Intraosseous Vascular Access Research Articles

Re-evaluating intra-cardiac arrest adjunctive medications and routes of drug administration.

This narrative review summarizes the evidence for the most commonly used intra-cardiac arrest adjunctive medications and routes of administration and discusses promising new therapies from preclinical animal models. Large trials on the administration of calcium as well as the combination of vasopressin and glucocorticoids during cardiac arrest have been published. Calcium administration during cardiopulmonary resuscitation does not improve outcomes and might cause harm. Vasopressin and glucocorticoid administration during cardiopulmonary resuscitation improve the chance of return of spontaneous circulation but has uncertain effects on survival. We identified a total of seven ongoing clinical trials investigating the potential role of bicarbonate, of vasopressin and glucocorticoids, and of intravenous versus intraosseous vascular access. Several medications such as levosimendan and inhaled nitric oxide show promise in preclinical studies, and clinical trials are either planned or actively recruiting. Large trials on intra-cardiac arrest administration of calcium and vasopressin with glucocorticoids have been performed. Several trials are ongoing that will provide valuable insights into the potential benefit of other intra-cardiac arrest medications such as bicarbonate as well as the potential benefit of intravenous or intraosseous vascular access.

Barriers to utilization of intraosseous vascular access in pediatric emergencies.

Barriers to utilization of intraosseous vascular access in pediatric emergencies.

Intraosseous vascular access - step by step

Probably everyone who works in emergency medicine has been in the situation of having to insert a peripheral vein under time pressure in difficult venous conditions. So what do I do if I don't succeed? Establish a peripheral venous catheter? In recent years, the intraosseous approach has become increasingly popular as an alternative procedure. In this article, you will be guided step by step through the creation of an intraosseous access.

Evolution of the use of intraosseous vascular access in prehospital advanced cardiopulmonary resuscitation: The IOVA-CPR study.

Obtaining vascular access is crucial in critically ill patients. The EZ-IO® device is easy to use and has a high insertion success rate. Therefore, the use of intraosseous vascular access (IOVA) has gradually increased. We aim to determine how IOVA was integrated into management of vascular access during out-of-hospital cardiac arrest (OHCA) resuscitation. Analysing the data from the OHCA French registry for events occurring between 1 January 2013 and 15 March 2021, we studied: demography, circumstances of occurrence and management including vascular access, delays and evolution. The primary outcome was the rate of IOVA implantation. Among the 7156 OHCA included in the registry, we analysed the 3964 (55%) who received cardiopulmonary resuscitation. The vascular access was peripheral in 3122 (79%) cases, intraosseous in 775 (20%) cases and central in 12 (<1%) cases. The use of IOVA has increased linearly (R2 = 0.61) during the 33 successive trimesters studied representing 7% of all vascular access in 2013 and 33% in 2021 (p = 0.001). It was significantly more frequent in traumatic cardiac arrest: 12% versus 5%; p < 0.0001. The first epinephrine bolus occurred significantly later in the IOVA group, at 6 (4-10) versus 5 (3-8) min; p < 0.0001. Survival rate in the IOVA group was significantly lower, at 1% versus 7%; p < 0.0001. The insertion rate of IOVA significantly increased over the studied period, to reach 30% of all vascular access in the management OHCA patients. The place of the intraosseous route in the strategy of venous access during the management of prehospital cardiac arrest has yet to be determined.

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.

Epidemiology, use, and practice of the intraosseous route in an out-of-hospital emergency department: a retrospective cross-sectional study.

The Spanish Emergency Medical Services, according to the model we know today, were formed during the 80s and 90s of the 20th century. The Health Emergency Service (EMS), 061 La Rioja, began to assist the population of La Rioja in November 1999. An essential part of the mission of the SES is the provision of care and the transfer of critical patients using advanced life support unit (ALSU) techniques. In daily practice, out-of-hospital emergency services are faced with situations in which they must deal with the care of serious or critically ill patients, in which the possibility of being able to channel peripheral vascular access as part of ALSU quickly may be difficult or impossible. In these cases, cannulation of intraosseous (IO) vascular access may be the key to early and adequate care. This study aimed to determine the incidence and epidemiology use of IO vascular access in SES 061 La Rioja during the year 2022. We performed observational retrospective cross-sectional studies conducted in 2022. It included a population of 4.364 possible patients as a total of interventions in the community of La Rioja in that year. A total of 0.66% of patients showed a clinical situation that required the establishment of IO vascular access to enable out-of-hospital stabilization; this objective was achieved in 41.3%. A total of 26.1% of patients who presented with cardiorespiratory arrest (CA) were stabilized, while 100% presented with shock and severe trauma. IO vascular access provides a suitable route for out-of-hospital stabilization of critically ill patients when peripheral vascular access is difficult or impossible.

