Intraosseous Devices Research Articles

Comparison of two intraosseous access devices in adult patients under resuscitation in the emergency department: A prospective, randomized study

Introduction Current guidelines recommend intraosseous (IO) vascular access in adults if peripheral venous access is unavailable. Most available data derive from children, animal models, cadaver studies or the prehospital setting. Therefore we compared two different IO access devices in adults under resuscitation in the hospital setting. Patients and methods This prospective, randomized clinical study compared two different IO access devices in adults (≥18 years of age) under trauma or medical resuscitation admitted to our emergency department with impossible peripheral venous access. Each adult was randomized to either spring-loaded BIG Bone Injection Gun or battery-powered EZ-IO. Outcome measures included success rates on first attempt, procedure times and complications. Results Forty consecutive adults under resuscitation were enrolled. Twenty patients received the BIG, another twenty patients the EZ-IO. Over all success rate on first attempt was 85% and mean procedure time 2.0 min ± 0.9. Comparing the two devices, success rate on first attempt was 80% for the BIG versus 90% for the EZ-IO and mean procedure time was 2.2 min ± 1.0 for the BIG versus 1.8 min ± 0.9 for the EZ-IO. The differences between both IO devices were not statistically significant. No other relevant complications like infection, extravasation or bleeding were observed. Conclusions IO vascular access was a reliable and safe method to gain rapid vascular access for in-hospital adult emergency patients under resuscitation. Further studies are necessary regarding comparative effectiveness of different IO devices.

Biomechanical aspects of intraosseous distraction osteosynthesis of the shin with drive apparatuses

The need in this scientific research was caused by testing of drive intraosseous devices for tibial lengthening in order to establish strength characteristics of the device. The results of the tests, conducted on intraosseous devices, confirmed high technological characteristics of their design even under maximum calculated loads, thereby demonstrating their high safety for application to clinical practice.

Current use of intraosseous infusion in Danish emergency departments

Results Overall response rate was 95% (n = 19). Of the responding Danish emergency departments 74% (n = 14) have intraosseous devices. Despite this 33% (n = 6) of the departments did not use intraosseous devices at all and in 68% (n = 13) it was used infrequently. In 47% (n = 9) of the departments there had never been any training sessions in the use of intraosseous devices, and 42% (n = 8) did not have standard operating procedures on IOI. The indication for IOI use was often not clearly defined and only 11% (n = 2) consistently used IOI on relevant indication. This was a surprise since 95% (n = 18) of responders were aware that IOI can be used in both paediatric and adult resuscitation.

Current use of intraosseous infusion in Danish emergency departments: a cross-sectional study.

BackgroundIntraosseous infusion (IOI) is recommended when intravenous access cannot be readily established in both pediatric and adult resuscitation. We evaluated the current use of IOI in Danish emergency departments (EDs).MethodsAn online questionnaire was e-mailed to the Heads of Department of the twenty EDs currently established in Denmark. The questionnaire focused on the use of IOI in the EDs and included questions on frequency of use, training, equipment and attitudes towards IOI.ResultsWe received a total of 19 responses (response rate of 95%). Of the responding 19 Danish EDs 74% (n = 14) reported having intraosseous devices available. The median number of IOI procedures performed in these departments over the preceding 12 months was 5.0 (range: 0-45). In 47% (n = 9) of the departments, prior training sessions in the use of intraosseous devices had not been provided, and 42% (n = 8) did not have local guidelines on IOI. The indication for IOI use was often not clearly defined and only 11% (n = 2) consistently used IOI on relevant indication. This is surprising as 95% (n = 18) of responders were aware that IOI can be utilized in both pediatric and adult resuscitation.ConclusionsThe study shows considerable variations in IOI usage in Danish EDs despite the fact that IOI devices were available in the majority of EDs. In addition, in many EDs there were no local guidelines on IOI and no training in the procedure. We recommend more extensive training of medical staff in IOI techniques in Danish EDs.

