Intraosseous Catheter Research Articles

Blueprint for Implementing New Processes in Acute Care: Rescuing Adult Patients With Intraosseous Access.

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.

Military-to-civilian translation of battlefield innovations in operative trauma care

Historic improvements in operative trauma care have been driven by war. It is unknown whether recent battlefield innovations stemming from conflicts in Iraq/Afghanistan will follow a similar trend. The objective of this study was to survey trauma medical directors (TMDs) at level 1-3 trauma centers across the United States and gauge the extent to which battlefield innovations have shaped civilian practice in 4 key domains of trauma care. Domains were determined by the use of a modified Delphi method based on multiple consultations with an expert physician/surgeon panel: (1) damage control resuscitation (DCR), (2) tourniquet use, (3) use of hemostatic agents, and (4) prehospital interventions, including intraosseous catheter access and needle thoracostomy. A corresponding 47-item electronic anonymous survey was developed/pilot tested before dissemination to all identifiable TMD at level 1-3 trauma centers across the US. A total of 245 TMDs, representing nearly 40% of trauma centers in the United States, completed and returned the survey. More than half (n = 127; 51.8%) were verified by the American College of Surgeons. TMDs reported high civilian use of DCR: 95.1% of trauma centers had implemented massive transfusion protocols and the majority (67.7%) tended toward 1:1:1 packed red blood cell/fresh-frozen plasma/platelets ratios. For the other 3, mixed adoption corresponded to expressed concerns regarding the extent of concomitant civilian research to support military research and experience. In centers in which policies reflecting battlefield innovations were in use, previous military experience frequently was acknowledged. This national survey of TMDs suggests that military data supporting DCR has altered civilian practice. Perceived relevance in other domains was less clear. Civilian academic efforts are needed to further research and enhance understandings that foster improved trauma surgeon awareness of military-to-civilian translation.

Intraosseous versus central venous catheter utilization and performance during inpatient medical emergencies.

Intraosseous access is a rapid and effective route of fluid and drug administration. Its use has been proven in emergency medicine, pediatrics, and the military. We aimed to assess its performance and utilization against landmark-guided central venous catheter placement during inpatient medical emergencies. Prospective observational study. Eight hundred fifty-six-bed urban teaching hospital. Adult inpatients requiring central venous access during medical emergencies. Intraosseous device training was added to standard central venous catheter training beginning in February 2012. Intraosseous were used as primary access in cardiac arrests and secondary access if central venous catheter placement failed during noncardiac arrest emergencies. An online survey was conducted among intraosseous and central venous catheter operators to assess their experience and any barriers to use. Seventy-nine adults had central access placement from February 2012 to July 2013. Sixty were during medical emergency team calls, and 19 were cardiac arrests. Thirty-one received intraosseous device, and 48 received a central venous catheter. First-pass success was significantly higher for intraosseous than for central venous catheter (90.3 vs 37.5%; 95% CI, 80-101 vs 24-51; p<0.001). Mean placement times were significantly shorter for intraosseous than for central venous catheter (1.2 vs 10.7 min; p<0.001). There were a total of 33 intraosseous versus 169 central venous catheter attempts with fewer attempts on average per patient during intraosseous placement (1.1 vs 2.8; p<0.001). There were three intraosseous-related complications and 22 central venous catheter-related complications. Our survey showed high satisfaction with intraosseous training and operation. Among the barriers cited, timely intraosseous kit acquisition was most common. It is feasible to incorporate intraosseous use during medical emergency team calls. Intraosseous had significantly higher first-pass success rates and faster placement compared with central venous catheters. Intraosseous operators reported high satisfaction and confidence in its use. Prospective randomized studies comparing intraosseous and central venous catheter are warranted.

Intraosseous and intravenous administration of antibiotics yields comparable plasma concentrations during experimental septic shock.

BackgroundWe aimed to investigate whether comparable antibiotic concentrations could be reached with intraosseous and intravenous administration during septic shock.MethodsIn 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.ResultsFor 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).ConclusionsIn 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.

