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

Sternal Morphologic Characteristics of U.S. Military Males by Computed Tomography: Implications for Intraosseous Access

INTRODUCTION

Sternal intraosseous (IO) access has advantages over humeral and tibial access for fluid resuscitation in military medical settings due to superior flow rates and pharmacokinetics. However, the morphology of the young adult manubrial cortical and medullary bone as it relates to IO catheter tips of currently available FDA-approved IO access devices is unclear.

MATERIALS AND METHODS

Computed tomography manubrium images of active duty service members (N = 93) aged 18 to 30 were assessed by radiologists, including manubrial height, width, and cortical thickness, as well as total thickness and medullary thickness at the thickest (superior) and thinnest (inferior) parts of the manubrium. Inference regarding medullary or cortical IO catheter tip placement rates were made for FAST1 (5.5 mm catheter depth) and TALON (4.5 mm catheter depth) sternal IO devices. Data were analyzed using ANOVA, non-parametric, and correlational statistics at P < 0.05.

RESULTS

As inferred from case-specific CT-derived manubrium dimensions and maximal catheter tip penetration depths, both FAST1 and TALON would be placed in the target medullary space on 100% of opportunities if properly applied in the superior manubrium and on 99% of opportunities if properly applied in the inferior manubrium. Age was not significantly related to IO-relevant manubrial dimensions.

CONCLUSIONS

Present findings suggest that both FAST1 and TALON sternal IO catheter tips can be successfully placed into the target medullary bone with high accuracy in male military members aged 18 to 30 who require rapid resuscitation.

The relationship between intraosseous catheter tip placement, flow rates, and infusion pressures in a high bone density cadaveric swine (Sus scrofa) model

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.

Does an instructional video as a stand-alone tool promote the acquisition of practical clinical skills? A randomised simulation research trial of skills acquisition and short-term retention

BACKGROUND

The effectiveness of instructional videos as a stand-alone tool for the acquisition of practical skills is yet unknown because instructional videos are usually didactically embedded. Therefore, we evaluated the acquisition of the skill of a humeral intraosseous access via video in comparison to that of a self-study with an additional retention test.

METHODS

After ethical approval, we conducted two consecutive studies. Both were designed as randomised controlled two-armed trials with last-year medical students as independent samples at our institutional simulation centre of a tertiary university hospital centre. In Study 1, we randomly assigned 78 participants to two groups: Vid-Self participants watched an instructional video as an intervention, followed by a test, and after seven days did a self-study as a control, followed by a test. Self-Vid ran through the trial in reverse order. In Study 2, we investigated the influence of the sequence of the two teaching methods on learning success in a new sample of 60 participants: Vid-Self watched an instructional video and directly afterward did the self-study followed by a test, whereas Self-Vid ran through that trial in reverse order. In Studies 1 and 2, the primary outcome was the score (worst score = 0, best score = 20) of the test after intervention and control. The secondary outcome in Study 1 was the change in score after seven days.

RESULTS

Study 1: The Vid-Self (Participants n = 42) was superior to the Self-Vid (n = 36) (mean score 14.8 vs. 7.7, p < 0.001). After seven days, Self-vid outperformed Vid-Self (mean score 15.9 vs. 12.5, p < 0.001). Study 2: The Vid-Self (n = 30) and Self-Vid (n = 30) scores did not significantly differ (mean 16.5 vs. mean 16.5, p = 0.97).

CONCLUSION

An instructional video as a stand-alone tool effectively promotes the acquisition of practical skills. The best results are yielded by a combination of an instructional video and self-study right after each other, irrespective of sequence.

TRIAL REGISTRATIONS

ClinicalTrials.gov: NCT05066204 (13/04/2021) (Study 1) and NCT04842357 (04/10/2021) (Study 2).

Resuscitation and Evaluation With Intraosseous Access: A Review of the Literature in Trauma and Non-Trauma Patients

According to trauma resuscitation guidelines, intraosseous (IO) access is appropriate when failure to gain intravenous (IV) access is present in trauma, burn, shock, or resuscitation settings for adults or when two failed attempts have been made in the resuscitation of a pediatric patient. However, their effectiveness and use have been debated due to concerns on flow rates, extravasation, compartment syndrome, and osteomyelitis. The objective of this review is to examine the current literature regarding intraosseous access in trauma resuscitation, focusing on interventions and complication rates.

Intraosseous access in the resuscitation of patients with trauma: the good, the bad, the future

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.

Intraosseous Versus Intravenous Vancomycin in Tourniquetless Primary Total Knee Arthroplasty: A Randomized Trial

INTRODUCTION

Intraosseous (IO) administration of vancomycin at the time of total knee arthroplasty (TKA) has been shown to be safer and more effective than intravenous (IV) administration at preventing early periprosthetic joint infection. Previous studies have relied on tourniquet inflation to enhance local tissue concentrations and mitigate systemic release.

METHODS

A single-blinded, randomized clinical trial was performed on 20 patients (10 IV, 10 IO) undergoing primary TKA. The control (IV) group received weight-dosed vancomycin approximately 1 hour prior to the incision and weight-dosed cefazolin immediately prior to the incision. The interventional (IO) group received weight-dosed cefazolin immediately prior to the incision and 500 mg of vancomycin delivered via the IO technique at the time of the incision. Systemic samples for vancomycin levels were taken prior to the incision and at closure. During the procedure, tissue samples were taken from the distal femur, proximal tibia, and suprapatellar synovium. There were no differences in patient demographics or changes in serum creatinine from preoperative to postoperatively between groups.