Intraosseous Devices: A Randomized Controlled Trial Comparing Three Intraosseous Devices

Introduction. Access to the circulation is mandatory for adequate treatment in medical emergency situations. Intraosseous (IO) infusion is a safe, fast, and effective alternative for gaining access to the circulation, if intravenous access fails. In the last decade, the IO method gained renewed interest. New devices have been developed, such as the Bone Injection Gun (BIG) 15G/18G and the First Access for Shock and Trauma 1 (FAST1). Objective. To determine which IO needle is preferable for gaining IO access in patients requiring acute administration of fluids or medication in a prehospital setting. Methods. In this single-blind prospective randomized trial, the IO needles were added to the equipment of the helicopter emergency medical services (HEMS) system. The HEMS nurses received training in proper use of all needles. Children (1–13 years) were randomized to the Jamshidi 15G or the BIG 18G, and adults (≥ 14 years) were randomized to the Jamshidi 15G, the BIG 15G, or the FAST1. All patients requiring acute administration of fluids or medication, without successful insertion of an intravenous (IV) catheter, were included. The IO needles were compared in terms of insertion time, success rate, bone marrow aspiration, adverse events during placement, and user satisfaction. Results. Sixty-five adult and 22 pediatric patients were included. The treatment groups were similar with respect to age, gender, mortality, and trauma mechanism (p ≥ 0.05). The median insertion times ranged from 38 seconds for the Jamshidi 15G to 49 seconds for the BIG 15G and 62 seconds for the FAST1 (p = 0.004). The devices did not differ with respect to success rates (adults overall 80% and children overall 86%), complication rates, and user satisfaction. Conclusions. The Jamshidi 15G needle could be placed significantly faster than the FAST1. The devices had similar success rates, complication rates, and user-friendliness. Intraosseous devices provide a safe, simple, and fast method for gaining access to the circulation in emergency situations.

317: A Manometric Method for Evaluating Flow Dynamics and Thrombus Burden of Intraosseous Devices: Theory and Application

317: A Manometric Method for Evaluating Flow Dynamics and Thrombus Burden of Intraosseous Devices: Theory and Application

Comparison of Two Mechanical Intraosseous Infusion Devices: A Randomized Crossover Trial

Introduction: Administration of medications via the intraosseous (IO) route has proven to be a lifesaving procedure in critically ill or injured children. Two mechanical IO infusion devices have been approved for use in children, the spring-loaded IO infusion device (bone injection gun, BIG) and the battery-powered IO infusion drill (EZ-IO). The objective of this pilot study was to compare the success rates for insertion and the ease-of-use of the two devices. Patients and Methods: A randomized crossover study was conducted in a local paramedic training course with 29 paramedic students participating.

Comparison of two mechanical intraosseous infusion devices: A pilot, randomized crossover trial

Introduction Administration of medications via the intraosseous (IO) route has proven to be a lifesaving procedure in critically ill or injured children. Two mechanical IO infusion devices have been approved for use in children, the spring-loaded IO infusion device (Bone Injection Gun, BIG) and the battery-powered IO infusion drill (EZ-IO). The objective of this pilot study was to compare the success rates for insertion and the ease-of-use of the two devices. Patients and methods A randomized crossover study was conducted in a local paramedic training course with 29 paramedic students participating. Participants watched two videos describing the use of the two devices, followed by a demonstration on how to use each device on a turkey bone model. Then subjects were divided into two study groups: BIG-first or EZ-IO-first. Each participant performed one insertion attempt with each device independently. All attempts were filmed by a video camera. Successful placement was defined as the visualization of fluid flow from the marrow cavity. Following the study procedure, participants completed a two-item questionnaire recording their ranking of the ease-of-use of each device and their “first choice device”. Results Participants had a significantly higher one-attempt success rate with the EZ-IO than with the BIG (28/29 vs 19/29, p = 0.016), and selected the EZ-IO as their first choice (20/29). Participants of the EZ-IO-first group assessed the EZ-IO as easier to use than the BIG ( p = 0.0039). The subjects of the BIG-first group found no difference in the ease-of-use between the two devices ( p = 0.32). Conclusions As tested by paramedic students on a turkey bone model, the EZ-IO demonstrated higher success rates than the BIG and was the preferred device. Future studies are planned to determine which of the two devices is more appropriate for obtaining IO access in the setting of paediatric emergencies.

