Intraosseous Needle Research Articles

Prehospital Resuscitation of Children

The majority of professionals involved in pre-hospital emergency care do not have explicit paediatric training and have limited experience in the care of life-threatening paediatric emergencies. There is often a fear of being overwhelmed. However, no special paediatric expertise is primarily required to successfully perform resuscitation in children. In addition, the scope of the measures required for successful paediatric resuscitation is on average significantly smaller than for adults. It is essential to know clear and easy-to-implement courses of action, such as those provided by the resuscitation guidelines. For the technical implementation of airway protection, mask-bag ventilation and the laryngeal mask are essential, and for access to the venous system, the intraosseous needle is an aid that overcomes all difficulties almost without exception. With additional support from reference sources, calculation aids and length-related systems, a high level of drug therapy safety can be achieved. In summary, through thorough individual and institutional preparation for paediatric emergencies, safe primary care is feasible by emergency service personnel of any speciality.

Pre-hospital intraosseous use in children: Indications and success rate.

Intraosseous (IO) needle insertion is an effective method to obtain circulatory access in unwell children. We conducted a 12-month retrospective record review of children aged less than 18 years who had a recorded IO attempt by Ambulance Victoria paramedics. Sixty-five children underwent IO attempt during pre-hospital care, 60 had IO outcome recorded and were included. 58/60 (96.7%) children had IO successfully placed, 35 were aged <5 years. Cardiorespiratory arrest (39/58, 67.2%) and status epilepticus (11/58, 19%) were the most common indications. While IO placement is uncommonly performed pre-hospital, in critical situations there is a high success rate.

374 User Characteristics of Six Intraosseous Devices in a High Bone Density Humerus and Sternum Cadaveric Swine (Sus Scrofa) Model

Intraosseous (IO) infusion, the pressurized injection of fluids into bone through a catheter, is a life-preserving resuscitative technique for treating critical care patients and trauma patients with severe hemorrhage. To be effective as a bridge to central venous access, IO infusion flow rates must be sufficient to sustain life but at pressures low enough to avoid complications. However, little is known regarding end user characteristics of available battery-powered and manual IO devices. User characteristics are important, because to be efficient and effective, an IO device should optimally have a minimal set-up (placement) time and be perceived as easy and comfortable to use, resistant to bending and displacement, effective and trustworthy in meeting the demands of rapid resuscitation, and cause minimal hand fatigue. The present study was specifically designed to fill this important gap in the literature. Three experienced emergency medicine residents each inserted a variety of commercially available 15-gauge IO catheters in cadaveric swine (Sus scrofa) proximal humeri and sternums with bone density similar to adult humans (1.0-1.1 gm/cm2) in a randomized prospective experimental design, and then infused 500 cc of isotonic crystalloid using push-pull technique with a 60cc syringe. Devices included the battery-powered EZ-IO Rapid Infuser and the manual Jamshidi IO, Persys NIO, SAM Manual IO, Tactical Advanced Lifesaving IO Needle (TALON), and PYNG FASTR devices (30 trials per device, 10 per user). Pressures were measured using an in-line manometer. Subjective user characteristics were assessed across eight Likert-type items, which were analyzed individually and as a composite score. Objective and user ratings data were analyzed using ANOVA and nonparametric statistics at p<.05. Infusion flow rates, mean pressures, and peak pressures were generally similar across devices and locations, save that the TALON in the sternum conferred roughly 50% higher flow rates at 30% lower mean pressures and 15% lower peak pressures than other devices in sternum or humerus (each p<.0001). The EZ-IO demonstrated the fastest set-up times and the highest composite user ratings (Figure 1), including highest ratings for each of the eight survey items (p<.0001). The TALON conferred intermediate set-up times and next-highest user ratings overall. The Jamshidi had the longest set-up times, the slowest infusion rates, and relatively low user ratings. IO access devices differ in construction, method of application, effectiveness, and user characteristics. The commonly used battery-powered EZ-IO had the fastest set-up times and the highest user ratings. While the present study was limited by the utilization of a cadaveric swine model rather than an in vivo model, findings suggest the possibility that the TALON, which performed well in objective assessments and user ratings, may be worth considering as a manual backup to the battery-operated EZ-IO Rapid Infuser. Combined, these results highlight the importance of studying the end user characteristics of IO infusion devices towards preserving the lives of critically ill or injured patients requiring rapid fluid or blood product resuscitation.

