuscitation, is needed for prompt administration of drugs and fluids. • Intraosseous access is recommended by American Heart Association and European Resuscitation council if vascular access is not readily obtainable to prevent delay in treatment. What is New: • This simulated pediatric resuscitation compared performance of four commercially available pediatric intraosseous devices in a manikin model. • NIO® outperformed BIG®, EZ-IO®, and Jamshidi in first attempt success rates and time of procedure among novice users.

Vascular access through the intraosseous route in pediatric emergencies

Obtaining venous access in critically ill children is an essential procedure to restore blood volume and administer drugs during pediatric emergencies. The first option for vascular access is through a peripheral vein puncture. If this route cannot be used or if a prolonged period of access is necessary, then the intraosseous route is an effective option for rapid and safe venous access. The present work is a descriptive and exploratory literature review. The study's aim was to describe the techniques, professional responsibilities, and care related to obtaining venous access via the intraosseous route in pediatric emergencies. We selected 22 articles (published between 2000 and 2011) that were available in the Latin American and Caribbean Health Sciences (LILACS) and MEDLINE databases and the SciELO electronic library, in addition to the current protocol of cardiopulmonary resuscitation from the American Heart Association (2010). After the literature search, data were pooled and grouped into the following categories of analysis: historical aspects and physiological principles; indications, benefits, and contraindications; professional assignments; technical principles; care during the access; and possible complications. The results of the present study revealed that the intraosseous route is considered the main secondary option for vascular access during the emergency response because the technique is quick and easily executed, presents several non-collapsible puncture sites, and enables the rapid and effective administration of drugs and fluid replacement.

Comparison of mechanical and manual bone marrow puncture needle for intraosseous access; a randomized simulation trial

Background

During resuscitation, when it is difficult or impossible to establish peripheral venous access, intraosseous route (IO) is considered as an alternative to a central venous line. However, it is sometimes difficult for obtain IO access with conventional manual bone puncture needle. Recently, powered mechanical bone marrow needle was developed. We compared the performance of the manual and mechanical bone marrow puncture needle for adult, child and infant simulation.

Methods

22 anesthesiologists, who has never used bone marrow puncture needle, performed manual (Dickman™, Cook Medical) or mechanical (EZ-IO™, Teleflex) bone marrow puncture to simulated adult, child and infant tibia. Puncture success rate, insertion time, and subjective difficulty utilizing visual analogue scale was assessed.

Results

In adult settings, with the manual bone marrow needle, only 3 of 22 participants could succeed in the IO route keep, while all participants did in the mechanical bone marrow puncture needle (P < 0.001). In child and infant settings, all trials were successful in both manual and mechanical bone marrow puncture needles (P = 1.00). In adult simulations, IO insertion took significantly longer with manual bone marrow puncture (54.8 ± 15.8 s) than without compressions (3.7 ± 2.1 s; P < 0.001). In child and infant simulations, the IO insertion time was significantly smaller in mechanical trials than in manual ones (child simulation; manual 9.3 ± 4.6 s, mechanical 2.2 ± 0.8 s, P < 0.001, infant simulation; manual 2.0 ± 1.1 s, mechanical 1.5 ± 0.8 s, P = 0.003).

Although the VAS score was not significantly higher with manual trials than in mechanical trials among the three simulations (adult simulation, P < 0.001, child simulation, P < 0.001, infant simulation P = 0.006).

Conclusions

We conclude that in simulations managed by anesthesiologists who had no clinical experiences with bone marrow puncture, the mechanical bone puncture needle performed better than the manual one for emergency IO route access.

Fat Intravasation from Intraosseous Flush and Infusion Procedures

STUDY HYPOTHESIS

The primary study objective was to delineate the procedural aspects of intraosseous (IO) infusions responsible for fat intravasation by testing the hypothesis that the fat content of effluent blood increases during IO infusions.

