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Agostinucci JM, Alhéritière A, Metzger J, Nadiras P, Martineau L, Bertrand P, Gentilhomme A, Petrovic T, Adnet F, Lapostolle F. Evolution of the use of intraosseous vascular access in prehospital advanced cardiopulmonary resuscitation: The IOVA-CPR study. Int J Nurs Pract 2024; 30:e13244. [PMID: 38409923 DOI: 10.1111/ijn.13244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 12/05/2023] [Accepted: 01/26/2024] [Indexed: 02/28/2024]
Abstract
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.
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Affiliation(s)
- Jean-Marc Agostinucci
- SAMU 93 - UF Recherche-Enseignement-Qualité Université Paris 13, Sorbonne Paris Cité, Inserm U942, Hôpital Avicenne, Bobigny, France
| | - Armelle Alhéritière
- SAMU 93 - UF Recherche-Enseignement-Qualité Université Paris 13, Sorbonne Paris Cité, Inserm U942, Hôpital Avicenne, Bobigny, France
| | - Jacques Metzger
- SAMU 93 - UF Recherche-Enseignement-Qualité Université Paris 13, Sorbonne Paris Cité, Inserm U942, Hôpital Avicenne, Bobigny, France
- Service Mobile d'Urgence et de Réanimation, Centre Hospitalier Delafontaine, Saint-Denis, France
| | - Pierre Nadiras
- Service Mobile d'Urgence et de Réanimation, Groupe Hospitalier Intercommunal Le Raincy-Montfermeil, Montfermeil, France
| | - Laurence Martineau
- Service Mobile d'Urgence et de Réanimation, Centre Hospitalier Intercommunal Robert Ballanger, Aulnay-sous-Bois, France
| | - Philippe Bertrand
- SAMU 93 - UF Recherche-Enseignement-Qualité Université Paris 13, Sorbonne Paris Cité, Inserm U942, Hôpital Avicenne, Bobigny, France
| | - Angélie Gentilhomme
- SAMU 93 - UF Recherche-Enseignement-Qualité Université Paris 13, Sorbonne Paris Cité, Inserm U942, Hôpital Avicenne, Bobigny, France
| | - Tomislav Petrovic
- SAMU 93 - UF Recherche-Enseignement-Qualité Université Paris 13, Sorbonne Paris Cité, Inserm U942, Hôpital Avicenne, Bobigny, France
| | - Frédéric Adnet
- SAMU 93 - UF Recherche-Enseignement-Qualité Université Paris 13, Sorbonne Paris Cité, Inserm U942, Hôpital Avicenne, Bobigny, France
| | - Frédéric Lapostolle
- SAMU 93 - UF Recherche-Enseignement-Qualité Université Paris 13, Sorbonne Paris Cité, Inserm U942, Hôpital Avicenne, Bobigny, France
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Kim Y, Lee SH, Chang SW, Huh Y, Kim S, Choi JW, Cho HJ, Lee GJ. The Efficacy of Intraosseous Access for Initial Resuscitation in Patients with Severe Trauma: A Retrospective Multicenter Study in South Korea. J Clin Med 2024; 13:3702. [PMID: 38999268 PMCID: PMC11242245 DOI: 10.3390/jcm13133702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 06/05/2024] [Accepted: 06/21/2024] [Indexed: 07/14/2024] Open
Abstract
Background/Objective: In patients with severe trauma, intraosseous (IO) access is an alternative when intravenous (IV) access proves challenging. However, detailed insights into its utilization patterns and effectiveness are lacking. This study aims to evaluate the use and efficacy of IO access in hemodynamically unstable patients with trauma at level-1 trauma centers in South Korea. Methods: Data from six centers over 12 months were analyzed, focusing on patients with traumatic cardiac arrest or shock. Overall, 206 patients were included in the study: 94 in the IO group and 112 in the IV group. Results: The first-attempt success rate was higher in the IO group than in the IV group (90.4% vs. 75.5%). The procedure time in the IO group was also shorter than that in the IV group. The fluid infusion rate was lower in the IO group than in the IV group; however, the use of a pressure bag with IO access significantly increased the rate, making it comparable to the IV infusion rate. Further, regarding IO access, a humeral site provided a higher infusion rate than a tibial site. Conclusions: IO access offers a viable alternative to IV access for the initial resuscitation in patients with trauma, providing advantages in terms of procedure time and first-attempt success rate. The use of a pressure bag and a humeral site for IO access afforded infusion rates comparable to those associated with IV access.
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Affiliation(s)
- Youngmin Kim
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon 21556, Republic of Korea; (Y.K.); (S.H.L.)
| | - Seung Hwan Lee
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon 21556, Republic of Korea; (Y.K.); (S.H.L.)
- Department of Traumatology, Gachon University College of Medicine, Incheon 21565, Republic of Korea
| | - Sung Wook Chang
- Department of Thoracic and Cardiovascular Surgery, Dankook University Hospital, Cheonan 31116, Republic of Korea;
| | - Yo Huh
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon 16499, Republic of Korea;
| | - Sunju Kim
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea;
| | - Jeong Woo Choi
- Department of Emergency Medicine, Wonkwang University Hospital, Iksan 54538, Republic of Korea;
| | - Hang Joo Cho
- Department of Trauma Surgery, Uijeongbu St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea;
| | - Gil Jae Lee
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon 21556, Republic of Korea; (Y.K.); (S.H.L.)
- Department of Traumatology, Gachon University College of Medicine, Incheon 21565, Republic of Korea
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Fink PB, Wheeler AR, Smith WR, Brant-Zawadzki G, Lieberman JR, McIntosh SE, Van Tilburg C, Wedmore IS, Windsor JS, Hofmeyr R, Weber D. Wilderness Medical Society Clinical Practice Guidelines for the Treatment of Acute Pain in Austere Environments: 2024 Update. Wilderness Environ Med 2024; 35:198-218. [PMID: 38651342 DOI: 10.1177/10806032241248422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
The Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the management of pain in austere environments. Recommendations are graded based on the quality of supporting evidence as defined by criteria put forth by the American College of Chest Physicians. This is an update of the 2014 version of the "WMS Practice Guidelines for the Treatment of Acute Pain in Remote Environments" published in Wilderness & Environmental Medicine 2014; 25:41-49.
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Affiliation(s)
- Patrick B Fink
- Department of Emergency Medicine, University of Utah, Salt Lake City, UT
| | - Albert R Wheeler
- Department of Emergency Medicine, St. John's Health, Jackson, WY
| | - William R Smith
- Department of Emergency Medicine, St. John's Health, Jackson, WY
| | | | | | - Scott E McIntosh
- Department of Emergency Medicine, University of Utah, Salt Lake City, UT
| | | | - Ian S Wedmore
- Uniformed Services University of the Health Sciences, Bethesda, MD
| | | | - Ross Hofmeyr
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - David Weber
- Mountain Rescue Collective, LLC, Park City, UT
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Intraosseous Regional Administration of Antibiotic Prophylaxis for Total Knee Arthroplasty: A Systematic Review. J Arthroplasty 2023; 38:769-774. [PMID: 36280158 DOI: 10.1016/j.arth.2022.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 10/12/2022] [Accepted: 10/14/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Intraosseous regional administration (IORA) of antibiotics after tourniquet inflation has recently been introduced as a technique to deliver antibiotics directly to the surgical site among patients undergoing total knee arthroplasty (TKA). METHODS PubMed and Embase were queried for studies reporting on IORA for perioperative prophylaxis during TKA. Primary outcome measures were local tissue antibiotic concentrations and rates of prosthetic joint infection (PJI). Eight studies were included for analysis. Four studies (all randomized controlled trials) compared local tissue concentrations between patients receiving IORA and intravenous (IV) antibiotics. Six studies assessed the rate of PJI among patients receiving IORA versus IV antibiotics. RESULTS All studies found a statistically significant increase in antibiotic concentration in femoral bone and fat samples in patients who were treated with IORA (44.04 μg/g [fat] and 49.3 μg/g [bone] following 500 mg of intraosseous vancomycin) versus IV (3.5 μg/g [fat] and 5.2 μg/g [bone] following 1 g IV of vancomycin). The two studies powered to determine differences in PJI rates found a statistically significant decrease in the rate of PJI among patients receiving IORA versus IV antibiotics. The incidence of PJI in patients treated with IORA and IV antibiotics across all studies was 0.3 and 1.1%, respectively. CONCLUSION Perioperative IORA of antibiotics in TKA provides local tissue concentrations of antibiotics that are on average 10 times higher than IV administration alone. Although more adequately powered investigations are necessary to determine the effectiveness of IORA in reducing PJI rates, adoption of IORA should be considered in high-risk patients where elevated tissue antibiotic concentrations would be of a maximum benefit.
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Wang D, Deng L, Zhang R, Zhou Y, Zeng J, Jiang H. Efficacy of intraosseous access for trauma resuscitation: a systematic review and meta-analysis. World J Emerg Surg 2023; 18:17. [PMID: 36918947 PMCID: PMC10012735 DOI: 10.1186/s13017-023-00487-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 02/28/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND During medical emergencies, intraosseous (IO) access and intravenous (IV) access are methods of administering therapies and medications to patients. Treating patients in emergency medical situations is a highly time sensitive practice; however, research into the optimal access method is limited and existing systematic reviews have only considered out-of-hospital cardiac arrest (OHCA) patients. We focused on severe trauma patients and conducted a systematic review to evaluate the efficacy and efficiency of intraosseous (IO) access compared to intravenous (IV) access for trauma resuscitation in prehospital care. MATERIALS AND METHOD PubMed, Web of Science, Cochrane Library, EMBASE, ScienceDirect, banque de données en santé publique and CNKI databases were searched for articles published between January 1, 2000, and January 31, 2023. Adult trauma patients were included, regardless of race, nationality, and region. OHCA patients and other types of patients were excluded. The experimental and control groups received IO and IV access, respectively, in the pre-hospital and emergency departments for salvage. The primary outcome was success rate on first attempt, which was defined as secure needle position in the marrow cavity or a peripheral vein, with normal fluid flow. Secondary outcomes included mean time to resuscitation, mean procedure time, and complications. RESULTS Three reviewers independently screened the literature, extracted the data, and assessed the risk of bias in the included studies; meta-analyses were then performed using Review Manager (Version 5.4; Cochrane, Oxford, UK). The success rate on first attempt was significant higher for IO access than for IV access (RR = 1.46, 95% CI [1.16, 1.85], P = 0.001). The mean procedure time was significantly reduced (MD = - 5.67, 95% CI [- 9.26, - 2.07], P = 0.002). There was no significant difference in mean time to resuscitation (MD = - 1.00, 95% CI [- 3.18, 1.17], P = 0.37) and complications (RR = 1.22, 95% CI [0.14, 10.62], P = 0.86) between the IO and IV groups. CONCLUSION The success rate on first attempt of IO access was much higher than that of IV access for trauma patients, and the mean procedure time of IO access was significantly less when compared to IV access. Therefore, IO access should be suggested as an urgent vascular access for hypotensive trauma patients, especially those who are under severe shock.