The effect of the APLS-course on self-efficacy and its relationship to behavioural decisions in paediatric resuscitation

Aims Self-efficacy may predict performance following life-support training but may be negatively influenced by experiences during training. To investigate both this and the use of self-efficacy in self-assessment we investigated the relationship between self-efficacy and measured performance during a simulated resuscitation, and the effect of death of a simulated patient on self-efficacy. Materials and methods Consultant and trainee paediatricians and anaesthesiologists scored their self-efficacy for paediatric resuscitation skills before taking an unannounced simulated resuscitation test and objective structured clinical examination (OSCE)-tests of chest compressions and bag- and mask-ventilation. Performance in the simulation was scored by three independent expert observers and the OSCE's using a modified Berden and ventilation penalty scores. Results Self-efficacy for the relevant skill was significantly higher in doctors choosing to give chest compressions, to intubate or insert an intraosseous device and in those who decided to intubate early. Self-efficacy correlated moderately with the quality of global performance on the simulation but not with the OSCE scores, nor was quality of individual skills during the simulation related to self-efficacy. Self-efficacy was higher in doctors who had taken the Advanced Paediatric Life Support (APLS)-course. Death of the simulated patient had a negative effect on self-efficacy. Conclusion Self-efficacy seems to be predictive of certain actions during a simulated resuscitation but does not correlate with quality of performance of resuscitation skills. Self-efficacy might therefore be useful as a predictor of the application of learning, but cannot be recommended for self-assessment. There is evidence to support the unwritten rule during simulation training the patient should not be allowed to die.

Boning up on intraosseous devices

Boning up on intraosseous devices

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

Introduction Intraosseous needle insertion for vascular access is a standard procedure used in paediatric resuscitation. The introduction of newer automated intraosseous devices has recently expanded its role to include resuscitation in patients of all ages. Managing resuscitation can be challenging and a misplaced intraosseous needle may confound effective resuscitation. Colour Doppler ultrasound has been recently proposed as a method to confirm intraosseous needle placement. The ability to rapidly determine the correct position of an intraosseous needle during resuscitation would allow the delivery of medication or fluid infusion into the vascular space to be verified, thus optimizing resuscitation. Furthermore, complications from intraosseous infusion extravasating into soft tissues, such as compartment syndrome, or tissue necrosis can be avoided. Methods We describe the point-of-care sonographic technique and colour Doppler ultrasound findings of intraosseous needle confirmation in a case series of critically ill patients requiring resuscitation, highlighting the utility of this sonographic application. Results Colour Doppler ultrasound detected extraosseous flow in incorrectly positioned intraosseous needles, and intraosseous flow in correctly positioned intraosseous needles in six critically ill patients requiring resuscitation. Conclusions The use of point-of-care colour Doppler ultrasound to determine the location of both manually inserted or automated placement of intraosseous access during resuscitation is feasible, can be rapidly performed, may verify delivery of resuscitative medications or infusions, and avoid complications from extravasation.

Intraossäre Fehlpunktion

In cases of emergency it can sometimes be difficult or even impossible to achieve peripheral venous access. However, intraosseous (IO) devices enable vascular access even under adverse conditions due to the abundant, non-collapsible intramedullary vessels which are able to rapidly transport drugs and infusions to the central circulation. Therefore, the current European Resuscitation Council (ERC) guidelines favour IO access even in adults if rapid peripheral venous catheterization is not possible.Appropriate training in homologous IO devices is imperative for successfully achieving vascular access. Lacking or insufficient training may lead to complications. The present article describes a case of incorrect IO device application on a severely injured patient in the resuscitation room. Flawed patient positioning and incorrect handling of the IO device led to displacement of the device. Therefore, the intraosseous administration of drugs or infusions was not possible.

Diploic venous anatomy studied in‐vivo by MRI

Calvarial diploic venous anatomy has been studied post-mortem, but few studies have addressed these venous structures in-vivo. Previous work in our laboratory has shown that intraosseous infusion through the skull diploic space near the diploic veins in animals and humans does access the superior sagittal sinus and the systemic venous system. We developed a volumetric method of imaging the diploic veins in-vivo using MRI, intravenous gadolinium, and digital subtraction to provide for three-dimensional depiction and exact localization of these veins. We hypothesized that this technique would allow for an assessment of the probability of existence, distribution, and concentration of diploic veins in the skull. We scanned 31 neurosurgical patients, and were able to create 3D diploic venous maps in 74% of them. These maps were processed using Adobe Photoshop CS2. Mathworks MatLab 6.5, once customized, counted the number of pixels occupied by the diploic veins in the processed image. The probability of veins was highest in the occipital regions (100%). The inferior occipital (4.1%) and posterior parietal (4.1%) regions had the highest concentrations of diploic veins. Digital subtraction venography using a volumetric MRI sequence can demonstrate the diploic veins in-vivo. The inferior occipital region may be the best area for an intraosseous infusion device because it has the greatest likelihood of containing a vein and also has the highest concentration of veins.

