Intraosseous Research Articles

Literature Review for Office-Based Anesthesia

Literature Review for Office-Based Anesthesia

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

Intraosseous infusion (IO) remains an underutilized technique for obtaining vascular access in adults, despite its potentially life-saving benefits in trauma patients. In rural and remote areas, shortage of training equipment and human capacity (i.e., simulators) are the main contributors to the shortage of local training courses aiming at the development and maintenance of IO skills. Specifically, current training equipment options available for trainees include commercially available simulators, which are often expensive, or animal tissues, which lack human anatomical features that are necessary for optimal learning and pose logistical and ethical issues related to practice on live animals. Three-dimensional (3D) printing provides the means to create cost-effective, anatomically correct simulators for practicing IO where existing simulators may be difficult to access, especially in remote areas. This technical report aims to describe the development of maxSIMIO, a 3D-printed adult proximal tibia IO simulator, and present feedback on the design features from a clinical co-design team consisting of 18 end-point users. Overall, the majority of the feedback was positive and highlighted that the maxSIMIO simulator was helpful for learning and developing the IO technique. The majority of the clinical team responders also agreed that the simulator was more anatomically accurate compared to other simulators they have used in the past. Finally, the survey results indicated that on average, the simulator is acceptable as a training tool. Notable suggestions for improvement included increasing the stability of the individual parts of the model (such as tightening the skin and securing the bones), enhancing the anatomical accuracy of the experience (such as adding a fibula), making the bones harder, increasing the size of the patella, making it more modular (to minimize costs related to maintenance), and improving the anatomical positioning of the knee joint (i.e., slightly bent in the knee joint). In summary, the clinical team, located in rural and remote areas in Canada, found the 3D-printed simulator to be a functional tool for practicing the intraosseous technique. The outcome of this report supports the use of this cost-effective simulator for simulation-based medical education for remote and rural areas anywhere in the world.

Can Non-Physician Providers Use Ultrasound to Aid in Establishing Peripheral IV Access in Patients Who are Difficult to Cannulate? A Scoping Review.

Non-physician performed point-of-care ultrasound (POCUS) is emerging as a diagnostic adjunct with the potential to enhance current practice. The scope of POCUS utility is broad and well-established in-hospital, yet limited research has occurred in the out-of-hospital environment. Many physician-based studies expound the value of POCUS in the acute setting as a therapeutic and diagnostic tool. This study utilized a scoping review methodology to map the literature pertaining to non-physician use of POCUS to improve success of peripheral intravenous access (PIVA), especially in patients predicted to be difficult to cannulate. Ovid MEDLINE, CINAHL Plus, EMBASE, and PubMed were searched from January 1, 1990 through April 15, 2021. A thorough search of the grey literature and reference lists of relevant articles was also performed to identify additional studies. Articles were included if they examined non-physician utilization of ultrasound-guided PIVA (USGPIVA) for patients anticipated to be difficult to cannulate. A total of 158 articles were identified. A total of 16 articles met the inclusion criteria. The majority of participants had varied experience with ultrasound, making accurate comparison difficult. Training and education were non-standardized, as was the approach to determining difficult intravenous access (DIVA). Despite this, the majority of the studies demonstrated high first attempt and overall success rates for PIVA performed by non-physicians. Non-physician USGPIVA appears to be a superior method for PIVA when difficulty is anticipated. Additional benefits include reduced requirement for central venous catheter (CVC) or intraosseous (IO) needle placement. Paramedics, nurses, and emergency department (ED) technicians are able to achieve competence in this skill with relatively little training. Further research is required to explore the utility of this practice in the out-of-hospital environment.

