Intraosseous Infusion Technique Research Articles

The Development and Initial End-Point User Feedback of a 3D-Printed Adult Proximal Tibia IO Simulator.

Intraosseous infusion (IO) remains an underutilized technique for obtaining vascular access in adults, despite its potentially life-saving benefits in trauma patients. In rural and remote areas, shortage of training equipment and human capacity (i.e., simulators) are the main contributors to the shortage of local training courses aiming at the development and maintenance of IO skills. Specifically, current training equipment options available for trainees include commercially available simulators, which are often expensive, or animal tissues, which lack human anatomical features that are necessary for optimal learning and pose logistical and ethical issues related to practice on live animals. Three-dimensional (3D) printing provides the means to create cost-effective, anatomically correct simulators for practicing IO where existing simulators may be difficult to access, especially in remote areas. This technical report aims to describe the development of maxSIMIO, a 3D-printed adult proximal tibia IO simulator, and present feedback on the design features from a clinical co-design team consisting of 18 end-point users. Overall, the majority of the feedback was positive and highlighted that the maxSIMIO simulator was helpful for learning and developing the IO technique. The majority of the clinical team responders also agreed that the simulator was more anatomically accurate compared to other simulators they have used in the past. Finally, the survey results indicated that on average, the simulator is acceptable as a training tool. Notable suggestions for improvement included increasing the stability of the individual parts of the model (such as tightening the skin and securing the bones), enhancing the anatomical accuracy of the experience (such as adding a fibula), making the bones harder, increasing the size of the patella, making it more modular (to minimize costs related to maintenance), and improving the anatomical positioning of the knee joint (i.e., slightly bent in the knee joint). In summary, the clinical team, located in rural and remote areas in Canada, found the 3D-printed simulator to be a functional tool for practicing the intraosseous technique. The outcome of this report supports the use of this cost-effective simulator for simulation-based medical education for remote and rural areas anywhere in the world.

Intraosseous Access in the Prehospital Setting: Literature Review

Although the majority of Australian intensive care paramedics use the manual intraosseous infusion technique (MAN-IO), several other semiautomatic devices now are available, such as the bone injection gun (BIG) and the semiautomatic intraosseous infusion system (EZ-IO). Given the choice of devices now available, questions have been raised regarding success rates, accuracy, decay of skills, and adverse events. Review the literature regarding the use of intraosseous (IO) devices in the prehospital setting. Selected electronic databases (Medline, Embase, and CINAHL) were searched, and a hand search was conducted for grey-literature that included studies from the commencement of the process to the end of May 2010. Inclusion criteria were any study reporting intraosseous insertion and/or infusion (adult and pediatric) by paramedics in the prehospital setting. The search located 2,100 articles; 20 articles met the inclusion criteria. The review also noted that use of IO access (regardless of technique) offers a safe and simple method for gaining access to the patients' vascular system. A number of studies found that the use of semiautomatic devices offers better and faster intraosseous access compared with the use of manual devices, and also were associated with fewer complications. The findings also suggest that the use of semiautomatic devices can reduce insertion times and the number of insertion attempts when contrasted with the use of manual insertion techniques. Despite these findings, statistically no specific IO device has proven clinical superiority. While manual IO techniques currently are used by the majority of Australian paramedics, the currently available evidence suggests that semiautomatic devices are more effective. Further research, including cost-benefit analyses, is required at a national level to examine skill acquisition, adverse effects, and whether comparative devices offer clinically significant advantages.