RESULTS

Significant differences in systemic vancomycin levels (ug/mL) were found at the start of the case (IV = 27.9 ± 4.9 versus IO = 0 ± 0, P = 0.0004) and at the end of the case (IV = 19.6 ± 2.6 versus IO = 7.8 ± 1.0, P = 0.001). No significant differences were seen in the average vancomycin concentration in the distal femur (IV = 61.0 ± 16.0 versus IO = 66.2 ± 12.3, P = 0.80), proximal tibia (IV = 52.8 ± 13.5 versus IO = 57.1 ± 17.0, P = 0.84), or suprapatellar synovial tissue (IV = 10.7 ± 5.3 versus IO = 9.0 ± 3.3, P = 0.80). There were no complications associated with vancomycin administration in either group.

CONCLUSION

This study demonstrates the utility of IO vancomycin in tourniquetless TKA with similar local tissue and significantly lower systemic concentrations than IV administration.

Adapting the Gamified Educational Networking Online Learning Management System to Test a Decentralized Simulation-Based Education Model to Instruct Paramedics-in-Training on the Emergency Intraosseous Access and Infusion Skill

Intraosseous (IO) access and infusion is a safe and rapid alternative to intravenous access in obtaining vascular access for administering fluids and drugs. Healthcare professionals, such as primary and advanced care paramedics, use IO access and infusion in emergency circumstances where peripheral intravenous routes are inaccessible. IO access skills require hands-on training, which can be done remotely if the participants have access to simulation, instructions, guidance, and feedback. For the purpose of moving the training outside of the simulation laboratories, we have developed (1) an inexpensive and scalable three-dimensional (3D) printed and silicone-based advanced adult proximal tibial IO access and infusion simulator and (2) a unique learning management system (LMS) for remote simulation-based training. The LMS was built using the Django platform and supports experiential learning by providing access to educational and instructional content (including virtual simulation and serious games), allowing peers to communicate among themselves and with subject-matter experts, provide and receive feedback asynchronously, and engage in learning using gamification elements. The aim of this technical report is to describe the process of development and the final product of the LMS as a research and educational tool to scaffold remote learning of emergency IO skills by paramedics-in-training.

Sex differences in appropriate insertion depth for intraosseous access in adults: An exploratory radiologic single-center study

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.

Evolution of the use of intraosseous vascular access in prehospital advanced cardiopulmonary resuscitation: The IOVA-CPR study

INTRODUCTION

Obtaining vascular access is crucial in critically ill patients. The EZ-IO® device is easy to use and has a high insertion success rate. Therefore, the use of intraosseous vascular access (IOVA) has gradually increased.

AIM

We aim to determine how IOVA was integrated into management of vascular access during out-of-hospital cardiac arrest (OHCA) resuscitation.

METHODS

Analysing the data from the OHCA French registry for events occurring between 1 January 2013 and 15 March 2021, we studied: demography, circumstances of occurrence and management including vascular access, delays and evolution. The primary outcome was the rate of IOVA implantation.

RESULTS

Among the 7156 OHCA included in the registry, we analysed the 3964 (55%) who received cardiopulmonary resuscitation. The vascular access was peripheral in 3122 (79%) cases, intraosseous in 775 (20%) cases and central in 12 (<1%) cases. The use of IOVA has increased linearly (R2  = 0.61) during the 33 successive trimesters studied representing 7% of all vascular access in 2013 and 33% in 2021 (p = 0.001). It was significantly more frequent in traumatic cardiac arrest: 12% versus 5%; p < 0.0001. The first epinephrine bolus occurred significantly later in the IOVA group, at 6 (4-10) versus 5 (3-8) min; p < 0.0001. Survival rate in the IOVA group was significantly lower, at 1% versus 7%; p < 0.0001.

CONCLUSION

The insertion rate of IOVA significantly increased over the studied period, to reach 30% of all vascular access in the management OHCA patients. The place of the intraosseous route in the strategy of venous access during the management of prehospital cardiac arrest has yet to be determined.

Impact of a Multidisciplinary Simulation-Based Training Program on the Multiple Techniques of Intraosseous Access: A Prospective Multicentric Study

OBJECTIVES

The aim of this study was to assess intraosseous (IO) access placement performance during a multidisciplinary simulation-based training (SBT) program according to the professional status, experience of caregivers, and the setting of the course.

METHOD

This prospective, multicentric study included emergency physicians, residents, certified registered nurse anesthetists, registered nurses, and students. It was carried out between April 6, 2020 and April 30, 2021 in emergency medical services, an emergency department, and a simulation center. Trainee performance was evaluated by 2 independent observers using a validated scale, before and after SBT. Self-assessment of satisfaction was carried out. Interobserver reproducibility was analyzed by intraclass correlation coefficient. The continuous variables were compared using a Student t test or a nonparametric Mann-Whitney U test. Comparative analysis between the different groups used analysis of variance. Correlation analysis was performed by a nonparametric Spearman test. A P value of 0.05 was considered significant.

RESULTS

Ninety-eight participants were included. Intraclass correlation coefficient between the 2 observers was 0.96. Performance significantly increased after training, regardless of the site or device used (for the semiautomatic device, P = 0.004 in tibia and P = 0.001 in humeral; for the manual device, P < 0.001). Simulation-based training significantly reduced time for IO access ( P = 0.02). After SBT, no difference was found according to professional status and the setting of the course. Performance was not correlated with professional experience. All trainees were satisfied with the training.

CONCLUSIONS

Simulation-based training improved the IO access using a semiautomatic or a manual device, regardless of the experience or status of the trainees. Simulation-based training would work for many disciplines regardless of locations (simulation or clinical facilities).

Compartment Syndrome Resulting From Improper Intraosseous Cannulation: A Case Report

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.