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

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

EMS Use and Success Rates of Intraosseous Infusion for Pediatric Resuscitations: A Large Regional Health System Experience

Objective Access of intraosseous (IO) compartments is a commonly used technique that is an invaluable asset in emergency resuscitation. Prehospital IO success rates using semi-automatic insertion devices vary between 70 and 100% of pediatric patients. There are limited data on time to insertion and duration of IO function in the prehospital setting. Recent studies limited to the pediatric emergency department (PED) setting have also suggested that IOs may be less successful in the infant population. We explored the use of IO access for pediatric resuscitation, encompassing the prehospital and pediatric emergency department (PED) settings. Methods This is a retrospective review of emergency medical services (EMS) patient care reports and PED data of patients aged 0–17 years old and transported by regional ground EMS agencies in Southwestern Ontario, Canada from 2012 to 2019. Mean and median time to first insertion and IO function (from insertion to IO failure, IV access, transfer to ICU, or death) were calculated. Results Successful prehospital IO access was achieved in 83.7% of patients. The median time required to achieve IO access was 4 min (IQR 3-7) and mean duration of IO function was 27.6 min (SD: 14.8). Patients less than 1 year old had fewer functional IOs (25.9% vs. 75.0%), more insertion attempts (2 vs. 1), and shorter duration of IO function (18.8 vs. 32.2 mins) than the older age group (p < 0.05). Conclusions This is the first study to provide time to IO access and IO duration in the prehospital setting, and the first prehospital evidence to suggest inferior IO function in infants <1 year old, compared to other ages. This highlights unique challenges for infants that have implications for the PED, interfacility transport, and critical care settings.

Higher Tissue Concentrations of Vancomycin Achieved With Low-Dose Intraosseous Injection Versus Intravenous Despite Limited Tourniquet Duration in Primary Total Knee Arthroplasty: A Randomized Trial

Vancomycin use has been suggested in high risk patients undergoing total knee arthroplasty (TKA). Previous literature has shown that a lower dose (500 mg) of vancomycin given by intraosseous regional administration (IORA) achieves tissue concentrations 4-10 times higher than intravenous (IV) administration. There is increasing interest in performing TKA with limited tourniquet inflation time. The purpose of this study is to evaluate whether IORA of vancomycin can achieve effective tissue concentrations with limited tourniquet inflation time. Based on prior power calculations, 24 patients undergoing primary TKA were randomized into 2 groups. Group IV-Systemic received weight-based (15 mg/kg) vancomycin with the tourniquet inflated for cementation only. Group IORA received 500 mg vancomycin via IORA after tourniquet inflation which remained inflated for 10minutes, then reinflated for cementation only. Vancomycin concentrations from tissue, serum, and drain fluid were compared between the 2 groups. Median vancomycin concentrations in tissue were significantly higher (5-15 times) at all time points in the IORA group. Concentrations in fat at the time of wound closure, after the tourniquet had been deflated for most of the procedure, were 5.2 μg/g in Group IV-Systemic and 33.1 μg/g in Group IORA (P < .001). Median bone concentrations taken just prior to cementation were 7.9 μg/g in Group IV-Systemic and 21.8 μg/g in Group IORA (P= .006). There were no complications related to IORA. For surgeons who wish to limit tourniquet time and when indicated to use vancomycin, low-dose vancomycin IORA achieves tissue concentrations 5-15 times higher than those achieved by IV administration. Level 1 therapeutic randomized trial.

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

ObjectiveThis study evaluated physician preferences and values related to the most commonly used (traditional) powered intraosseous (IO) system and a novel powered IO system featuring a passive safety needle, battery life indicator, and snap‐securement/skin attachment.MethodsEmergency physicians participated in an IO simulation using both the traditional and novel IO systems. Participants completed a 27‐item postsimulation questionnaire to state their preferences toward each IO system and values related to the novel IO system features using a multiple choice, 11‐point value ranking scale (0 = no value, 10 = extremely valuable) and free‐text answer questions.ResultsAmong the 22 study participants, 90.9% (95% confidence interval [CI]: 70.8%, 98.9%) preferred the novel IO system; top reasons for this preference were the novel IO system's passive safety needle and snap‐securement/skin attachment. Participants who preferred the traditional IO system (9.1%) noted its ease of use and familiarity. Many physicians preferred the novel IO system's needle (81.8%; 95% CI: 59.7%, 94.8%), powered driver (77.3%; 95% CI: 54.6%, 92.2%), and snap‐securement/skin attachment (100%; 95% CI: 84.6%, 100%) compared with the traditional IO system. Safety and ease of use were the most common preference explanations. Of the participants, 100% provided a value score ≥7 for the novel IO system's passive safety needle (mean score, 9.45), whereas fewer participants (59.1%) gave a value score ≥7 for the multilight battery life indicator (mean score, 6.68).ConclusionThis study demonstrates that emergency physicians prefer and value a novel IO system with features that enhance safety and ease of use. These results provide insight into important factors related to IO systems for emergency physicians.