Are Powered Intraosseous Insertion Devices Safe and Effective in Children

Intraosseous vascular access has long been standard care when rapid peripheral intravenous access cannot be achieved in a critically ill or injured

Powered Intraosseous Insertion Provides Safe and Effective Vascular Access for Pediatric Emergency Patients

For decades, intraosseous (IO) access has been a standard of care for pediatric emergencies in the absence of conventional intravenous access. After the recent introduction of a battery-powered IO insertion device (EZ-IO; Vidacare Corporation, San Antonio, TX), it was recognized that a clinical study was needed to demonstrate device safety and effectiveness for pediatric patients. We measured the insertion success rate, patient pain levels during insertion and infusion, insertion time, types of fluid and drugs administered, device ease of use on a scale of 1 (easy) to 5 (difficult), and complications. There were 95 eligible patients in the study; 56% were males. Mean patient age was 5.5 +/- 6.1 years. Successful insertion and infusion was achieved in 94% of the patients. Insertion time was 10 seconds or less in 77% of the one-attempt successful cases reporting time to insertion. There were 4 minor complications (4%), but none significant. For patients with a Glasgow Coma Scale (GCS) score >8, mean insertion pain score was 2.3 +/- 2.8, and mean infusion pain score was 3.2 +/- 3.5. The device was rated easy to use 71% of the time (n = 49) and the mean score was 1.4. The results of this study support the use of the powered IO insertion device for fluid and drug delivery to children in emergency situations. The rare and minor complications suggest that the powered IO device is a safe and effective means of achieving vascular access in the resuscitation and stabilization of pediatric patients.

162: Evaluation of a Powered Intraosseous Device for Bone Marrow Sampling

The importance of bone marrow examination in the evaluation of leukemia, multiple myeloma, anemia, pancytopenia, and other disorders is well established. The objective for this study was to evaluate the ability of a powered bone marrow aspiration device to penetrate the intraosseous medullary space of the iliac crest, and to aspirate bone marrow samples for the ultimate purpose of diagnosing disease and monitoring the course of disease and medical therapy. The device was used to obtain bone marrow samples in accordance with accepted practice guidelines and device's directions for use. Among other data, insertion success, time to insertion, and complications were recorded. Patient pain levels were rated from 0 to 10 (10=extreme pain). Device operators rated the use of the device from 0 to 10 (10=outstanding). There were 55 patients in the study from three centers. Successful insertion and aspiration of bone marrow samples were achieved in 54 of the 55 patients (98.1%). Mean insertion time was 4.9 ± 3.0 seconds; significantly faster than the 7.3 minutes reported by Kuball et al∗ (one-sample t-test, p < 0.001). There were no complications. The mean insertion pain score was 2.5 ± 2.2 and the mean aspiration pain score was 3.7 ± 2.5. On a scale of 0 to 10, the six operators rated the ease of use of the device at a mean score of 8.3 ± 1.7. Findings suggest that the powered aspiration device is safe and effective for bone marrow aspirations; and that through the use of powered device, needle placement time can be reduced—thereby reducing patient pain.∗ Kuball J, Schüz J, Gamm H, Weber M. Bone marrow punctures and pain. Acute Pain 2004;6(1):9–14. The importance of bone marrow examination in the evaluation of leukemia, multiple myeloma, anemia, pancytopenia, and other disorders is well established. The objective for this study was to evaluate the ability of a powered bone marrow aspiration device to penetrate the intraosseous medullary space of the iliac crest, and to aspirate bone marrow samples for the ultimate purpose of diagnosing disease and monitoring the course of disease and medical therapy. The device was used to obtain bone marrow samples in accordance with accepted practice guidelines and device's directions for use. Among other data, insertion success, time to insertion, and complications were recorded. Patient pain levels were rated from 0 to 10 (10=extreme pain). Device operators rated the use of the device from 0 to 10 (10=outstanding). There were 55 patients in the study from three centers. Successful insertion and aspiration of bone marrow samples were achieved in 54 of the 55 patients (98.1%). Mean insertion time was 4.9 ± 3.0 seconds; significantly faster than the 7.3 minutes reported by Kuball et al∗ (one-sample t-test, p < 0.001). There were no complications. The mean insertion pain score was 2.5 ± 2.2 and the mean aspiration pain score was 3.7 ± 2.5. On a scale of 0 to 10, the six operators rated the ease of use of the device at a mean score of 8.3 ± 1.7. Findings suggest that the powered aspiration device is safe and effective for bone marrow aspirations; and that through the use of powered device, needle placement time can be reduced—thereby reducing patient pain. ∗ Kuball J, Schüz J, Gamm H, Weber M. Bone marrow punctures and pain. Acute Pain 2004;6(1):9–14.