Alternative intraosseous infusion technique via spinal needle, valuable tool for paediatric resuscitation

Alternative intraosseous infusion technique via spinal needle, valuable tool for paediatric resuscitation

Low-cost solution for high fidelity simulation training in pediatric resuscitation improves clinical performance in pediatric resuscitation

S76 Abstracts / Resuscitation 81S (2010) S1–S114AP166Out-of-hospital pediatric cardiopulmonary arrest in a rural communityIglesias-Vazquez A., Rodriguez-Nu˜nez A., Sanchez-Santos L., Chayan-Zas L., BarreiroDiaz M.V., Aguilera Luque J.M.Public Emergency Medical System of Galicia, SpainPurpose of the study: Cardiorespiratory arrest (CRA) is a rare event in childhood andits characteristics are not well known all over the world. Our objective was to know thecharacteristics of pediatric CRA and the immediate results of CPR in Galicia.Materials and methods: Prospective observational study. Data were prospectivelyrecorded following the Utstein’s style guidelines. All children (0–16) who suffered anout-of-hospital CRA in Galicia and were assisted by the Emergency System staff, fromJune 2002 to February 2005 were included in the study.Results: 31 cases were analyzed. Time CRA-CPR was lower than 10min in 32.2% andlonger than 20min in 29.0%. 22.6% of children received bystander CPR. The first recordedrhythmwasasystolein67.7%.Bag-maskventilationwasusedin80.6%and87%ofpatientswereintubated.Aperipheralvenousaccesswasachievedin67.7%andintraosseousaccesswas used in 16.1% of patients. Statistical analysis indicates a low and non-significant rela-tionship between intubation and bystander CPR with survival. We think that an increasein the number of children of the study would show this initial difference much better.After initial CPR, restoration of spontaneous circulation was achieved in 38.7%. In 32.2%CPR was unsuccessful. Out of 21 patients who arrived at hospital 11 were dead beforeadmission (35.5%) and 10 (32.2%) were admitted; 4 died during hospital stay (12.9%) and6 survived until hospital discharge (19.4%).Conclusions: Pediatric CRA characteristics and CPR results in Galicia are comparableto references from other communities. Programs to increase bystander CPR, to improvelaypeople basic CPR skillfulness and to update life support knowledge of health staff areneeded.doi:10.1016/j.resuscitation.2010.09.311AP167Alternative intraosseous infusion technique via spinal needle, valuable tool for pae-diatric resuscitationCraiu M.

Intraossäre Infusion

Timely establishment of venous access in infants and toddlers can prove a particularly challenging task. Since the 1940s the technique of intraosseous infusion has established itself as a valuable alternative means for rapid, efficient and safe delivery of drugs and fluids to critically ill children. Whereas international guidelines for paediatric emergency medical care have assigned intraosseous infusion a high priority, most anaesthetists utilize this well-proven technique with great reluctance. This article describes the technique of intraosseous infusion, introduces two different cannulation systems, and discusses its potential indications in paediatric anaesthesia, based on current emergency medical care guidelines as well as some of our own case studies. In particular, children with acutely life-threatening conditions, such as circulatory arrest, laryngospasm, acute airway haemorrhage, hypovolaemic shock or hypothermia secondary to extensive burns, should receive an intraosseous cannula if intravenous access cannot be rapidly established. Future discussion may reveal whether a transiently inserted intraosseous infusion would also be indicated if the child with difficult or impossible venous access presents without acute life-threatening conditions for anaesthesia. Successful application of the intraosseous infusion technique requires immediate access to the necessary equipment, intensive education, continuous training and clear guidelines for its application in an anaesthesia department.

Comparison of two intraosseous infusion systems for adult emergency medical use

The current guidelines of the European Resuscitation Council (ERC) stipulate that an intraosseous access should be placed if establishing a peripheral venous access for cardiopulmonary resuscitation (CPR) would involve delays. The aim of this study was therefore to compare a manual intraosseous infusion technique (MAN-IO) and a semi-automatic intraosseous infusion system (EZ-IO) using adult human cadavers as a model. After receiving verbal instruction and giving their written informed consent, the participants of the study were randomized into two groups (group I: MAN-IO, and group II: EZ-IO). In addition to the demographic data, the following were evaluated: (1) Number of attempts required to successfully place the infusion, (2) Insertion time, (3) Occurrence of technical complications and (4) User friendliness. Evaluation protocols from 84 study participants could be evaluated (MAN-IO: n=39 vs. EZ-IO: n=45). No significant differences were seen in the study participants' characteristics. Insertion times (MW+/-S.D.) of the respective successful attempts were comparable (MAN-IO: 33+/-28s vs. EZ-IO: 32+/-11s). When using the EZ-IO, the access was successfully established significantly more often on the first attempt (MAN-IO: 79.5% vs. EZ-IO: 97.8%; p<0.01). The EZ-IO was also found to have more advantages in terms of technical complications (MAN-IO: 15.4% vs. EZ-IO: 0.0%; p<0.01) and user friendliness (school grading system: MAN-IO: 1.9+/-0.7 vs. EZ-IO: 1.2+/-0.4; p<0.01). In an adult human cadaver model, the semi-automatic system was proven to be more effective. The EZ-IO gave more successful results, was associated with fewer technical complications, and is user friendlier.