Evaluation of the NIO and T.A.L.O.N Intraosseous Devices as Placed by U.S. Army Conventional Force Combat Medics—A Randomized Crossover Study

In recent U.S. Military conflicts, hemorrhage remains the leading cause of preventable death with 30%-40% mortality rates. Management consists of effective bleeding control and rapid resuscitation with blood products. Rapid and accurate circulatory access is crucial in battlefield trauma management. This study evaluates the insertion success rate and time to successfully insert the NIO automatic intraosseous (IO) device and the Tactical Advanced Lifesaving IO Needle (TALON) manual IO device. The primary outcome is successful first attempt insertion. Secondary outcomes are the time taken for the successful insertion, user-reported "ease of use" for both devices, and user-reported device preference. This is a prospective randomized crossover study comparing the NIO and TALON devices. As they are often the frontline health care providers, combat medics (68W) were recruited to participate in this study. They were randomized into two cohorts based on the IO device and location they would start first. Each medic performed a total of four IO cannulations on the proximal tibia and the humeral head of cadaveric human models. Sixty medics participated in the study, performing a total of 240 IO insertions, 120 with NIO (60 at the proximal tibia and 60 at the humeral head) and 120 with TALON (60 at the proximal tibia and 60 at the humeral head). The first attempt success rate was 89.2% for the NIO and 83.3% for the TALON, P = .19. The time to successful first attempt insertion for the NIO [M = 24.71 seconds, SD = 4.72] and the TALON, [M = 24.70 seconds, SD = 4.74] were similar, P = .98. The differences between the success of device insertion and time to successful insertion did not achieve statistical significance. The "ease of use" score (5-point Likert Scale) for the NIO [M = 4.73] and the TALON, [M = 4.11], demonstrated a significant difference, P < .001. Ninety percent [n = 54] of the combat medics preferred the NIO versus only 10% [n = 6] preferred TALON. Our findings indicate that the overall insertion success rate and time to successful insertion were similar between NIO automatic IO device and the TALON manual IO device. In our study, Army combat medics learned how to use both devices rapidly but felt the NIO automatic IO device easier to use and overwhelmingly preferred this device.

Comparison of three intraosseous access devices for resuscitation of term neonates: a randomised simulation study

ObjectivesTo compare the success rates and ease of use of three intraosseous (IO) access devices used in term neonates.DesignA three-arm randomised controlled simulation study was conducted.SettingA simulation laboratory.ParticipantsSeventy-two paediatric residents...

Simulating Early Clinical Experiences With Surgical Procedures in the Anatomy Laboratory.

BackgroundThere is evidence to suggest that early exposure to clinical experiences could bolster a medical student’s education and prepare them to tackle the problem-based learning encountered during clinical rotations. We hypothesized that incorporating common surgical procedures into the gross anatomy laboratory during preclinical years would enhance the anatomical learning experience for students. The incorporation of these procedures would not be disruptive to the normal conduct of the anatomy laboratory, nor result in exorbitant costs.ObjectivesThe goal of a more integrated curriculum is to better enable medical students by providing them a unique learning experience, so that they may more readily recall the knowledge needed to deal with the complex problems of clinical work. Recognizing the importance of this concept, we have incorporated multiple common clinical procedures into our anatomy curriculum as a pilot program.MethodsSeven common surgical procedures, including intraosseous needle insertion, venous cut-down, chest tube insertion, surgical cricothyroidotomy, core needle liver biopsy, appendectomy, and hysterectomy, were taught as a part of this study. Video instructions on each of the surgical procedures were provided before each corresponding laboratory. Surveys were distributed to study participants to measure their satisfaction with the procedures and whether or not it was disruptive to the allotted laboratory time.ResultsBoth students and faculty who were sampled in the study reported that they were satisfied with the procedures (96.5% and 100%, respectively), that the procedures did not interfere with laboratory times (96% and 100%), and that the procedures facilitated clinical learning (98% and 100%).ConclusionThis study demonstrated that providing a novel surgical teaching program to medical students was beneficial to their education and non-disruptive to the conventional anatomy curriculum. This exercise further facilitates osteopathic education by demonstrating how structure and function organize surgical practice. The integration of Edward Via College of Osteopathic Medicine, Auburn Campus's (VCOM-AC’s) surgical procedures into other medical school anatomy courses can yield more prepared and confident students as they venture into their clinical rotations.

