Intraosseous Needle Research Articles

A prospective evaluation of tibial insertion sites for intraosseous needles to gain vascular access in Asian neonates

A prospective evaluation of tibial insertion sites for intraosseous needles to gain vascular access in Asian neonates

Can the rigid stylet from an intravenous catheter be an alternative vascular access device for intraosseous catheterisation?

AbstractBackgroundIt may be challenging for practitioners to secure vascular access in animals, especially in a state of shock.AimThis study aimed to evaluate the clinical relevance of commercial 16‐gauge intravenous (IV) catheter stylet vs. 15‐gauge intraosseous (IO) vascular access in emergencies.MethodsSix healthy dogs were used in this study. After general anaesthesia, IO catheterisation was performed on both trochanteric fossae of the femurs using a commercial 16‐gauge IV catheter stylet and EZIO 15‐gauge IO needle. The pressures were measured by manual, gravity and mechanical infusion for 5 min each. Additionally, insertion time and success rate were recorded.ResultsIn hand infusion, mean pressure of a 16‐gauge IO (605.06 ± 49.13 mmHg) was statistically lower than that of a 15‐gauge EZIO IO catheterisation (718.84 ± 93.09 mmHg). In gravity infusion, there was no significant difference in pressure during injection between the 16‐gauge IV catheter (52.23 ± 14.48 mmHg) and 15‐gauge EZIO IO catheterisation (50.68 ± 11.89 mmHg). In mechanical infusion, mean pressure of the 15‐gauge EZIO IO catheterisation (128.25 ± 50.16 mmHg) was lower than that of the 16‐gauge IV catheter (152.56 ± 67.23 mmHg). The insertion times of a 16‐gauge IV catheter and 15‐gauge EZIO IO catheterisation were 16.79 ± 0.92 and 11.65 ± 1.70 s, respectively. The success rates of the insertion were similar between both groups.ConclusionThis study shows that IO catheterisation with a commercial IV catheter stylet can be an alternative method of IO catheterisation in an emergency, especially for rapid vascular access.

Application Times, Placement Accuracy, andUser Ratings ofCommercially Available Manual andBattery-Powered Intraosseous Catheters ina High Bone Density Cadaveric Swine Model.

Intraosseous (IO) infusion, the pressurized injection of fluids into bone through a catheter, is a life-preserving resuscitative technique for treating trauma patients with severe hemorrhage. However, little is known regarding the application times, placement accuracy, and end-user ratings of battery-powered and manual IO access devices. This study was specifically designed to fill these knowledge gaps on six FDA-approved IO access devices. Three experienced U.S. Navy Emergency Medicine residents each placed commercially available 15-gauge IO catheters in cadaveric swine (Sus scrofa) proximal humeri and sternums in a randomized prospective experimental design. 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 First Access for Shock and Trauma 1 (30 trials per device, 10 per user, 210 total trials). Application times, placement accuracy in medullary (zone 1) and trabecular (zone 2) bone while avoiding cortical (zone 3) bone, and eight subjective user ratings were analyzed using ANOVA and nonparametric statistics at P < .05. The EZ-IO demonstrated the fastest application times, high rates in avoiding zone 3, and the highest user ratings (P < .0001). The TALON conferred intermediate placement times, highest rates of avoiding zone 3, and second-highest user ratings. The SAM Manual IO and Jamshidi performed poorly, with mixed results for the PerSys NIO and PYNG First Access for Shock and Trauma 1. The battery-powered EZ-IO performed best and remains the IO access device of choice. The present findings suggest that the TALON should be considered as a manual backup to the EZ-IO.

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.