Lactated Ringer's solution or 0.9% sodium chloride as fluid therapy in pigeons (Columba livia) submitted to humerus osteosynthesis

The study aimed to compare the effects of intraosseous infusion of lactated Ringer's and 0.9% sodium chloride solutions on the electrolytes and acid-base balance in pigeons submitted to humerus osteosynthesis. Eighteen pigeons were undergoing to isoflurane anesthesia by an avalvular circuit system. They were randomly assigned into two groups (n=9) receiving lactated Ringer's solution (LR) or 0.9% sodium chloride (SC), in a continuous infusion rate of 20mL/kg/h, by using an intraosseous catheter into the tibiotarsus during 60-minute anesthetic procedure. Heart rate (HR), and respiratory rate (RR) were measured every 10 min. Venous blood samples were collected at 0, 30 and 60 minutes to analyze blood pH, PvCO2, HCO3 -, Na+ and K+. Blood gases and electrolytes showed respiratory acidosis in both groups during induction, under physical restraint. This acidosis was evidenced by a decrease of pH since 0 min, associated with a compensatory response, observed by increasing of HCO3 - concentration, at 30 and 60 min. It was not observed any changes on Na+ and K+ serum concentrations. According to the results, there is no reason for choosing one of the two solutions, and it could be concluded that both fluid therapy solutions do not promote any impact on acid-base balance and electrolyte concentrations in pigeons submitted to humerus osteosynthesis.

Relationships of intraosseous and systemic pressure waveforms in a Swine model.

Despite some focus on the use of intraosseous (IO) catheters to obtain laboratory samples, very little is known about the potential for obtaining other forms of clinical data. Largely unstudied is the relationship between IO pressures (IOPs) and systemic hemodynamic pressures such as mean arterial pressure (MAP) and central venous pressures (CVP). The objective was to explore the relationship between hemodynamic parameters (blood pressures) measured through an IO catheter and intravascular catheters placed in the arterial and central venous circulation. Eight pigs (Sus scrofa) weighing 30 to 45 kg were sedated with a short-acting agent, intubated with a cuffed endotracheal tube, and anesthetized with 2% to 3% isoflurane. Intravascular catheters were placed into the femoral or carotid artery and the femoral or jugular vein for MAP and CVP measurements. IO catheters, 15 mm for the sternum and 25 mm for the long bones, were placed percutaneously into the proximal tibia, proximal femur, proximal humerus, right proximal ulna, and/or sternum. Pressures were recorded during normotension, hypotension, and hypertension. Averaged across all eight animals, the means (ranges) for baseline systemic pressures were as follows: MAP = 66.5 (55.6 to 76.7) mm Hg, tibia IOP = 17.4 (9.3 to 34.5) mm Hg, femur IOP =18.4 (3.3 to 33.1) mm Hg, humerus IOP = 15.7 (2.8 to 28.9) mm Hg, ulna IOP = 16.0 (7.9 to 25.6) mm Hg, sternum IOP = 5.7 (-0.5 to 47.9) mm Hg, and CVP = 2.7 mm Hg (-3.3 to 7.9) mm Hg. The best median correlation occurred between femur IOP and mean MAP (r = 0.65). The four highest correlations between IOP and MAP were associated with mean femur IOP. Only one IO site had a correlation coefficient over 0.50 for CVP. The long bones tended to correlate better with the MAP and the sternum tended to correlate better with the CVP. Nonlinearity was observed in the actively rising pressure phases, which can be explained by a hysteresis model. The relationship between IOP and MAP or CVP is variable by site, with the MAP and CVP tending to be estimated by the femur and sternum, respectively. The relationship to actively rising pressures is nonlinear and a hysteresis model is proposed to explain the phase change. Further experimentation is needed to refine the IOP relationship to the MAP and CVP and assess the potential of these measurements to provide clinically relevant information.