P0189 / #1816: PAEDIATRIC IO INSERTION, RETROSPECTIVE AUDIT, FINDINGS AND OUTCOMES FROM A PAEDIATRIC CRITICAL CARE TRANSPORT TEAM 2018-2020

Aims & Objectives: Aim was to evaluated the presenting complaint, indications, insertion sites, complications associated with Intraosseous needle (IO) insertion. The objective of this study was to audit the use of IO’s in the paediatric critical care population. Methods: Retrospective case note review of all patients who underwent IO insertion between January 2018-June 2020. Results: A documented 271 patients had IO insertions over a 30 months. 52% were in patients under 1 year old. 30% presenting with a respiratory illness. The commonest indication for IO insertion was for more venous access (22%) along with resuscitation (22%) The commonest sites for insertion were the tibia (56%). 14% of patients underwent > 2 insertion attempts and of these patients the final successful site was the distal femur. Of the patients who had multiple attempts at insertion the majority failed due to extravasation (83%), plus anecdotal reports of inadequate length and placement. 1 out 271 patients reported long term complications from an IO insertion site. Conclusions: Anaylised data shows care with needle size and insertion site is required to minimize short term complications. Longer term complications are rare, making IO insertion a valuable tool in the resuscitation and stabilisation of critically ill children.

Efficiency of concentrated bone marrow aspirate combination with temporary fixation of the scaphoid-trapezius-trapezoidal joint in Kienbeck’s disease

Method of concentrated bone marrow aspirate (BMAC) injection into aseptic bone necrosis of different localizations are described in the literature, however, without demonstrating structural and functional results for Kienbeck’s disease. Objective. To establish functional and radiological changes at injection of concentrated bone marrow aspirate into lunate bone in combination with scaphoid-trapezoid-trapezius joint temporary fixation in patients with idiopathic lunate bone necrosis. Methods. The procedure was performed in 11 patients. Age 18–46 years (28,9 ± 9,5) 6 women, 5 males. Kienbeck's disease stage II — 4 patients, IIIa — in 2, IIIb in 5 patients. Bone marrow aspirate concentration from the ili­ac bone was obtained using Arthrex-Angel technique, injection of 2–3 ml of the concentrate with intraosseous needle under X-ray control into the focus of aseptic necrosis of the lunate bone, STT-fixation of the wrist joint in the position of rotational correction of the scaphoid. Immobilization followed for 2 months, than remo­val of the K-wires and rehabilitation. X-ray, CT control and DASH testing before the procedure and in a year. Results. Five patients (45 %) had a distinct positive clinical and radiological dynamics, definite positive changes on CT (pathological fracture consolidation, lunate bone remodeling), as well as DASH scale improvement, maintenance of wrist joint radiometric parameters and an increase in strength and range of motions in the wrist. Four patients had no significant dynamics, and in two patients there was a distinct decline in function, advance lunate bone destruction, and an increased wrist joint instability. Conclusions. The technique requires advance revision of the conditions under which it demonstrates its effectiveness. Today it can be recommended in addition to other surgical procedures (shortening of the radius, STT arthrodesis), which have more predicted effectiveness.

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.

Decompression of Subdural Hematomas Using an Intraosseous Needle in the Emergency Department: A Case Series.

IntroductionTraumatic subdural hematomas beget significant morbidity and mortality if not rapidly decompressed. This presents a unique challenge to the emergency physician without immediate neurosurgical support.Case ReportWe report two cases of patients in Los Angeles County with traumatic subdural hematomas and clinical deterioration in the emergency department (ED) who were treated with decompression using an intraosseous needle drill.DiscussionWe believe these cases represent the first use of this technique to temporize a subdural hematoma in the ED.

Subchondral pressures and perfusion during weight bearing

BackgroundJoints withstand huge forces, but little is known about subchondral pressures and perfusion during loading. We developed an in vitro calf foot model to explore intraosseous pressure (IOP) and subchondral perfusion during weight bearing.MethodsFreshly culled calf forefeet were perfused with serum. IOP was measured at three sites in the foot using intraosseous needles, pressure transducers, and digital recorders. IOP was measured during perfusion, with and without a tourniquet and with differing weights, including static loading and dynamic loading to resemble walking.ResultsIOP varied with perfusion pressure. Static loading increased subchondral IOP whether the bone was non-perfused, perfused, or perfused with a proximal venous tourniquet (p < 0.0001). Under all perfusion states, IOP was proportional to the load (R2 = 0.984). Subchondral IOP often exceeded perfusion pressure. On removal of a load, IOP fell to below the pre-load value. Repetitive loading led to a falling IOP whether the foot was perfused or not.ConclusionSuperimposed on a variable background IOP, increased perfusion and physiological loading caused a significant increase in subchondral IOP. Force was thereby transmitted through subchondral bone partly by hydraulic pressure. A falling IOP with repeat loading suggests that there is an intraosseous one-way valve. This offers a new understanding of subchondral perfusion physiology.

