Intraossäre Infusion

To the Editor:—In their editorial “No substitute for the Intravenous Route,” Donati and Guay 1come to the conclusion that, apart from succinylcholine, the intramuscular route is a poor alternative for administration of neuromuscular blocking agents in life-threatening situations in pediatric anesthesia. We fully agree with this conclusion and with the statement that all possible strategies to relieve laryngospasm should be considered. It is unfortunately true that there are still situations in which intravenous access cannot be obtained quickly. Indeed, the fact that all new neuromuscular blocking drugs have been investigated for rapidity of action after intramuscular administration indicates the continuing interest in finding ways of reliable and rapid neuromuscular blockade in the absence of venous access. Rather than continue to search for a neuromuscular blocker with rapid onset of action after intramuscular administration, we believe that the intraosseous route already offers an efficient alternative by which good intubating conditions can be rapidly obtained using currently available neuromuscular blocking drugs. Therefore, we disagree with the authors’ final statement that all efforts should be focused on a search for intravenous access and no site, including the femoral route, should be rejected to relieve laryngospasm. 1We are convinced that in the dreaded “cannot insert the intravenous catheter, cannot ventilate” scenario, the intraosseous route offers an excellent substitute. Ample scientific evidence proves that this route is easy, fast, and devoid of serious complications. 2Instead of losing time with repeated futile attempts at venous cannulation in emergency situations, intraosseous access should be established right away. The intraosseous infusion technique is proven, quick, and efficient in the emergency care of both children and adults. 2It is simple and has been used successfully by paramedical personnel. Parenteral access is obtained within 30–60 s, and there are few complications. Essentially, all fluids and drugs can be administered by the intraosseous route with faster central circulation times and better pharmacokinetics compared with peripheral intravenous injection. In prehospital emergency medicine, emergency departments, and pediatric intensive care units, its use is recommended in critically ill pediatric patients when intravenous access cannot be established within 90–120 s. The newly published Pediatric Advanced Life Support guidelines suggest it be the route of first choice in cardiocirculatory arrest. 3Nonetheless, intraosseous infusion remains a technique rarely used in operating rooms. Although elective use of intraosseous infusion in children with difficult vascular access during anesthesia remains debatable, there is no question that it provides simple, safe, and highly successful parenteral access in all emergency situations. 4,5Pediatric anesthesiologists take pride in their ability to establish intravenous access in difficult circumstances; however, we should not let this pride stand in the way of more rapid access by use of the intraosseous needle. This technique should be part of basic anesthesia training to ensure better management of pediatric emergencies when intravenous access is not available. Every anesthesiologist should become proficient in intraosseous technique and should not hesitate to use it in an emergency. Sets with all equipment required should be readily available in all locations where children are anesthetized.

Calcium administration and post-cardiac arrest ionized calcium values according to intraosseous or intravenous administration – A post hoc analysis of a randomized trial

The safety of intraosseous infusions: Risks of fat and bone marrow emboli to the lungs

Background: Intraosseous (IO) access are being widely used in resuscitation of patients with difficult intra-venous (IV) access. The United Kingdom Resuscitation Council guidelines recommend the use of IO access, after two minutes of failed IV access in adult patients or two failed IV attempts in pediatric patients. There are various complications associated with IO access such as extravasation of the infusion fluid or medications, bleeding, infection and pain1. Compartment syndrome is a rare complication associated with IO access. This is reported commonly in children where in certain cases the affected limb required amputation. We report a case where an adult patient developed compartment syndrome secondary to IO access. Methods: A 52-year-old lady who was on dialysis for renal failure presented to the Emergency Department (ED) with septic shock. She was in peri-arrest and had a difficult IV access. Therefore an IO needle was inserted to her right tibia and resuscitation was carried out with fluids and medications. She required emergency intubation and ventilation and was later admitted to the Intensive Care Unit (ICU). The following day, it was found that she developed a compartment syndrome of the right lower leg where she had the IO access. Results: Patient was taken to the theatre for an urgent fasciotomy of the affected leg by the orthopedic surgeons with input from plastic surgeons. She made a steady but full recovery and was discharged home later. Conclusions: Compartment syndrome is a rare complication of IO access (0.6%) 1. Careful monitoring of the IO site is recommended. It is advisable to remove the IO needle once a definitive IV access is established. 1. Complication with Intraosseous Access: Scandinavian Users' Experience. Hallas et al. West J Emerg Med. 2013 Sep; 14(5): 440–443.