Determining Intraosseous Needle Placement Using Point-of-Care Ultrasound in a Swine (Sus scrofa) Model.

Intraosseous (IO) access is critical in resuscitation, providing rapid access when peripheral vascular attempts fail. Unfortunately, misplacement commonly occurs, leading to possible fluid extravasation and tissue necrosis. Current research exploring the utility of bedside ultrasound in confirming IO line placement is limited by small sample sizes of skeletally immature subjects or geriatric cadaveric models. The objective of this study was to investigate the potential value of ultrasound confirming IO needle placement in a live tissue model with bone densities approximated to the young adult medical or trauma patient. In this randomized, blinded prospective study, IO devices were placed into the bilateral humeri of 36 sedated adult swine (N = 72) with bone densities approximating that of a 20-39-year-old adult. Of the 72 lines, 53 were randomized to the IO space ("correct") and 19 into the subcutaneous tissue ("incorrect"). Four emergency physicians with variable ultrasound experience and blinded to needle location independently assessed correct or incorrect needle placements based on the presence of an intramedullary "flare" on color power Doppler (CPD) during a saline flush. Participants adjusted the ultrasound beam trajectory and recorded assessments up to three times, totaling 204 separate observations. Overall, sensitivity for placement confirmation was 72% (95% CI: 64%-79%). Specificity was 79% (95% CI: 66%-89%). First assessment and final assessment results were similar. More experienced sonographers demonstrated greater success in identifying inaccurate placements with a specificity of 86% (95% CI: 63%-96%). Within the context of this study, point-of-care ultrasound with CPD did not reliably confirm IO line placement. However, more accurate assessments of functional and malpositioned catheters were noted in sonographers with greater than 4 years of experience. Future study into experienced sonographers' use of CPD to confirm IO catheter placement is needed.

Emergency Decompressive Craniostomy "Burr Hole" Using an Intraosseous Vascular Access System in a Resource-Limited Setting: A Technical Report on a Cadaver.

This paper describes an alternative approach to emergency burr hole evacuation of epidural hematoma using the intraosseous (IO) vascular access system. The IO vascular access system is commonly available in the Emergency Department. We demonstrate that it can be used in rare situations where immediate neurosurgical intervention and the standard cranial drill and brace are not available for burr hole craniostomy.

Performance comparison of intraosseous devices and setups for infusion of whole blood in a cadaveric swine bone model.

Intraosseous (IO) access can provide a critical bridge for blood product infusion when peripheral venous access is not obtainable. Successful pressurized IO infusion requires flow rates sufficient to preserve life, but with infusion pressures low enough to avoid clinical complications (e.g., hemolysis, bone damage, fat emboli). However, the optimal method for pressured IO delivery of blood was unknown. Three trained physicians infused 500 mL of whole blood through a 15-gauge, 45 mm IO catheter into fresh, high bone density cadaveric swine proximal humeri. Participants applied eight different pressure infusion strategies: (1) gravity, (2) pressure bag, (3) pressure bag actively maintained at or above 300 mmHg, (4) hand pump, (5) hand pump with pressure bag, (6) push-pull with 10 mL syringe, (7) push-pull with 60 mL syringe, and a (8) Manual Rapid Infuser in a randomized within-subjects design (30 trials per method, 240 trials total). The primary outcomes of flow rates, mean and peak pressures, and user ratings were contrasted using ANOVA at p < 0.05. The Manual Rapid Infuser conferred the highest flow rates (199 ± 3 mL/min) and most favorable user ratings, but also the highest mean and peak pressures. Push-pull conferred the next highest flow rates (67 ± 5 mL/min for 60 mL, 56 ± 2 mL/min for 10 mL) and pressures, with intermediate-to-high user ratings. Hand pump flow rates were essentially identical with (45 ± 4 mL/min) or without (44 ± 3 mL/min) pressure bag, with high user ratings without a pressure bag. Pressure bag and gravity methods conferred low flow rates and user ratings. Some pressured IO infusion methods can achieve flow rates adequate to serve as a resuscitative bridge in the massively hemorrhaged trauma victim, but flow rates and pressures vary greatly across IO pressurized infusion methods. Manual Rapid Infuser and push-pull methods conferred high flow rates but also relatively high pressures, highlighting the importance of using in vivo models in future research to assess the possible clinical complications of using these promising methods. Combined, present findings highlight the importance of studying pressurized IO methods towards preserving the life of the critically injured trauma victim.