Utilisation de la voie intraosseuse chez l’adulte en France en 2012

ObjectivesTo evaluate theoretical and practical knowledges of intraosseous (IO) access in adults patients in France in 2012. Study designNational observational descriptive transversal study as survey of opinion and practices. Materials and methodsAn email, with an URL to online computerized quiz, was sent to residents and medical doctors who were working, in France, in anesthesiologist units, intensive care units or emergency units. Several questions were asked about theoretical and practical knowledges concerning IO access. ResultsAfter 1359 responses, 396 (29%) practitioners have used an IO kit mainly in case of cardiopulmonary arrest in adults (68%). The insurance of operators in this technique and the rate of physicians who has even put an IO catheter increased with the years of experience of physicians. The reasons given for not using an IO access were no trouble placing a peripheral vein (77%) and unfamiliarity with the equipment and technology (32%). Most of practitioners (753 [55%]) have been trained and 90% (n=265) of untrained doctors believe that training was necessary. The powered system was the most used (71%). ConclusionOnly 29% of practitioners have ever used an IO kit. With the new IO kits, a theoretical and practical training is needed to ensure IO kit used.

Board 399 - Research Abstract LMA/IO Placement Versus ETT/UVC Placement during Simulation in New NRP Trainees (Submission #471)

Introduction/Background Endotracheal intubation is the preferred procedure taught in the Neonatal Resuscitation Program (NRP) when a secure airway is needed. Studies show that pediatric residents are successful only 21-62% of the time, often requiring multiple attempts and taking longer than recommended. The laryngeal mask airway (LMA) is an alternate device that can be used to provide a secure airway. The preferred procedure taught in NRP for obtaining emergency vascular access is umbilical venous catheter (UVC) placement. Studies have shown intraosseous (IO) insertion to require less skill and practice and take less time than UVC placement for emergency vascular access. Pediatric residents can take six times as long to place an emergency UVC compared to IO. The purpose of this study was to compare the success and time to establish a secure airway and emergency vascular access during simulated neonatal resuscitation using LMA/IO versus endotracheal tube (ETT)/UVC in new NRP trainees. Methods Seventeen fourth year medical students on a pediatric rotation were recruited. They completed NRP training two days prior to study participation. The participants viewed a video demonstration of the four skills (ETT, LMA, UVC and IO) and performed each procedure on a manikin or task trainer with guidance from an experienced NRP provider. The students then participated in a simulated delivery room scenario, where a secure airway and vascular access were needed. They were randomized to either LMA and IO or ETT and UVC. The scenarios were recorded for data collection and analysis. Data was also collected in real time by observers in the delivery room. After the delivery room scenario, the students were surveyed to assess experience and perceived confidence with each skill. Results Success of LMA placement was 100% versus 62.5% with ETT (p = 0.082). The median number of attempts was 1 for the LMA versus 2.5 for ETT (p = .009). The median total airway management time using LMA was 88 seconds versus 173 seconds with ETT (p < .001) and median procedure time of LMA insertion was 23 seconds, compared to 119 seconds for ETT (p = .015). The rate of success and median time to obtain vascular access using IO catheter versus UVC did not significant differ (both p > 0.4). Conclusion In this pilot study in a simulated delivery room setting, there was a statistically significant difference in the time to placement and number of attempts favoring LMA versus ETT. IO insertion was faster than UVC placement, although not statistically significant with the small sample size. If larger studies support our findings, NRP training may need to include LMA as the preferred method for a secure airway, particularly in those who do not routinely perform delivery room resuscitation. Disclosures None.

Successful cardiopulmonary resuscitation following cardiopulmonary arrest in a geriatric chinchilla

To describe the successful application of CPR in a geriatric chinchilla employing basic and advanced life support measures during cardiopulmonary arrest (CPA). A 13-year-old female intact chinchilla presented to a general and multispecialty referral hospital for a dental procedure. During recovery from anesthesia the patient suffered CPA and CPR was initiated. Noninvasive positive pressure mask ventilation was initiated and external chest compressions were performed. An 18-Ga needle was introduced into the medullary cavity of the right humerus as an intraosseous catheter and provided access for administration of drugs and fluids. After return of spontaneous circulation was noted mannitol was administered via the intraosseous catheter to alleviate suspected increased intracranial pressure. Clinical improvement was noted shortly after administration. Monitoring during the recovery period showed a normal sinus cardiac rhythm and a SpO₂ of 100% while on supplemental oxygen. Neurologic function continued to improve over the following hours. Oxygen therapy was provided via an oxygen cage, and administration of antimicirobials, gastrointestinal protectants, and nutritional supplementation were part of the post resuscitation care. Oxygen therapy was discontinued after 24 hours, during which time normal behaviors were observed and neurologic status was considered appropriate. The patient was discharged 48 hours after CPA. Published reports from clinical practice on the outcomes of CPR for exotic small mammals are limited. This report details the successful outcome of the use of combined basic and advanced life support measures for the provision of CPR in a chinchilla. This report also highlights the utility of an intraosseous catheter for administration of drugs and fluids novel to this species during resuscitation and recovery. To the authors' knowledge this is the first published report of successful CPR following CPA in a geriatric chinchilla.