Pediatric postmortem CT angiography: validation of vascular access for PMCT angiography in stillbirths, babies and toddlers

PurposeThe use of angiography in postmortem CT angiography (PMCTA) has several advantages. In adults, femoral vascular access is well established. Due to the small and specific anatomy in fetuses and infants, the technique has to be adapted, especially regarding the vascular access. The aim of this study was to evaluate vascular access for pediatric PMCTA (pedPMCTA).Materials and MethodsTen pedPMCTAs were performed in stillbirths, babies, and one toddler. A femoral approach by cannulation of the femoral artery and vein, an umbilical approach by cannulation of the umbilical vessels, and an intraosseous approach by an intraosseous needle were evaluated by handling and resulting imaging.ResultsThe insertion of a cannula with a size of 18–20 G in the femoral vessels was possible in babies. An umbilical access with peripheral venous cannulas with a size of 14–20 G was feasible in stillbirths and newborns. An intraosseous access is advisable as equal alternative to umbilical and in cases where a femoral access is not possible. The most significant problem with the vascular access is the extravasation of contrast media, but this can be reduced significantly with practice.ConclusionWhen performing pedPMCTA, an umbilical vascular access is recommended if an umbilical cord with open vessels is still present. Otherwise, a bone marrow access should be preferred in the presence of an arteriovenous shunt or if only the venous system needs to be shown. If that is not the case, the femoral access with the possibility to separate venous and arterial scan should be used.

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

Finding the most suitable puncture site for intraosseous access in term and preterm neonates: an ultrasound-based anatomical pilot study

The purpose of this prospective ultrasound-based pilot study was to identify the most suitable tibial puncture site for intraosseous (IO) access in term and preterm neonates, describe tibial dimensions at this site, and provide anatomical landmarks for rapid localization. We measured the tibial dimensions and distances to anatomical landmarks at puncture sites A (proximal: 10 mm distal to the tibial tuberosity; distal: 10 mm proximal to the malleolus medialis) and B (chosen by palpation of the pediatrician), in 40 newborns in four weight groups (< 1000 g; 1000–2000 g, 2000–3000 g, and 3000–4000 g). Sites were rejected if they fell short of the assumed safety distance to the tibial growth plate of 10 mm. If both A and B were rejected, puncture site C was determined sonographically at the maximum tibial diameter while maintaining the safety distance. Puncture site A violated the safety distance in 53% and 85% (proximally and distally, respectively) and puncture site B in 38% and 33%. In newborns weighing 3000–4000 g, at median (IQR), the most suitable puncture site at the proximal tibia was 13.0 mm (12.0–15.8) distal to the tuberosity and 6.0 mm (4.0–8.0) medial to the anterior rim of the tibia. The median (IQR) diameters at this site were 8.3 mm (7.9–9.1) (transverse) and 9.2 mm (8.9–9.8) (anterior–posterior). The diameters increased significantly with increasing weight. Conclusion: This study adds concise, practical information on the implementation of IO access in neonatal patients: the tibial dimensions in newborns in four different weight groups and initial data on anatomical landmarks to easily locate the IO puncture site. The results may help implement IO access in newborns more safely.What is Known:• Intraosseous access is a feasible option for emergency administration of vital drugs and fluids in newborns undergoing resuscitation when an umbilical venous catheter is impossible to place.• Severe complications of IO access due to malpositioned IO needles have been reported in neonates.What is New:• This study reports the most suitable tibial puncture sites for IO access and the tibial dimensions, in newborns of four weight groups.• The results can help to implement safe IO access in newborns.

Spotlight on Research

Journal of Paramedic PracticeVol. 15, No. 4 Spotlight on ResearchSpotlight on ResearchRobert Wynne, Pete GregoryRobert WynneLecturer in Paramedic Practice, University of WolverhamptonSearch for more papers by this author, Pete GregoryAssociate Dean and Head of School of Allied Health and Midwifery, University of WolverhamptonSearch for more papers by this authorRobert Wynne; Pete GregoryPublished Online:5 Apr 2023https://doi.org/10.12968/jpar.2023.15.4.172AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Berger D, Petrie A, Lubin JS. The ability of paramedics to accurately locate correct anatomical sites for intraosseous needle insertion. Cureus. 2023;15(1):1–8. http://e33355.10.7759/cureus.33355 Google ScholarCarvalho Mota MT, Goldfinger VP, Lokerman R et al.. Prehospital accuracy of (H)EMS pelvic ring injury assessment and the application of non-invasive pelvic binder devices. Injury. 2023. https://doi.org/10.1016/j.injury.2023.02.015 Crossref, Google Scholar FiguresReferencesRelatedDetails 2 April 2023Volume 15Issue 4ISSN (print): 1759-1376ISSN (online): 2041-9457 Metrics History Published online 5 April 2023 Published in print 2 April 2023 Information© MA Healthcare LimitedPDF download

