Intraosseous Needle Placement Research Articles

Emergency Department Pediatric Code Cart In Situ Rolling Refresher Training Program

BackgroundEmergency department nurses manage the code cart during infrequent pediatric emergencies in a rural, tertiary care center. A rolling refresher training program was developed to educate nurses on this low-frequency, high-risk skill. MethodsAn uncontrolled intervention study was completed with a 6-month follow-up. A program was created consisting of four scenarios and 17 code cart skills based on pediatric advanced life support algorithms. Each participant was assessed and trained to master each skill. ResultsAbout 56 participants were included. There was retained statistically significant improvement in first attempt successes between training 1 and 3 in the following skills: obtaining supplies for placing an IV and for intraosseous needle placement, delivering a weight-based appropriate fluid bolus, preparation and delivery of a weight-based epinephrine infusion, preparation and delivery of weight-based dose of adenosine, and a weight-based appropriate dose of epinephrine. ConclusionOur training program demonstrated improvement in a majority of these low-frequency, high-risk skills after an initial and repeated training every 6 months.

Popliteal Artery Injury and Loss of Limb After Intraosseous Needle Placement During Resuscitation

Popliteal Artery Injury and Loss of Limb After Intraosseous Needle Placement During Resuscitation

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.

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.

Checking the basis of intraosseous access-Radiological study on tibial dimensions in the pediatric population.

Malposition of intraosseous needles in pediatric patients is frequently reported. Incorrect needle length and penetration depth related to the puncture site and level are possible causes. Aim of this study was to analyze anatomic dimensions of the proximal tibia in the pediatric population with respect to intraosseous needle placement and needle tip position. Plain lower leg radiographs of children aged from birth to 16years of age were analyzed. Pretibial tissue layer, cortical bone thickness, and the diameter of the medullary cavity were measured at two different puncture levels. Data were analyzed as descriptive statistics and by polynomial regression plots and set in context to commonly used EZ-IO® needle lengths of 15 and 25mm. Radiographs from 190 patients (104 boys/86 girls) were included. When fully inserted to skin level, up to 10.5% of needles do not reach medullary cavity at one and 18.5% at two patient's fingerbreadths distal to tibial tuberosity. The opposite cortical wall is touched or penetrated in 16% and 25%, respectively. Up to 96% of too deep needle tip positions occur in children younger than 24months, as do too superficial tip positions in 59%. Puncture level and needle length have a great influence on potential needle tip positions. Infants and toddlers are at highest risk for malpositioning. Due to relevant growth-related differences in tibial anatomy, an age-related and well-reflected approach is crucial to successfully establish intraosseous access.

Hypovolemic Shock in a Child: A Pediatric Simulation Case.

Volume depletion is a common problem in pediatrics. Interns need to be able to recognize critical illness such as hypovolemic shock, obtain access, and manage complications. This simulation case involves a child with hypovolemic shock who requires intraosseous (IO) needle placement. While designed for subinterns in pediatrics, it is relevant for clerkship students and interns in family medicine and emergency medicine. In this case, a 3-year-old child presents with vomiting, diarrhea, and lethargy, and is in hypovolemic shock. As IV access cannot be obtained, he requires IO access. Laboratory results reveal hypoglycemia, hypernatremia, and acute kidney injury. Required equipment includes an IV arm task trainer and a child mannequin with IO capacity (or a child mannequin plus a separate IO task trainer). Learning objectives include recognizing and managing hypovolemic shock, hypoglycemia, and electrolyte disturbances; obtaining IO access; and communicating with a distraught parent. Critical actions include attempting IO access, requesting labs, and administering fluids. Students complete a selfassessment survey following the case. A pilot study was conducted in 2017 with all subinterns (N = 16) on the pediatric service. Students' perceived competence in assessment and management of volume depletion and procedural skills such as IO placement were high following the session, and students rated the case as a highly beneficial learning experience. This clinical simulation case allows students to demonstrate clinical reasoning skills, procedural skills, and management skills regarding hypovolemic shock. It may be used as part of a curriculum for fourth-year students entering pediatric residency.