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Affiliation(s)
- Dong Wang
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32, Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China.,Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, 610072, China
| | - Lei Deng
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32, Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China.,Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, 610072, China.,Sichuan Province Clinical Research Center for Emergency and Critical Care Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Ruipeng Zhang
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32, Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China.,Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, 610072, China
| | - Yiyue Zhou
- Department of Biology, Sorbonne University, 75005, Paris, France
| | - Jun Zeng
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32, Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China.,Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, 610072, China.,Sichuan Province Clinical Research Center for Emergency and Critical Care Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Hua Jiang
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32, Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China. .,Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, 610072, China. .,Sichuan Province Clinical Research Center for Emergency and Critical Care Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China.
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Intraosseous Tibial Resuscitation After a Total Knee Arthroplasty Leading to Osteonecrosis and Loosening of the Tibial Component. Arthroplast Today 2023; 19:101088. [PMID: 36691465 PMCID: PMC9860108 DOI: 10.1016/j.artd.2022.101088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 12/06/2022] [Accepted: 12/10/2022] [Indexed: 01/15/2023] Open
Abstract
A 51-year-old woman suffered cardiac arrest requiring emergent intraosseous access that abutted the tibial component of her total knee arthroplasty. She developed a wound at the site and knee pain which was concerning for deep infection. Subsequent imaging was consistent with osteonecrosis developing around the tibial component. The component eventually loosened, requiring a revision surgery. Her deep cultures remained negative throughout. Her findings are most consistent with osteonecrosis and aseptic loosening of her prosthesis. While intraosseous access may be beneficial during resuscitation, it has complications. This is the first reported case of osteonecrosis secondary to intraosseous access leading to prosthetic loosening necessitating a revision surgery.
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Fat embolism after intraosseous catheters in pediatric forensic autopsies. Int J Legal Med 2022; 137:787-791. [PMID: 35771256 PMCID: PMC10085886 DOI: 10.1007/s00414-022-02848-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/27/2022] [Indexed: 10/17/2022]
Abstract
In our center, we performed the autopsy of a child who died from drowning and presented, at autopsy, a major pulmonary fat embolism (PFE). A cardiopulmonary resuscitation (CPR) was performed, including infusion by intraosseous catheter (IIC). No other traumatic lesions and diseases classically related to a risk of PFE were detected. According to some animal studies, we considered the IIC as the only possible cause for PFE. However, we could not find literature to confirm this hypothesis in humans, especially in a pediatric population. To verify the occurrence of PFE after IIC in a pediatric population, we retrospectively selected 20 cases of pediatric deaths autopsied in our center, in which a CPR was performed, without bone fractures or other possible causes of PFE: 13 cases with IIC (group A) and 7 cases without IIC (group B). Several exclusion criteria were considered. The histology slides of the pulmonary tissue were stained by Oil Red O. PFE was classified according to the Falzi scoring system. In group A, 8 cases showed PFE: 4 cases with a score 1 of Falzi and 4 cases with a score 2 of Falzi. In group B, no case showed PFE. The difference between the two groups was statistically significant. The results of our study seem to confirm that IIC can lead to PFE in a pediatric population and show that the PFE after IIC can be important (up to score 2 of Falzi). To the best of our knowledge, our study is the first specifically focused on the occurrence of PFE after IIC in a pediatric population by using autoptic data.
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Kummer T, Maldonado G, Reichard RR. Intraosseus administration of an ultrasound contrast agent in a case of pediatric blunt abdominal trauma. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2022.102264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Johnson JG, Chinnadurai SK. Drug Delivery and Safety Considerations. Vet Clin North Am Exot Anim Pract 2021; 25:1-11. [PMID: 34823686 DOI: 10.1016/j.cvex.2021.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Anesthetic drugs must be delivered at the appropriate dose and route of administration to produce the expected anesthetic effects. This is important for patient safety because anesthetic drugs function by depressing the central nervous and cardiovascular systems, which if improperly dosed or administered could cause potentially life-threatening effects. Several routes of administration and different drug delivery methods are available to safely and reliably anesthetize zoologic companion animal patients. Because of the nature of zoologic companion animal practice, anesthetic procedures pose risks that the anesthetist should understand to carefully plan procedures that are as safe and efficient as possible.
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Affiliation(s)
- James G Johnson
- Department of Animal Health, Saint Louis Zoo, One Government Drive, St Louis, MO 63110, USA; Department of Veterinary Preventative Medicine, College of Veterinary Medicine, The Ohio State University, Columbus, OH 43210, USA.
| | - Sathya K Chinnadurai
- Department of Animal Health, Saint Louis Zoo, One Government Drive, St Louis, MO 63110, USA
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Sulava E, Bianchi W, McEvoy CS, Roszko PJ, Zarow GJ, Gaspary MJ, Natarajan R, Auten JD. Single Versus Double Anatomic Site Intraosseous Blood Transfusion in a Swine Model of Hemorrhagic Shock. J Surg Res 2021; 267:172-181. [PMID: 34153560 DOI: 10.1016/j.jss.2021.04.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 04/05/2021] [Accepted: 04/10/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Blood transfusion via single site intraosseous access is a critical modality when caring for a trauma victim that lacks intravascular access. Flow rates and potential clinical complications when utilizing two sites of intraosseous access are not well known. MATERIALS AND METHODS Anesthetized adult female Yorkshire swine (Sus scrofa; n = 48; 76.7 ± 1.75kg; range 66-90kg) were cannulated and then bled approximately 30% total blood volume. Swine were randomly assigned to treatment groups: single sited humerus, single sited sternum, dual sited humerus or dual sited humerus and sternum. Flow rates, hemolysis, physiologic measurements, biochemical variables, and pulmonary histologic inflammation and occlusion were contrasted between groups. RESULTS Dual sited intraosseous transfusion flow rates (128ml/min, 95% CI 123-132) were double the flow rates of single sites (65ml/min, 95% CI 60-70), P < .0001.Single sited humeral flow rates were greater than sternal flow rates, with respective averages of 74ml/min and 55ml/min, though not reaching statistical significance (P < 0.17). There was no significant elevation of plasma free hemoglobin in any group after transfusion as compared to baseline (P = 0.7). Groups did not significantly differ in vitals or biochemical variables. Most pulmonary specimens had some intraparenchymal fat embolism, however no animals had evidence of occlusive intra-arterial fat embolism. CONCLUSIONS Dual anatomic site, pressure bag driven, intraosseous blood transfusion approximately doubles flow rates without evidence of clinical complications or hemolysis. Further research using a survivability model is needed to characterize long-term complications from pressurized IO transfusions.
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Affiliation(s)
- Eric Sulava
- Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia; Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia.
| | - William Bianchi
- Department of Emergency Medicine, Naval Medical Center San Diego, San Diego, California; Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia
| | - Christian S McEvoy
- Department of General Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia; Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia
| | - Paul J Roszko
- Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia; Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia
| | - Gregory J Zarow
- Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia
| | - Micah J Gaspary
- Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia; Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia
| | - Ramesh Natarajan
- Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia; Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia
| | - Jonathan D Auten
- Department of Emergency Medicine, Naval Medical Center San Diego, San Diego, California; Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia
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Besserer F, Kawano T, Dirk J, Meckler G, Tijssen JA, DeCaen A, Scheuermeyer F, Beno S, Christenson J, Grunau B. The association of intraosseous vascular access and survival among pediatric patients with out-of-hospital cardiac arrest. Resuscitation 2021; 167:49-57. [PMID: 34389454 DOI: 10.1016/j.resuscitation.2021.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 05/10/2021] [Accepted: 08/01/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION In pediatric out-of-hospital cardiac arrest (OHCA) the effect of intraosseous (IO) or intravenous (IV) access on outcomes is unclear. METHODS We analyzed prospectively collected data of non-traumatic OHCA in the Resuscitation Outcomes Consortium registry from 2011 to 2015. We included EMS-treated patients ≤17 years of age, classified patients based on vascular access routes, and calculated success rates of IO and IV attempts. After excluding patients with obvious non-cardiac etiologies and those with unsuccessful vascular access or multiple routes, we fit a logistic regression model to evaluate the association of IO vascular access (reference IV access) with the primary outcome of survival, using multiple imputation to address missing data. We analyzed a subgroup of patients at least 2 years of age. RESULTS There were 1549 non-traumatic OHCA: 895 (57.8%) patients had an IO line attempted with 822 (91.8%) successful; 488 (31.5%) had an IV line attempted with 345 (70.7%) successful (difference 21%, 95% CI 17 to 26%). Of the 761 patients included in our logistic regression, 601 received IO (30 [5.2%] survived) and 160 received IV (40 [25%] survived) vascular access. Intraosseous access was associated with a decreased probability of survival (adjusted OR 0.46; 95% CI 0.21-0.98). Patients at least 2 years of age showed a similar association (adjusted OR 0.36; CI 0.15-0.86). CONCLUSIONS Intraosseous access was associated with decreased survival among pediatric non-traumatic OHCA. These results are exploratory and support the need for further study to evaluate the effect of intravascular access method on outcomes.