Self-Efficacy in the Cannulation Technique for Intraosseous Access in Pediatric Cardiac Arrest: Egg Versus Bone

OBJECTIVES

The use of intraosseous (IO) access is recommended in cardiac arrest when peripheral venous access is not accessible. Various methodologies exist that are used for teaching and learning about cannulation of the IO route both in education and in research. The purpose of the present study was to compare self-efficacy in the cannulation technique for IO access through different techniques.

METHODS

A randomized comparative study was conducted. A total of 118 nursing students participated. The participants were randomly distributed into 2 intervention groups: chicken bone and egg. A checklist was used for data collection to evaluate the IO cannulation technique in nursing students and another to analyze self-efficacy.

RESULTS

The average total score of self-efficacy for all participants was 8.84 (standard deviation (SD) = 0.98). No statistically significant differences were found when comparing the total self-efficacy score and the intervention group ( U = 1604.500; z = -0.733; P = 0.463). No statistically significant differences were found between both groups for the average total score of the procedure ( U = 6916.500; z = -0.939; P = 0.348). The egg group carried out the IO cannulation procedure in a significantly less amount of time (M = 126.88, SD = 82.18) than the chicken bone group (M = 183.77, SD = 108.28), finding statistically significant differences ( U = 4983.500; z = -5.326; P < 0.001).

CONCLUSIONS

Using an egg to teach and learn about IO access could be considered a methodology that is equally effective as using a chicken bone, with the advantage of achieving IO access in a lesser amount of time.

Hypertonic Saline Administration via Intraosseous Access During Symptomatic Hyponatremia

Hyponatremia is a common lab finding. Symptomatology varies greatly and can depend on the degree of hyponatremia and its chronicity. Causes of hyponatremia are also vast and include heart failure, renal injury, liver disease, and gastrointestinal losses, or it can be induced by medication. Treatment depends on the suspected etiology. However, in life-threatening conditions such as seizures or coma, urgent 3% saline is required. Administration of 3% saline is usually through peripheral and central IV access. This case report highlights an alternative route in administering 3% saline, intraosseous vascular access, when other options have been exhausted.

Nurses' knowledge and self-assessment of their clinical experiences of intraosseous access: A multicentre cross-sectional study

BACKGROUND

Intraosseous access is an effective and safe option when difficult vascular access occurs. The knowledge, competence, and clinical experience of nurses are collectively essential for the successful implementation of this approach in clinical practice. Education and clinical learning are the main pillars supporting this new practice to ensure patient safety. The aim of this study was to identify the nurses' knowledge and clinical experience of intraosseous access and the factors associated with the adoption of this procedure.

METHODS

A cross-sectional study was carried out from October to December 2020. A convenience sample of 432 nurses from four Italian hospitals were involved. A structured questionnaire was used to assess the nurses' knowledge of the intraosseous access guidelines and their clinical experience.

RESULTS

Most participants were female (71.5%) with more than 10 years of experience (63.7%) working in an emergency (38.9%) and medical (37.7%) setting. Most of the participants demonstrated their knowledge of the use of a device e.g., it is used if vascular access is not rapidly achieved in a child (83.1%) and the boluses of liquids required in the intraosseous procedure (72.7%). A few participants reported having placed intraosseous access (3.5%). A higher level of educational preparation and working in emergency and paediatric settings were associated with increased knowledge.

CONCLUSIONS

Our findings highlighted a sub-optimal level of knowledge of the IO procedure, little experience of this practice in clinical contexts, also associated with a lack of adequate protocols and devices available to nurses. Nurses need to develop their knowledge and practice the skill clinically to embed this practice. University and nurse educators should emphasise the relevance of this practice in nursing education and training, so as to improve the nursing care practice and level of patient safety.

Emergency provider preference for powered intraosseous devices and satisfaction with features improving safety, reliability, and ease-of-use

BACKGROUND

Powered intraosseous (IO) systems are valuable devices for emergent situations, with limited data on user preferences. A simulation/survey-based study was conducted among emergency medical service (EMS) providers to evaluate attitudes toward general powered IO system features to measure preferences/satisfaction for the most-commonly used and a novel powered IO system (with a passive safety needle, battery life indicator, and snap-securement/dressing).

RESEARCH DESIGN AND METHODS

Forty-two EMS providers completed a simulated activity using both powered IO systems and a 30-item questionnaire, including multiple choice, free-text, ranking, and Likert-like questions. Ranking scores were reported using a scale of 0 (least important/satisfactory) to 100 (most important/satisfactory). Statistical significances were evaluated via Wilcoxon signed-rank sum test.

RESULTS

Providers indicated driver performance (mean score ± SD; 77.8 ± 27.5) and IO needle safety mechanism (63.1 ± 27.9) as the most important features. Participants reported significantly higher (p < 0.001) satisfaction with the novel IO system overall, and its needle safety, battery life indicator, securement/dressing, and ease-of-use. Powered driver performance satisfaction was similar and favorable for the novel (88.1 ± 18.2) and traditional (87.1 ± 15.3) systems.

CONCLUSIONS

These findings highlight the value of clinician/user input and demonstrate EMS providers are more satisfied with a powered IO system featuring design elements intended to enhance safety and ease-of-use.

Intraosseous regional prophylactic antibiotics decrease the risk of infection in total knee arthroplasty compared with intravenous antibiotics: a systematic review and meta-analysis

Purpose

Surgical site infection (SSI) is a rare and serious complication of total knee arthroplasty (TKA), which causes a poor prognosis for patients. The purpose of this study was to explore the effect of intraosseous (IO) antibiotics in preventing infection and complications after TKA compared with intravenous (IV) antibiotics and to provide a certain theoretical basis for clinical treatment.

Methods

The review process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched the PubMed, Embase, Ovid, Web of Science, and the Cochrane Central Register of Controlled Trials databases about trials on IO antibiotics (into the proximal tibia before skin incision) to prevent infections in TKA from the respective inception dates to September 30, 2022. The infection occurred within 3 months after surgery. Both researchers individually screened the studies in accordance with the inclusion and exclusion criteria, performed the literature quality evaluation and data extraction, and used Stata 17 software for data analysis.

