Intraosseous Needle Research Articles

New techniques in fetal surgery

Optimal fetal management during and after fetal surgery has been limited by an inability to reliably monitor the fetal heart rate and temperature, and by a lack of access to the fetal circulation. In order to solve these problems, we used early third trimester fetal sheep to develop: (1) an implantable radiotelemetry device that transmits the fetal electrocardiogram and temperature, and (2) an intraosseous access technique. A miniaturized radiotelemeter was implanted subcutaneously in the axilla of four fetal sheep. Safe implantation of the radiotelemeter was technically feasible and the device reliably recorded the fetal electrocardiogram and temperature both intraoperatively and postoperatively. Although many possible routes for access to the fetal circulation have been tried experimentally and clinically for both resuscitation and blood sampling, none have proven satisfactory. We assessed the use of intraosseous access in fetal sheep (n = 6) for both infusion and blood sampling. Access with an intraosseous needle was obtained in both sheep fetuses and human fetal cadavers. Blood gas values (pH, PCO 2, and PO 2) obtained from the medullary cavity of fetal sheep accurately reflected peripheral venous values. Resuscitation drugs reached the fetal circulation via the intraosseous route: sodium bicarbonate elevated venous bicarbonate levels from 28.4 ± 1.7 to 31.8 ± 2.1 mEq/dL ( P < .05); injected glucose increased venous glucose levels by 520 ± 108 mg/dL ( P < .01); and injection of calcium chloride elevated venous calcium levels from 11.8 ± 0.7 to 15.2 ± 2.2 mEq/dL ( P < .05). Intraosseous infusion of epinephrine (0.01 mg/kg) had rapid physiological effect, measured as a 30 mm Hg increase in fetal mean blood pressure at 45 seconds after injection ( P ≤ .01). Application of the implantable radiotelemeter and intraosseous access techniques may enhance fetal surgery safety by improving fetal monitoring and permitting reliable access to the fetal circulation.

Typing and screening of blood from intraosseous access

To determine if intramedullary aspirate from intraosseous needle placement can be used as a source for evaluating blood compatibility. A prospective, nonrandomized, crossover study. Patients admitted to the hematology/oncology service undergoing bone marrow aspiration for medical purposes. Patients had simultaneous samples of bone marrow aspiration from the posterior iliac crest and peripheral venous blood drawn and sent for typing and screening. The paired samples were evaluated for ABO and Rh typing as well as the presence of human leukocyte activity by evaluating the reaction strength between the marrow and venous samples. No differences were seen in the reaction strength between the paired samples in any subjects for ABO and Rh typing (P = .90, yielding beta = .0523). In addition, human leukocyte activity was detected in both the marrow and venous samples in one patient. Bone marrow aspirates following intraosseous infusion can be used for accurate and reliable typing and screening of blood.

Intraosseous Transfusion in an Anesthetized Swine Model Using 51Cr-Labeled Autologous Red Blood Cells

Peripheral venous access can often be difficult to obtain in infants and young children. Landmark articles in the 1940s showed that the intraosseous (IO) route was a viable one for resuscitation. While anecdotal reports and clinical experience suggest that blood products can be transfused via the IO route, it has not been specifically studied nor documented. We performed a prospective study to document the feasibility of red blood cell transfusion via the IO space. We studied the rapid infusion of 51Cr-labeled red blood cells via the IO space through an 18-gauge IO needle in three normovolemic immature swine. Serial central venous samples were removed at 30 seconds and at 1, 5, 15, 30, and 60 minutes and analyzed for evidence of radiolabeling. Our results revealed rapid delivery of radiolabeled red blood cells into the central circulation with no evidence of early heomolysis. Highest counts were seen in samples taken at 30 seconds to 1 minute. We conclude that the IO route is a viable means for blood transfusion in a nonhemorrhagic model.

Effect of intraosseous saline infusion on hematologic parameters

To examine the effects of intraosseous saline infusion on hematologic parameters. Eight New Zealand White rabbits were anesthetized with intramuscular ketamine. An initial blood sample was withdrawn from a earlobe vein on induction of anesthesia. An 18-gauge intraosseous needle was then inserted into the rabbit's proximal tibia, and 10 mL/kg of normal saline was infused over one minute. Two additional blood samples were obtained 15 and 30 minutes after the intraosseous infusion. Complete blood counts were performed on the blood samples. Significant differences were found in monocytes, basophils, and nucleated RBCs from samples drawn before and after intraosseous infusion. The microscopic examination of the peripheral blood smear revealed an increase in the number of burr cells, schistocytes, and polychromasia in the postinfusion samples. We advocate caution in the interpretation of hematologic studies performed on blood samples obtained shortly after an intraosseous infusion.