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Affiliation(s)
- Floyd Besserer
- Department of Emergency Medicine, University of British Columbia, Canada; BC Emergency Health Services, British Columbia, Canada; Canadian Resuscitation Outcomes Consortium, Canada.
| | - Takahisa Kawano
- Canadian Resuscitation Outcomes Consortium, Canada; Department of Emergency Medicine, University of Fukui Hospital, Fukui Prefecture, Japan
| | - Justin Dirk
- School of Medicine, Queen's University, Ontario, Canada
| | - Garth Meckler
- Department of Emergency Medicine, University of British Columbia, Canada; BC Emergency Health Services, British Columbia, Canada; Canadian Resuscitation Outcomes Consortium, Canada; Department of Pediatrics, University of British Columbia, Canada
| | - Janice A Tijssen
- Canadian Resuscitation Outcomes Consortium, Canada; Department of Paediatrics, Western University, Canada
| | - Allan DeCaen
- Canadian Resuscitation Outcomes Consortium, Canada; Department of Paediatrics, University of Alberta, Canada
| | - Frank Scheuermeyer
- Department of Emergency Medicine, University of British Columbia, Canada; Canadian Resuscitation Outcomes Consortium, Canada; Centre for Health Evaluation and Outcome Sciences, Canada
| | - Suzanne Beno
- Department of Paediatrics, University of Toronto, Canada
| | - Jim Christenson
- Department of Emergency Medicine, University of British Columbia, Canada; Canadian Resuscitation Outcomes Consortium, Canada; Centre for Health Evaluation and Outcome Sciences, Canada
| | - Brian Grunau
- Department of Emergency Medicine, University of British Columbia, Canada; BC Emergency Health Services, British Columbia, Canada; Canadian Resuscitation Outcomes Consortium, Canada; Centre for Health Evaluation and Outcome Sciences, Canada
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Arakawa J, Woelber E, Working Z, Meeker J, Friess D. Complications of Intraosseous Access: Two Case Reports From a Single Center. JBJS Case Connect 2021; 11:01709767-202106000-00038. [PMID: 33979829 DOI: 10.2106/jbjs.cc.19.00382] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASES Intraosseous (IO) access is an effective surrogate for intravascular access in critically ill patients. We present 2 cases of IO complications. The first patient is a 44-year-old man with deep peroneal nerve sensorimotor dysfunction due to possible missed acute compartment syndrome from improper placement of a tibial IO needle. The second patient is an immunosuppressed 69-year-old man with idiopathic factor VIII deficiency who required amputation 7 months after right tibia IO access. CONCLUSION These adverse events of IO access are limited in the literature. We make recommendations to reduce these outcomes.
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Affiliation(s)
- Jordan Arakawa
- Department of Orthopaedics & Rehabilitation, Oregon Health and Science University, Portland, Oregon
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Biesterveld BE, O'Connell R, Kemp MT, Wakam GK, Williams AM, Pai MP, Alam HB. Validation of intraosseous delivery of valproic acid in a swine model of polytrauma. Trauma Surg Acute Care Open 2021; 6:e000683. [PMID: 33791436 PMCID: PMC7978107 DOI: 10.1136/tsaco-2021-000683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/04/2021] [Accepted: 02/28/2021] [Indexed: 11/03/2022] Open
Abstract
Background Intraosseous (IO) drug delivery may be necessary in emergency situations when intravenous access is unattainable. Valproic acid (VPA) is a histone deacetylase inhibitor that has previously been shown to improve survival in preclinical models of lethal polytrauma. In this study, we sought to compare serum levels of intravenously and IO-delivered VPA, and to analyze the effect of IO-delivered VPA. Methods Swine were subjected to 40% blood volume hemorrhage, brain injury, femur fracture, rectus crush injury and liver laceration. After 1 hour of shock, animals were randomized (n=3/group) to receive normal saline resuscitation (control), normal saline+intravenous VPA 150 mg/kg (intravenous group) or normal saline +IO VPA 150 mg/kg (IO group). Serum levels of VPA were assessed between groups, and proteomics analyses were performed on IO and control groups on heart, lung and liver samples. Results Intravenous and IO serum VPA levels were similar at 1, 3, 5 and 7 hours after starting the infusion (p>0.05). IO-delivered VPA induced significant proteomics changes in the heart, lung and liver, which were most pronounced in the lung. Biologic processes affected included inflammation, metabolism and transcriptional & translational machinery. The control group had 0% survival, and the intravenous and IO group both had 100% survival to the end of the experiment (p<0.05). Discussion IO-delivered VPA is noninferior to intravenous administration and is a viable option in emergent situations when intravenous access is unattainable. Level of evidence Not applicable (animal study).
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Affiliation(s)
- Ben E Biesterveld
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Rachel O'Connell
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA.,Department of Surgery, Northwestern University, Evanston, Illinois, USA
| | - Michael T Kemp
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Glenn K Wakam
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Aaron M Williams
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Manjunath P Pai
- Department of Clinical Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Hasan B Alam
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA.,Department of Surgery, Northwestern University, Evanston, Illinois, USA
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[S3 Guideline Sepsis-prevention, diagnosis, therapy, and aftercare : Long version]. Med Klin Intensivmed Notfmed 2021; 115:37-109. [PMID: 32356041 DOI: 10.1007/s00063-020-00685-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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15
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Intraosseous or Peripheral IV Access in Pediatric Cardiac Arrest? Results From the French National Cardiac Arrest Registry. Pediatr Crit Care Med 2021; 22:286-296. [PMID: 33433156 DOI: 10.1097/pcc.0000000000002659] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Despite the evolving recommendations that favor the use of intraosseous access in pediatric resuscitation, the impact of vascular access type on survival in young children has not been demonstrated. The aim of this study was to assess the impact of the intravascular injection route on the return on spontaneous circulation, survival to hospital admission (0 day), and 30 days or survival to hospital discharge, by comparing survival rates in young children having intraosseous and peripheral IV access. The second aim was to compare the rates of favorable neurologic outcome after 30 days or survival to hospital discharge. DESIGN This was a multicenter retrospective comparative study between July 2011 and October 2018. SETTING Based on the French cardiac arrest registry data. PATIENTS All prepubescent (males < 12 yr old, females < 10 yr old) victims of an out-of-hospital cardiac arrest. INTERVENTIONS Patients with adrenaline administration by intraosseous versus peripheral venous technique were compared, using propensity score matching. MEASUREMENTS AND MAIN RESULTS The analysis included 603 prepubescent patients, 351 (58%) in the intraosseous group and 252 (42%) in the peripheral IV group. Intraosseous group patients were younger, lighter, with more medical cause for arrest. The intraosseous group had lower survival rates at 30 days or hospital discharge (n = 6; 1.7%) than the peripheral IV group (n = 12; 4.8%) (p = 0.030). After matching, 101 pairs of patients were created. No difference was observed on return of spontaneous circulation or 0-day survival rates (odds ratio = 1.000 [95% CI, 0.518-1.930]; odds ratio = 0.946 [95% CI, 0.492-1.817], respectively) and on 30 days or hospital discharge survival (n = 3 in both groups) (odds ratio = 1.000 [95% CI, 0.197-5.076]). Meaningful statistical evaluation of neurologic status among survivors was precluded by inadequate numbers. CONCLUSIONS The type of injection route (intraosseous or peripheral venous access) does not appear to have an impact on survival of out-of-hospital cardiac arrest in a prepubescent population, but limitations of propensity matching limit a definitive conclusion.
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Myftiu A, Hedtmann G, Kollmar R. [Uncomplicated thrombolysis treatment with rt-PA via an intraosseous access after acute ischemic stroke]. DER NERVENARZT 2020; 91:534-536. [PMID: 32347326 DOI: 10.1007/s00115-020-00914-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Anisa Myftiu
- Klinik für Neurologie und Neurointensivmedizin, Klinikum Darmstadt GmbH, Grafenstraße 9, 64283, Darmstadt, Deutschland.
| | - Günter Hedtmann
- Klinik für Neurologie und Neurointensivmedizin, Klinikum Darmstadt GmbH, Grafenstraße 9, 64283, Darmstadt, Deutschland
| | - Rainer Kollmar
- Klinik für Neurologie und Neurointensivmedizin, Klinikum Darmstadt GmbH, Grafenstraße 9, 64283, Darmstadt, Deutschland
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Intraosseous Administration of Hypertonic Saline in Acute Brain-Injured Patients: A Prospective Case Series and Literature Review. Neurologist 2020; 24:176-179. [PMID: 31688708 DOI: 10.1097/nrl.0000000000000248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Central venous catheters are often used to administer hypertonic saline (HTS) but might be associated with serious complications. Intraosseous (IO) access is an alternative method of medication and fluid delivery which is not associated with life-threatening complications and can be inserted faster than CVCs. METHODS A prospective case series was conducted on critically ill neurological patients that did not have central venous access, and for whom 3% HTS was indicated. Nonverbal indicators of pain were measured using the critical care pain observation tool. The pain score and serum sodium levels were collected at baseline, at 2, 6, 12, 18, and 24 hours after administration of 3% HTS using IO access. The area surrounding the IO insertion site was monitored for needle placement, extravasation, and tissue damage. RESULTS Five patients were enrolled. Three had an IO placed in the proximal humerus and 2 in the proximal tibia. Most patients did not have nonverbal indicators of pain during insertion and initial bolus. Serum sodium levels increased appropriately, as determined by the care providers. There were no cases of device dislodgement, extravasation, infection, soft tissue injury, or other local complications. CONCLUSIONS In this prospective case series, IO administration of 3% HTS was feasible, well-tolerated on the basis of nonverbal indicators of pain in the majority of patients and resulted in an appropriate rise in serum sodium levels. IO fills a niche among vascular access options for HTS, in emergent neurological situations when central venous access is not readily available or peripheral intravenous access is difficult to obtain.