The association of tibial vs. humeral intraosseous vascular access with patient outcomes in adult out-of-hospital cardiac arrests

AimHumeral and tibial intraosseous (IO) vascular access can deliver resuscitative medications for out-of-hospital cardiac arrest (OHCA), however the optimal site is unclear. We examined the association between IO tibia vs. humerus as the first-attempted vascular access site with OHCA outcomes. MethodsWe used prospectively-collected data from the British Columbia Cardiac Arrest registry, including adult OHCAs treated with IO humerus or IO tibia as the first-attempted intra-arrest vascular access. We fit logistic regression models on the full study cohort and a propensity-matched cohort, to estimate the association between IO site and both favorable neurological outcomes (Cerebral Performance Category 1–2) and survival at hospital discharge. ResultsWe included 1041 (43%) and 1404 (57%) OHCAs for whom IO humerus and tibia, respectively, were the first-attempted intra-arrest vascular access. Among humerus and tibia cases, 1010 (97%) and 1369 (98%) had first-attempt success, and the median paramedic arrival-to-successful access interval was 6.7 minutes (IQR 4.4–9.4) and 6.1 minutes (IQR 4.1–8.9), respectively. In the propensity-matched cohort (n = 2052), 31 (3.0%) and 44 (4.3%) cases had favourable neurological outcomes in the IO humerus and IO tibia groups, respectively; compared to IO humerus, we did not detect an association between IO tibia with favorable neurological outcomes (OR 1.44; 95% CI 0.90–2.29) or survival to hospital discharge (OR 1.29; 95% CI 0.83–2.01). Results using the full cohort were similar. ConclusionsWe did not detect an association between the first-attempted intra-arrest IO site (tibia vs. humerus) and clinical outcomes. Clinical trials are warranted to test differences between vascular access strategies.

166 Real World Evidence Demonstrates Safety and Performance of Intraosseous Vascular Access, Including for Longer Duration of Use in Pediatric Patients

166 Real World Evidence Demonstrates Safety and Performance of Intraosseous Vascular Access, Including for Longer Duration of Use in Pediatric Patients

Intravenous vs. intraosseous vascular access during out-of-hospital cardiac arrest – protocol for a randomised clinical trial

ObjectiveDuring cardiac arrest, current guidelines recommend attempting intravenous access first and to consider intraosseous access if intravenous access is unsuccessful or impossible. However, these recommendations are only based on very low-certainty evidence. Therefore, the “Intravenous vs Intraosseous Vascular Access During Out-of-Hospital Cardiac Arrest“ (IVIO) trial aims to determine whether there is a difference in patient outcomes depending on the type of vascular access attempted during out-of-hospital cardiac arrest. This current article describes the clinical IVIO trial. MethodsThe IVIO trial is an investigator-initiated, randomised trial of intravenous vs. intraosseous vascular access during adult non-traumatic out-of-hospital cardiac arrest in Denmark. The intervention will consist of minimum two attempts (if unsuccessful on the first attempt) to successfully establish intravenous or intraosseous vascular access during cardiac arrest. The intraosseous group will be further randomised to the humeral or tibial site. The primary outcome is sustained return of spontaneous circulation and key secondary outcomes include survival and survival with a favourable neurological outcome at 30 days. A total of 1,470 patients will be included. ResultsThe trial started in March 2022 and the last patient is anticipated to be included in the spring of 2024. The primary results will be reported after 90-day follow-up and are anticipated in mid-2024. ConclusionThe current article describes the design of the Danish IVIO trial. The findings of this trial will help inform future guidelines for selecting the optimal vascular access route during out-of-hospital cardiac arrest.

Intraosseous Vascular Access in Cardiac Arrest: A Systematic Review of the Literature, with Implications for Future Research

Intraosseous Vascular Access in Cardiac Arrest: A Systematic Review of the Literature, with Implications for Future Research

Nursing Staff Knowledge on the Use of Intraosseous Vascular Access in Out-Of-Hospital Emergencies.