Nouvelle technique mini-invasive pour éliminer le contenu de moelle osseuse nécrotique de l’os épiphysaire : étude préliminaire sur l’os cadavérique

IntroductionLegg–Calvé–Perthes disease is a juvenile ischemic osteonecrosis which produces extensive necrotic cell debris and release of damage associated molecular patterns (DAMPs) in the femoral head. The necrotic bone environment induces a chronic inflammatory repair response with excessive bone resorption leading to deformity and early osteoarthritis. Currently, there is no minimally invasive method to clear the necrotic materials from the bone to decrease the inflammatory burden of the necrotic environment and to improve the healing process. HypothesisWe hypothesized that a novel minimally invasive two-needle saline washing technique would be effective to remove cell debris, proteins, and fat from the marrow space of porcine cadaveric humeral heads (HHs). Materials and methodsTwenty-two HHs were subjected to three freeze-thaw cycles to simulate osteonecrosis prior to the wash procedure which consisted of placement of two 15-gauge intraosseous needles followed by incremental saline wash. After the washout procedure, the solutions were collected for measurements of turbidity, protein concentration, and cell count. The HHs were analyzed by optical scanning and histology. ResultsThe solution collected after each wash showed a significant decrease in the turbidity, cell count, and protein concentration (p<0.05). Histologic assessment showed significantly decreased cell debris and adipocytes in the washed group compared to the unwashed group (p<0.001). Discussion/conclusionThe two-needle intraosseous wash technique effectively removed cell debris and proteins from the marrow space. The technique may be used to reduce the necrotic cell debris and DAMPs present in the necrotic bone. Level of evidenceIII, in vitro comparative study.

Exposure and Confidence With Critical Nonairway Procedures: A Global Survey of Pediatric Emergency Medicine Physicians.

Children rarely experience critical illness, resulting in low exposure of emergency physicians (EPs) to critical procedures. Our primary objective was to describe senior EP confidence, most recent performance, and/or supervision of critical nonairway procedures. Secondary objectives were to compare responses between those who work exclusively in PEM and those who do not and to determine whether confidence changed for selected procedures according to increasing patient age. Survey of senior EPs working in 96 emergency departments (EDs) affiliated with the Pediatric Emergency Research Networks. Questions assessed training, performance, supervision, and confidence in 11 nonairway critical procedures, including cardiopulmonary resuscitation (CPR), vascular access, chest decompression, and cardiac procedures. Of 2446 physicians, 1503 (61%) responded to the survey. Within the previous year, only CPR and insertion of an intraosseous needle had been performed by at least 50% of respondents: over 20% had performed defibrillation/direct current cardioversion. More than 50% of respondents had never performed or supervised ED thoracotomy, pericardiocentesis, venous cutdown, or transcutaneous pacing. Self-reported confidence was high for all patient age groups for CPR, needle thoracocentesis, tube thoracostomy, intraosseous needle insertion, and defibrillation/DC cardioversion. Confidence levels increased with increasing patient age for central venous and arterial line insertion. Respondents working exclusively in PEM were more likely to report being at least somewhat confident in defibrillation/DC cardioversion, intraosseous needle insertion, and central venous line insertion in particular age groups; however, they were less likely to be at least somewhat confident in ED thoracotomy and transcutaneous pacing. Cardiopulmonary resuscitation and intraosseous needle insertion were the only critical nonairway procedures performed by at least half of EPs within the previous year. Confidence was higher for these procedures, and needle and tube thoracostomy. These data may inform the development of continuing medical education activities to maintain pediatric procedural skills for emergency physicians.