Anesthesia through an intraosseous line using an 18-gauge intravenous needle for emergency pediatric surgery

Study ObjectiveTo describe the success and complication rate of intraosseous (IO) access for delivery of anesthesia with the use of an 18-gauge (G) intravenous (IV) needle. DesignProspective study. SettingChildren’s Welfare Teaching Hospital, Baghdad, Iraq. Patients300 critically ill infants and toddlers, age 3 weeks to 16 months, requiring emergency surgery for intra-abdominal or pelvic conditions, in whom peripheral or central access was not obtainable. Patients presented for surgery between 2007 and 2010. InterventionsIn 26 patients, the IO catheter was established when peripheral access was not obtained at the outset of surgery; in 4 patients standard peripheral vascular access failed during the surgical procedure and IO access was obtained. An 18-G IV needle was placed into the proximal tibia and attached to an extension set with a 3-way stopcock to deliver anesthesia. Main ResultsFor 26 critically ill children and 4 other children, IV access failed during delivery of anesthesia; vascular access was successfully obtained within minutes in all 30 infants (100%) using the intraosseous route. Ninety percent (27/30) of patients awoke immediately postoperatively in good condition; 10% (3/30) went to the pediatric intensive care unit (PICU) for further care due to their critical preoperative condition. Complications associated with use of the IO route were considered minor (3/30 pts [10%]) and included extravasation of fluid in two cases and cellulitis in one. ConclusionThe IO route provided for rapid delivery of anesthesia, induction, and maintenance in this series of critically ill infants undergoing emergency surgery when other vascular access routes failed. Few complications were noted. Intraosseous access was achieved through a simple technique using an 18-gauge IV needle.

Intraosseous Vascular Access is Safe, Effective and Costs less than Central Venous Catheters for Patients in the Hospital Setting

Central venous catheters (CVCs) are often placed to resuscitate unstable emergency department (ED) patients. In an observational study, we assessed intraosseous (IO) vascular access in the hospital, and compared results to published experiences with CVC placement. Patients who would typically receive a CVC were considered for the study. Vascular access was gained using a powered IO device. Data collection included placement success, placement time, ease-of-use, satisfaction with flow rates, complications and subsequent CVC placement. A total of 105 cases were studied from six centers. Mean age was 48.0±28.0 years and 53% were men; 85% of the patients were medical cases, and 53% were in cardiac/respiratory arrest. Of those, 48% returned to spontaneous circulation. A total of 94% of placements were successful on the first attempt. Mean time to IO access was 103.6±96.2 seconds. There was one serious complication - a lower extremity compartment syndrome. IO access costs $100/patient. The data revealed faster and more successful IO catheter placement than reported for CVCs, few complications and high user satisfaction. For simple placements, cost savings for IO access vs. CVCs was $195/procedure. If 20% of the 3.5 million CVCs placed annually were replaced with IO catheters, cost savings could approach $650 million/year. We conclude that IO access in place of CVCs delivers high value in terms of being a safe, fast and effective mode of vascular access for patients in the hospital setting, with potentially substantial cost savings. These data indicate that IO access is a cost effective and viable alternative to problematic CVC lines.