Results

Five studies that enrolled 3801 patients were included in this meta-analysis. The results showed that IO antibiotics were effective in reducing the incidence of SSI (OR: 0.25, P = 0.001) and periprosthetic joint infections (OR: 0.16, P = 0.004) relative to IV. Moreover, the percentage of infection due to Gram-positive bacteria (OR: 0.18, P = 0.025) was reduced in the IO group compared with that in IV group, but Gram-negative bacteria levels were not significantly reduced (P = 0.14). There was no difference between the two groups for other systemic adverse effects of the drug.

Conclusions

IO antibiotics in TKA are safe and effective alternatives to IV antibiotics. Large randomized clinical studies comparing infection rates and related complications with IO and IV antibiotics are required.

Efficacy of intraosseous access for trauma resuscitation: a systematic review and meta-analysis

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.

Intraosseous Tibial Resuscitation After a Total Knee Arthroplasty Leading to Osteonecrosis and Loosening of the Tibial Component

A 51-year-old woman suffered cardiac arrest requiring emergent intraosseous access that abutted the tibial component of her total knee arthroplasty. She developed a wound at the site and knee pain which was concerning for deep infection. Subsequent imaging was consistent with osteonecrosis developing around the tibial component. The component eventually loosened, requiring a revision surgery. Her deep cultures remained negative throughout. Her findings are most consistent with osteonecrosis and aseptic loosening of her prosthesis. While intraosseous access may be beneficial during resuscitation, it has complications. This is the first reported case of osteonecrosis secondary to intraosseous access leading to prosthetic loosening necessitating a revision surgery.

Drug routes in out-of-hospital cardiac arrest: A summary of current evidence

Recent evidence showing the clinical effectiveness of drug therapy in cardiac arrest has led to renewed interest in the optimal route for drug administration in adult out-of-hospital cardiac arrest. Current resuscitation guidelines support use of the intravenous route for intra-arrest drug delivery, with the intraosseous route reserved for patients in whom intravenous access cannot be established. We sought to evaluate current evidence on drug route for administration of cardiac arrest drugs, with a specific focus on the intravenous and intraosseous route. We identified relevant animal, manikin, and human studies through targeted searches of MEDLINE in June 2022. Across pre-hospital systems, there is wide variation in use of the intraosseous route. Early administration of cardiac arrest drugs is associated with improved patient outcomes. Challenges in obtaining intravenous access mean that the intraosseous access may facilitate earlier drug administration. However, time from administration to the central circulation is unclear with pharmacokinetic data limited mainly to animal studies. Observational studies comparing the effect of intravenous and intraosseous drug administration on patient outcomes are challenging to interpret because of resuscitation time bias and other confounders. To date, no randomised controlled trial has directly compared the effect on patient outcomes of intraosseous compared with intravenous drug administration in cardiac arrest. The International Liaison Committee on Resuscitation has described the urgent need for randomised controlled trials comparing the intravenous and intraosseous route in adult out-of-hospital cardiac arrest. Ongoing clinical trials will directly address this knowledge gap.

Attitudes towards the Utilization of Intraosseous Access in Prehospital and Emergency Medicine Nursing Personnel

Background and Objectives: Insertion of an intraosseous access device enables intravascular access for critically ill patients in a prehospital and emergency department setting even when intravenous access is not possible. The aim of our study was to assess the attitudes of prehospital and emergency department nursing staff towards the utilization of intraosseous access devices. Materials and Methods: We performed quantitative research using a closed-ended structured questionnaire distributed to prehospital unit and associated emergency department nursing staff serving a population of around 200,000 inhabitants. Results: We distributed 140 questionnaires, and 106 were returned and completed. Of these, 69 (65.1%) respondents needed more than three attempts to achieve peripheral intravenous access at least once in the last year and 29 (27.4%) required central venous access because of impossible intravenous access. In the last five years, 8 (7.5%) respondents used endotracheal route for administration of medications. Despite this, only 48 (45.3%) of respondents have ever used the intraosseous route. Also, 79 (74.5%) respondents received at least some training in obtaining IO access; however, 46 (43.4%) answered that education regarding intraosseous access is not sufficient, and 92 (86.8%) answered that they wanted additional training regarding intraosseous access. Conclusions: Prehospital and emergency department nursing staff are aware of the importance of intraosseous access and understand the need for additional education and certification in this field.

Emergency Critical Skills Training for Pre-clinical Physician Assistant Students: Mixed Method Comparison of Training Method

INTRODUCTION

The fast-paced nature of physician assistant (PA) programs warrants an emphasis on high-fidelity, critical care skills training. Generally, manikins or task trainers are used for training and assessing. Soft-preserved cadavers provide a high-fidelity model to teach high-acuity, low-opportunity procedures; however, their effectiveness in PA pre-clinical training is not well understood.

OBJECTIVE

This study compared procedural competency of task trainer and soft-preserved cadaver trained pre-clinical PA (pcPA) students in completing tube thoracostomy, endotracheal intubation, intraosseous infusion, and needle thoracostomy.

METHODS

A randomized controlled study was conducted with pcPA students (n = 48) at a midwestern program. Participants were randomly assigned to cadaver trained (CT), task trainer (TT), or control group (CG). We assessed procedural competency using skill-specific rubrics and performed qualitative analysis of student comments regarding skill-specific procedural preparedness.