Intraosseous Infusion

This is a review article of intraosseous infusion methods and devices.

Does intraosseous equal intravenous? A pharmacokinetic study

Study Objective Despite the growing popularity of intraosseous infusion for adults in emergency medicine, to date there has been little research on the pharmacokinetics of intraosseously administered medications in humans. The objective of the study was to compare the pharmacokinetics of intraosseous vs intravenous administration of morphine sulfate in adults. Methods The study followed a prospective, randomized, crossover design. Each subject was equipped with an indwelling intraosseous access device and an intravenous line. Subjects were randomized to receive a 5-mg bolus of morphine sulfate infused intraosseously or intravenously, followed by the alternate administration route 24 hours later. Serial venous blood samples (5 mL) were taken at baseline and at 13 time points over 8 hours postinfusion. Blood samples were analyzed for morphine concentration by radioimmunoassay. Pharmacokinetic parameters were calculated from the data, including maximum plasma concentration ( C max), time to maximum concentration ( T max), and area under plasma concentration-time curve (AUC), among others. Data were analyzed by analysis of variance. Results No statistically significant differences were observed between intraosseous and intravenous administration of morphine sulfate for nearly all of the pharmacokinetic parameters including C max (235 ± 107 vs 289 ± 197 ng/mL, mean ± SD, IO vs IV, respectively), T max (1.3 ± 0.5 vs 1.4 ± 0.5 minutes), and AUC (0-∞) (4372 ± 1785 vs 4410 ± 1930 ng min −1 mL −1). There was, however, a statistically significant difference in the volume of distribution in the central compartment, V d ( P = .0247), which in the opinion of the investigators was thought to be due to a minor deposition effect near the intraosseous port or in the bone marrow. Conclusion The results support the bioequivalence of intraosseous and intravenous administration of morphine sulfate in adults.

Evaluation of a Powered Intraosseous Device for Bone Marrow Sampling.

The importance of bone marrow examination in the evaluation of leukemia, multiple myeloma, anemia, pancytopenia, and other disorders is well established. The objective for this study was to evaluate the ability of a powered bone marrow aspiration device to penetrate the intraosseous medullary space of the iliac crest, and to aspirate bone marrow samples for the ultimate purpose of diagnosing disease and monitoring the course of disease and medical therapy. The device was used to obtain bone marrow samples in accordance with accepted practice guidelines and device's directions for use. Among other data, insertion success, time to insertion, and complications were recorded. Patient pain levels were rated from 0 to 10 (10=extreme pain). Device operators rated the use of the device from 0 to 10 (10=outstanding). There were 55 patients in the study from three centers. Successful insertion and aspiration of bone marrow samples were achieved in 54 of the 55 patients (98.1%). Mean insertion time was 4.9±3.0 seconds; significantly faster than the 7.3 minutes reported by Kuball et al* (one-sample t-test, p<0.001). There were no complications. The mean insertion pain score was 2.5±2.2 and the mean aspiration pain score was 3.7±2.5. On a scale of 0 to 10, the six operators rated the ease of use of the device at a mean score of 8.3±1.7. Findings suggest that the powered aspiration device is safe and effective for bone marrow aspirations.

122: Powered Needle Insertion Provides Safe and Effective Vascular Access for Pediatric Emergency Patients

For decades, intraosseous vascular access has been the standard of care for pediatric emergencies in the absence of conventional intravenous access. Until recently, limitations inherent in the design of manual (hand powered) and impact-driven intraosseous devices made the access procedure cumbersome, painful to the patient, and time consuming.