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Jousi M, Björkman J, Nurmi J. Point-of-care analyses of blood samples from intraosseous access in pre-hospital critical care. Acta Anaesthesiol Scand 2019; 63:1419-1425. [PMID: 31290560 DOI: 10.1111/aas.13443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/13/2019] [Accepted: 06/30/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Intraosseous (IO) access is used for fluid and medication administration in emergency situations when difficulties with vascular access are encountered. IO access would be readily available to take samples for point-of-care (POC) analysis, but there is scarce evidence about the reliability of POC analysis of IO samples among emergency patients. The aim of this study was to evaluate the feasibility and reliability of POC analysis of IO samples in critically ill pre-hospital patients. METHODS We performed a prospective, observational study in 35 critically ill pre-hospital patients. After inserting a humeral IO needle, we immediately drew an IO sample. We compared the results to an arterial sample drawn from the same patient within 5 (blood gases) or 15 (other parameters) minutes. Samples were analysed with an i-STAT® POC analyser for blood gases, acid-base balance, electrolytes, glucose and haemoglobin. The agreement between each patient's IO and arterial samples was analysed using the Bland-Altman method. The results were compared to responses about acceptable bias on a questionnaire sent to 16 experienced emergency physicians. RESULTS The analysis was successful for 23 patients (70%). Higher age was associated with failed analyses. The average bias was acceptable for base excess, pH, standard bicarbonate, glucose, ionized calcium and sodium. IO potassium values were systematically higher than arterial values. IO haemoglobin values had widely varying agreement. CONCLUSION When vascular access is challenging, IO access can be used for emergency POC analyses to help guide clinical decision-making. However, the limitations of IO POC analyses must be carefully considered.
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Affiliation(s)
- Milla Jousi
- Emergency Medicine University of Helsinki and Department of Emergency Medicine and Services, Helsinki University Hospital Helsinki Finland
- FinnHEMS Research and Development UnitVantaa Finland
| | - Johannes Björkman
- Department of Anaesthesiology Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Jouni Nurmi
- Emergency Medicine University of Helsinki and Department of Emergency Medicine and Services, Helsinki University Hospital Helsinki Finland
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Strein M, Holton-Burke JP, Smith LR, Brophy GM. Prevention, Treatment, and Monitoring of Seizures in the Intensive Care Unit. J Clin Med 2019; 8:E1177. [PMID: 31394791 PMCID: PMC6722541 DOI: 10.3390/jcm8081177] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 07/30/2019] [Accepted: 08/01/2019] [Indexed: 12/25/2022] Open
Abstract
The diagnosis and management of seizures in the critically ill patient can sometimes present a unique challenge for practitioners due to lack of exposure and complex patient comorbidities. The reported incidence varies between 8% and 34% of critically ill patients, with many patients often showing no overt clinical signs of seizures. Outcomes in patients with unidentified seizure activity tend to be poor, and mortality significantly increases in those who have seizure activity longer than 30 min. Prompt diagnosis and provision of medical therapy are crucial in order to attain successful seizure termination and prevent poor outcomes. In this article, we review the epidemiology and pathophysiology of seizures in the critically ill, various seizure monitoring modalities, and recommended medical therapy.
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Affiliation(s)
- Micheal Strein
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA 23298-0533, USA
| | - John P Holton-Burke
- Department of Neurology, Virginia Commonwealth University Health System, Richmond, VA 23298-0599, USA
| | - LaTangela R Smith
- Department of Neurology, Virginia Commonwealth University Health System, Richmond, VA 23298-0599, USA
| | - Gretchen M Brophy
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA 23298-0533, USA.
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Clinical Survey and Predictors of Outcomes of Pediatric Out-of-Hospital Cardiac Arrest Admitted to the Emergency Department. Sci Rep 2019; 9:7032. [PMID: 31065052 PMCID: PMC6505536 DOI: 10.1038/s41598-019-43020-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 04/08/2019] [Indexed: 12/19/2022] Open
Abstract
Pediatric out-of-hospital cardiac arrest (OHCA) is a rare event with severe sequelae. Although the survival to hospital-discharge (STHD) rate has improved from 2–6% to 17.6–40.2%, only 1–4% of OHCA survivors have a good neurological outcome. This study investigated the characteristics of case management before and after admittance to the emergency department (ED) associated with outcomes of pediatric OHCA in an ED. This was a retrospective study of data collected from our ED resuscitation room logbooks dating from 2005 to 2016. All records of children under 18 years old with OHCA were reviewed. Outcomes of interest included sustained return of spontaneous circulation (SROSC), STHD, and neurological outcomes. From the 12-year study period, 152 patients were included. Pediatric OHCA commonly affects males (55.3%, n = 84) and infants younger than 1 year of age (47.4%, n = 72) at home (76.3%, n = 116). Most triggers of pediatric OHCA were respiratory in nature (53.2%, n = 81). Sudden infant death syndrome (SIDS) (29.6%, n = 45), unknown medical causes (25%, n = 38), and trauma (10.5%, n = 16) were the main causes of pediatric OHCA. Sixty-two initial cardiac rhythms at the scene were obtained, most of which were asystole and pulseless electrical activity (PEA) (93.5%, n/all: 58/62). Upon ED arrival, cardiopulmonary resuscitation (CPR) was continued for 32.66 ± 20.71 min in the ED and 34.9% (n = 53) gained SROSC. Among them, 13.8% (n = 21) achieved STHD and 4.6% (n = 7) had a favorable neurological outcome. In multivariate analyses, fewer ED epinephrine doses (p < 0.05), witness of OHCA (p = 0.001), and shorter ED CPR duration (p = 0.007) were factors that increased the rate of SROSC at the ED. A longer emergency medical service (EMS) scene interval (p = 0.047) and shorter ED CPR interval (p = 0.047) improved STHD.
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21
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Chalopin T, Lemaignen A, Guillon A, Geffray A, Derot G, Bahuaud O, Agout C, Rosset P, Castellier C, De Pinieux G, Valentin AS, Bernard L, Bastides F. Acute Tibial osteomyelitis caused by intraosseous access during initial resuscitation: a case report and literature review. BMC Infect Dis 2018; 18:665. [PMID: 30558553 PMCID: PMC6296120 DOI: 10.1186/s12879-018-3577-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 12/03/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intra-osseous (IO) access is recommended in cases of pre-hospital emergency or resuscitation when intravascular (IV) route is difficult or impossible. Despite recent improvement in IO devices and increasing indications, it remains rarely used in practice. Various complications have been reported but are uncommon. CASE PRESENTATION We report a case of massive acute tibial osteomyelitis in an adult male three months after an IO catheter insertion for emergency drug infusion. We review the literature on association between IO access and acute osteomyelitis in children and adults. CONCLUSIONS Emergency-care givers and radiologists should be informed about this infrequent complication in order to make early diagnosis and initiate adequate antibiotic therapy.
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Affiliation(s)
- Thomas Chalopin
- Department of Internal Medicine and Infectious Diseases, University Hospital of Tours, Hospital Bretonneau, Tours, France
- François Rabelais University, Tours, France
| | - Adrien Lemaignen
- Department of Internal Medicine and Infectious Diseases, University Hospital of Tours, Hospital Bretonneau, Tours, France
- François Rabelais University, Tours, France
| | - Antoine Guillon
- Department of Intensive Care Unit, University Hospital of Tours, Tours, France
| | - Arnaud Geffray
- Department of Medical Imaging, University Hospital of Tours, Tours, France
| | - Gaelle Derot
- Department of Medical Imaging, University Hospital of Tours, Tours, France
| | - Olivier Bahuaud
- Department of Internal Medicine and Infectious Diseases, University Hospital of Tours, Hospital Bretonneau, Tours, France
- François Rabelais University, Tours, France
| | - Charles Agout
- Department of Orthopedic Surgery, University Hospital of Tours, Tours, France
| | - Philippe Rosset
- Department of Orthopedic Surgery, University Hospital of Tours, Tours, France
| | - Claire Castellier
- Department of Anatomopathology, University Hospital of Tours, Tours, France
| | | | | | - Louis Bernard
- Department of Internal Medicine and Infectious Diseases, University Hospital of Tours, Hospital Bretonneau, Tours, France
- François Rabelais University, Tours, France
| | - Frederic Bastides
- Department of Internal Medicine and Infectious Diseases, University Hospital of Tours, Hospital Bretonneau, Tours, France
- François Rabelais University, Tours, France
- 2 boulevard Tonnellé, 37044 Tours, Cedex 9 France
| | - Centre De Référence Des Infections Ostéo-Articulaires Du Grand-Ouest (CRIOGO) Study Team
- Department of Internal Medicine and Infectious Diseases, University Hospital of Tours, Hospital Bretonneau, Tours, France
- François Rabelais University, Tours, France
- Department of Intensive Care Unit, University Hospital of Tours, Tours, France
- Department of Medical Imaging, University Hospital of Tours, Tours, France
- Department of Orthopedic Surgery, University Hospital of Tours, Tours, France
- Department of Anatomopathology, University Hospital of Tours, Tours, France
- Bacteriological Laboratory, University Hospital of Tours, Tours, France
- 2 boulevard Tonnellé, 37044 Tours, Cedex 9 France
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Abstract
Objectives We studied subchondral intraosseous pressure (IOP) in an animal model during loading, and with vascular occlusion. We explored bone compartmentalization by saline injection. Materials and Methods Needles were placed in the femoral condyle and proximal tibia of five anaesthetized rabbits and connected to pressure recorders. The limb was loaded with and without proximal vascular occlusion. An additional subject had simultaneous triple recordings at the femoral head, femoral condyle and proximal tibia. In a further subject, saline injections at three sites were carried out in turn. Results Loading alone caused a rise in subchondral IOP from 11.7 mmHg (sd 7.1) to 17.9 mmHg (sd 8.1; p < 0.0002). During arterial occlusion, IOP fell to 5.3 mmHg (sd 4.1), then with loading there was a small rise to 7.6 mmHg (sd 4.5; p < 0.002). During venous occlusion, IOP rose to 20.2 mmHg (sd 5.8), and with loading there was a further rise to 26.3 mmHg (sd 6.3; p < 0.003). The effects were present at three different sites along the limb simultaneously. Saline injections showed pressure transmitted throughout the length of the femur but not across the knee joint. Conclusion This is the first study to report changes in IOP in vivo during loading and with combinations of vascular occlusion and loading. Intraosseous pressure is not a constant. It is reduced during proximal arterial occlusion and increased with proximal venous occlusion. Whatever the perfusion state, in vivo load is transferred partly by hydraulic pressure. We propose that joints act as hydraulic pressure barriers. An understanding of subchondral physiology may be important in understanding osteoarthritis and other bone diseases. Cite this article: M. Beverly, S. Mellon, J. A. Kennedy, D. W. Murray. Intraosseous pressure during loading and with vascular occlusion in an animal model. Bone Joint Res 2018;7:511–516. DOI: 10.1302/2046-3758.78.BJR-2017-0343.R2.