METHODS

IO cannulas were inserted into the proximal tibiae of 35 anesthetized swine (Sus scrofa, 50.1 ± 3.5 kg) and intravasated fat was assessed using a lipophilic fluoroprobe (Nile red) and by vascular ultrasound imaging. Effluent blood bone marrow fat was assessed at baseline, during flush, and with regimens of controlled infusion pressures (73-300 mmHg) and infusion flow rates (0.3-3.0 mL per second). Fat intravasation was also assessed with IO infusions at different tibial cannulation sites and in the distal femur. In 7 animals, the lipid uptake of alveolar macrophages and lung tissue assessed for fat embolic burden using oil red O stain 24 hours post infusion. Additionally, bone marrow shear-strain was assessed radiographically with IO infusions.

RESULTS

Fat intravasation was observed during all IO infusion regimens, with subclinical pulmonary fat emboli persisting 24 hours post infusion. It was noted that initial flush was a significant factor in fat intravasation, low levels of intravasation occurred with infusions ≤300 mmHg, fat intravasation and bone marrow shear-strain increased with IO infusion rates, and intravasation was influenced by cannula insertion site. Ultrasound findings suggest that echogenic particles consistent with fat emboli are carried in fast and slow venous blood flow fields. Echo reflective densities were observed to rise to the nondependent endovascular margins and coalesce in accordance with Stoke's law. In addition, ultrasound findings suggested that intravasated bone marrow fat was thrombogenic.

CONCLUSION

Results suggest that in swine the intravasation of bone marrow fat is a common consequence of IO infusion procedures and that its magnitude is influenced by the site of cannulation and infusion forces. Although the efficacy and benefits of IO infusions for emergent care are well established, emergency care providers also should be cognizant that infusion procedures affect bone marrow fat intravasation.

Videos in clinical medicine. Insertion of an intraosseous needle in adults

Intraosseous needle insertion is used as a temporary measure when intravascular access cannot be achieved through peripheral or central venous routes. The intraosseous needle may remain in situ for 72 to 96 hours, but it is best removed within 6 to 12 hours, as soon as an alternative site of intravascular access has been established. The intraosseous route provides fast and reliable vascular access in emergency medical situations. The use of the appropriate technique will ensure that the procedure is performed as safely and effectively as possible.

A randomized trial comparing two intraosseous access devices in intrahospital healthcare providers with a focus on retention of knowledge, skill, and self-efficacy

INTRODUCTION

Intraosseous access is recommended in vitally compromised patients if an intravenous access cannot be easily obtained. Intraosseous infusion can be initiated by various healthcare providers. Currently, there are two mechanical intraosseous devices approved by the U.S. Food and Drug Administration (FDA) for use in adults and children. A comparison is made in this study of the theoretical and practical performance by anesthesiologists and registered nurses of anesthesia (RNAs) in the use of the battery-powered device (device A) versus the spring-loaded needle device (device B). This study entailed a 12-month follow-up of knowledge, skill retention, and self-efficacy measured by standardized testing.

METHODS

A prospective randomized trial was performed, initially comparing 15 anesthesiologists and 15 RNAs, both on using the two types of intraosseous devices. A structured lecture and skill station was given with the educational aids provided by the respective manufacturers. Individual knowledge and practical skills were tested at 0, 3, and 12 months after the initial course.

RESULTS

There was no statistical significant difference in the retention of theoretical knowledge between RNAs and anesthesiologists on all testing occasions. However, the self-efficacy of the anesthesiologists is significantly higher (p < 0.01) than the self-efficacy of the RNAs for both devices, on any testing occasion. Insufficient skills were local disinfection (both groups, both devices) and attachment of the needle to the intravenous line (RNAs with both devices). In 33 % of all device B handlings, unsafe practice occurred.

CONCLUSION

The use of device A is safer in handling in comparison to device B at 12 months follow-up. The hypothesis that doctors are more qualified in obtaining intraosseous access has been disproven, as anesthesiologists were as successful as RNAs. However, the low self-efficacy of RNAs in the use of intraosseous devices could diminish the chance of them actually using one.