Emergency provider preference for powered intraosseous devices and satisfaction with features improving safety, reliability, and ease-of-use

ABSTRACT Background Powered intraosseous (IO) systems are valuable devices for emergent situations, with limited data on user preferences. A simulation/survey-based study was conducted among emergency medical service (EMS) providers to evaluate attitudes toward general powered IO system features to measure preferences/satisfaction for the most-commonly used and a novel powered IO system (with a passive safety needle, battery life indicator, and snap-securement/dressing). Research Design and Methods Forty-two EMS providers completed a simulated activity using both powered IO systems and a 30-item questionnaire, including multiple choice, free-text, ranking, and Likert-like questions. Ranking scores were reported using a scale of 0 (least important/satisfactory) to 100 (most important/satisfactory). Statistical significances were evaluated via Wilcoxon signed-rank sum test. Results Providers indicated driver performance (mean score ± SD; 77.8 ± 27.5) and IO needle safety mechanism (63.1 ± 27.9) as the most important features. Participants reported significantly higher (p < 0.001) satisfaction with the novel IO system overall, and its needle safety, battery life indicator, securement/dressing, and ease-of-use. Powered driver performance satisfaction was similar and favorable for the novel (88.1 ± 18.2) and traditional (87.1 ± 15.3) systems. Conclusions These findings highlight the value of clinician/user input and demonstrate EMS providers are more satisfied with a powered IO system featuring design elements intended to enhance safety and ease-of-use.

A Quest for Better Strategy in Pediatric Intraosseous Placement Using Radiographic Measurements in Patients Younger Than 2 Years.

Intraosseous (IO) needles are used to obtain vascular access in pediatric patients during emergent situations. Recent literature has raised concern about high rates of IO malposition in younger children. Despite the widespread use of IO access in the pediatric population, there is scarce evidence regarding the ideal needle length or optimal access site. This study uses a radiographic approach to determine the appropriate IO needle length and access site to minimize the risk of malposition in children younger than 2 years. Radiographs of the lower extremities were obtained from the electronic database from a single tertiary care center. Using lateral views, anteroposterior measurements were obtained at 2 axial planes, located 1 cm superior to distal femur physis and 1 cm inferior to distal tibia physis. Based on the measurements, we calculated the probable needle tip positions if the needle was placed to the hub at the skin level using the EZ-IO (Teleflex Ltd, Wayne, PA) preset needle sizes. For subjects younger than 6 months, the 25-mm needle minimized malposition in the femur site with a 45.7% appropriate position rate, and the 15-mm needle minimized malposition in the tibia site with a 57.1% appropriate position rate. For the older age groups, we did not find a standard needle that would consistently minimize malposition in the femur site. For the tibia site, the 25-mm needle minimized malposition risk, with appropriate position rates of 81.0%, 87.5%, and 91.1% in the 6- to 12-month, 13- to 18-month, and 19- to 24-month groups, respectively.

Minimally invasive puncture with twist intraosseous drill needle combined with hematoma drainage in the treatment of acute epidural hematoma in pediatric patients: A technical note

ObjectiveThe current neurosurgical intervention for treatment of acute epidural hematoma (AEDH) usually involves a craniotomy. Despite its effectiveness, open surgical decompression has several limitations. The twist intraosseous drill needle (TIDN) is considered a feasible alternative in adult patients with AEDH. AEDH treatment with TIDN in pediatric patients has not yet been described. The study aimed to report the efficacy and safety of minimally invasive puncture with a TIDN combined with hematoma drainage for the treatment of AEDH in pediatric patients. MethodsWe retrospectively collected medical records of children with AEDH who underwent TIDN surgery at our institution from January 2017 to May 2021, and analyzed their clinical and imaging results. A detailed step-by-step surgical guide was provided. ResultsThree pediatric patients with AEDH received TIDN treatment (including two males and one female; average age 7.66 years, range from 5 to 11 years). There were no intraoperative or postoperative complications in any case; 1 day after the operation, the AEDH was cleared in one of the three patients, and a slight hematoma remained in two patients. The remaining hematoma was evacuated after injecting urokinase into the hematoma cavity during indwelling drainage. ConclusionFor pediatric patients with AEDH in a stable condition with a clear consciousness, TIDN puncture combined with hematoma drainage is safe, effective, and less invasive, and may present a viable surgical alternative option.