Design, Development, and Validation of an Intra-Osseous Needle Placement Guide

Intra-osseous (IO) needles are an easy and reliable alternative to intravenous (IV) access in the prehospital and emergency settings for treating patients in shock. The advantage of utilizing an IO is that secure, noncollapsible peripheral venous access can be obtained rapidly in critically ill patients. Placement of IO needles in the proximal tibia, humerus, or sternum, however, requires knowledge of human anatomy and the requisite skill to position, align, and place the device. In the developing world, this is not always available, and in the chaos of an in-hospital code, prehospital trauma, or a mass-casualty incident, even trained providers can have trouble correctly placing IV or IO needles. The Tib-Finder is an intuitive drill guide that significantly improves efficiency with which IO can be placed in the proximal tibia. Here, we present the conceptualization, design, and creation of an alpha-prototype Tib-Finder drill guide in less than 90 days; initial validation was achieved through analysis of anthropometric measurements of human skeletons, and usability studies were performed using untrained volunteers and mannequins. The Tib-Finder is intended to provide first responders and medical personnel, in the first world and the developing world, a way to accurately and repeatably locate the proximal tibia and achieve safe, rapid intravascular access in critically ill patients. Further, it eliminates the need for direct contact between patients and caregivers and improves the ease-of-use of IO devices by first responders and healthcare providers.

Intraosseous Needle Placement Confirmation by Doppler Ultrasonography

SESSION TITLE: Rapid Session: Bedside Imaging SESSION TYPE: Original Investigation Slide PRESENTED ON: Wednesday, November 1, 2017 at 07:30 AM - 08:30 AM PURPOSE: The 2015 guidelines for advanced cardiac life support (ACLS) recommend intraosseous (IO) access, if intravenous (IV) access is not readily attainable. The safety record for IO access is excellent. However, serious complications have been reported in the literature. In our institution, we experienced a limb threatening complication from a dislodged IO line despite standard confirmation. A properly placed IO line must be through the cortex of the bone and situated within the marrow cavity. Standard methods for confirmation of IO placement include aspiration of bone marrow, firm placement of the IO needle into the bone, and no evidence of extravasation. The traditional confirmation methods have as high as a 60% false positive rate for IOs that have incorrect penetrating placement, and a 10% false positive rate for incorrect subcutaneous placement. An alternative method to confirm IO placement is the use of color Doppler ultrasonography, which provides a noninvasive method for verification of correct IO placement. METHODS: Confirmation of correct IO placement was performed in a series of patients who received IO access during emergent resuscitation. Confirmation of IO placement with color Doppler was accomplished using a 7.5 MHz linear ultrasound probe placed adjacent to the IO site with the tomographic plane placed to intersect with the tip of the IO needle and the color Doppler map adjusted to target the needle tip area. Injection of 10 cc of agitated saline through the IO needle confirmed appropriate placement if the color signal showed subperiosteal color Doppler velocity pattern. The results of the color Doppler studies were compared to results of standard indices of IO placement. RESULTS: A total of 15 IO needle placements were studied. All were confirmed to be in appropriate subperiosteal position place using the three standard confirmation methods. The color Doppler technique confirmed placement in all 15 cases, indicating a perfect correlation between the methods. CONCLUSIONS: From this preliminary study, color Doppler ultrasonography may be a useful adjunct to standard confirmation techniques for intraosseous needle placement, as it allows for rapid identification of incorrect placement of IO lines, which in turn may prevent serious limb injury. The limitation of the technique is the requirement of operator training and machine availability. CLINICAL IMPLICATIONS: Using point-of-care color doppler ultrasonography helps quickly identify incorrect placement of IO lines. This, in turn, may help prevent serious, limb threatening injuries. DISCLOSURE: The following authors have nothing to disclose: Zubair Hasan, Karan Singh, Atul Palkar, Yonatan Greenstein, Paul Mayo No Product/Research Disclosure Information