Critical procedures in pediatric emergency medicine

Children comprise approximately one-quarter of all visits to most emergency departments. Children are generally healthier than adults, yet there are similar priorities in assessment and management of pediatric patients. The initial approach to airway, breathing, and circulation still applies and is first and foremost in the evaluation of young infants and children. There are certain anatomic, physiologic, developmental, and social considerations that are unique to this population and must be taken into account during their evaluation and treatment. In this review, we present and discuss an evidence-based approach to high-yield procedures necessary for all emergency physicians taking care of children.

Powered intraosseous device (EZ-IO) for critically ill patients

We reviewed the charts of 25 patients who underwent powered intraosseous line insertion between July 1, 2008 and August 31, 2010 to determine its users, indications, procedural details, success rates, and complications. Intraosseous (IO) line was inserted in the anteromedial aspect of the proximal tibia in all patients. The first attempt was successful in 80%, and the median duration for insertion of the IO line was 4 hours. Extravasation was the most common complication. Ninety-six percent of the physicians had undergone prior training in IO insertion. Because of its high success and short procedure time, IO access should be the first alternative to failed vascular access in critically ill children. Training in IO should be extended to all who care for pediatric patients in inpatient as well as in prehospital and emergency department settings.

Comparison of first-attempt success between tibial and humeral intraosseous insertions during out-of-hospital cardiac arrest

BACKGROUND

Intraosseous (IO) needle insertion is often utilized in the adult population for critical resuscitation purposes. Standard insertion sites include the proximal humerus and proximal tibia, for which limited comparison data are available.

OBJECTIVE

This study compared the frequencies of IO first-attempt success between humeral and tibial sites in out-of-hospital cardiac arrest.

METHODS

This observational study was conducted in an urban setting between August 28, 2009, and October 31, 2009, and included all medical cardiac arrest patients for whom resuscitative efforts were performed. Cardiac arrest protocols stipulate that paramedics insert an IO line for initial vascular access. During the first month of the study, the proximal humerus was the preferred primary insertion site, whereas the tibia was preferred throughout the second month. The primary outcome was first-attempt success, defined as secure IO needle position in the marrow cavity and normal fluid flow. Any needle dislodgment during resuscitation was also recorded. The association between first-attempt IO success and initial IO insertion location was analyzed using a test of independent proportions and 95% confidence intervals (CIs) for the difference in proportions.

RESULTS

There were 88 cardiac arrest patients receiving IO placement, with 58 (65.9%) patients receiving their initial IO attempt in the tibia. The rate of first-time IO success at the tibia was significantly higher than that observed at the humerus (89.7% vs. 60.0%; p < 0.01). There were 18 initial successes at the humerus; for six (33.3%) of these, the needle became dislodged during resuscitation, compared with 52 initial successes at the tibia, with three (5.8%) dislodgments. The rate of total success for initial IO placements was significantly lower for the humerus (40.0%) compared with that for the tibia (84.5%; p < 0.01) during resuscitation efforts.

CONCLUSIONS

In this subset of patients, tibial IO needle placement appeared to be a more effective insertion site than the proximal humerus. Success rates were higher with a lower incidence of needle dislodgments. Further randomized studies are required in order to validate these results.

Principles of pediatric emergency care

BACKGROUND

Children account for only a small percentage of pre-hospital emergency patients but are a special challenge for the treating physician.

METHODS

The Medline database was selectively searched for articles appearing up to June 2009. The authors added other important literature of which they were aware.

RESULTS

The broad spectrum of diseases, the wide age range with the physiological and anatomical changes that occur in it, and the special psychological, emotional, and communicative features of children make pediatric emergencies a special challenge for emergency physicians.

CONCLUSIONS

A mastery of basic emergency techniques including clinical evaluation of the child, establishment of venous access, airway management, resuscitation, and drug dosing is essential for the successful emergency treatment of children. We recommend classifying the common non-traumatic pediatric emergencies by four cardinal manifestations: respiratory distress, altered consciousness, seizure, and shock. Classifying these rare emergency situations in this way helps assure that their treatment will be goal-oriented and appropriate to the special needs of sick children.