RESULTS

Intervention groups surpassed the control group on all skills. The CT students exhibited significantly higher procedural competency compared to TT-trained students in endotracheal intubation (p = 0.0003) and intraosseous infusion (p = 0.0041). Thematic analysis of student comments revealed pre-training students consistently felt unprepared and lacked confidence to perform needle thoracostomy, tube thoracostomy, and endotracheal intubation. Post-training perceptions, CT/TT, focused on preparedness and confidence. The CT group also consistently described the impact of realistic simulation.

CONCLUSION

High-fidelity training with soft-preserved cadavers may be the most effective way to prepare pcPA students to perform endotracheal intubation and intraosseous infusion. Student perspectives on procedural preparedness highlight the importance of multidimensional, realistic training methods.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40670-022-01575-0.

A narrative review of historic and current approaches for patients with difficult venous access: considerations for the emergency department

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.

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.

The Development and Initial End-Point User Feedback of a 3D-Printed Adult Proximal Tibia IO Simulator

Intraosseous infusion (IO) remains an underutilized technique for obtaining vascular access in adults, despite its potentially life-saving benefits in trauma patients. In rural and remote areas, shortage of training equipment and human capacity (i.e., simulators) are the main contributors to the shortage of local training courses aiming at the development and maintenance of IO skills. Specifically, current training equipment options available for trainees include commercially available simulators, which are often expensive, or animal tissues, which lack human anatomical features that are necessary for optimal learning and pose logistical and ethical issues related to practice on live animals. Three-dimensional (3D) printing provides the means to create cost-effective, anatomically correct simulators for practicing IO where existing simulators may be difficult to access, especially in remote areas. This technical report aims to describe the development of maxSIMIO, a 3D-printed adult proximal tibia IO simulator, and present feedback on the design features from a clinical co-design team consisting of 18 end-point users. 

Overall, the majority of the feedback was positive and highlighted that the maxSIMIO simulator was helpful for learning and developing the IO technique. The majority of the clinical team responders also agreed that the simulator was more anatomically accurate compared to other simulators they have used in the past. Finally, the survey results indicated that on average, the simulator is acceptable as a training tool. Notable suggestions for improvement included increasing the stability of the individual parts of the model (such as tightening the skin and securing the bones), enhancing the anatomical accuracy of the experience (such as adding a fibula), making the bones harder, increasing the size of the patella, making it more modular (to minimize costs related to maintenance), and improving the anatomical positioning of the knee joint (i.e., slightly bent in the knee joint). In summary, the clinical team, located in rural and remote areas in Canada, found the 3D-printed simulator to be a functional tool for practicing the intraosseous technique. The outcome of this report supports the use of this cost-effective simulator for simulation-based medical education for remote and rural areas anywhere in the world.

Comparison of intraosseous and intravenous iodinated contrast administration for CT imaging in Hispaniolan Amazon parrots (Amazona ventralis)

Establishing and maintaining intravenous access for contrast medium during CT imaging can be difficult in birds due to their small size and thin walled vessels. Intraosseous (IO) catheters are an alternative to intravenous catheters and are often used for fluid or medication administration in birds. To determine the feasibility of IO iodinated contrast enhancement for CT in birds, 10 adult Hispaniolan Amazon parrots (Amazona ventralis) weighing 260-325 g, were enrolled in a prospective randomized blinded crossover group study to evaluate the differences in contrast route administration. The parrots underwent pre- and postcontrast CT scans using both routes of contrast administration with a wash-out period of at least 1 week between the two methods. Scans were evaluated subjectively for diagnostic quality and objectively with Hounsfield units measured over three organs: the brain, right kidney, and liver. All scans were diagnostic, and there was no statistically significant measurable difference in contrast enhancement between the two methods in any of the three organs. Subjectively, IO catheters were technically more difficult to place, but once in place, they were easier to manipulate for the imaging procedure and provided no complications upon removal. Minimal adverse side effects were noted from the IO catheters. In this small study, IO iodinated contrast administration was comparable in enhancement characteristics to intravenous administration for CT imaging in Hispaniolan Amazon parrots.

Physician preferences associated with powered intraosseous access systems: Safety features, reliability, and ease of use

Objective

This study evaluated physician preferences and values related to the most commonly used (traditional) powered intraosseous (IO) system and a novel powered IO system featuring a passive safety needle, battery life indicator, and snap‐securement/skin attachment.

Methods

Emergency physicians participated in an IO simulation using both the traditional and novel IO systems. Participants completed a 27‐item postsimulation questionnaire to state their preferences toward each IO system and values related to the novel IO system features using a multiple choice, 11‐point value ranking scale (0 = no value, 10 = extremely valuable) and free‐text answer questions.

Results

Among the 22 study participants, 90.9% (95% confidence interval [CI]: 70.8%, 98.9%) preferred the novel IO system; top reasons for this preference were the novel IO system's passive safety needle and snap‐securement/skin attachment. Participants who preferred the traditional IO system (9.1%) noted its ease of use and familiarity. Many physicians preferred the novel IO system's needle (81.8%; 95% CI: 59.7%, 94.8%), powered driver (77.3%; 95% CI: 54.6%, 92.2%), and snap‐securement/skin attachment (100%; 95% CI: 84.6%, 100%) compared with the traditional IO system. Safety and ease of use were the most common preference explanations. Of the participants, 100% provided a value score ≥7 for the novel IO system's passive safety needle (mean score, 9.45), whereas fewer participants (59.1%) gave a value score ≥7 for the multilight battery life indicator (mean score, 6.68).

Conclusion

This study demonstrates that emergency physicians prefer and value a novel IO system with features that enhance safety and ease of use. These results provide insight into important factors related to IO systems for emergency physicians.

Clinical Management of Intraosseous Access in Adults in Critical Situations for Health Professionals

There are health professionals who are unaware of the ideal management of the intraosseous route, despite the fact that it has been scientifically considered an alternative to the peripheral venous route when the patient is in critical condition. Thanks to continuous development, there has been a need to provide emergency services with materials that manage to provide satisfactory care, despite the difficulties faced by health personnel.