Alternative ways to introduce resuscitation at the prehospital stage in emergency conditions

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.

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

There are health professionals who are unaware of the ideal management of the intraosseous route, despite the fact that it has been scientifically considered an alternative to the peripheral venous route when the patient is in critical condition. Thanks to continuous development, there has been a need to provide emergency services with materials that manage to provide satisfactory care, despite the difficulties faced by health personnel. Objectives: The objective of this systematic bibliographic review is to update the theoretical and practical knowledge and strategies for the insertion and proper management of the intraosseous route as an emergency vascular access for nursing professionals. Data sources, study eligibility criteria: The search for the articles was carried out in various scientific databases with the help of a search string (January 2015 and May 2021), which combined the keywords and Boolean operators. Study appraisal and synthesis methods: Eighteen articles were chosen after a review of 1920 database articles, following the application of the inclusion and exclusion criteria. Results: Intraosseous infusion is an effective and safe technique, which increases patient survival. Therefore, it is of crucial importance that all nursing professionals know how to handle the different intraosseous devices in situations in which it is not possible to achieve immediate peripheral venous access. Conclusions and implications of key findings: It is of great need to have devices or fast and effective alternatives that allow us to develop safe interventions by health professionals.

Relationship Between Arterial and Intraosseous Pressure in African Grey Parrots (Psittacus erithacus).

The aim of this study was to determine the relationship between arterial pressure and intraosseous (IO) pressure obtained by conventional IO needle in African grey parrots (Psittacus erithacus). Twelve healthy African grey parrots with mean body weight 465.25 g were anesthetized in an induction chamber with 5% isoflurane and 100% oxygen, followed by intubation and connection to a pressure-limited intermittent-flow ventilator. A 24-gauge catheter was placed into the deep radial artery in one wing and a 22-gauge needle was placed into the distal ulnar medullary cavity in the contralateral wing. Both cannulas were connected to a 9-cm noncompliant tube and then linked to a disposable pressure sensor. Pressures and waveforms from both cannulas were recorded for 10 minutes while isoflurane was maintained at 3%. The results showed that the arterial pressure values were normally distributed (P < .05), whereas the IO pressure values were not (P > .05). Arterial and IO pressure were not correlated (P > 0.05), but IO pressure and heart rate were positively correlated (Spearman's rank correlation coefficient, 0.58; P < .05). Multiple characteristics of the IO waveforms were observed, including distinguishable continuous waveforms (n = 8), a single wave crest (n = 4), respiratory variation (n = 7), and a dicrotic notch (n = 3), and IO waveforms were appearing at a similar or delayed point relative to the related arterial waveforms (n = 8). Although IO pressure was not correlated with arterial pressure in the African grey parrots under the study conditions, the positive correlation between IO pressure and heart rate and the IO waveform characteristics suggest that the inflow arterioles likely account for the retained arterial waveform radiating into the IO space. These findings are consistent with those from all previously tested mammals. Therefore, insights into potential future improvements of the measuring techniques and protocols can be reached by thoroughly reviewing the current knowledge on IO pressure in mammals.