Prehospital intraosseus access with the bone injection gun by a helicopter-transported emergency medical team

BACKGROUND

To evaluate the use of the bone injection gun to obtain vascular access in the prehospital setting by an Helicopter-Transported Emergency Medical Team.

METHODS

Prospective descriptive study to assess the frequency and success rate of the use of the bone injection gun in prehospital care by a Helicopter-Transported Emergency Medical Team.

RESULTS

In 40 of 780 (5.1%) patients, an attempt was made to obtain intraosseous access with the bone injection gun. Intraosseous access was attempted more often in children than in adults (p < 0.01). The success rate was 71% (10 out of 14) in children <16 years and 73% (19 out of 26) in adults (p = 1.0). There were no complications to the health care providers involved and no unwanted sequels to the patients involved.

CONCLUSIONS

The bone injection gun is an effective and safe device for the resuscitation of patients in a prehospital setting. It seems to be equivalent in success rate as intraosseous needles in children, but it seems to be more successful in adults.

Initiation of a pediatric mock code program at a children's hospital

BACKGROUND

Pediatric cardiopulmonary arrests are rare. Mock codes were instituted to bridge the gap between opportunity and reality.

AIM

The goal was to improve medical caregivers' skills in pediatric resuscitation.

METHODS

All pediatric and internal medicine/pediatric (med/peds) residents were anonymously surveyed pre- and post-intervention about confidence level about codes and code skills. Twenty mock codes were conducted during the 1 year intervention period. Statistical comparisons were made between each resident pre- and post-survey, graduating third-year residents (PGY3s) prior to intervention versus PGY3s with mock codes and pediatric versus med/peds residents.

RESULTS

All residents significantly improved in their perception of overall skill level during the study (p < 0.0001). PGY3s were significantly more confident in their skills than PGY2s or PGY1s and PGY2s were significantly more confident than PGY1s both pre- and post-mock codes (p < 0.0001). Med/peds residents were significantly more confident in their skills than pediatric residents both pre- (p = 0.041) and post-intervention (p = 0.016). The two skills with the lowest score post-intervention were the ability to place an interosseous line and the ability to manage cardiac dysrhythmias.

CONCLUSIONS

Pediatric mock codes can improve resident confidence and self-assessment of their resuscitation skills. Data from surveys such as this can be used to design future skill-based educational initiatives.

Feasibility of point-of-care colour Doppler ultrasound confirmation of intraosseous needle placement during resuscitation

INTRODUCTION

Intraosseous needle insertion for vascular access is a standard procedure used in paediatric resuscitation. The introduction of newer automated intraosseous devices has recently expanded its role to include resuscitation in patients of all ages. Managing resuscitation can be challenging and a misplaced intraosseous needle may confound effective resuscitation. Colour Doppler ultrasound has been recently proposed as a method to confirm intraosseous needle placement. The ability to rapidly determine the correct position of an intraosseous needle during resuscitation would allow the delivery of medication or fluid infusion into the vascular space to be verified, thus optimizing resuscitation. Furthermore, complications from intraosseous infusion extravasating into soft tissues, such as compartment syndrome, or tissue necrosis can be avoided.

METHODS

We describe the point-of-care sonographic technique and colour Doppler ultrasound findings of intraosseous needle confirmation in a case series of critically ill patients requiring resuscitation, highlighting the utility of this sonographic application.

RESULTS

Colour Doppler ultrasound detected extraosseous flow in incorrectly positioned intraosseous needles, and intraosseous flow in correctly positioned intraosseous needles in six critically ill patients requiring resuscitation.

CONCLUSIONS

The use of point-of-care colour Doppler ultrasound to determine the location of both manually inserted or automated placement of intraosseous access during resuscitation is feasible, can be rapidly performed, may verify delivery of resuscitative medications or infusions, and avoid complications from extravasation.