Effectiveness of a Drill-assisted Intraosseous Catheter versus Manual Intraosseous Catheter by Resident Physicians in a Swine Model

Introduction:Our objective was to compare the effectiveness, speed, and complication rate of the traditional manually placed intraosseous (IO) catheter to a mechanical drill-assisted IO catheter by emergency medicine (EM) resident physicians in a training environment.Methods:Twenty-one EM residents participated in a randomized prospective crossover experiment placing 2 intraosseous needles (Cook® Intraosseous Needle, Cook Medical, Bloomington, IN; and EZ-IO® Infusion System, Vidacare, San Antonio, TX). IO needles were placed in anesthetized mixed breed swine (mass range: 25 kg to 27.2 kg). The order of IO placement and puncture location (proximal tibia or distal femur) were randomly assigned. IO placement time was recorded from skin puncture until the operator felt they had achieved successful placement. We used 3 verification criteria: aspiration of marrow blood, easy infusion of 10 mL saline mixed with methylene blue, and lack of stained soft tissue extravasation. Successful placement was defined as meeting 2 out of the 3 predetermined criteria. We surveyed participants regarding previous IO experience, device preferences, and comfort levels using multiple choice, Likert scale, and visual analog scale (VAS) questions. IO completion times, VAS, and mean Likert scales were compared using Student’s t-test and success rates were compared using Fisher’s exact test with p<0.05 considered significant.Results:Drill-assisted IO needle placement was faster than manually placed IO needle placement (3.66 versus 33.57 seconds; p=0.01). Success rates were 100% with the drill-assisted IO needle and 76.2% with the manual IO needle (p=0.04). The most common complication of the manual IO insertion was a bent needle (33.3% of attempts). Participants surveyed preferred the drill-assisted IO insertion more than the manual IO insertion (p<0.0001) and felt the drill-assisted IO was easier to place (p<0.0001).Conclusion:In an experimental swine model, drill-assisted IO needle placement was faster and had less failures than manual IO needle placement by inexperienced resident physicians. EM resident physician participants preferred the drill-assisted IO needle.

Comparison of Intraosseous and Peripheral Venous Fluid Dynamics in the Desert Tortoise (Gopherus agassizii)

The efficacy of intraosseous catheterization has not been described previously in the desert tortoise (Gopherus agassizii). The goal of this study was to describe and compare the efficacy of four intraosseous catheter sites (humerus, femur, plastocarapacial junction [bridge], and gular region of the plastron) to jugular catheterization. Five adult tortoises were catheterized in each of the sites at least once. The distribution of a bolus injection of radiopharmaceutical (technetium-99m-diethylenetriaminepentaacidic acid [99mTc -DTPA]) was monitored via gamma camera over 2-min periods at five time intervals over 24 min. Compared to jugular catheterization, the humerus and femur sites provided the next best vascular access, with 84.4 and 61.8% of activity reaching the systemic circulation by 7 min, respectively. The bridge and gular catheter sites were less effective with only 41.9 and 40.8% systemic activity, respectively. Intraosseous catheters were no more technically difficult to place than jugular catheters and were less commonly dislodged, making them a viable option for vascular access in tortoises.

186 A Pre-Clinical Study to Determine the Time to Bone Sealing and Healing Following Intraosseous Vascular Access

186 A Pre-Clinical Study to Determine the Time to Bone Sealing and Healing Following Intraosseous Vascular Access

Intraosseous Catheter Placement in Children

This video demonstrates the placement of intraosseous catheters in children and reviews the indications, contraindications, placement techniques, and potential complications. Both manual insertion and insertion with the use of a power-assisted device are shown.

Intraosseous Catheter Placement in Children

Obtaining vascular access in acutely ill or injured children can be challenging. Intraosseous access provides a means for delivery of medications, crystalloid fluids, colloids, and blood products during pediatric resuscitation. In addition, when intraosseous access is achieved, blood samples can be obtained for laboratory analysis. Numerous studies show that an intraosseous catheter can be placed more rapidly than a central venous catheter and that this technique is more reliable than venous cutdown. . . .