Intraosseous infusion of liposome-encapsulated hemoglobin (HbV) acutely prevents hemorrhagic anemia-induced lethal arrhythmias, and its efficacy persists with preventing proarrhythmic side effects in the subacute phase of severe hemodilution model.

Artificial oxygen carriers (HbV) can treat hemorrhagic shock with lethal arrhythmias (VT/VF). No reports exist on subacute HbV's effects. Acute and subacute resuscitation effects with anti-arrhythmogenesis of HbV were studied in 85% blood exchange rat model (85%-Model). Lethal 85%-Model was created by bone marrow transfusion and femoral artery bleeding in 80 SD rats in HbV-administered group (HbV-group), washed erythrocyte-administered group (wRBC-group), and 5% albumin-administered group (ALB-group). Survival rates, anti-arrhythmic efficacy by optical mapping system (OMP) with electrophysiological study (EPS) in Langendorff heart, cardiac autonomic activity by heart rate variability (HRV) and ventricular arrhythmias by 24-h electrocardiogram telemetry monitoring (24h-ECG) in awake, and left ventricular function by echocardiography (left ventricular ejection fraction [LVEF]) were measured. All rats in HbV- and wRBC-groups survived for 4 weeks, whereas no rats in ALB-group. HbV and wRBC acutely suppressed VT/VF in Langendorff heart through ameliorating action potential duration dispersion (APDd) analyzed by OMP with EPS. For subacute analysis, 50% blood exchange by 5% albumin was used (ALB-group 50). Subacute salutary effect on APDd and VT/VF inducibility was confirmed in HbV- and wRBC-groups. 24h-ECG showed that HbV and wRBC suppressed none-sustained ventricular tachycardia (NSVT) and sympathetic component of HRV (LF/HF) with preserved LVEF (HbV-group, wRBC-group vs. ALB-group 50; NSVT numbers/days, 0.5±0.3, 0.4±0.3 vs. 3.9±1.2*; LF/HF, 1.1±0.2, 0.8±0.2 vs. 3.5±1.0*; LVEF, 84±5, 83±4, vs. 77±4%*; *p<0.05). Collectively, HbV has sustained antiarrhythmic effect in subacute 85%-Model by ameliorating electrical remodeling and improving arrhythmogenic modifying factors (HRV and LVEF). These findings are useful in now continuing clinical trials of HbV.

Mineral Nanomedicine to Enhance the Efficacy of Adjuvant Radiotherapy for Treating Osteosarcoma

It is vital to remove residual tumor cells after resection to avoid the recurrence and metastasis of osteosarcoma. In this study, a mineral nanomedicine, europium-doped calcium fluoride (CaF2:Eu) nanoparticles (NPs), is developed to enhance the efficacy of adjuvant radiotherapy (i.e., surgical resection followed by radiotherapy) for tumor cell growth and metastasis of osteosarcoma. In vitro studies show that CaF2:Eu NPs (200 μg/mL) exert osteosarcoma cell (143B)-selective toxicity and migration-inhibiting effects at a Eu dopant amount of 2.95 atomic weight percentage. These effects are further enhanced under X-ray irradiation (6 MeV, 4 Gy). Furthermore, in vivo tests show that intraosseous injection of CaF2:Eu NPs and X-ray irradiation have satisfactory therapeutic efficacy in controlling primary tumor size and inhibiting primary tumor metastasis. Overall, our results suggest that CaF2:Eu NPs with their osteosarcoma cell (143B)-selective toxicity and migration-inhibiting effects combined with radiotherapy might be nanomedicines for treating osteosarcoma after tumor resection.

Development and Evaluation of a Three-Dimensional-Printed Pediatric Intraosseous Infusion Simulator To Enhance Medical Training.