BackgroundRapid and reliable vascular access is crucial during cardiopulmonary resuscitation for out-of-hospital cardiac arrest (OHCA). While intraosseous (IO) and intravenous (IV) access are used, their comparative effectiveness for patient outcomes remains uncertain.MethodsWe searched PubMed, Embase, and ClinicalTrials.gov for RCTs comparing IO vs. IV access in adults with OHCA. The primary outcome was survival (30 days or until discharge), while secondary outcomes included sustained ROSC, favorable neurological outcome, successful first-attempt vascular access, and time from emergency medical service arrival to access. Pooled odds ratios (OR), mean differences (MD), and 95% confidence intervals (CI) were calculated.ResultsFour RCTs with 9475 patients were included. No significant differences were found between IO and IV groups in survival (6.6% vs. 6.9%, OR 0.99, 95% CI 0.84–1.18) or favorable neurological outcome (4.7% vs. 4.6%, OR 1.07, 95% CI 0.88–1.30). The sustained ROSC rate was numerically, but not significantly, lower in IO vs. IV access (24.6% vs. 27.0%, OR 0.92, 95% CI 0.80–1.06). IO access had a higher first-attempt success rate (92.3% vs. 62.3%; OR 6.18, 95% CI 3.50–10.91) and was 15 s faster than IV for vascular access (IO: 11.03 ± 5.57, IV: 11.35 ± 6.16 min, MD − 0.25, 95% CI − 0.48 to − 0.01).ConclusionsIO access had a higher first-attempt success rate and faster establishment than IV access, but no significant differences were found in survival or favorable neurological outcomes in adults with OHCA. Sustained ROSC was numerically lower with IO access than IV access, although the difference was not statistically significant.Graphical abstract

Intraosseous (IO) infusion is a well-established intervention to obtain vascular access in pediatric emergency medicine but is rarely used in routine pediatric anesthesia. In this observational study, we report on a series of 14 children in whom semi-elective IO infusion was performed under inhalational anesthesia after peripheral intravenous (IV) access had failed. Patient and case characteristics, technical details, and estimated timings of IO infusion as well as associated complications were reviewed. Data are median and range. IO infusion was successfully established in fourteen children [age: 0.1-6.00 years (median 0.72 years); weight: 3.5-12.0 kg (median 7.0 kg)]. The majority suffered from chronic cardiac, metabolic, or dysmorphic abnormalities. Estimated time taken from inhalational induction of anesthesia until insertion of an intraosseous needle was 26.5 min (15-65 min). The proximal tibia was cannulated in all patients. The automated EZIO IO system was used in eight patients and the manual COOK system in six patients. Drugs administered included hypnotics, opioids, neuromuscular blocking agents and reversals, cardiovascular drugs, antibiotics, and IV fluids. The IO cannulas were removed either in the operating theatre (n = 5), in the recovery room (n = 5), or in the ward (n = 4), after 73 min (19-225 min) in situ. There were no significant complications except one accidental postoperative dislocation. IO access represents a quick and reliable alternative for pediatric patients with prolonged difficult or failed IV access after inhalational induction of anesthesia.

133 Intraosseous Infusions from the Proximal Humerus Reach the Heart in Less Than 3 Seconds in Human Volunteers

Intravenous access is critical in infants and children with severe shock or cardiac arrest. However, it is in these clinic situations that venous access may be most difficult. The technique of intraosseous infusion may provide a useful alternative to intravenous access in the initial phases of resuscitation. The method of insertion, indications, contraindications, and complications are reviewed.

Intraosseous infusion for burns resuscitation

The technique of intraosseous infusion has attracted increasing interest in recent years, and has proven valuable for drug administration. This study was undertaken to determine whether it was also a potential route for fluid resuscitation. Thirteen- or eighteen-gauge tibial intraosseous needles were placed in eight "large" (mean weight, 14.4 kg) and eight "small" (mean weight, 5.8 kg) swine and the flow rate of blood and saline measured under gravity and 300 mm Hg. Flow was significantly greater using 13-gauge needles in the "large" swine, significantly greater for saline than for blood, and for pressure infusion versus gravity in all animals. A fluid bolus of 20 ml/kg could be given to all animals in less than 10 minutes using pressure infusion. These data suggest that intraosseous infusion is a reasonable initial step in fluid resuscitation of pediatric subjects until more conventional vascular access has been established.

Intraosseous infusions by prehospital personnel in critically ill pediatric patients.

BackgroundDuring 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 methodPubMed, 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.ResultsThree 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.ConclusionThe 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.