Intraosseous infusion of fluids in the initial management of hypovolemic shock in young subjects

Immediate aggressive fluid resuscitation of a child with life-threatening hemorrhagic shock provides the difference between life and death. Obtaining venous access in the hypovolemic child sometimes is difficult and time consuming. In order to evaluate the benefit of prehospital administration of intraosseous fluids into the tibial bone marrow as a method of gaining quick access to the systemic circulation and in resuscitating victims from severe hypovolemic shock, 13 puppies weighing 4.6 to 10 kg were subjected to progressive, controlled exsanguination until their mean arterial pressure (MAP) was 20% or less of their baseline MAP for 5 minutes (maxishock). Then an 18-gauge intraosseous needle was inserted into the tibial bone marrow and lactated Ringer's solution was infused at 300 mm Hg of pressure until a volume three times the blood loss had been administered. The MAP, central venous pressure, arterial blood gases, hematocrit, serum lactate, and urine output were recorded at 10, 20, 30, 45, 60, 90, and 120 minutes after the onset of maxishock. At the end of the experiment the left lung of each animal was sent to the pathology department to investigate the possibility of bone marrow emboli. The results were compared with a group of control dogs with maxishock and no treatment, and a group of dogs with maxishock treated with a canine military antischock trousers inflated to 50 to 55 mm Hg and no fluids. The average needle insertion time was 16 seconds; the rate of infusion of fluids varied from a maximum of 25.7 mL/min to a minimum of 4.5 mL/min, with a mean of 10.6 mL/min. The overall survival, recovery of MAP, urine output, and lactic acid clearance were significantly better in the group of dogs treated with intraosseous fluids when compared with the other two groups. We conclude that the emergency administration of intraosseous fluids in both safe and efficacious in the initial resuscitation of hypovolemic shock when the intravenous route in the field is unavailable.

Comparison Study of Intraosseous, Central Intravenous, and Peripheral Intravenous Infusions of Emergency Drugs

Intraosseous infusion of emergency drugs is a lifesaving alternative to intravenous administration when intravenous access cannot be rapidly established. We studied the comparative pharmacokinetics of the following six emergency drugs and solutions: epinephrine hydrochloride, 0.01 mg/kg; sodium bicarbonate, 1 mEq/kg; calcium chloride, 10 mg/kg; hydroxyethyl starch, 10 mL/kg; 50% dextrose in water, 250 mg/kg; and lidocaine hydrochloride, 1 mg/kg. Studies were conducted in normotensive, anesthetized dogs, with three animals studied with each of the drugs or solutions and each animal being treated with all three routes of administration (central intravenous, peripheral intravenous, and intraosseous) in randomized sequence. The effects of epinephrine were also assessed in a shock model. The intraosseous route of administration was comparable with the central and peripheral intravenous routes for all of the emergency drugs and solutions studied, with equivalent magnitudes of peak effect or drug level and equal or longer durations of action. Time to placement of the intraosseous needle varied from 15 seconds to 5 minutes, with a mean of 60 seconds. Time to placement of the needle varies with the skill and experience of the individual. With experience, all individuals could place the intraosseous needle in 60 seconds or less. The intraosseous route is comparable in effect to the central and peripheral intravenous routes of drug administration for epinephrine, sodium bicarbonate, hydroxyethyl starch, calcium chloride, 50% dextrose in water, and lidocaine and is a clinically feasible alternative when intravenous access will be critically delayed.

Comparison of serum phenobarbital levels after single versus multiple attempts at intraosseous infusion

Serum drug levels from a single intraosseous attempt in nontraumatized bone have proven comparable to levels from IV drug infusions. However, in the clinical situation, inexperienced personnel may make multiple intraosseous attempts, which could allow significant extravasation from multiple intramedullary entrance sites. Serum drug levels arising from multiple intraosseous attempts in traumatized bone were compared with those arising from single intraosseous attempts in nontraumatized bone. We administered phenobarbital to 24 dogs randomly divided into single- (11) and multiple-attempt (13) groups. In the multiple-attempt group, we created three intramedullary insertion sites in a linear fashion and infused through only the central site. In the single-attempt group, only a single infusion site was created. Phenobarbital then was infused into the intramedullary space, and central venous phenobarbital samples were collected at one-, three-, six-, and ten-minute intervals. The single-attempt group attained significantly higher serum phenobarbital levels at each interval compared with the multiple-attempt group (P less than .0001). Therefore, to be an effective mode of therapy, it is critical to achieve single-attempt intraosseous needle placement for intraosseous infusion.