The Ability of Paramedics to Accurately Locate Correct Anatomical Sites for Intraosseous Needle Insertion.

Introduction Intraosseous (IO) access is an alternative to peripheral intravenous access, in which a needle is inserted through the cortical bone into the medullary spaceusing either a manual driver or an electric drill. Although studies report high success rates of IO access, failures are often attributed to incorrect site placement due tofailure to adhere to anatomical landmarks. This study was designed to evaluate the ability of paramedics to locatethe correct anatomic location for IO needle insertion. Methods Participants were paramedics who were recruited at Pennsylvania's annual statewide Emergency Medical Services (EMS) conference. After completinga demographics survey which included information about their training and practice environment, they were asked to identify which IO sites were permitted for IO placement using the EZ IO® drill and to place a sticker at those locations on a human volunteer. A transfer sheet was utilized, and the distance between the participants' sticker and the location as marked by a physician board-certified in both Emergency Medicine and Emergency Medical Services was recorded. Descriptive statistics and t-tests were calculated from the records. Results Of 30 paramedics who participated in the study, 25 (83%) had been in practice for more than five years (range: 1-37 years), 13 (46%) reported running more than 20 calls per week, and 23 (79%) reported that they only or mostly provide 9-1-1 EMS response. Ten (36%) participants were currently certified in PHTLS, and 16 (57%) had previously been PHTLS certified. All participants reported having been trained in IO insertion. Seventeen (57%) reported having utilized an IO ≤10 times in the field, and 13 (43%) reported >10 field IO insertions. When asked to identify appropriate IO insertion sites for the EZ IO drill, 26 paramedics (90%) correctly identified both the proximal humerus and proximal tibia. The average distance from the landmark for the humeral insertion site was 5.06 cm, with a statistically significant difference in the means for those who didand did not rotate the arm internally before identifying the humeral IO insertion site (p < .01). The average distance from the landmark at the tibial insertion site was 4.13 cm. Conclusion Although a high percentage of paramedics were able to verbally identify the correct location for IO placement, fewer were able to locate the insertion site on a human volunteer. Our results suggest a need for hands-on refresher training to maintain competency at IO insertion, as it is a rarely utilized procedure in the field.

Ex vivo study of detergent-assisted intraosseous bone wash treatment of osteonecrosis.

Avascular necrosis (AVN) involves ischemic cell death of the bone. AVN leaves an abundance of necrotic lipids and debris in the bone marrow, which instigates inflammatory bone repair. Consequently, the necrotic bone microenvironment stimulates excessive bone resorption, leading to joint deformities and osteoarthritis. Here, we performed a detergent-assisted bone wash using poloxamer 407 (P407) to clean the necrotic bone environment by removing lipids and necrotic debris. The new concept was tested using an established ex vivo AVN model of porcine cadaver humeral heads. The P407 wash was performed using P407 solution and followed with saline via two intraosseous needles. Visual inspection and image analyses of average pixel light intensity showed that the P407 wash produced a better-cleaned bone than the saline wash. Analyses of the collected bone wash solution showed a two-fold increase in triglycerides (101 vs. 53 mmol/head, p = 0.006) and a 10-fold increase in the dry weight of the removed debris (1.34 vs. 0.13 g/head, p = 0.02) with the P407 wash compared to saline. The histological evaluation showed significantly decreased Oil-Red-O (fats) staining in the P407-washed bone compared with the saline-washed bone. The in vitro assays of Alizarin red and qPCR showed the P407 wash neither altered the osteogenic behaviors of porcine bone marrow-derived mesenchymal cells (pBMMCs) nor raised inflammatory responses of porcine bone marrow-derived macrophages (pBMMs). In conclusion, detergent-assisted bone wash using P407 produced a better removal of nonsoluble debris from the bone marrow space than the saline wash without causing changes to osteogenesis or inflammatory reactions.

