Intraosseous Puncture Research Articles

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.

Desenvolvimento de simulador de baixo custo para o ensino de punção intraóssea na pediatria

Simulators are interactive and dynamic tools that stimulate, encourage new ideas, and instigate knowledge acquisition to support problem solving and decision making. Their use is fundamental in health professionals’ training. This is a technological study for the experimental development of a low-cost prototype for training technical skills in intraosseous puncture, using the methodology of problematization. Intraosseous puncture is a simple procedure, quick to perform, and with a high success rate, all advantageous characteristics in emergency facilities. In recent years, it was observed that prior training in simulators for patient safety was required, making it essential in quality professional training. It is concluded that the model presented becomes feasible in teaching of intraosseous puncture procedure as it allows this skill training in a safe and low-cost way.

Use of Intraosseous Vascular Access During Neonatal Resuscitation at a Tertiary Center.

Introduction: Emergency vascular access is rarely required during neonatal resuscitation. We aimed to analyze frequency of use, success, and complication rates of intraosseous (IO) vascular access in neonates at a single tertiary neonatal intensive care unit.Method: We performed a questionnaire-based survey among pediatric residents, pediatricians, and neonatologists, asking for the use of IO access in neonates between April 1st, 2015, and April 30th, 2020. We then reviewed electronic patient charts of all identified neonates for demographic data as well as indications and complications of IO puncture.Results: All 41 questionnaires were answered. Nine physicians had attempted IO access 15 times in a total of 12 neonates. Among them were eight term neonates, three preterm neonates, and one former extreme preterm neonate at a post-menstrual age of 42 weeks (m:f = 6:6). The overall success rate was 75%. IO access was attempted primarily during post-natal resuscitation (11/12 neonates, 91.7%) and after unsuccessful peripheral venous puncture (8/12 neonates, 66.7%). It was used to administer adrenaline, fluid and/or blood, and emergency sedation after intubation. Minor short-term complications were reported in three of nine successful IO punctures (33.3%).Discussion: Over the study period of 61 months, IO access was rarely attempted during neonatal resuscitation. Our success rate was lower than reported elsewhere, suggesting that IO puncture may be more challenging in neonates than in older infants and children. No severe short-term complications occurred.

Family's presence in the pediatric emergency room: opinion of health's professionals

ObjectiveTo learn the opinion of health professionals regarding the presence of family during pediatric emergency care. MethodsCross-sectional study, performed with 46 health professionals, members of the medical and nursing team of a pediatric emergency service. The data were collected via the application of a questionnaire composed by variables related to the opinion of professionals about the studied subject, in line with the professional category and the vocational training time, as well as invasive procedures during which the presence of family is authorized by the professionals. ResultsThe medical staff and the professionals with shorter time after graduation (<10 years) were more favorable to the presence of family during emergency procedures. Regarding the complexity of the procedures, the nursing staff proved more favorable to the presence of family during less complex procedures – peripheral venous puncture and fluid sample – whereas the consent of the medical staff was similar, regardless the performed procedure – peripheral venous puncture, fluid sample, intraosseous puncture, tracheal intubation and cardiopulmonary resuscitation. ConclusionsIn order to allow the presence of family in the emergency room, it is necessary to sensitize health professionals, especially the nursing staff and the longer-term acting professionals, which are more resistant to allow the family to stay with the child during the emergency care.

Presença da família em sala de emergência pediátrica: opiniões dos profissionais de saúde

ObjectiveTo learn the opinion of health professionals regarding the presence of family during pediatric emergency care. MethodsCross‐sectional study, performed with 46 health professionals, members of the medical and nursing team of a pediatric emergency service. The data were collected via the application of a questionnaire composed by variables related to the opinion of professionals about the studied subject, in line with the professional category and the vocational training time, as well as invasive procedures during which the presence of family is authorized by the professionals. ResultsThe medical staff and the professionals with shorter time after graduation (<10 years) were more favorable to the presence of family during emergency procedures. Regarding the complexity of the procedures, the nursing staff proved more favorable to the presence of family during less complex procedures–peripheral venous puncture and fluid sample–whereas the consent of the medical staff was similar, regardless the performed procedure–peripheral venous puncture, fluid sample, intraosseous puncture, tracheal intubation and cardiopulmonary resuscitation. ConclusionsIn order to allow the presence of family in the emergency room, it is necessary to sensitize health professionals, especially the nursing staff and the longer‐term acting professionals, which are more resistant to allow the family to stay with the child during the emergency care.