OBJECTIVES

The objective of this systematic bibliographic review is to update the theoretical and practical knowledge and strategies for the insertion and proper management of the intraosseous route as an emergency vascular access for nursing professionals. Data sources, study eligibility criteria: The search for the articles was carried out in various scientific databases with the help of a search string (January 2015 and May 2021), which combined the keywords and Boolean operators.

STUDY APPRAISAL AND SYNTHESIS METHODS

Eighteen articles were chosen after a review of 1920 database articles, following the application of the inclusion and exclusion criteria.

RESULTS

Intraosseous infusion is an effective and safe technique, which increases patient survival. Therefore, it is of crucial importance that all nursing professionals know how to handle the different intraosseous devices in situations in which it is not possible to achieve immediate peripheral venous access. Conclusions and implications of key findings: It is of great need to have devices or fast and effective alternatives that allow us to develop safe interventions by health professionals.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Advanced Vascular Access in Small Animal Emergency and Critical Care

In canine and feline patients presenting in a state of hemodynamic collapse, obtaining vascular access can be challenging. Delays in achieving vascular access interfere with delivery of patient care. In human medicine, definitions of difficult vascular access are variable and include the need for multiple placement attempts or involvement of specialized teams and equipment. Incidence and risk factors for difficult vascular access have not been well studied in veterinary patients, which limits understanding of how best to address this issue. Alternatives to percutaneous peripheral or central intravenous catheterization in dogs and cats include venous cutdowns, umbilical access in newborns, corpus cavernosum access in males, ultrasound-guided catheterization, and intraosseous catheterization. In recent years, advances in ultrasonography and intraosseous access techniques have made these more accessible to veterinary practitioners. These vascular access techniques are reviewed here, along with advantages, limitations, and areas for future study of each technique.

Osteoprotective Effects in Postmenopausal Osteoporosis Rat Model: Oral Tocotrienol vs. Intraosseous Injection of Tocotrienol-Poly Lactic-Co-Glycolic Acid Combination

Osteoporosis, the most common bone disease, is associated with compromised bone strength and increased risk of fracture. Previous studies have shown that oxidative stress contributes to the progression of osteoporosis. Specifically, for postmenopausal osteoporosis, the reduction in estrogen levels leads to increased oxidative stress in bone remodeling. Tocotrienol, a member of vitamin E that exhibits antioxidant activities, has shown potential as an agent for the treatment of osteoporosis. Most studies on the osteoprotective effects of tocotrienols had used the oral form of tocotrienols, despite their low bioavailability due the lack of transfer proteins and high metabolism in the liver. Several bone studies have utilized tocotrienol combined with a nanocarrier to produce a controlled release of tocotrienol particles into the system. However, the potential of delivering tocotrienol-nanocarrier combination through the intraosseous route has never been explored. In this study, tocotrienol was combined with a nanocarrier, poly lactic-co-glycolic acid (PLGA), and injected intraosseously into the bones of ovariectomized rats to produce targeted and controlled delivery of tocotrienol into the bone microenvironment. This new form of tocotrienol delivery was compared with the conventional oral delivery in terms of their effects on bone parameters. Forty Sprague-Dawley rats were divided into five groups. The first group was sham operated, while other groups were ovariectomized (OVX). Following 2 months, the right tibiae of all the rats were drilled at the metaphysis region to provide access for intraosseous injection. The estrogen group (OVX + ESTO) and tocotrienol group (OVX + TTO) were given daily oral gavages of Premarin (64.5 mg/kg) and annatto-tocotrienol (60 mg/kg), respectively. The locally administered tocotrienol group (OVX + TTL) was given a single intraosseous injection of tocotrienol-PLGA combination. After 8 weeks of treatment, both OVX + TTO and OVX + TTL groups have significantly lower bone markers and higher bone mineral content than the OVX group. In terms of bone microarchitecture, both groups demonstrated significantly higher trabecular separation and connectivity density than the OVX group (p < 0.05). Both groups also showed improvement in bone strength by the significantly higher stress, strain, stiffness, and Young's modulus parameters. In conclusion, daily oral tocotrienol and one-time intraosseous injection of tocotrienol-PLGA combination were equally effective in offering protection against ovariectomy-induced bone changes.

Rabbit Sedation and Anesthesia

With the increasing frequency of rabbits as veterinary patients, the expectation for high-quality, intensive veterinary care, and resultantly an understanding of anesthesia has been increasing. Sedation and general anesthesia are commonly required for many routine and emergency procedures in rabbits, and this results in the need for a strong awareness of anesthetic principles, knowledge of limitations of anesthesia, and maintenance of high standards of anesthesia.

Distal femur versus humeral or tibial IO, access in adult out of hospital cardiac resuscitation

BACKGROUND

Intraosseous (IO) vascular access is a well-established method for fluid and drug administration in the critically ill. The Food and Drug Administration has approved adult IO access at the proximal humerus, proximal tibia, and the sternum; all three sites have significant limitations. The Distal Femur is away from the chest, with high flow rates. The objective of this study was to evaluate the distal femur site during resuscitation of adult out-of-hospital cardiac arrest.

METHODS

A retrospective analysis of adult out of hospital cardiac arrest patients treated by the San Antonio Fire Department. IO access was obtained by first-responders (paramedics or EMT-basic) or EMS paramedics. All resuscitation attempts from 2017 to 2018 data were analyzed. The protocol did not dictate the preference of IO site. The primary measure: number of OHCA patients in each subgroup: IO femur, IO humerus, IO tibia. Secondary measures: paramedic or basic operator, dislodgement rate, and total fluid infused.