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Affiliation(s)
- M Beverly
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Nuffield Orthopaedic Centre, Oxford, UK
| | - S Mellon
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Nuffield Orthopaedic Centre, Oxford, UK
| | - J A Kennedy
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Nuffield Orthopaedic Centre, Oxford, UK
| | - D W Murray
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Nuffield Orthopaedic Centre, Oxford, UK
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Cho Y, You Y, Park JS, Min JH, Yoo I, Jeong W, Ryu S, Lee J, Kim S, Cho SU, Oh SK, Lee J, Ahn HJ. Comparison of right and left ventricular enhancement times using a microbubble contrast agent between proximal humeral intraosseous access and brachial intravenous access during cardiopulmonary resuscitation in adults. Resuscitation 2018; 129:90-93. [PMID: 29928956 DOI: 10.1016/j.resuscitation.2018.06.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 06/08/2018] [Accepted: 06/15/2018] [Indexed: 10/28/2022]
Abstract
AIM The present study aimed to compare the ventricular enhancement time between humeral intraosseous access (HIO) and brachial intravenous access (BIV) during cardiopulmonary resuscitation (CPR) in adult humans. To our knowledge, this is the first such study during CPR in adult humans. METHODS This prospective single-centre observational cohort study assessed the medical records of patients who underwent CPR between January 2018 and March 2018. The primary endpoints were the left and right ventricular enhancement (LVE and RVE, respectively) times after administration of a microbubble contrast agent via HIO or BIV. Continuous variables are reported as means and standard deviations depending on normal distribution, while categorical variables are reported as frequencies and percentages. The paired t-test and analysis of variance were used to compare HIO and BIV. Differences were considered significant at a P-value <0.05. RESULTS The study included 10 patients. The HIO time (15.60 ± 6.45 s) was significantly lower than the BIV time (20.80 ± 7.05 s; P = 0.009). The RVE time was significantly lower with HIO (5.60 ± 1.71 s) than with BIV (15.40 ± 3.24 s; P < 0.001). Additionally, the LVE time was significantly lower with HIO (120.20 ± 4.18 s) than with BIV (132.00 ± 3.09 s; P < 0.001). CONCLUSION Our results indicated that the arrival times of a drug at the right and left ventricles are significantly lower with HIO than with BIV in an adult cardiac arrest model.
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Affiliation(s)
- Yongchul Cho
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | - Yeonho You
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea.
| | - Jung Soo Park
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea; Department of Emergency Medicine, College of Medicine, Chungnam National University, 282, Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Jin Hong Min
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | - Insool Yoo
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea; Department of Emergency Medicine, College of Medicine, Chungnam National University, 282, Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Wonjoon Jeong
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | - Seung Ryu
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | - Jinwoong Lee
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | - Seungwhan Kim
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | - Sung Uk Cho
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | - Se Kwang Oh
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | - Junwan Lee
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | - Hong Joon Ahn
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
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Yee D, Deolankar R, Marcantoni J, Liang SY. Tibial Osteomyelitis Following Prehospital Intraosseous Access. Clin Pract Cases Emerg Med 2017; 1:391-394. [PMID: 29849365 PMCID: PMC5965223 DOI: 10.5811/cpcem.2017.9.35256] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 09/12/2017] [Accepted: 09/22/2017] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Derek Yee
- Washington University School of Medicine, Division of Medical Education, St. Louis, Missouri
| | - Rahul Deolankar
- Washington University School of Medicine, Division of Diagnostic Radiology, St. Louis, Missouri
| | - Jodie Marcantoni
- Washington University School of Medicine, Division of Infectious Diseases, St. Louis, Missouri
| | - Stephen Y Liang
- Washington University School of Medicine, Division of Emergency Medicine St. Louis, Missouri.,Washington University School of Medicine, Division of Infectious Diseases, St. Louis, Missouri
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Burgert JM, Martinez A, O'Sullivan M, Blouin D, Long A, Johnson AD. Sternal Route More Effective than Tibial Route for Intraosseous Amiodarone Administration in a Swine Model of Ventricular Fibrillation. PREHOSP EMERG CARE 2017; 22:266-275. [PMID: 28910187 DOI: 10.1080/10903127.2017.1358782] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The pharmacokinetics of IO administered lipid soluble amiodarone during ventricular fibrillation (VF) with ongoing CPR are unknown. This study measured mean plasma concentration over 5 minutes, maximum plasma concentration (Cmax), and time to maximum concentration (Tmax) of amiodarone administered by the sternal IO (SIO), tibial IO (TIO), and IV routes in a swine model of VF with ongoing CPR. METHODS Twenty-one Yorkshire-cross swine were randomly assigned to three groups: SIO, TIO, and IV. Ventricular fibrillation was induced under general anesthesia. After 4 minutes in VF, 300 mg amiodarone was administered as indicated by group assignment. Serial blood specimens collected at 30, 60, 90, 120, 150, 180, 240, and 300 seconds were analyzed using high performance liquid chromatography with tandem mass spectrometry. RESULTS The mean plasma concentration of IV amiodarone over 5 minutes was significantly higher than the TIO group at 60 seconds (P = 0.02) and 90 seconds (P = 0.017) post-injection. No significant differences in Cmax between the groups were found (P <0.05). The Tmax of amiodarone was significantly shorter in the SIO (99 secs) and IV (86 secs) groups compared to the TIO group (215 secs); P = 0.002 and P = 0.002, respectively. CONCLUSIONS The SIO and IV routes of amiodarone administration were comparable. The TIO group took nearly three times longer to reach Tmax than the SIO and IV groups, likely indicating depot of lipid-soluble amiodarone in adipose-rich tibial yellow bone marrow. The SIO route was more effective than the TIO route for amiodarone delivery in a swine model of VF with ongoing CPR. Further investigations are necessary to determine if the kinetic differences found between the SIO and TIO routes in this study affect survival of VF in humans.
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Elliott A, Dubé PA, Cossette-Côté A, Patakfalvi L, Villeneuve E, Morris M, Gosselin S. Intraosseous administration of antidotes – a systematic review. Clin Toxicol (Phila) 2017. [DOI: 10.1080/15563650.2017.1337122] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Audrée Elliott
- Department of Environmental Health and Toxicology, Institut National de Santé Publique du Québec, Québec, QC, Canada
| | - Pierre-André Dubé
- Department of Environmental Health and Toxicology, Institut National de Santé Publique du Québec, Québec, QC, Canada
- Faculty of Pharmacy, Université Laval, QC, Canada
| | - Amélie Cossette-Côté
- Department of Pharmacy, Centre Intégré de Santé et de Services Sociaux du Bas-Saint-Laurent, Hôpital de Rimouski, Rimouski, QC, Canada
| | - Laura Patakfalvi
- Department of Family Medicine & Hospital Medicine, McGill University, Montreal, Canada
| | - Eric Villeneuve
- Department of Pharmacy, McGill University Health Centre, Montréal, Québec, Canada
| | - Martin Morris
- Schulich Library of Physical Sciences, Life Sciences and Engineering, McGill University, Montreal, Canada
| | - Sophie Gosselin
- Department of Medicine and Emergency Medicine, McGill University Health Centre, Montréal, Québec, Canada
- Centre antipoison du Québec, Province of Alberta Drug Information Service, Québec, Canada
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Feinstein BA, Stubbs BA, Rea T, Kudenchuk PJ. Intraosseous compared to intravenous drug resuscitation in out-of-hospital cardiac arrest. Resuscitation 2017. [PMID: 28629995 DOI: 10.1016/j.resuscitation.2017.06.014] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIMS Although the intraosseous (IO) route is increasingly used for vascular access in out-of-hospital cardiac arrest (OHCA), little is known about its comparative effectiveness relative to intravenous (IV) access. We evaluated clinical outcomes following OHCA comparing drug administration via IO versus IV routes. METHODS This retrospective cohort study evaluated Emergency Medical Services (EMS)-treated adults with atraumatic OHCA in a large metropolitan EMS system between 9/1/2012-12/31/2014. Access was classified as IO or IV based on the route of first EMS drug administration. Study endpoints were survival to hospital discharge, return of spontaneous circulation (ROSC) and survival to hospital admission. RESULTS Among 2164 adults with OHCA, 1800 met eligibility criteria, 1525 of whom were treated via IV and 275 principally via tibial-IO routes. Compared to IV, IO-treated patients were younger, more often women, had unwitnessed OHCA, a non-cardiac aetiology, and presented with non-shockable rhythms. IO versus IV-treated patients were less likely to survive to hospital discharge (14.9% vs 22.8%, p=0.003), achieve ROSC (43.6% vs 55.5%, p<0.001) or be hospitalized (38.5% vs 50.0% p<0.001). In multivariable adjusted analyses, IO treatment was not associated with survival to discharge (odds ratio (OR) (95% confidence interval) 0.81 (0.55, 1.21), p=0.31), but was associated with a lower likelihood of ROSC (OR=0.67 (0.50, 0.88), p=0.004) and survival to hospitalization (OR=0.68 (0.51, 0.91), p=0.009). CONCLUSION Though not independently associated with survival to discharge, principally tibial IO versus IV treatment was associated with a lower likelihood of ROSC and hospitalization. How routes of vascular access influence clinical outcomes after OHCA merits additional study.
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Affiliation(s)
| | - Benjamin A Stubbs
- Department of Family Medicine, University of Washington, United States
| | - Tom Rea
- Department of Medicine, University of Washington, United States
| | - Peter J Kudenchuk
- Department of Medicine, Division of Cardiology, University of Washington, Box 356422, 1959 NE Pacific Street, Seattle, WA, 98195-6422, United States.