Intraosseous Infusion as a Bridge to Definitive Access

Intraosseous (IO) needle placement is an alternative for patients with difficult venous access. The purpose of this retrospective study was to examine indications and outcomes associated with IO use at a Level 1 trauma center (January 2008-May 2015). Data points included demographics, time to insertion, intravenous (IV) access points, indications, infusions, hospital and intensive care unit length of stay, and mortality. Of 68 patients with IO insertion analyzed (63.2% blunt trauma, 29.4% penetrating trauma, and 7.4% medical), 56 per cent were hypotensive on arrival and 38.2 per cent asystolic. The most common indications for IO infusion were difficult IV access (69%) and rapid sequence intubation (20.6%). The median time to IO access was three minutes. IV access was gained after IO in 72.1 per cent of patients. Through IO access, 30.9 per cent patients received crystalloid, 29.4 per cent received Advanced Care Life Support (ACLS) medications, 25 per cent rapid sequence intubation medications, 20.6 per cent blood products, and 2.9 per cent seizure medications. Overall, 80.9 per cent were intubated in the Emergency Department (ED), 26.5 per cent had ED thoracotomy, and 20.6 per cent had a laparotomy. Median crystalloid infused through IO was 180 cc in pediatric patients and 1 L in adults, respectively. Extravasation, the most common complication, was experienced by 7.4 per cent of patients. Inhospital mortality was 72.9 per cent. IO access should be considered when there is a need for rapid intervention requiring vascular access.

Accuracy of paediatric intraosseous needle placement from post mortem imaging

Abstract Introduction Accurate placement of intraosseous needles (ION) is an important part of emergency paediatric resuscitation. The objective of our study was to assess the accuracy of ION placement through post mortem radiological imaging techniques. Methods We retrospectively reviewed post mortem skeletal surveys (PMSS) performed at our institution in an observational study for the presence or absence of ION on each image of the lower and upper limbs, some of whom had also undergone post mortem CT (PMCT). Placement was documented as correct or incorrect (in soft tissues, through the bone, or within the physis). Results 115/150 ION were correctly sited (76.7%) in 273 complete PMSS reviewed. 23/35 (65.7%) incorrectly sited ION were within the soft tissues of the leg, 8/35 (22.9%) had gone through the bone, and 4/35 (11.4%) were epiphyseal. 43/66 (65.2%) ION were correctly sited on PMCT, with 65.2%, 30.4% and 4.4% within the soft tissues, gone through the bone and epiphyseal respectively. In 5 discrepant cases, PMCT demonstrated inaccurate ION placement which was termed “correct” on PMSS. Conclusions Up to a third of ION found at PM imaging are incorrectly placed and lie mostly within the soft tissues of the leg. We highlight this error rate to educate those placing ION in an emergency situation.

Characteristics of Children Who Undergo Intraosseous Needle Placement.

Intraosseous (IO) access is a standard of care for pediatric emergencies in the absence of conventional intravenous access. Intraosseous needles provide access for resuscitation fluids and medications and are often placed in the emergency department. However, there are no studies to date that describe the characteristics of pediatric IO needle recipients or their dispositions and outcomes. This study examined the characteristics and disposition of children following IO needle placement by prehospital and emergency room teams before being transported to a children's hospital. We conducted a retrospective descriptive analysis of pediatric patients who had an IO needle placed as a part of their transport care. Data was extracted from a Level 1 trauma tertiary care children's hospital transport database from 1993 to 2009. We measured diagnosis, insertion reason, insertion time (day vs. night shift), complications, and disposition of patients after IO needle placement. There were 143 eligible patients in the study; 65% were males. Mean patient's age was 1.2 years (range: 0.01-13 years). Intraosseous needles were placed most often for patients with cardiopulmonary compromise. Of the 143 patients transported, 53% (n = 76) were placed for no intravenous access and 34% (n = 49) were placed for nonperfusing rhythm. The majority of the IO needles were placed during the daytime (0700-1900 hr), and most patients experienced no complications (n = 67; 47%). However, of those who experienced a complication, 27% were due to infiltration of the IO needle. Of those admitted to hospital, 58% (n = 83) were ultimately discharged home. Intraosseous access provides a safe and reliable method for rapidly achieving a route for administration of medications, fluids and blood products. It is a lifesaving measure with most IO needles successfully placed by referring facilities prior to transport, with few reported complications.