Invasive emergency techniques - In-field-amputation

On-scene invasive emergency procedures, such as Cricothyroidotomy, chest drain, intraosseous puncture or even in-field-amputation, are often unavoidable, when indicated, and present a major challenge for the emergency physician. Personal, temporal or local conditions are often unsuitable. Even with regular intervention by the Emergency Medical Service, "last resort" measures occur very infrequently, particularly in relation to paediatric emergencies. As well as theoretical training, practice-oriented course concepts are essential in order to achieve high quality in these procedures. This article presents the use of in-field-amputation, with reference to indication, implementation, problems and risks. It is part of a series of four articles on the subject of invasive emergency techniques.

Intraosseous vascular access through the anterior mandible--a cadaver model pilot study.

BackgroundSeveral insertion sites have been described for intraosseous puncture in cases of emergencies when a conventional vascular access cannot be established. This pilot study has been designed to evaluate the feasibility of the mandibular bone for the use of an intraosseous vascular access in a cadaver model.Methodology/Principal Findings17 dentistry and 16 medical students participating in a voluntary course received a short introduction into the method and subsequently used the battery powered EZ-IO system with a 15 mm cannula for a puncture of the anterior mandible in 33 cadavers. The time needed to perform each procedure was evaluated. India ink was injected into the accesses and during the anatomy course cadavers were dissected to retrace the success or failure of the puncture. Dental students needed 25.5±18.9(mean±standard deviation)s and medical students 33±20.4 s for the procedure (p = 0.18). Floor of mouth extravasation occurred in both groups in 3 cases. Success rates were 82 and 75% (p = 0.93).Conclusions/SignificanceDespite floor of mouth extravasation of injected fluid into a mandibular intraosseous access might severely complicate this procedure, the anterior mandible may be helpful as an alternative to other intraosseous and intravenous insertion sites when these are not available in medical emergencies.

Invasive emergency techniques - intraosseous devices

On-site invasive emergency procedures, such as cricothyroidotomy, chest drainages, intraosseous puncture or the even rarer on-site amputations, are often unavoidable when indicated, and present a major challenge for the emergency physician. Personal, temporal or local conditions are often unsuitable. Even with regular participation in the emergency medical services, "last resort" measures occur very infrequently, particularly in paediatric emergencies. As well as theoretical training, practice-oriented course concepts are essential in order to achieve high quality in these procedures. In this article we describe the use of intraosseous devices on adults and children, with reference to the indication, implementation, problems and risks. It is the third part of a series of four articles on the subject of invasive emergency techniques.

Invasive emergency techniques--decompression of the pleura

On-scene invasive emergency procedures, such as cricothyroidotomy, chest drain, intraosseous puncture or even on-field-amputation, are often unavoidable, when indicated, and present a major challenge for the emergency physician. Personal, temporal or local conditions are often unsuitable. Even with regular intervention by the emergency medical service, "last resort" measures occur very infrequently, particularly in relation to paediatric emergencies. Beside a theoretical education, practice-oriented course concepts are necessary to achieve a high quality of these measures. This article presents the use of decompression of the pleura on adults and children, with reference to indication, implementation, problems and risks. It is the second part of a series of four articles on the subject of invasive emergency techniques.

Invasive emergency techniques--cricothyroidotomy

On-scene invasive emergency procedures, such as cricothyroidotomy, chest drain, intraosseous puncture or even on-field-amputation, are often unavoidable, when indicated, and present a major challenge for the emergency physician. Personal, temporal or local conditions are often unsuitable. Even with regular intervention by the emergency medical service, "last resort" measures occur very infrequently, particularly in relation to paediatric emergencies. As well as theoretical training, practice-oriented course concepts are essential in order to achieve high quality in these procedures. This article presents the use of cricothyroidotomy on adults and children, with reference to indication, implementation, problems and risks. It is part of a series of four articles on the subject of invasive emergency techniques.

Kinderanästhesie - Der schwierige Venenzugang

Venipunctures in children are difficult. Some factors can hardly be influenced, for example, a well-developed subcutaneous fat tissue. Technical devices may help to identify invisible veins. With the help of ultrasound deep peripheral veins on the wrists and ankles can be presented and punctured. Stiff resistance of a child thwarts any successful puncture. Children should therefore be adequately sedated, if cannot be induced by mask. Missing practice venipuncture and inadequate knowledge of appropriate puncture sites can be met easily by practicing and reading.The possibility of intraosseous puncture today is standard of anesthesia care for children. Within in a few seconds, a secure access to the vein system can be created.

Is intraosseous puncture an alternative emergency vascular access in dental practice?