Complete Neurological Recovery After Emergency Burr Hole Placement Utilizing EZ-IO® for Epidural Hematoma

BackgroundPost-traumatic epidural hematoma (EDH) accounts for 1–3% of pediatric closed head injury admissions. There is a 2.5:1 male predominance. Etiology varies by age; motor vehicle collisions are the primary cause of EDH in adolescents. Post-traumatic EDH accompanies up to 4% of adult head injuries, and is associated with 10% mortality in adults and 5% mortality in children. In North America, standard of care for post-traumatic EDH includes decompressive craniotomy or trepanation via burr hole. Such lifesaving care is typically provided in the operating room by consulting neurosurgery teams or other personnel trained in the use of burr hole equipment. Case ReportThe case of a 17-year-old female patient who presented to a community emergency department (ED) after being involved in a motor vehicle collision is discussed. At the scene of the accident, she refused emergency medical services transport and was brought to the ED via private vehicle. She quickly decompensated in the ED and required intubation. Neurosurgical services were not available and transport to the nearest pediatric trauma center was delayed due to weather. Decompression and drainage of her EDH was accomplished with an EZ-IO® driver and intraosseous needle under virtual guidance of a pediatric neurosurgeon until definitive care could be obtained. The patient made a full neurologic recovery. Why Should an Emergency Physician Be Aware of ThisEDHs have high morbidity and mortality. In settings without access to neurosurgical services, and where ED access to or familiarity with burr hole equipment is limited, the EZ-IO® device may be a temporizing and lifesaving intervention until definitive neurosurgical care can be obtained.

Validation of a 3-Dimensional-Printed Infant Tibia for Intraosseous Needle Insertion Training.

Current bone models used for pediatric intraosseous (IO) placement training are expensive or lack anatomic and/or functional fidelity. This technical report describes the development and validation of a 3-dimensional printed (3DP) tibia from a pediatric lower extremity computed tomography scan for IO procedural training. Multiple 3DP tibia models were printed using a dual-extrusion fused-filament fabrication printer. Models underwent iterative optimization until 2 final models, one of polypropylene (3DP clear) and the other of polylactic acid/polypropylene (3DP white), were selected. Using an exploratory sequential mixed-methods design, a novel IO bone model assessment tool was generated. Physicians then used the assessment tool to evaluate and compare common IO bone models to the novel 3DP models during IO needle insertion. Thirty physicians evaluated the provided pediatric IO bone models. Compared with a chicken bone as a reference, the 3DP white bone had statistically significantly higher mean scores of anatomy, heft, sense of being anchored in the bone, quality of bone resistance, and "give" when interfaced with an IO needle. Twenty-two of the 30 participants ranked the 3DP white bone as either 1st or 2nd in terms of ranked preference of pediatric IO bone model. A 3DP white bone costs $1.10 to make. The 3DP IO tibia models created from real-life computed tomography images have high degrees of anatomic and functional realism. These IO training models are easily replicable, highly appraised, and can be printed at a fraction of the cost of commercially available plastic models.

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.

To sim or not to sim-choosing wisely for procedural skills training in paediatrics.

Simulation is a commonly used modality to teach paediatric procedural skills, however, it is resource intensive. Which paediatric skills are best taught using simulation is not known. This study aims to examine what skills to simulate, allowing for the best use of resources in ever expanding curricula. We administered a questionnaire to community and hospitalist general paediatricians in Canada asking them to rate the importance of maintaining competency in each paediatric procedural skill and the frequency with which they perform the skill in their practice. Skills that were rated as highly important and also high frequency were: bag-mask ventilation (BMV), lumbar puncture, neonatal cardiopulmonary resuscitation (CPR), specimen procurement for infectious diseases, immunization, and ear curettage. Skills that were rated as highly important but low frequency were: paediatric CPR, intraosseous needle insertion, neonatal intubation, defibrillation, gathering specimens for evidence of child maltreatment, paediatric intubation, cervical spine immobilization, and oral/nasogastric tube placement. Paediatric procedural skills are rated variably in terms of importance and frequency of use in general paediatric practice. Eight skills of high importance are infrequently performed and should be targeted for teaching via simulation.

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.

Drainage of an Extradural Haematoma by Intraosseous Needle in a Remote Hospital

Drainage of an Extradural Haematoma by Intraosseous Needle in a Remote Hospital