Intraosseous infusions in adults

Intraosseous (IO) access in adults via the distal tibia has never been a widely accepted technique. Yet there have been occasional reports of the successful use of this procedure. This study was done to demonstrate the utility of IO infusions in the adult patient, including those patients in cardiac arrest. Twenty-two patients, aged 36 through 84 (mean 65.1 years), who arrived in the emergency department (ED) in cardiac arrest from nonhypovolemic causes and in whom an intravenous line was not established prior to arrival or was found to be inadequate (nonfunctioning or poorly functioning) upon arrival in the ED, had an IO needle (13-gauge Kormed/Jamshidi®, Pharmaseal Division, Baxter Healthcare Corp., Valencia, CA) placed above the medial malleolus. The IO needle was then connected to a standard IV tubing, with a pressure bag or pressure device delivering 300 mm Hg to the solution bag. The resultant flow rate through the IV line ranged from 5 to 12 mL/min. The IO needle was placed and flow established in under one minute in all patients. Temporally related pharmacologic effects were observed after the IO administration of sodium bicarbonate, lidocaine, atropine, and vasopressors. This study shows that I.O. access can be quickly and easily obtained in adults in the medial supramalleolar position during cardiac arrest. This method of drug administration appears to hold promise as another useful modality for adults and older children during nontraumatic resuscitations.

Intraosseous Crystalloid and Blood Infusion in a Swine Model

The technique of intraosseous infusion has attracted increasing interest in recent years, and has proven valuable for drug administration. This study was undertaken to determine whether it was also a potential route for fluid resuscitation. Thirteen- or eighteen-gauge tibial intraosseous needles were placed in eight "large" (mean weight, 14.4 kg) and eight "small" (mean weight, 5.8 kg) swine and the flow rate of blood and saline measured under gravity and 300 mm Hg. Flow was significantly greater using 13-gauge needles in the "large" swine, significantly greater for saline than for blood, and for pressure infusion versus gravity in all animals. A fluid bolus of 20 ml/kg could be given to all animals in less than 10 minutes using pressure infusion. These data suggest that intraosseous infusion is a reasonable initial step in fluid resuscitation of pediatric subjects until more conventional vascular access has been established.

Intraosseous needles: new and improved.

Intraosseous needles: new and improved.

Analysis of growth plate abnormalities following intraosseous infusion through the proximal tibial epiphysis in pigs.

Intraosseous infusion has become an increasingly popular technique for vascular access in critically ill or injured children. Continuing acceptance of this procedure by physicians and possibly by prehospital personnel may lead to inadvertent placement through the immature growth plate. In our study, we intentionally penetrated the epiphyseal plate with the intraosseous needle and infused fluids in order to observe what complications, if any, might arise from this procedure. Twenty pigs 3 to 4 weeks old had a bone marrow aspiration needle introduced into the medullary cavity through the tibial epiphysis under fluoroscopic visualization. Sodium bicarbonate at 2 mEq/kg (n = 10) or 0.9 normal saline at 2 mL/kg (n = 10) was infused through the intraosseous needle. Radiographs of the involved growth plates were taken at two months and six months after infusion. No growth disturbances or growth plate abnormalities were detected clinically or radiographically through the rapid growth phase of the porcine tibia. Therefore, we believe that intraosseous infusion is a safe method of alternative vascular access associated with no significant growth defects despite injury to the developing growth plate from placement and infusion.

Intraosseous infusions: A usable technique

Intraosseous infusions were widely used in pediatric patients during the 1930s and 1940s. Recent reports have re-introduced this concept and confirmed its safety and ready accessability for fluid and drug administration. However, these reports have not addressed the difficulties encountered during insertion of the intraosseous needle. Spinal needles, standard metal intravenous (IV) needles, and bone marrow biopsy needles have been suggested for intraosseous infusion. These needles were tested for ease of insertion on a pediatric cadaver leg. The site for needle placement was also evaluated during the study. It was found that the 13-gauge Kormed/Jamshidi disposable bone marrow/aspiration needle was the easiest to insert and did not plug with bone or tissue during insertion. An area proximal to the medial malleolus was found to provide a stable, relatively flat, and easily penetrable location for needle placement. This method was successfully utilized in ten pediatric and five adult patients. Intraosseous needle placement is a safe, rapid method to gain access to the venous circulation. By utilizing these techniques, a stable, usable fluid line can be established in even the most dehydrated pediatric patients.