RESULTS

There were 2,198 patients meeting inclusion criteria: 888 femur, 696 humerus, 432 tibia. Distal femur increased 2.5 times in the 2018 cohort compared to the 2017 cohort, with a corresponding decrease in humerus (factor of 0.29). Proximal tibia remained unchanged. Dislodgement rates and total infusion (ml) remained unchanged.

CONCLUSIONS

The distal femur IO was feasible and associated with similar measured performance parameters as other IO sites in adult OHCA for both advanced and basic life support personnel.

Intraosseous Regional Prophylactic Antibiotics Decrease the Risk of Prosthetic Joint Infection in Primary TKA: A Multicenter Study

BACKGROUND

Recent studies have demonstrated that the administration of regional prophylactic antibiotics by intraosseous (IO) injection achieves tissue concentrations around the knee that are 10- to 15-fold higher than intravenous (IV) delivery of prophylactic antibiotics. It is currently unknown whether the use of regional prophylactic antibiotics for primary TKA would result in a lower risk of prosthetic joint infection (PJI).

QUESTIONS/PURPOSES

(1) Is IO injection of prophylactic antibiotics associated with a decreased risk of early (< 12 months) deep PJI compared with traditional IV prophylactic antibiotics? (2) What other patient factors are associated with an increased risk of early PJI after TKA, and do regional prophylactic antibiotics influence these risk factors? (3) Can IO antibiotics be administered to all patients, and what complications occurred from the delivery of IO prophylactic antibiotics?

METHODS

A retrospective comparative study of all primary TKAs (1909 TKAs) over a 5-year period (January 2013 to December 2017) was performed to determine the risk of early PJI. Three primary TKAs did not meet the study inclusion criteria and were excluded from the study, leaving a total of 1906 TKAs (725 IO, 1181 IV) for analysis at a minimum of 12 months after index procedure. Both cohorts exhibited similar ages, BMI, and American Society of Anesthesiologists (ASA) grades; however, a greater proportion of patients in the IO cohort were smokers (p = 0.01), while a greater proportion of patients were diabetic in the IV cohort (p = 0.006). The PJI risk between IO and IV delivery techniques was compared while adjusting for patient demographics and medical comorbidities. Complications related to IO delivery-inability to administer via IO technique, compartment syndrome, fat embolism, and red man syndrome with vancomycin use-were recorded.

RESULTS

The delivery of regional prophylactic antibiotics by the IO technique resulted in a lower PJI risk than IV prophylactic antibiotics (0.1% [1 of 725] compared with 1.4% [16 of 1181]; relative risk 0.10 [95% CI 0.01 to 0.77]; p = 0.03). BMI (β = -0.17; standard error = 0.08; p = 0.02), diabetes (β = -1.80; standard error = 0.75; p = 0.02), and renal failure (β = -2.37; standard error = 0.84; p = 0.01) were factors associated with of PJI, while smoking, sex, and ASA score were not contributing factors (p > 0.05). Although BMI, diabetes, and renal failure were identified as infection risk factors, the use of IO antibiotics in these patients did not result in a lower PJI risk compared with IV antibiotics (p > 0.05). IO antibiotics were able to be successfully administered to all patients in this cohort, and there were no complications related to the delivery of IO antibiotics.

CONCLUSION

Surgeons should consider administering regional prophylactic antibiotics in primary TKA to reduce the risk of early PJI. Future randomized prospective clinical trials are needed to validate the efficacy of regional prophylactic antibiotics in reducing the PJI risk in primary TKA.

LEVEL OF EVIDENCE

Level III, therapeutic study.

[Use of the intraosseous infusion device in the resuscitation ambulances of the Paris fire brigade]

In the Paris Fire Brigade, in the context of cardiac arrest, the nurses have the greatest reported experience of intraosseous infusion. The adverse events reported are rare, given that the procedure is performed on patients in absolute emergency. All these elements are in favour of discussing a redefinition of the practice of intraosseous infusion by nurses in the specific context of immediate life-saving emergencies.

Intraosseous Specimens Submitted to the Laboratory: A Case Report and Review

Intraosseous (IO) devices are used for vascular access in settings where venous access is initially unobtainable, such as prehospital trauma care or cardiac arrest. While IO devices are effective for infusion of blood, fluids, and medications, there is limited data on the analytical equivalence of specimens taken out of IO devices and peripheral venous blood. Despite this, IO device manufacturers and clinical resources state that IO specimens can be submitted for laboratory analysis. As reported in this case, IO specimens may be drawn and labeled as 'peripheral blood'. IO specimens are not always caught by automated sample quality testing and may proceed through analysis without any warning signal to the laboratory. There are potential regulatory risks in accepting IO samples for analysis without validation. IO infusion is a valuable technique for vascular access in critically ill patients, but clinical laboratories will need to determine their own policies for identifying and handling IO specimens.

Finding alternative sites for intraosseous infusions in newborns

AIM

Intraosseous (IO)-access plays an alternative route during resuscitation. Our study in preterm and term stillborns was performed to find alternative IO puncture sites beside the recommended proximal tibia.

METHODS

The cadavers used were legal donations. 20 stillborns (mean: 29.2weeks, IQR 27.1-39.6) were investigated. Spectral-CT were analysed to calculate the diameter and circumferences of: i) proximal humerus ii) distal femur iii) proximal tibia iv) diaphyseal tibial. Contrast medium was applied under video documentation to investigate the drainage into the vascular system.