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med 2017; 45:486-552. [PMID: 28098591 DOI: 10.1097/ccm.0000000000002255] [Citation(s) in RCA: 1917] [Impact Index Per Article: 273.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012." DESIGN A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.
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Singh S, Aggarwal P, Lodha R, Agarwal R, Gupta AK, Dhingra R, Karve JS, Jaggu SK, Bhargava B. Feasibility study of a novel intraosseous device in adult human cadavers. Indian J Med Res 2017; 143:275-80. [PMID: 27241639 PMCID: PMC4892072 DOI: 10.4103/0971-5916.182616] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background & objectives: Intraosseous (IO) access is an alternative to difficult intravenous (iv) access during emergency clinical situations. Existing IO solutions are expensive, require power supply and trained manpower; limiting their use in resource constrained settings. To address these limitations, a novel IO device has been developed. The objectives of this study were to evaluate functionality and safety of this device in adult human cadavers. Methods: The ability of the IO device to penetrate the proximal and/or distal tibia was evaluated in three adult cadavers. Subjective parameters of loss of resistance, stable needle hold, easy needle withdrawal and any damage to the device were evaluated during the study. The insertion time was the objective parameter measured. Four sets of radiographs per insertion confirmed the position of the needle and identified complications. Results: A single physician performed 12 IO access procedures using the same device. Penetration of proximal and/or distal tibia was achieved in all instances. It was successful in the first attempt in eight (66.7%) and during second attempt in the remaining. The mean time to insertion was 4.1 ± 3.1 sec. Appropriate insertion of needle in the intra-medullary space of bone was confirmed with radiological examination in 10 (83.3%) insertions. In two occasions after penetrating the cortical layer of bone, the device overshot the intra-medullary space, as detected by radiological examination. Device got bent during insertion in one instance. There was no evidence of needle breakage or bone fracture. The needle could be withdrawn effortlessly in all instances. Interpretation & conclusions: The novel IO device could successfully penetrate the adult cadaver bones in most cases. Further studies are needed to confirm these results on a large sample.
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Affiliation(s)
- Sandeep Singh
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Praveen Aggarwal
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Lodha
- Department of Paediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Ramesh Agarwal
- Department of Paediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Arun Kr Gupta
- Department of Radio-Diagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Renu Dhingra
- Department of Anatomy, All India Institute of Medical Sciences, New Delhi, India
| | - Jayant Sitaram Karve
- Stanford-India Biodesign Programme, All India Institute of Medical Sciences, New Delhi, India
| | - Srinivas Kiran Jaggu
- Stanford-India Biodesign Programme, All India Institute of Medical Sciences, New Delhi, India
| | - Balram Bhargava
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
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Nassar BS, Kerber R. Improving CPR Performance. Chest 2017; 152:1061-1069. [PMID: 28499516 DOI: 10.1016/j.chest.2017.04.178] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 04/07/2017] [Accepted: 04/27/2017] [Indexed: 01/21/2023] Open
Abstract
Cardiac arrest continues to represent a public health burden with most patients having dismal outcomes. CPR is a complex set of interventions requiring leadership, coordination, and best practices. Despite the widespread adoption of new evidence in various guidelines, the provision of CPR remains variable with poor adherence to published recommendations. Key steps health-care systems can take to enhance the quality of CPR and, potentially, to improve outcomes, include optimizing chest compressions, avoiding hyperventilation, encouraging intraosseous access, and monitoring capnography. Feedback devices provide instantaneous guidance to the rescuer, improve rescuer technique, and could impact patient outcomes. New technologies promise to improve the resuscitation process: mechanical devices standardize chest compressions, capnography guides resuscitation efforts and signals the return of spontaneous circulation, and intraosseous devices minimize interruptions to gain vascular access. This review aims at identifying a discreet group of interventions that health-care systems can use to raise their standard of cardiac resuscitation.
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Affiliation(s)
- Boulos S Nassar
- Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA.
| | - Richard Kerber
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA
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Effect of Canal Anastomosis on Periapical Fluid Pressure Build-up during Needle Irrigation in Single Roots with Double Canals using a Polycarbonate Model. Sci Rep 2017; 7:1582. [PMID: 28484231 PMCID: PMC5431501 DOI: 10.1038/s41598-017-01697-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 03/31/2017] [Indexed: 12/03/2022] Open
Abstract
Sodium hypochlorite is an effective irrigant for chemical debridement of root canals. However, increasing the intracanal pressure during irrigant delivery may result in irrigant extrusion into the bone and soft tissues surrounding the tooth. Because clinicians often encounter teeth with intracanal communications, the objective of the present study was to examine the effects of canal anastomosis on the generation of periapical fluid pressure at different fluid flow rates and insertion depths. Two similar polycarbonate models were used to simulate a single root with double canals, one containing, and the other without communicating channels between the canals. For both models, periapical pressure increased with increasing irrigant flow rates and insertion depths of a 30-gauge side-venting needle. In the presence of communicating channels, the magnitude of pressure build-up decreased by almost 90% irrespective of the fluid flow rate or needle insertion depth. Pressure reduction in anastomoses-containing roots provides an explanation why pressure generation in single roots is considerably higher. Nevertheless, it is still possible in teeth with canal anastomoses for pressure exceeding the intraosseous pressure to be generated when the fluid flow rate is sufficiently high and when the needle tip is close to the apical terminus.
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Blueprint for Implementing New Processes in Acute Care: Rescuing Adult Patients With Intraosseous Access. J Trauma Nurs 2017; 22:266-73. [PMID: 26352658 DOI: 10.1097/jtn.0000000000000152] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The intraosseous (IO) access initiative at an urban university adult level 1 trauma center began from the need for a more expeditious vascular access route to rescue patients in extremis. The goal of this project was a multidisciplinary approach to problem solving to increase access of IO catheters to rescue patients in all care areas. The initiative became a collaborative effort between nursing, physicians, and pharmacy to embark on an acute care endeavor to standardize IO access. This is a descriptive analysis of processes to effectively develop collaborative strategies to navigate hospital systems and successfully implement multilayered initiatives. Administration should empower nurse to advance their practice to include IO for patient rescue. Intraosseous access may expedite resuscitative efforts in patients in extremis who lack venous access or where additional venous access is required for life-saving therapies. Limiting IO dwell time may facilitate timely definitive venous access. Continued education and training by offering IO skill laboratory refreshers and annual e-learning didactic is optimal for maintaining proficiency and knowledge. More research opportunities exist to determine medication safety and efficacy in adult patients in the acute care setting.
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med 2017; 43:304-377. [PMID: 28101605 DOI: 10.1007/s00134-017-4683-6] [Citation(s) in RCA: 3758] [Impact Index Per Article: 536.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 01/06/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012". DESIGN A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.
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Fu X, Tan J, Sun CG, Leng HJ, Xu YS, Song CL. Intraosseous Injection of Simvastatin in Poloxamer 407 Hydrogel Improves Pedicle-Screw Fixation in Ovariectomized Minipigs. J Bone Joint Surg Am 2016; 98:1924-1932. [PMID: 27852910 DOI: 10.2106/jbjs.15.00937] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Osteoporosis leads to poor osseointegration and reduces implant stability. Statins have been found to stimulate bone formation, but the bioavailability from oral administration is low. Local application may be more effective at augmenting bone formation and enhancing implant stability. This study was performed to evaluate the efficacy of an intraosseous injection of simvastatin in thermosensitive poloxamer 407 hydrogel to enhance pedicle-screw fixation in calcium-restricted ovariectomized minipigs. METHODS Nine mature female Guangxi Bama minipigs underwent bilateral ovariectomy and were fed a calcium-restricted diet for 18 months. Simvastatin (0, 0.5, or 1 mg) in thermosensitive poloxamer 407 hydrogel was injected into the lumbar vertebrae (L4-L6), and titanium alloy pedicle screws were implanted. Bone mineral density (BMD) measurements of the lumbar vertebrae were determined by dual x-ray absorptiometry (DXA) before and 3 months after treatment. The lumbar vertebrae were harvested and analyzed with use of microcomputed tomography, biomechanical pull-out testing, histological analysis, and Western blot analysis for bone morphogenetic protein (BMP)-2 and vascular endothelial growth factor (VEGF) expression. RESULTS Evaluation over a 3-month study period demonstrated that the BMD of the vertebrae injected with 0.5 and 1.0 mg of simvastatin had increased by 31.25% and 31.09%, respectively, compared with vehicle-only injection (p ≤ 0.00014 for both) and increased by 32.12% and 28.16%, respectively, compared with the pre-treatment levels (p < 0.0001 for both). A single injection of simvastatin in poloxamer 407 increased trabecular volume fraction, thickness, and number and decreased trabecular separation (p ≤ 0.002). The bone formation and mineral apposition rates significantly increased (p ≤ 0.023). The percentage of osseointegration in the simvastatin 0.5 and 1-mg groups was 46.54% and 42.63% greater, respectively, than that in the vehicle-only group (p ≤ 0.006), and the maximum pull-out strength was 45.75% and 51.53% greater, respectively, than in the vehicle-only group (p ≤ 0.0005). BMP-2 and VEGF expressions were higher than for the vehicle-only injection. CONCLUSIONS A single intraosseous injection of simvastatin in thermosensitive poloxamer 407 hydrogel stimulated bone formation, increased BMD, improved bone microstructure, promoted osseointegration, and significantly enhanced the stability of pedicle screws in calcium-restricted ovariectomized minipigs. CLINICAL RELEVANCE These results provide rationale for evaluating intraosseous injection of simvastatin in poloxamer 407 to enhance implant fixation in patients with osteoporosis.