In healthcare practice, there may be critically injured patients in whom catheterisation of a peripheral venous access is not possible. In these cases, intraosseous access may be the preferred technique, using an intraosseous vascular access device (IOVA). Such devices can be used for infusion or administration of drugs in the same way as other catheterisations, which improves emergency care times, as it is a procedure that can be performed in seconds to a minute. The aim of this study was to analyse the level of knowledge of nursing staff working in emergency departments regarding the management of the intraosseous vascular access devices. To this end, a cross-sectional online study was carried out using an anonymous questionnaire administered to all professionals working in emergency and critical care units (ECCUs) in Granada district (Spain). The results show that 60% of the participants believe that with the knowledge they have, they would not be able to perform intraosseous vascular access, and 74% of the participants believe that the low use of this device is due to insufficient training. The obtained results suggest that the intraosseous access route, although it is a safe and quick way of achieving venous access in critical situations, is considered a secondary form of access because the knowledge of emergency and critical care professionals is insufficient, given the totality of the participants demanding more training in the management of intraosseous access devices. Therefore, the implementation of theoretical/practical training programmes related to intraosseous access (IO) could promote the continuous training of nurses working in ECCUs, in addition to improving the quality of care in emergency and critical care situations.

Experience of using intraosseous access in a multidisciplinary hospital (Children’s Republican Clinical Hospital of Kazan, Ministry of Health of the Republic of Tatarstan)

Introduction. The Children’s Republican Clinical Hospital of the Ministry of Health of the Republic of Tatarstan in Kazan is a hospital with 1,180 beds, designed for planned and emergency care throughout the Republic of Tatarstan. In stationary medical institutions there are 5 intensive care units, ambulance transport services with numerous resuscitation vehicles, and an air ambulance service. Every year, more than 10,000 (up to 15,000) planned surgical interventions are performed at the hospital, and almost all patients of varying severity are treated at the institution. As in all world practice, despite the high level of professionalism of nursing staff and doctors, the widespread use of modern peripheral and central venous catheters, ultrasound equipment and other devices to assist in catheterization, the rate of unsuccessful catheterization attempts remains quite high, especially in the emergency segment. medical care.Tasks: systematization of knowledge on intraosseous vascular access (IVA), analysis of the work performed. At the current stage of providing medical care to the pediatric population, our hospital maintains a protocol for vascular access in pediatrics and has developed an internal protocol for intraosseous access to analyze the work done, take into account complications and evaluate its effectiveness.Materials and methods. An analysis was carried out for the installation of intraosseous vascular access for two-year periods, starting from 2015. This article considers the period of 2017–2018, for which the most complete data were collected. During this period, 58 protocols were recorded in children of various age groups with various pathologies in a critical situation.

Pediatric Emergencies in Helicopter Emergency Medical Services: A National Population-Based Cohort Study From Denmark

To examine the diagnostic pattern, level of severity of illness or injuries, and mortality among children for whom a physician-staffed helicopter emergency medical service (HEMS) was dispatched. Population-based cohort study including patients aged less than 16 years treated by the Danish national HEMS from October 1, 2014, to September 30, 2018. Diagnoses were retrieved from inhospital medical records, and the severity of illness or injuries was assessed by a severity score on scene, administration of advanced out-of-hospital care, need for intensive care in a hospital, and mortality. In total, 651 HEMS missions included pediatric patients aged less than 1 year (9.2%), 1 to 2 years (29.0%), 3 to 7 years (28.3%), and 8 to 15 years (33.5%). A third of the patients had critical emergencies (29.6%), and for 20.1% of the patients, 1 or more out-of-hospital interventions were performed: intubation, mechanical chest compressions, intraosseous vascular access, blood transfusion, chest tube insertion, and/or ultrasound examination. Among the 525 patients with hospital follow-up, the most frequent hospital diagnoses were injuries (32.2%), burns (11.2%), and respiratory diseases (7.8%). Within 24 hours of the mission, 18.1% of patients required intensive care. Twenty-nine patients (5.1%, 95% confidence interval [CI] 3.6 to 7.3) died either on or within 1 day of the mission, and the cumulative 30-day mortality was 35 of 565 (6.2%, 95% CI 4.5 to 8.5) (N=565 first-time missions). On Danish physician-staffed HEMS missions, 1 in 5 pediatric patients required advanced out-of-hospital care. Among hospitalized patients, nearly one-fifth of the patients required immediate intensive care and 6.2% died within 30 days of the mission.