RESULTS

In term newborns, diameter of the cortex of the proximal humeral head is 12.1 ± 1.8 mm, distal end of the femur 11.9 ± 3.4 mm and the proximal tibial bone 12.0 ± 2.4 mm with cross-sectional diameter of 113.5 ± 19.7 mm2, 120.6 ± 28.2 mm2 and 111.6 ± 29.5 mm2, respectively. Regarding the preterm groups, there is a strong age-related growth in diameter and cross -sectional size. The diaphyseal area is the smallest in all measured bones with an age-dependent increase and is about half of that of metaphyseal diameters (proximal and distal) and about one third of that of metaphyseal cross sectional areas. The proximal femoral head region has the largest diameter of all measured bones with an egg-shaped formation with an extensive joint capsula. All investigated metaphyseal areas lack a clearly enclosed bone marrow cavity. Infusion of contrast medium into the distal femoral end and the proximal humerus head demonstrate the drainage of contrast medium into the central venous system within seconds.

CONCLUSION

Proximal humeral head and distal femoral end might be alternative IO areas which may lead to further IO puncture sites in neonates.

Sternal Intraosseous Devices: Review of the Literature

Introduction

The intraosseous (IO) route is one of the primary means of vascular access in critically ill and injured patients. The most common sites used are the proximal humerus, proximal tibia, and sternum. Sternal IO placement remains an often-overlooked option in emergency and prehospital medicine. Due to the conflicts in Afghanistan and Iraq the use of sternal IOs have increased.

Methods

The authors conducted a limited review, searching PubMed and Google Scholar databases for “sternal IO,” “sternal intraosseous,” and “intraosseous” without specific date limitations. A total of 47 articles were included in this review.

Results

Sternal IOs are currently FDA approved for ages 12 and older. Sternal IO access offers several anatomical, pharmacokinetic, hemodynamic, and logistical advantages over peripheral intravenous and other IO points of access. Sternal IO use carries many of the same risks and limitations as the humeral and tibial sites. Sternal IO gravity flow rates are sufficient for transfusing blood and resuscitation. In addition, studies demonstrated they are safe during active CPR.

Conclusion

The sternal IO route remains underutilized in civilian settings. When considering IO vascular access in adults or older children, medical providers should consider the sternum as the recommended IO access, particularly if the user is a novice with IO devices, increased flow rates are required, the patient has extremity trauma, or administration of a lipid soluble drug is anticipated.

Intraosseous administration of hydroxocobalamin after enclosed structure fire cardiac arrest

Smoke inhalation is the most common cause of acute cyanide poisoning in the developed world. Hydroxocobalamin is an antidote for cyanide poisoning. There is little published about human intraosseous antidote administration. We present a case of intraosseous hydroxocobalamin administration in an adult smoke inhalation victim, found in cardiac arrest inside her burning manufactured home. Return of spontaneous circulation was achieved after 20 min of cardiopulmonary resuscitation. Five grams of hydroxocobalamin were subsequently given intraosseously. On hospital arrival, patient was found to have a respiratory-metabolic acidosis. She had red-coloured urine without haematuria, a known sequela of hydroxocobalamin administration. Patient's neurological status deteriorated, and she died 4 days after admission. This case highlights that intraosseously administered hydroxocobalamin seems to adequately flow into the marrow cavity and enter the circulatory system despite the non-compressible glass antidote vial. This appears to be only the second reported human case of intraosseous hydroxocobalamin administration.

Critical Care Management of the Patient With Anaphylaxis: A Concise Definitive Review

OBJECTIVES

Anaphylaxis is a rapidly progressive life-threatening syndrome manifesting as pruritus, urticaria, angioedema, bronchospasm and shock. The goal of this synthetic review is to provide a practical, updated approach to the evaluation and management of this disorder and associated complications.

DATA SOURCES

A MEDLINE search was conducted with the MeSH of anaphylaxis, anaphylactic reaction, anaphylactic shock, refractory anaphylaxis and subheadings of diagnosis, classification, epidemiology, complications and pharmacology. The level of evidence supporting an intervention was evaluated based on the availability of randomized studies, expert opinion, case studies, reviews, practice parameters and other databases (including Cochrane).

STUDY SELECTION

Selected publications describing anaphylaxis, clinical trials, diagnosis, mechanisms, risk factors and management were retrieved (reviews, guidelines, clinical trials, case series) and their bibliographies were also reviewed to identify relevant publications.

DATA EXTRACTION

Data from the relevant publications were reviewed, summarized and the information synthesized.

DATA SYNTHESIS

This is a synthetic review and the data obtained from a literature review was utilized to describe current trends in the diagnosis and management of the patient with anaphylaxis with a special emphasis on newer evolving concepts of anaphylaxis endotypes and phenotypes, management of refractory anaphylaxis in the ICU setting and review of therapeutic options for the elderly patient, or the complicated patient with severe cardiorespiratory complications. Most of the recommendations come from practice parameters, case studies or expert opinions, with a dearth of randomized trials to support specific interventions.

CONCLUSION

Anaphylaxis is a rapidly progressive life-threatening disorder. The critical care physician needs to be familiar with the diagnosis, differential diagnosis, evaluation, and management of anaphylaxis. Skilled intervention in ICUs may be required for the patient with complicated, severe, or refractory anaphylaxis.

Inadvertent intraosseous injection during fluoroscopy-guided joint injection of two adult patients

Two cases of inadvertent intraosseous injection during fluoroscopy-guided joint injection are presented. The first case occurred during a pre-MRI hip arthrogram while the second case happened during a glenohumeral joint steroid injection. Both cases were performed on osteopenic female patients over 60 years old who reported significant pain during injection of contrast and fluoroscopic imaging showed pooling of contrast in bone during attempted injection. Both procedures were corrected by retracting the needle to achieve intraarticular injection. Being aware of intraosseous injection as a possible reason for difficulty during the procedure both guides the operator to proper correction (retraction of the needle) and also avoids a non-diagnostic or less effective procedure.

Intraosseous contrast administration for emergency stroke CT

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.