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Affiliation(s)
- X Fu
- Departments of Orthopedics (X.F., J.T., C.G.S., H.J.L., and C.L.S.) and Neurology (Y.S.X.), Peking University Third Hospital, Beijing, People's Republic of China
| | - J Tan
- Departments of Orthopedics (X.F., J.T., C.G.S., H.J.L., and C.L.S.) and Neurology (Y.S.X.), Peking University Third Hospital, Beijing, People's Republic of China
| | - C G Sun
- Departments of Orthopedics (X.F., J.T., C.G.S., H.J.L., and C.L.S.) and Neurology (Y.S.X.), Peking University Third Hospital, Beijing, People's Republic of China.,Beijing Key Laboratory of Spinal Diseases, Beijing, People's Republic of China
| | - H J Leng
- Departments of Orthopedics (X.F., J.T., C.G.S., H.J.L., and C.L.S.) and Neurology (Y.S.X.), Peking University Third Hospital, Beijing, People's Republic of China.,Beijing Key Laboratory of Spinal Diseases, Beijing, People's Republic of China
| | - Y S Xu
- Departments of Orthopedics (X.F., J.T., C.G.S., H.J.L., and C.L.S.) and Neurology (Y.S.X.), Peking University Third Hospital, Beijing, People's Republic of China
| | - C L Song
- Departments of Orthopedics (X.F., J.T., C.G.S., H.J.L., and C.L.S.) and Neurology (Y.S.X.), Peking University Third Hospital, Beijing, People's Republic of China .,Beijing Key Laboratory of Spinal Diseases, Beijing, People's Republic of China
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Boysen SR, Pang JM, Mikler JR, Knight CG, Semple HA, Caulkett NA. Comparison of tranexamic acid plasma concentrations when administered via intraosseous and intravenous routes. Am J Emerg Med 2016; 35:227-233. [PMID: 27816438 DOI: 10.1016/j.ajem.2016.10.054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 10/18/2016] [Accepted: 10/22/2016] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION There is a lack of information regarding intraosseous (IO) administration of tranexamic acid (TXA). Our hypothesis was that a single bolus IO injection of TXA will have a similar pharmacokinetic profile to TXA administered at the same dose IV. METHODS Sixteen male Landrace cross swine (mean body weight 27.6±2.6kg) were divided into an IV group (n=8) and an IO group (n=8). Each animal received 30mg/kg TXA via an IV or IO catheter, respectively. Jugular blood samples were collected for pharmacokinetic analysis over a 3h period. The maximum TXA plasma concentration (Cmax) and corresponding time as well as distribution half-life, elimination half-life, area under the curve, plasma clearance and volume of distribution were calculated. One- and two-way analysis of variance for repeated measures (time, group) with Tukey's and Bonferonni post hoc tests were used to compare TXA plasma concentrations within and between groups, respectively. RESULTS Plasma concentrations of TXA were significantly higher (p<0.0001) in the IV group during the TXA infusion. Cmax occurred at 4min after initiation of the bolus in the IV group (9.36±3.20ng/μl) and at 5min after initiation of the bolus in the IO group (4.46±0.49ng/μl). Plasma concentrations were very similar from the completion of injection onwards. There were no significant differences between the two administration routes for any other pharmacokinetic variables measured. CONCLUSION The results of this study support pharmacokinetic bioequivalence of IO and IV administration of TXA.
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Affiliation(s)
- Søren R Boysen
- Department of Veterinary Clinical and Diagnostic Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada.
| | - Jessica M Pang
- Department of Veterinary Clinical and Diagnostic Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada
| | - John R Mikler
- Defence Research and Development Canada - Suffield Research Centre, Box 4000, Station Main, Medicine Hat, Alberta T1A 8K6, Canada
| | - Cameron G Knight
- Department of Veterinary Clinical and Diagnostic Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada
| | - Hugh A Semple
- Defence Research and Development Canada - Suffield Research Centre, Box 4000, Station Main, Medicine Hat, Alberta T1A 8K6, Canada
| | - Nigel A Caulkett
- Department of Veterinary Clinical and Diagnostic Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada
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Wolfson DL, Tandoh MA, Jindal M, Forgione PM, Harder VS. Adult Intraosseous Access by Advanced EMTs: A Statewide Non-Inferiority Study. PREHOSP EMERG CARE 2016; 21:7-13. [DOI: 10.1080/10903127.2016.1209262] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Lieberman P, Nicklas RA, Randolph C, Oppenheimer J, Bernstein D, Bernstein J, Ellis A, Golden DBK, Greenberger P, Kemp S, Khan D, Ledford D, Lieberman J, Metcalfe D, Nowak-Wegrzyn A, Sicherer S, Wallace D, Blessing-Moore J, Lang D, Portnoy JM, Schuller D, Spector S, Tilles SA. Anaphylaxis--a practice parameter update 2015. Ann Allergy Asthma Immunol 2016; 115:341-84. [PMID: 26505932 DOI: 10.1016/j.anai.2015.07.019] [Citation(s) in RCA: 309] [Impact Index Per Article: 38.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 07/12/2015] [Indexed: 12/12/2022]
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Monsieurs K, Nolan J, Bossaert L, Greif R, Maconochie I, Nikolaou N, Perkins G, Soar J, Truhlář A, Wyllie J, Zideman D. Kurzdarstellung. Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0097-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Douma MJ, Bara GS, O'Dochartaigh D, Brindley PG. Double-barrelled resuscitation: A feasibility and simulation study of dual-intraosseous needles into a single humerus. Injury 2015; 46:2239-42. [PMID: 26372229 DOI: 10.1016/j.injury.2015.08.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 08/09/2015] [Accepted: 08/17/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Resuscitation can be delayed, or impaired, by insufficient vascular access. This study examines whether dual-intraosseous needles, inserted into a single porcine humerus, can facilitate rapid and concomitant fluid and medication delivery. METHODS After inserting one- and then two-intraosseous needles into the same porcine humerus, we determined the rate of fluid administration using (i) an infusion pump set to 999mL/h, and (ii) a standard pressure-bag set to 300mmHg. Next, we concomitantly infused blood, crystalloid and medications into the same medullary canal, using the two-needle set-up. Humeri were inspected for fluid-leakage, needle-displacement, and bone damage. RESULTS Using an infusion pump, the mean normal-saline infusion-rate was significantly higher with dual-intraosseous needles compared to a single-intraosseous needle: the infusion-rate was 16mL/min using dual-needles versus 8mL/min for a single needle set-up (p<0.001). In contrast, using the pneumatic pressure-bag, the infusion rate was not statistically different when comparing dual-intraosseous needles versus single-intraosseous: the infusion-rate was 22mL/min versus 21ml/min (p=0.4) for 500mL, and 22ml/min versus 21ml/min (p=0.64) for one-litre, respectively. Blood product could be infused at a mean rate of 20mL/min through one needle while tranexamic acid was simultaneously infused through a second. There were no complications with a dual-intraosseous set-up (no fluid leakage; no needle-displacement; no high-pressure alarms, and no external bone-fractures or internal macrohistological damage) during any of our simulated resuscitation scenarios. CONCLUSIONS This is the first published study evaluating dual-intraosseous needles in a single bone. Despite limitations, this preliminary study (using a porcine humerus) suggests that dual-intraosseous needles are feasible. For critically-ill patients with limited insertion sites, dual-intraosseous (a.k.a. 'double-barrelled resuscitation') may facilitate rapid and concurrent resuscitation.
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Affiliation(s)
- Matthew J Douma
- Trauma and Emergency Services, Royal Alexandra Hospital, 10240 Kingsway Avenue NW, Edmonton, AB, Canada T5H3V9.
| | - Gurpaul S Bara
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.
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Monsieurs KG, Nolan JP, Bossaert LL, Greif R, Maconochie IK, Nikolaou NI, Perkins GD, Soar J, Truhlář A, Wyllie J, Zideman DA, Alfonzo A, Arntz HR, Askitopoulou H, Bellou A, Beygui F, Biarent D, Bingham R, Bierens JJ, Böttiger BW, Bossaert LL, Brattebø G, Brugger H, Bruinenberg J, Cariou A, Carli P, Cassan P, Castrén M, Chalkias AF, Conaghan P, Deakin CD, De Buck ED, Dunning J, De Vries W, Evans TR, Eich C, Gräsner JT, Greif R, Hafner CM, Handley AJ, Haywood KL, Hunyadi-Antičević S, Koster RW, Lippert A, Lockey DJ, Lockey AS, López-Herce J, Lott C, Maconochie IK, Mentzelopoulos SD, Meyran D, Monsieurs KG, Nikolaou NI, Nolan JP, Olasveengen T, Paal P, Pellis T, Perkins GD, Rajka T, Raffay VI, Ristagno G, Rodríguez-Núñez A, Roehr CC, Rüdiger M, Sandroni C, Schunder-Tatzber S, Singletary EM, Skrifvars MB, Smith GB, Smyth MA, Soar J, Thies KC, Trevisanuto D, Truhlář A, Vandekerckhove PG, de Voorde PV, Sunde K, Urlesberger B, Wenzel V, Wyllie J, Xanthos TT, Zideman DA. European Resuscitation Council Guidelines for Resuscitation 2015: Section 1. Executive summary. Resuscitation 2015; 95:1-80. [PMID: 26477410 DOI: 10.1016/j.resuscitation.2015.07.038] [Citation(s) in RCA: 568] [Impact Index Per Article: 63.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Koenraad G Monsieurs
- Emergency Medicine, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium.
| | - Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, Bristol, UK
| | | | - Robert Greif
- Department of Anaesthesiology and Pain Medicine, University Hospital Bern, Bern, Switzerland; University of Bern, Bern, Switzerland
| | - Ian K Maconochie
- Paediatric Emergency Medicine Department, Imperial College Healthcare NHS Trust and BRC Imperial NIHR, Imperial College, London, UK
| | | | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Heart of England NHS Foundation Trust, Birmingham, UK
| | - Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Jonathan Wyllie
- Department of Neonatology, The James Cook University Hospital, Middlesbrough, UK
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Bélondrade P, Lefort H, Bertho K, Perrochon JC, Jost D, Tourtier JP, Chabernaud JL. Guidelines for care of the newborn baby at birth knowledge by prehospital emergency physicians. Anaesth Crit Care Pain Med 2015; 35:17-23. [PMID: 29610057 DOI: 10.1016/j.accpm.2015.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 06/16/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION In 2010, the International Liaison Committee On Resuscitation (ILCOR) guidelines for care of the newborn baby immediately after birth were published. MATERIALS AND METHODS Using a questionnaire that was distributed to a sample of 44 prehospital emergency physicians (April 2014), we assessed knowledge of these guidelines, in particular specificities for newborns as compared to adults. Twenty-five questions, starting with a birth with no problems to one resulting in neonatal distress, were used to profile the practice of the surveyed physicians. RESULTS Among the solicited physicians, 30 responded to the questionnaire (68%). Priority was given to efficient respiratory resuscitation during the first minutes of extrauterine life and the difficulties of newborn respiratory adaptation are well-known, but their implementation remains imperfectly understood. The assessment showed very mixed results, partly explained by the low frequency of newborn scenarios experienced by the practitioners who responded to the questionnaire. CONCLUSION To move from guidelines to their practical implementation is always delicate, with room for improvement such as continuing education, knowledge assessment and practice in the context of a quality approach. Well accepted, this evaluation process could be renewed upon publication of the next guidelines on this subject, thus contributing to their knowledge.