Emergency Decompressive Craniostomy "Burr Hole" Using an Intraosseous Vascular Access System in a Resource-Limited Setting: A Technical Report on a Cadaver.

This paper describes an alternative approach to emergency burr hole evacuation of epidural hematoma using the intraosseous (IO) vascular access system. The IO vascular access system is commonly available in the Emergency Department. We demonstrate that it can be used in rare situations where immediate neurosurgical intervention and the standard cranial drill and brace are not available for burr hole craniostomy.

The association of intraosseous vascular access and survival among pediatric patients with out-of-hospital cardiac arrest

IntroductionIn pediatric out-of-hospital cardiac arrest (OHCA) the effect of intraosseous (IO) or intravenous (IV) access on outcomes is unclear. MethodsWe analyzed prospectively collected data of non-traumatic OHCA in the Resuscitation Outcomes Consortium registry from 2011 to 2015. We included EMS-treated patients ≤17 years of age, classified patients based on vascular access routes, and calculated success rates of IO and IV attempts. After excluding patients with obvious non-cardiac etiologies and those with unsuccessful vascular access or multiple routes, we fit a logistic regression model to evaluate the association of IO vascular access (reference IV access) with the primary outcome of survival, using multiple imputation to address missing data. We analyzed a subgroup of patients at least 2 years of age. ResultsThere were 1549 non-traumatic OHCA: 895 (57.8%) patients had an IO line attempted with 822 (91.8%) successful; 488 (31.5%) had an IV line attempted with 345 (70.7%) successful (difference 21%, 95% CI 17 to 26%). Of the 761 patients included in our logistic regression, 601 received IO (30 [5.2%] survived) and 160 received IV (40 [25%] survived) vascular access. Intraosseous access was associated with a decreased probability of survival (adjusted OR 0.46; 95% CI 0.21–0.98). Patients at least 2 years of age showed a similar association (adjusted OR 0.36; CI 0.15–0.86). ConclusionsIntraosseous access was associated with decreased survival among pediatric non-traumatic OHCA. These results are exploratory and support the need for further study to evaluate the effect of intravascular access method on outcomes.

Intraosseous vascular access in emergency and trauma settings: a comparison of the most universally used intraosseous devices

ABSTRACT Introduction: Obtaining successful vascular access is an essential component of the emergency and trauma setting. The modern practice of medicine advocates IO access for patients in a critical condition, especially when IV access is problematic or unobtainable. Various medical devices allowing for IO access have been coined and used in the management of critical patients. Areas covered: This study aims to review the literature regarding different intraosseous devices used to obtain vascular access (Bone Injection Gun (BIG), EZ-IO, NIO, Jamshidi, and First Access for Shock and Trauma (FAST-1) and discuss their clinical and experimental role in the emergency and trauma settings. Expert opinion: The development of medical technology contributes to an increasing number of intraosseous devices facilitating vascular access in challenging scenarios, including cardiopulmonary resuscitation, anaphylactic, or hypovolemic shock. Each of these devices provides an effective route for fluid resuscitation, drug delivery, laboratory evaluation, and shortening the timeframe for established vascular access, provided that the person obtaining the access is acquainted with the use of the device.

Sternal Intraosseous Devices: Review of the Literature.

IntroductionThe intraosseous (IO) route is one of the primary means of vascular access in critically ill and injured patients. The most common sites used are the proximal humerus, proximal tibia, and sternum. Sternal IO placement remains an often-overlooked option in emergency and prehospital medicine. Due to the conflicts in Afghanistan and Iraq the use of sternal IOs have increased.MethodsThe authors conducted a limited review, searching PubMed and Google Scholar databases for “sternal IO,” “sternal intraosseous,” and “intraosseous” without specific date limitations. A total of 47 articles were included in this review.ResultsSternal IOs are currently FDA approved for ages 12 and older. Sternal IO access offers several anatomical, pharmacokinetic, hemodynamic, and logistical advantages over peripheral intravenous and other IO points of access. Sternal IO use carries many of the same risks and limitations as the humeral and tibial sites. Sternal IO gravity flow rates are sufficient for transfusing blood and resuscitation. In addition, studies demonstrated they are safe during active CPR.ConclusionThe sternal IO route remains underutilized in civilian settings. When considering IO vascular access in adults or older children, medical providers should consider the sternum as the recommended IO access, particularly if the user is a novice with IO devices, increased flow rates are required, the patient has extremity trauma, or administration of a lipid soluble drug is anticipated.