Iatrogenic humeral anatomic neck fracture after intraosseous vascular access

Intraosseous infusion has become a key tool in the resuscitation of critically ill or injured patients, both in pre-hospital settings and in emergency departments. Intraosseous access is obtained through the percutaneous placement of a needle into the medullary space of a bone, thereby allowing access into the systemic venous circulation via the medullary space, which is essential to treat patients in shock, cardiac arrest, airway compromise, or major trauma. This becomes critically important when obtaining conventional intravenous access is difficult or impossible. Few cases of iatrogenic fracture have been reported for intraosseous access in the tibia and no case to-date has been reported of iatrogenic fracture secondary to humeral access. We report a case of a 55-year-old patient being resuscitated emergently with proximal humeral intraosseous infusion for cardiac and respiratory arrest secondary to status epilepticus. After successful resuscitation and removal of the intraosseous cannula, the patient noted new-onset shoulder pain. The patient was ultimately diagnosed with an iatrogenic fracture of the anatomic neck of the humerus through the intraosseous needle tract when the appropriate history was obtained in conjunction with cross-sectional imaging. As the use of intraosseous access expands, such fractures may well be seen more frequently. Intraosseous access is limited to the period of resuscitation and the cannula is often not present at the time of imaging. It is important for radiologists to recognize the findings related to intraosseous access as well as this complication with its characteristic locations and morphology.

Clinical outcome evaluation of intraosseous vancomycin in total knee arthroplasty.

BackgroundVancomycin is a commonly used prophylactic antibiotic for total joint replacement surgery to protect against methicillin-resistant Staphylococcus aureus. Studies have suggested intraosseous (IO) infusions provide superior local tissue antibiotic concentration compared with intravenous (IV) access in total knee arthroplasty (TKA). We reviewed patients receiving IO vancomycin before TKA, comparing complication rates to a matched group receiving IV prophylactic vancomycin.MethodsRetrospective review of TKA patients administered IO vancomycin (500 mg vancomycin in 200 mL normal saline), September 1, 2018 to March 1, 2019, was compared with TKAs performed with prophylactic IV vancomycin, January 1, 2018 to August 31, 2018. Before incision, an IO needle was inserted into the tibial tubercle region, delivering 100 mL of the mixed vancomycin solution. The needle was then removed and inserted into the distal femur, delivering 100 mL of the solution. Evaluation included preoperative and postoperative creatinine values, tourniquet time, and knee-related 30-day and 90-day complications. Data for primary and revision TKA surgery cases were analyzed independently.ResultsThere were 100 primary and 29 revision TKA cases in the control (IV) arm and 100 primary and 19 revision TKA cases in the intervention (IO) arm, comprising a study group of 248 cases. There were fifteen 30-day complications and eighteen 90-day complications overall. No significant differences in the complication rate or creatinine values were identified between IO and IV groups.ConclusionsIO vancomycin has an adequate safety profile in primary and revision TKA, eliminating the logistical challenge of timely prophylactic antibiotic administration.

Development of a novel minimally invasive technique to washout necrotic bone marrow content from epiphyseal bone: A preliminary cadaveric bone study

IntroductionLegg-Calvé-Perthes disease is a juvenile ischemic osteonecrosis which produces extensive necrotic cell debris and release of damage associated molecular patterns (DAMPs) in the femoral head. The necrotic bone environment induces a chronic inflammatory repair response with excessive bone resorption leading to deformity and early osteoarthritis. Currently there is no minimally invasive method to clear the necrotic materials from the bone to decrease the inflammatory burden of the necrotic environment and to improve the healing process. HypothesisWe hypothesized that a novel minimally invasive two-needle saline washing technique would be effective to remove cell debris, proteins, and fat from the marrow space of porcine cadaveric humeral heads (HHs). Materials and methodsTwenty-two HHs were subjected to three freeze-thaw cycles to simulate osteonecrosis prior to the wash procedure which consisted of placement of two 15-gauge intraosseous needles followed by incremental saline wash. After the washout procedure, the solutions were collected for measurements of turbidity, protein concentration, and cell count. The HHs were analyzed by optical scanning and histology. ResultsThe solution collected after each wash showed a significant decrease in the turbidity, cell count, and protein concentration (p<0.05). Histologic assessment showed significantly decreased cell debris and adipocytes in the washed group compared to the unwashed group (p<0.001). Discussion/conclusionThe two-needle intraosseous wash technique effectively removed cell debris and proteins from the marrow space. The technique may be used to reduce the necrotic cell debris and DAMPs present in the necrotic bone. Level of evidenceIII, in vitro comparative study.

Intraosseous Regional Administration of Antibiotic Prophylaxis in Total Knee Arthroplasty.

Intraosseous Regional Administration of Antibiotic Prophylaxis in Total Knee Arthroplasty.