Hintergrund An der Mehrzahl der zahnmedizinischen Fakultaten in Deutschland wird im Rahmen notfallmedizinischer Vorlesungen als Alternative zum periphervenosen („IV“) Zugang die intraossare („IO“) Punktion gelehrt. Ziel dieser Publikation ist es, innerhalb einer Gruppe von Studenten der Zahnmedizin am Modell drei unterschiedliche IO-Systeme zu vergleichen und der periphervenosen Punktion gegenuberzustellen.

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Intraosseous Anesthesia in Hemodynamic Studies in Children with Cardiopathy

Intraosseous (IO) access has been used with good results in emergency situations, when venous access is not available for fluids and drugs infusion. The objective of this study was to evaluate IO a useful technique for anesthesia and fluids infusion during hemodynamic studies and when peripheral intravascular access is unobtainable. The setting was an university hospital hemodynamics unit, and the subjects were twenty one infants with congenital heart disease enrolled for elective hemodynamic study diagnosis. This study compared the effectiveness of IO access in relation to IV access for infusion of anesthetics agents (ketamine, midazolam, and fentanyl) and fluids during hemodynamic studies. The anesthetic induction time, procedure duration, anesthesia recovery time, adequate hydration, and IV and IO puncture complications were compared between groups. The puncture time was significantly smaller in IO group (3.6 min) that in IV group (9.6 min). The anesthetic onset time (56.3 second) for the IV group was faster than IO group (71.3 second). No significant difference between groups were found in relation to hydration (IV group, 315.5 mL vs IO group, 293.2 mL), and anesthesia recovery time (IO group, 65.2 min vs IV group, 55.0 min). The puncture site was reevaluated after 7 and 15 days without signs of infection or other complications. Results showed superiority for IO infusion when considering the puncture time of the procedure. Due to its easy manipulation and efficiency, hydration and anesthesia by IO access was satisfactory for hemodynamic studies without the necessity of other infusion access.

Additions Are Needed

As advance analgesia is not possible, venipuncture must be performed on the conscious child. If there is an indication for venipuncture, tedious and painful failed punctures must be avoided. A maximum of two attempts should be made at the classical and promising sites of puncture. If those fail, intra-osseous puncture should be performed. The possible complications are of secondary importance only. The best puncture site is at the transition between the proximal and mid third of the lower leg. If the Cook needle is used, the infant’s lower leg must rest on the palm of the operator, in order to avoid greenstick fractures. The sentence “Symptomatic hyperglycemia in childhood is almost always due to diabetic ketoacidosis” is totally unacceptable. Ketoacidosis is a symptom, not the cause of excessive hyperglycemia. Volume replacement is actually very important in the therapy of hyperglycemic ketotacidosis. If however 0.9% NaCl solution is infused, the acidosis may be enhanced, as there is a lack of metabolisable anions. A balanced electrolyte solution is to be preferred here. Table 3 is not very helpful. It is hardly possible to distinguish between “dry” and “dried out” mucus membranes. Experience has shown that the clinical evaluation of the child should be based on the general condition, respiration and circulation, with the help of the Pediatric Assessment Triangle. This tool is a valuable didactic aid when the severity of a pediatric emergency is to be assessed.

Structured training in intraosseous infusion to improve potentially life saving skills in pediatric emergencies – Results of an open prospective national quality development project over 3 years

Children in emergencies need peripheral intravenous (IV) access in order to receive drugs or fluids. The success of IV access is associated with the age of patients and fails in up to 50% of children younger than 6 years. In such situations, it is essential that physicians and paramedics have a tool and easily learnable skills with a high chance of success. According to international guidelines intraosseous (IO) access would be the next step after failed IV access. Our hypothesis was that the success rate in IO puncturing can be improved by standardizing the training; so we developed an IO workshop. Twenty-eight hospitals and ambulance services participated in an evaluation process over 3 years. IO workshops and the distribution of standardized IO sets were coordinated by the study group of the University Hospital of Berne. Any attempted or successful IO punctures were evaluated with a standardized interview. We investigated 35 applications in 30 patients (a total of 49 punctures) between November 2001 and December 2004. IO puncture was not successful in 5 patients. The success rate depended neither on the occupation nor the experience of users. Attendance at a standardized IO workshop increased the overall success rate from 77% to 100%, which was statistically not significant (P = 0.074). Standardized training in IO puncturing seems to improve success more than previous experience and occupation of providers. However, we could not show a significant increase in success rate after this training. Larger supranational studies are needed to show a significant impact of teaching on rarely used emergency skills.