Vascular access is an essential and rate-limiting step during pediatric resuscitation efforts. Intraosseous (IO) access, an effective resuscitative strategy, remains underutilized in emergency departments. Many medical graduates report never performing the procedure before graduation, and it has been recommended that continuing education and in-servicing programs be implemented to increase the use and familiarity of IO access. The goal of this technical report is to describe the development and evaluation of a three-dimensional (3D)-printed Pediatric IO Infusion Model for simulation-based medical education. The simulator was designed by combining open-source models of a human skeleton and a lower leg surface scan in Blender (Blender Foundation, Amsterdam, Netherlands; www.blender.org), scaled to a pediatric size, and manipulated further using a JavaScript program. Polylactic acid was used to simulate bone while silicone molds were used as skin and soft tissue. Two trainers were produced and evaluated by seven emergency medicine physicians, two family medicine residents, and three medical students.Overall, the simulator was positively received with all participants indicating they would recommend it to assist in the training of others. Suggestions focused on enhancing the anatomical representations of both the skin and bones to enhance the learner experience. The content and outcomes of this report support the use of this simulator as part of simulation-based medical education.

Single intra-articular injection with or without intra-osseous injections of platelet-rich plasma in the treatment of osteoarthritis knee: A single-blind, randomized clinical trial

BackgroundSubchondral bony structure damage plays an essential role in the pathogenesis of osteoarthritis (OA) knee. An intra-articular injection cannot reach the damaged subchondral bony structure and treat its pathologies effectively. The objective of the study was to compare the clinical effects of single intra-articular injection with or without intra-osseous injections of PRP in the treatment of osteoarthritis (OA) knee. MethodsThis was a single-blind, parallel-group, randomized clinical trial. Fifty patients, with OA knee (K&L grade III), with ages between 50 and 65 years, were randomly allocated into ‘intra-osseous, intra-articular PRP’ (‘IO+IA-PRP’) (n = 25) or ‘intra-articular PRP’ group (‘IA-PRP’) (n = 25). Patients in the ‘IO+IA-PRP’ group received 18 ml PRP injection, and the ‘IA-PRP’ group received 8 ml PRP injection. Intra-osseous injections were given at the tibial plateau (5 ml) and femoral condyle (5 ml), along with intra-articular knee injection (8 ml), under fluoroscopic guidance. Outcomes were measured using VAS-pain, the knee injury and osteoarthritis outcome score (KOOS), and the treatment satisfaction scale. All patients (n = 50) were followed up till six months. ResultsThe mean age was 57.12(4.27) years and 57.00(4.96) years in the ‘IO+IA-PRP’ and ‘IA-PRP’ groups. Both groups showed significant improvement in pain relief (VAS pain) and KOOS parameters: pain, symptoms, ADL function, sport and recreation function, and quality of life. Compared to the ‘IA-PRP’ group, the ‘IO+IA-PRP’ group showed a greater reduction of VAS pain at six months. However, no significant difference was obtained in VAS pain-relief between these two groups (p = 0.422) at six months. Similarly, at 6 months, in inter-group comparison, except ‘sport and recreation function’ (p < 0.05), no significant differences were obtained in mean-scores of KOOS parameters: pain (p = 0.514); symptom (p = 0.148), ADL-function (p = 0.991), QoL-(p = 0.376). Patients in the ‘IO+IA-PRP’ group complained of significant ‘injection-associated’ adverse events and consumed a greater number of Acetaphenomen. ConclusionsBoth groups showed significant improvement following the intervention. Intra-osseous PRP injections did not provide any additional benefit over intra-articular PRP injection until six months regarding pain relief and functional improvement.

Feasibility of Obtaining Intraosseous and Intravenous Access Using Night Vision Goggle Focusing Adaptors.