BackgroundThe immediate administration of drugs and fluids is critical for successful resuscitation in out-of-hospital cardiac arrest (OHCA). Vascular access selection plays a pivotal role in ensuring timely delivery of therapeutic interventions during OHCA management. This study aims to compare the safety and efficacy of intraosseous (IO) and intravenous (IV) access in OHCA management.MethodsWe conducted a comprehensive search of PubMed, EMbase, Google Scholar, and the Cochrane Library databases to identify studies published up to February 20th, 2025, evaluating IO and IV access in OHCA patients. The outcomes of interest included return of spontaneous circulation (ROSC), survival from hospital admission to discharge, neurological outcome, comorbidities, and access time.ResultsTwenty-three studies, comprising 48945 cases of IO access and 188966 cases of IV access for OHCA management, were included. Overall, the rate of favorable neurological outcome was similar between patients with IO and IV access (odds ratio [OR] = 0.73; 95% confidence interval [CI] = 0.37 to 1.45, I2=95.3%). IO access was associated with significantly lower odds of shockable rhythms in both adult (OR = 0.77; 95% CI = 0.70 to 0.85, I2=86%) and pediatric (OR = 0.20; 95% CI = 0.12 to 0.33) patients. Additionally, IO access was linked to a lower rate of ROSC in pediatric OHCA patients (OR = 0.30; 95% CI = 0.21 to 0.42). Prospective studies and those with unadjusted time to intervention analysis demonstrated markedly lower rates of survival at discharge, favorable neurological outcome, and ROSC in the IO group compared to the IV group. It should also be noted that the interpretation of the results should take into account the high heterogeneity and potential biases, despite the corresponding subgroup analyses we conducted.ConclusionIn OHCA management, IO access may be associated with less favorable outcomes in terms of survival, neurological function, and ROSC compared to IV access. Further research is needed to address limitations and provide more robust evidence regarding the comparative effectiveness of intraosseous and intravenous access in this clinical setting.

Intraosseous infusion using the bone injection gun in the prehospital setting

Annotation. Objective – carrying out a comparative assessment of the advantages and disadvantages of intravenous (IV) and intraosseous (IO) resuscitation, which are used by emergency and emergency teams in the Vinnytsia region. The work used statistical data of the Vinnytsia Regional Center for Emergency Medical Care and Disaster Medicine for the period 2019-2021, carry through content analysis of domestic and foreign scientific sources, applied biblio-semantic, analytical, and statistical methods for studying the use of intraosseous and intravenous methods in emergency cases. According to the Vinnytsia Regional Center for Emergency Medical Care and Disaster Medicine for the three years 2019-2021. we observe a low percentage of use of intraosseous access 0,2% - 0,1%, respectively. In the event of an accident in the patient's condition “without changes” a total of 786 injections were carried out both intravenously and intraosseously. In 2019, out of the total number, non-infusion therapy was performed in 71,0% of male patients and 11,1% of female patients, and 11,2% intraosseously only in male patients. Compared to 2020, only 0,3% intraosseously (2 female patients) and in 2021, no intraosseous resuscitation was performed at all. In a state of “deterioration” during an accident (road accident, etc.) for 2019, 87,5% of men and 12,5% of women were injected with drugs intravenously; for 2020, 50% for both males and 50% for females were infused intravenously; for 2021, 87,5% of men and 12,5% of women underwent intravenous resuscitation, intraosseous resuscitation was never performed, provided that the condition of patients worsened. And “death in the presence” occurred during resuscitation for 2019 88,8% (of which 77,7% for men and 11,1% for women) by intravenous access and 11.2 VC (males); for 2020 88,9% intravenously (of which 72,2% for men and 16,7% for women) and 11,1% intraosseously (of which 1 male and 1 female article); in 2021, 65,0% of intravenous access was performed for men and 25,0% for women, while no patient received intraosseous access. In case of a sudden illness, the percentage of intraosseous resuscitation in the state of “deterioration” was as follows: for the period 2019-2021. no intraosseous access was performed. In the state of “death in the presence” for 2019, intraosseous infusion was 3,4%; 2020 – 3,8%; 2021 – 1,9%. Thus, the intraosseous method has several undeniable advantages compared to the intravenous one, but in Ukraine, it is little used in the practice of mobile emergency medical teams with a syringe gun (connector – BLG), both considering the age characteristics: for adults (blue) and children (red color) and prescribed in the fundamental algorithms of clinical/modern protocols for the treatment of circulatory arrest due to insufficient practical and theoretical skills of medical personnel of emergency teams. The analysis of the use of intraosseous methods in emergency medical care gave impetus to conducting theoretical and practical classes for future doctors to master skills and reduce prehospital and early hospital mortality in patients with complement fixation reactions.