240 An Observational Review of Pediatric Intraosseous Needle Placement in the Pediatric Emergency Department

240 An Observational Review of Pediatric Intraosseous Needle Placement in the Pediatric Emergency Department

G554(P) Implementation of an integrated inpatient paediatric mortality reduction intervention

Background Based at a University teaching hospital in Northern Ethiopia, the author was placed through Voluntary Services Oversea’s (VSO) as a Paediatric Senior. The department witnesses a high Paediatric mortality rate amongst inpatients (30%, non-neonatal). Ward level care is largely provided by junior doctors (Interns). A gap in knowledge and skills of up-to-date resuscitation practices was identified in this group. Project design The project included an intervention to improve Intern knowledge and skills. The intervention comprised development of a resuscitation protocol package with suitable training. A baseline audit of all Paediatric admissions (excluding neonates) over a three month period provided mortality data including specifics of disease category. This highlighted the conditions with highest rates of mortality at our hospital: severe acute malnutrition, coma, meningitis, congestive heart failure (CHF), hypovolaemic shock and meningitis. The Paediatric senior faculty developed five, locally appropriate, protocols to address the acute management of these conditions plus added three complementary protocols based on those promoted by the Emergency Triage, Assessment and Treatment (ETAT), WHO. The final protocol package included: respiratory distress, hypovolaemic shock, septic shock, coma, CHF, airway emergencies, seizure and cardio-pulmonary resuscitation (CPR). The nuances of acute malnutrition were addressed in each protocol. The package provided readily available, locally appropriate guidelines to provide evidence based information for Interns. The protocol package was implemented with a training programme of all Interns rotating through the Paediatric department during the study period (n = 21, September 6th to December 9th 2011). A full day simulation based training course was developed to introduce the concept and use of the protocol package plus development of key resuscitation skills: bag mask ventilation, CPR plus intra-osseous needle placement. Simulation based scenarios were developed to build on theoretical knowledge provided in short didactic lectures and allow practice of skills. Results 474 patients were admitted in the baseline group and 432 following the intervention. No change was observed for overall mortality (crude OR=0.72, 95% CI 0.40–1.29, p = 0.265). No change was observed in first-24-hour mortality (crude OR 0.97, 95% CI 0.37–2.55, p = 0.959). Total examination scores improved from median 32.6 to 73.5% (p Evaluation Two aspects were evaluated to aid measurement of success. An audit of inpatient admissions was carried out pre and post Intern training. Data was collected from the ward log book and entered into an Excel spreadsheet. The primary and secondary outcomes included crude mortality plus mortality within the first 24 h and were expressed as a percentage of admissions. Odds ratios for these outcomes were calculated using univariable logistic regression. Evaluation of Intern knowledge and skills took place pre- and post-training to assess the impact of the simulation based program. Testing took place in multiple choice format with videos of critically ill children to focus on pattern recognition and triage skills plus a theory paper to assess problem-solving in emergency situations. Procedural skills were tested by direct observation. Trainees were asked to demonstrate skills covered in the course while project coordinators applied a standardised, checklist-based marking tool to evaluate their performance. Median trainee examination scores were calculated as percentage answered correctly and pre- and post-training results were compared by Wilcoxon matched-pairs signed ranks test. Conclusions Combining care standardisation, management protocols, and simulation-based training did not red uce mortality among non-neonatal Paediatric inpatients in this study. Simulation-based training improved short-term test performance among Ethiopian medical trainees.