Intraosseous versus intravenous vascular access during cardiopulmonary resuscitation for out-of-hospital cardiac arrest: a systematic review and meta-analysis of observational studies

IntroductionThis study is aimed to investigate the association of intraosseous (IO) versus intravenous (IV) route during cardiopulmonary resuscitation (CPR) with outcomes after out-of-hospital cardiac arrest (OHCA).MethodsWe systematically searched PubMed, Embase, Cochrane Library and Web of Science from the database inception through April 2020. Our search strings included designed keywords for two concepts, i.e. vascular access and cardiac arrest. There were no limitations implemented in the search strategy. We selected studies comparing IO versus IV access in neurological or survival outcomes after OHCA. Favourable neurological outcome at hospital discharge was pre-specified as the primary outcome. We pooled the effect estimates in random-effects models and quantified the heterogeneity by the I2 statistics. Time to intervention, defined as time interval from call for emergency medical services to establishing vascular access or administering medications, was hypothesized to be a potential outcome moderator and examined in subgroup analysis with meta-regression.ResultsNine retrospective observational studies involving 111,746 adult OHCA patients were included. Most studies were rated as high quality according to Newcastle-Ottawa Scale. The pooled results demonstrated no significant association between types of vascular access and the primary outcome (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.27–1.33; I2, 95%). In subgroup analysis, time to intervention was noted to be positively associated with the pooled OR of achieving the primary outcome (OR: 3.95, 95% CI, 1.42–11.02, p: 0.02). That is, when the studies not accounting for the variable of “time to intervention” in the statistical analysis were pooled together, the meta-analytic results between IO access and favourable outcomes would be biased toward inverse association. No obvious publication bias was detected by the funnel plot.ConclusionsThe meta-analysis revealed no significant association between types of vascular access and neurological outcomes at hospital discharge among OHCA patients. Time to intervention was identified to be an important outcome moderator in this meta-analysis of observation studies. These results call for the need for future clinical trials to investigate the unbiased effect of IO use on OHCA CPR.

Intraosseous vascular access using the EZ-IO can be safely maintained in the adult proximal humerus and proximal tibia for up to 48 h: Report of a clinical study.

Historically, intraosseous (IO) vascular access devices cleared to market by the US FDA have been restricted to 24-h use. An observational study was conducted to determine the safety of IO access for a period up to 48 h in adult volunteers. A 2-arm randomized, stratified, parallel assignment, prospective interventional study was conducted at ICON Early Phase Services in San Antonio, Texas, United States. Study subjects were adult volunteers who were healthy or with a history of mild to moderate renal disease and/or controlled diabetes. Subjects were randomized to receive IO access (Arrow EZ-IO Vascular Access System, Teleflex Medical Incorporated, Morrisville, NC, USA) in the proximal humerus or the proximal tibia and maintain the indwelling catheter for 48 h. Subjects were monitored for the entire dwell time. A culture specimen was drawn from the indwelling catheter tip before removal and insertion site x-rays were taken. 121 subjects were randomized: 79 healthy, 39 with diabetes, and three with diabetes and renal insufficiency. The mean catheter dwell time was 48.0 ± 0.2 h. Overall first attempt success rate was 98.4%. Infusion pain was the most commonly reported adverse event. There were no serious complications or unanticipated adverse events. This is the first known study examining the safety of IO access over a 48-h dwell time. The study corroborates the literature findings, demonstrates device safety, and provides evidence supporting the extended indication for a dwell time to 48 h in adult patients. IO placement and infusion best practices/guidelines were confirmed or established.

Intraosseus route for thrombolysing acute stroke is safe and successful.

Use of intraosseous route in thrombolysis of acute stroke patients remains a rare entity. Here, we describe the first such case within UK of a 55-year-old female patient of acute stroke who was thrombolysed with Alteplase administered through intraosseous (IO) route. She initially presented to A&E with severe dysarthria dysphasia and left sided weakness with an NIHSS-8. Failing acquisition of an intravenous access an IO vascular access was secured and thrombolysis was administered She improved remarkably and had no complications. The challenge faced in this case, of acquiring an effective access within the time frame and safely administering the Alteplase without any local or systemic complications was well met with a favourable outcome. IO is an established method of obtaining vascular access in children and adults in acute emergency situations. It can be used for effective thrombolysis in acute stroke patients.