The optimal tactical lighting for performing medical procedures under low-light conditions is unclear. United States Navy medical personnel (N = 23) performed intravenous (IV) and intraosseous (IO) procedures on mannequins using a tactical headlamp, night vision goggles (NVGs), and night vision goggles with focusing adaptors (NVG+A) utilizing a randomized within-subjects design. Procedure success, time to completion, and user preferences were analyzed using analysis of variance (ANOVA) and nonparametric statistics at p < .05. IV success rates were significantly greater for the headlamp (74%) than for NVG (35%; p < .03) and somewhat greater than for NVG+A (52%; p = .18). IO success rates were high under each lighting condition (96% to 100%). Time to completion was significantly faster using headlamp (IV, 106 ± 28 s; IO, 47 ± 11 s) than NVG (IV, 168 ± 80 s; IO, 56 ± 17 s) or NVG-A (IV, 157 ± 52 s; IO, 59 ± 27 s; each p < .01). Posttesting confidence on a 1-to-5 scale was somewhat higher for NVG+A (IV, 2.9 ± 0.2; IO, 4.2 ± 0.2) than for NVG (IV, 2.6 ± 0.2; IO, 4.0 ± 0.2). Participants cited concerns with NVG+A depth perception and with adjusting the adaptors, and that the adaptors were not integrated into the NVG. While this mannequin study was limited by laboratory conditions and by the lack of practice opportunities, we found some small advantages of focusing adaptors over NVG alone but not over headlamp for IV and IO access in low-light conditions.

Location Matters in Syndesmosis Screw Breakage: Interosseous Breakage and Breakage Location Within the Tibia Affect Rates of Removal Secondary to Pain

Category:Ankle; Ankle; TraumaIntroduction/Purpose:Broken or loose syndesmotic screws are typically reported to be clinically asymptomatic, however, screw breakage can lead to significant pain depending on location. Syndesmosis screws that span the incisura are particularly at an increased risk for painful outcomes. In patients with intraosseous screw breakage, normal physiologic translation where the distal convex of the fibula fits into the concave tibial incisure can lead to painful bony erosion overtime. The purpose of this investigation is to assess variables that my predict location of syndesmosis screw breakage and to also assess the effect of screw breakage location on eventual removal secondary to pain.Methods:A retrospective analysis of 1,056 patients who underwent syndesmosis fixation revealed 88 patients (121 screws) who experienced pst-operative syndesmosis screw breakage and met predetermined inclusion criteria. Patient demographic data, BMI, comorbidities, pain scores, complication rate, and revision rate were all collected. Screw length, width, number, placement height above the tibial plafond, angle, location of breakage, breakage distance location on the screw and implant removal secondary to pain were also collected. A series of binomial logistic regressions were performed to ascertain the effects of the collected variables on the likelihood of breakage location and removal secondary to pain. Regression analysis included intraosseous versus clear space breakage, tibia versus fibula breakage, and removal secondary to pain in each breakage location group (tibia, fibula, clear space).Results:Of the 121 broken screws, 91 (75.2%) broke within an intraosseous (IO) location (68 patients, 77.3%). Twenty-eight screws (23%.1) (18 patients, 20.5%) broke exclusively within the clear space (CS). Sixty screws (52 patients, 59.9%), had IO breakage within the tibia, while 29 screws (24 patients 27.7%) had breakage within the fibula. Two screws (2 patients, 2.27%) occurred within an intraosseous location and the clear space. Intraosseous screw breakage was associated with higher risk removal secondary to pain (P=.020). Multiple screw usage associated with an increased risk for CS breakage (P =.012). IO and CS screw angle and placement had no effect on screw breakage location (P =.629, P =.570). Screw breakage closer to the CS (P=.001), increased number of screws used (P=.003), and higher patient pain scores (P =.003) were associated increased risk of removal due to pain within the IO tibia breakage group.Conclusion:Syndesmotic screw breakage location plays a more important role than previously reported. When compared to clear space, intraosseous breakage is associated with increased rates of removal due to pain. Breakage location within the tibia occurring closer to the clear space is associated with higher rates of removal secondary to pain and higher patient report pain scores. Usage of multiple screws was found to be the only significant predictor of clear space vs intraosseous breakage; all other variables were found to be non-contributary, including no appreciated significance of screw placement in relation to the tibial plafond or screw angle.

Demystifying the intraosseous infusion technique

Intraosseous infusion provides a safe and effective access to the vascular system that allows for administration of urgent therapies in both adults and children. It has few contraindications and complications are rare. The needle is most commonly inserted in the proximal tibia or anterior humerus. Different devices are available but those with a traditional drill are the most widespread. The intraosseous infusion procedure is easy and the learning curve is short, making it the best alternative when traditional intravenous access is not possible or delayed.