ABSTRACT 834

Background and aims: The use of intraosseous (IO) needles as an access for resuscitation in pediatric advance life support has led to more pediatric patients being transported with IO needles in place. It would be reasonable to expect that the disposition of these patients would be admission to the intensive care unit, but to date there have been no studies to support this supposition. Aims: To determine the characteristics and disposition of children following IO needle placement referred for transport from an outlying facility. Methods: A retrospective review of the transport database from 1993–2009 of pediatric patients who had an IO as a part of their care. The IRB waived the need for consent. Results: 143 children were transported to a level 1 trauma tertiary care children’s hospital from 25 referral facilities. Patients were 65% male and 35% female with a mean age of 1.20 years (range 0.01–13 years). All had IO’s placed placed by pre-hospital providers, the referral facility, or the transport team. Of the 143 patients transported, 53% were placed for no intravenous access and 34% were placed for no perfusing rhythm. Most common reason for admission to the hospital was combined system failure with 79% of patients admitted to the pediatric intensive care. Of those hospitalized, 58% were discharged home. Conclusions: IO placement is a life-saving measure with most IOs placed by referring facilities prior to transport and few reported complications.

IO（骨髄穿刺）実践セミナーおよび超音波カラードプラー骨髄穿刺針位置確認法の紹介

日本蘇生学会第32回大会ワークショップとしてIO（骨髄穿刺）実践セミナーを開催した．骨髄輸液レビュー（20分）ののち，用手針およびEZ-IO®にて骨付き鶏もも肉および脛骨モデル，上腕骨モデルへのハンズオン講習（20～40分）を行った．従来の骨髄針位置確認法に加え，本邦初紹介である超音波カラードプラー骨髄穿刺針位置確認法（ドプラー法）も行った．骨髄路はEZ-IO®により穿刺時間短縮が期待でき，小児のみならず成人にも応用できること，ドプラー法では客観的な穿刺成功判断や記録ができることを実習した．ドプラー法を普及することにより，受講者の骨髄穿刺法に対する不安感を軽減することができる．

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.

256 Relationship of Body Mass Index and Increased Difficulty With Intraosseous Needle Placement: Assessment of Tissue Depth Using Ultrasound

256 Relationship of Body Mass Index and Increased Difficulty With Intraosseous Needle Placement: Assessment of Tissue Depth Using Ultrasound

Comparison of First-Attempt Success Between Tibial and Humeral Intraosseous Insertions During Out-of-Hospital Cardiac Arrest

Background. Intraosseous (IO) needle insertion is often utilized in the adult population for critical resuscitation purposes. Standard insertion sites include the proximal humerus and proximal tibia, for which limited comparison data are available. Objective. This study compared the frequencies of IO first-attempt success between humeral and tibial sites in out-of-hospital cardiac arrest. Methods. This observational study was conducted in an urban setting between August 28, 2009, and October 31, 2009, and included all medical cardiac arrest patients for whom resuscitative efforts were performed. Cardiac arrest protocols stipulate that paramedics insert an IO line for initial vascular access. During the first month of the study, the proximal humerus was the preferred primary insertion site, whereas the tibia was preferred throughout the second month. The primary outcome was first-attempt success, defined as secure IO needle position in the marrow cavity and normal fluid flow. Any needle dislodgment during resuscitation was also recorded. The association between first-attempt IO success and initial IO insertion location was analyzed using a test of independent proportions and 95% confidence intervals (CIs) for the difference in proportions. Results. There were 88 cardiac arrest patients receiving IO placement, with 58 (65.9%) patients receiving their initial IO attempt in the tibia. The rate of first-time IO success at the tibia was significantly higher than that observed at the humerus (89.7% vs. 60.0%; p < 0.01). There were 18 initial successes at the humerus; for six (33.3%) of these, the needle became dislodged during resuscitation, compared with 52 initial successes at the tibia, with three (5.8%) dislodgments. The rate of total success for initial IO placements was significantly lower for the humerus (40.0%) compared with that for the tibia (84.5%; p < 0.01) during resuscitation efforts. Conclusions. In this subset of patients, tibial IO needle placement appeared to be a more effective insertion site than the proximal humerus. Success rates were higher with a lower incidence of needle dislodgments. Further randomized studies are required in order to validate these results.

0657: Feasibility of Point-of-Care Colour Doppler Ultrasound Confirmation of Intraosseous Needle Placement During Resuscitation

0657: Feasibility of Point-of-Care Colour Doppler Ultrasound Confirmation of Intraosseous Needle Placement During Resuscitation

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.