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Affiliation(s)
- Pascal Bélondrade
- Service des urgences/Samu, Centre hospitalier de Cayenne, rue des Flamboyants, BP 6006, 97300 Cayenne, France
| | - Hugues Lefort
- Service médical d'urgence, Brigade de sapeurs-pompiers de Paris, 1, place Jules-Renard, 75017 Paris, France.
| | - Kilian Bertho
- Antenne médicale spécialisée de Satory, 34, rue de la Martinière, 78000 Versailles, France
| | | | - Daniel Jost
- Service médical d'urgence, Brigade de sapeurs-pompiers de Paris, 1, place Jules-Renard, 75017 Paris, France
| | - Jean-Pierre Tourtier
- Service médical d'urgence, Brigade de sapeurs-pompiers de Paris, 1, place Jules-Renard, 75017 Paris, France
| | - Jean-Louis Chabernaud
- Smur pédiatrique (Samu 92), Pôle FAME, Hôpital Antoine-Béclère, 157, rue de la Porte-de-Trivaux, 92140 Clamart, France
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Maconochie IK, Bingham R, Eich C, López-Herce J, Rodríguez-Núñez A, Rajka T, Van de Voorde P, Zideman DA, Biarent D, Monsieurs KG, Nolan JP. European Resuscitation Council Guidelines for Resuscitation 2015. Resuscitation 2015; 95:223-48. [DOI: 10.1016/j.resuscitation.2015.07.028] [Citation(s) in RCA: 217] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Russell KW, Scaife CL, Weber DC, Windsor JS, Wheeler AR, Smith WR, Wedmore I, McIntosh SE, Lieberman JR. Wilderness Medical Society practice guidelines for the treatment of acute pain in remote environments: 2014 update. Wilderness Environ Med 2015; 25:S96-104. [PMID: 25498266 DOI: 10.1016/j.wem.2014.07.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 06/21/2014] [Accepted: 07/10/2014] [Indexed: 01/21/2023]
Abstract
The Wilderness Medical Society convened an expert panel to develop evidence-based guidelines for the management of pain in austere environments. Recommendations are graded on the basis of the quality of supporting evidence as defined by criteria put forth by the American College of Chest Physicians. This is an updated version of the original WMS Practice Guidelines for the Treatment of Acute Pain in Remote Environments published in Wilderness & Environmental Medicine 2014;25(1):41-49.
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Affiliation(s)
- Katie W Russell
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT (Drs Russell and Scaife)
| | - Courtney L Scaife
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT (Drs Russell and Scaife)
| | - David C Weber
- Denali National Park & Preserve Rescue, Talkeetna, AK (Mr Weber)
| | - Jeremy S Windsor
- Chesterfield Royal Hospital, Calow, Derbyshire, United Kingdom (Dr Windsor)
| | | | - William R Smith
- St. John's Medical Center, Jackson, WY (Drs Wheeler and Smith); Clinical Faculty, University of Washington School of Medicine, Seattle, WA (Dr Smith)
| | - Ian Wedmore
- University of Washington School of Medicine, Madigan Army Medical Center, Ft. Lewis, WA (Dr Wedmore)
| | - Scott E McIntosh
- Division of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT (Dr McIntosh)
| | - James R Lieberman
- Department of Anesthesia, Swedish Medical Center, Seattle, WA (Dr Lieberman).
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Wolf A, Mulier KE, Iyegha UP, Asghar JI, Beilman GJ. Safety of D-ß-Hydroxybutyrate and Melatonin for the Treatment of Hemorrhagic Shock With Polytrauma. Shock 2015; 44 Suppl 1:79-89. [DOI: 10.1097/shk.0000000000000315] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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STRANDBERG G, LARSSON A, LIPCSEY M, MICHALEK J, ERIKSSON M. Intraosseous and intravenous administration of antibiotics yields comparable plasma concentrations during experimental septic shock. Acta Anaesthesiol Scand 2015; 59:346-53. [PMID: 25557933 PMCID: PMC4338763 DOI: 10.1111/aas.12454] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 11/13/2014] [Indexed: 12/29/2022]
Abstract
BACKGROUND We aimed to investigate whether comparable antibiotic concentrations could be reached with intraosseous and intravenous administration during septic shock. METHODS In this randomized, prospective experimental study conducted at an animal research laboratory at the University Hospital of Uppsala, eight anesthetized pigs, weighing 21.2 to 29.1 kg (mean: 25.2 ± 2.3 kg), received endotoxin infusion at 4 μg/kg/h for 6 h. At the onset of clinical shock, alternatively after 3 h of endotoxemia, they received 75 mg/kg of cefotaxime and 7 mg/kg of gentamicin either in a proximal tibial intraosseous catheter or in a peripheral intravenous catheter. Mixed venous samples were taken after 5, 15, 30, 60, 120 and 180 min and analyzed for antibiotic concentrations. RESULTS For both antibiotics, plasma concentrations after intraosseous and intravenous administration followed similar curves throughout the observation period, and peak concentrations were comparable. Mean concentration area under the curve (AUC mg × h/l) for cefotaxime was 108.1 ± 19.5 after intraosseous and 116.5 ± 11.1 after intravenous administration; ratio 0.93, (95% CI 0.71-1.19). Mean AUC for gentamicin was 28.1 ± 6.8 for intraosseous and 32.2 ± 3.5 for intravenous administration; ratio 0.87 (95% CI 0.62-1.19). CONCLUSIONS In this porcine septic shock model, intraosseous and intravenous administration of gentamicin and cefotaxime yielded comparable concentrations. In an emergency, intraosseous administration of these antibiotics may be considered in severe infections when venous access is difficult.
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Affiliation(s)
- G. STRANDBERG
- Section of Anesthesiology & Intensive Care Department of Surgical Sciences Uppsala University Uppsala Sweden
| | - A. LARSSON
- Section of Clinical Chemistry Department of Medical Sciences Uppsala University Uppsala Sweden
| | - M. LIPCSEY
- Section of Anesthesiology & Intensive Care Department of Surgical Sciences Uppsala University Uppsala Sweden
| | - J. MICHALEK
- Department of Epidemiology and Biostatistics University of Texas Health Science Center San Antonio TX USA
| | - M. ERIKSSON
- Section of Anesthesiology & Intensive Care Department of Surgical Sciences Uppsala University Uppsala Sweden
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Non-specific post-mortem modifications on whole-body post-mortem computed tomography in sudden unexpected death in infancy. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.jofri.2015.02.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Emergency department diagnosis and treatment of anaphylaxis: a practice parameter. Ann Allergy Asthma Immunol 2015; 113:599-608. [PMID: 25466802 DOI: 10.1016/j.anai.2014.10.007] [Citation(s) in RCA: 153] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 10/06/2014] [Indexed: 11/21/2022]
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Rubal BJ, Meyers BL, Kramer SA, Hanson MA, Andrews JM, DeLorenzo RA. Fat Intravasation from Intraosseous Flush and Infusion Procedures. PREHOSP EMERG CARE 2014; 19:376-90. [PMID: 25495011 DOI: 10.3109/10903127.2014.980475] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY HYPOTHESIS The primary study objective was to delineate the procedural aspects of intraosseous (IO) infusions responsible for fat intravasation by testing the hypothesis that the fat content of effluent blood increases during IO infusions. METHODS IO cannulas were inserted into the proximal tibiae of 35 anesthetized swine (Sus scrofa, 50.1 ± 3.5 kg) and intravasated fat was assessed using a lipophilic fluoroprobe (Nile red) and by vascular ultrasound imaging. Effluent blood bone marrow fat was assessed at baseline, during flush, and with regimens of controlled infusion pressures (73-300 mmHg) and infusion flow rates (0.3-3.0 mL per second). Fat intravasation was also assessed with IO infusions at different tibial cannulation sites and in the distal femur. In 7 animals, the lipid uptake of alveolar macrophages and lung tissue assessed for fat embolic burden using oil red O stain 24 hours post infusion. Additionally, bone marrow shear-strain was assessed radiographically with IO infusions. RESULTS Fat intravasation was observed during all IO infusion regimens, with subclinical pulmonary fat emboli persisting 24 hours post infusion. It was noted that initial flush was a significant factor in fat intravasation, low levels of intravasation occurred with infusions ≤300 mmHg, fat intravasation and bone marrow shear-strain increased with IO infusion rates, and intravasation was influenced by cannula insertion site. Ultrasound findings suggest that echogenic particles consistent with fat emboli are carried in fast and slow venous blood flow fields. Echo reflective densities were observed to rise to the nondependent endovascular margins and coalesce in accordance with Stoke's law. In addition, ultrasound findings suggested that intravasated bone marrow fat was thrombogenic. CONCLUSION Results suggest that in swine the intravasation of bone marrow fat is a common consequence of IO infusion procedures and that its magnitude is influenced by the site of cannulation and infusion forces. Although the efficacy and benefits of IO infusions for emergent care are well established, emergency care providers also should be cognizant that infusion procedures affect bone marrow fat intravasation.
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