Determination of the Pretibial Soft Tissue Thickness in Children: Are Intraosseous Infusion Needles Long Enough?

The EZ-IO intraosseous (IO) needle is available in 2 needle sizes for children based on the patient weight. To date, there is no published evidence validating the use of weight-based scaling in children. We hypothesized that pretibial subcutaneous tissue thickness (PSTT) does not correspond with patient weight but rather with age and body mass index (BMI). Our objective was to describe the relationship of a patient's PSTT to their weight, age, and BMI in children less than 40 kg. One hundred patients who weighed less than 40 kg were recruited prospectively from October 2013 to April 2015 at a tertiary care pediatric emergency department. All sonographic assessments were performed by 1 of 2 emergency physicians certified in point-of-care ultrasound. A single sonographic image was taken over the proximal tibia corresponding to the site of IO insertion. In patients where both sonographers performed independent measurements, a Pearson correlation coefficient was determined. Univariate linear regression was performed to determine the relationship between age, weight, and BMI with PSTT. One hundred participants were recruited and ranged in age from 10 days to 14 years (mean [SD], 5.01 [3.14] years). Fifty-seven percent of participants were male. Patients' weights ranged from 3.5 to 39.3 kg (mean [SD], 21.42 [9.12] kg), and BMI ranged from 12.1 to 45.0 kg/m (mean [SD], 17.31 [4.00]). The mean (SD) PSTT across participants was 0.68 (0.2) cm. The intraclass correlation coefficient for agreement between the 2 sonographers was moderate (intraclass correlation coefficient, 0.602 [confidence interval, 0.385-0.757]). There were significant positive correlations between BMI and PSTT (r = 0.562, P = <0.001) as well as weight and PSTT (r = 0.293, P < 0.003). There was a weak correlation between age and PSTT (0.065, P = 0.521). Pretibial subcutaneous tissue thickness correlates most strongly with BMI, followed by weight, and weakly with age. Our findings suggest that current IO needle length recommendations should be based on BMI rather than weight. This would suggest that clinicians need to be aware that young patients in particular with large BMIs may pose problems with current weight-based needle length recommendations.

Maximising intraosseous flow rates: an in-vitro study

Background: Attaching a different or using no extension set with intraosseous (IO) needles may affect the time taken to administer fluid. An in-vitro study measured this effect. Methodology: Three methods of administration were examined (10 experiments for each approach): a fluid-giving set directly placed in the IO needle hub (direct-to-hub: DTH); a fluid-giving set connected to the EZ-IO device extension set (EZ set: EZS); and a fluid-giving set connected to a simple three-way extension set (three-way set: TWS). Results: Mean times for administration were 317 s for DTH (SD=15 s), 322 s for TWS (SD=8 s) and 361 s for EZS (SD=19 s). This demonstrated a significant difference between the three groups (ANOVA significance p&lt;0.0001). Conclusion: It may be possible for clinicians to increase IO flow rates by removing or replacing the extension set that is supplied with the EZ-IO needle set.

Intraosseous needles in pediatric cadavers: Rate of malposition

Aim of the studyIntraosseous vascular access is a commonly conducted procedure especially in pediatric resuscitation. Very high success rates for intraosseous (IO) devices are reported. Aim of the study was to describe the rates of malposition of intraosseous needles (ION) in pediatric cadavers via post-mortem computed tomography (PMCT). Methods212 consecutive pediatric cadavers underwent PMCT, of which 38 cadavers had visible ION and were included in the study. They were divided into two subgroups depending on their age (n = 22 infant cadavers (age <1 year) and n = 16 child cadavers (age ≥1 year)). Two independent readers evaluated the number and position of ION. ResultsIn 22 infant cadavers 34 ION were found. Malposition of at least one ION was visible in 14 subjects (64%), among which 7 cadavers (32%) even had no correctly placed ION, thus being without established vascular access. Overall, 16 of the 34 used ION devices (47%) were in malposition.23 ION were found in 16 child cadavers. In 8 subjects (50%) at least one ION was malpositioned, among which 3 cadavers (19%) had no correctly placed ION, resulting in a complete absence of vascular access. Overall, 9 of the 23 ION devices (39%) were malpositioned. ConclusionOur study showed relatively high malposition rates for ION devices in pediatric cadavers which was not to be assumed regarding the success rates of 80% and higher in previous literature. This should be clarified by further studies in living patients.