Intraosseous Injection of Iodinated Computed Tomography Contrast Agent in an Adult Blunt Trauma Patient

Intraosseous venous access can be life-saving in trauma patients when traditional methods for obtaining venous access are difficult or impossible. Because many blunt trauma patients require expeditious evaluation by computed tomography (CT) scans with intravenous contrast, it is important to evaluate whether intraosseous catheters can be used for administering CT contrast agents in lieu of waiting until secure peripheral intravenous or central venous catheter access can be established. Previous case reports have demonstrated that tibial intraosseous catheters can be used to safely administer CT contrast in the pediatric patient population. Here we report a case in which intraosseous access was the only means of administering intravenous contrast agent in an adult blunt trauma patient. An intraosseous catheter was placed in the standard manner in the right proximal humerus. Intravenous contrast agent was administered through the intraosseous catheter, using the standard blunt trauma protocol at our institution. CT scans were evaluated by a staff radiologist and assessed for the adequacy of diagnosis for blunt traumatic injuries. CT scans of the thorax, abdomen, and pelvis were considered to be adequate for diagnostic purposes and subjectively equivalent to those of studies using traditional central venous access. The intraosseous catheter was discontinued the following day. No complications of intraosseous placement or of contrast administration were identified. Intraosseous catheterization appears to be a feasible and effective alternative to traditional methods of venous access in the administration of iodinated contrast agents for CT evaluation in adult blunt trauma patients. Further study is warranted.

Systemic Fibrinolysis Through Intraosseous Vascular Access in ST-Segment Elevation Myocardial Infarction

In emergency situations, intraosseous cannulation represents an alternative route of vascular access when peripheral vein insertion is difficult. We present the first documented case of intraosseous systemic fibrinolysis in a patient with ST-segment elevation myocardial infarction. In this case, repetitive episodes of ventricular fibrillation occurred soon after first contact with emergency care providers. Given that the patient had difficult peripheral venous access, an intraosseous catheter was inserted. Fibrinolytics and antiarrhythmic drugs were administered though this line, resulting in resolution of coronary ischemia and electrical instability, without complications. Intraosseous cannulation represents a novel route for administration of systemic fibrinolysis in cases of difficult peripheral venous access in the out-of-hospital setting.

Proximal Humerus Intraosseous Infusion: A Preferred Emergency Venous Access

To assess the proximal humerus intraosseous (PHIO) catheter placement as a preferred method for venous access over conventional methods, including peripheral intravenous (PIV) and central venous catheters (CVCs), during emergency room resuscitation. In phase 1, conventional methods for venous access (PIV and CVC) were assessed for all patients presenting to the emergency department resuscitation bay. Outcome measures in both phases were speed, immediate complications, and pain. CVC placement was performed when PIV access was deemed impossible or when rapid volume resuscitation was needed. In phase 2, resuscitations requiring venous access or complicated by failed PIV access attempts underwent PHIO catheter placement. Sixty-two patients received either PIV (57) or CVC (5) catheterization, and 29 patients received 30 PHIO catheters. PHIO catheter placement was significantly faster than conventional methods (1.5 [SD 1.1] versus 3.6 minutes [SD 3.7; p < 0.001 for PIV, and 15.6 minutes [SD 6.7; p < 0.0056] for CVC). No major complications were identified in either phase. Minor complications for PIV access included extravasation and placement failure. Minor complications for CVC placement included inability to thread the guidewire. Minor complications with PHIO catheter placement included placement failure, poor flow, and catheter dislodgement. Pain scores associated with PHIO insertion and infusion were higher than those associated with PIV and CVC catheter placement. PHIO catheter placement is significantly faster than PIV and CVC placement with increased minor complication profile and perceived pain. PHIO venous access is absolutely life saving when PIV or CVC placement is difficult or impossible.

The Use of Multiple Intraosseous Catheters in Combat Casualty Resuscitation

During the current military engagements in Iraq and Afghanistan, establishing intravenous (IV) access for resuscitation of critically injured casualties remains a persistent challenge. Intraosseous (IO) access has emerged as a viable alternative in resuscitation. In this case report, a 19 year-old male soldier was severely wounded by a roadside bomb in Iraq. Given the heavy initial blood loss, anatomic location of the injuries and gross wound contamination, peripheral IV access could not be established. Instead, multiple IO catheters were used to initiate fluid resuscitation prior to transfer to a combat support hospital. To our knowledge, this is the first report of such extensive usage of IO catheters. Multiple IO catheters can be placed rapidly and safely and may help solve the challenge of establishing vascular access for resuscitation of critically injured casualties.