Intraosseous infusion for burns resuscitation

Two examples of resuscitation of a scalded child by intraosseous infusion, following failed peripheral venous cannulation, are presented. The technique of intraosseous infusion is reviewed and it is concluded that this technique provides a valuable second-line technique for establishing emergency venous access in children. It is quick, reliable and enables the rapid infusion of intravenous fluids and drugs into the systemic venous system. Complications are rare but can be serious and close observation of the infusion site is advisable.

Intraosseous infusion in pediatric patients

In traumatically injured or medically unstable pediatric patients requiring resuscitation, gaining intravenous access often is frustrating for the physician and agonizing for the patient. Even when cardiopulmonary resuscitation is performed by trained professionals, cardiac arrests in children in the prehospital setting have a mortality of 79% to 100%. Immediate vascular access such as that obtained by intraosseous infusion improves survival. The intraosseous infusion technique uses the medullary cavity in the tibia as a "noncollapsible vein" for parenteral infusion. It is indicated in a child in shock or cardiac arrest when two attempts to access peripheral vasculature have failed or when more than 2 minutes have elapsed in the attempt to gain access. Epinephrine, bicarbonate, calcium, lidocaine, and volume expanders can be infused via the intraosseous route. Complications rarely occur. The technique described here is gaining acceptance in both prehospital and emergency department settings.

Adoption of intraosseous infusion technique for prehospital pediatric emergency care

A telephone survey was conducted, contacting 51 designated state EMS offices, to determine the extent of use of intraosseous (IO) infusions in prehospital pediatric emergency care nationally and to identify common means of promoting IO adoption, training EMS personnel, and monitoring intraosseous field use. Less than half of the respondents reported actual prehospital use of IO infusions in pediatric patients, and an additional third indicated that they were unaware of any future plans for introducing the technique into EMS practice. This study's documentation of the current limited prehospital use of intraosseous infusions indicates a need for concerted efforts to promote broad adoption and continued evaluation of the IO technique in prehospital pediatric emergency care. Suggestions to enhance adoption include increased utilization of existing successful IO teaching approaches, development of national EMS standards regarding intraosseous infusions, active involvement of EMS regulatory agencies for widespread practice changes, and consistent quality assurance activities.

Emergency intraosseous infusion in severely burned children

Severely burned patients require rapid administration of large volumes of isotonic fluids. Obtaining adequate intravenous (IV) access in children with greater than 70% total body surface area burns may be difficult, time-consuming, and sometimes impossible. This report describes the use of intraosseous infusion technique as a life-saving means of establishing IV access in two severely burned children.

Intraosseous Infusion

IMMEDIATE vascular access is required for the optimal management of many emergencies in children, including cardiopulmonary arrest, burns, prolonged life-threatening status epilepticus, and shock due to trauma, dehydration, or sepsis.1 2 3 In many of these critically ill children, however, it is not easy to gain access to the vascular system. In one study at a pediatric medical center, for example, placement of an intravenous catheter required 10 minutes or more in 24 percent of the children in cardiac arrest.4 The technique of intraosseous infusion offers hope for rapid vascular access in such critically ill young children. The technique is not a . . .

The safety of intraosseous infusions: Risks of fat and bone marrow emboli to the lungs

The technique of intraosseous infusion is a life-saving emergency alternative when IV access is impossible or will be critically delayed. Concerns about its safety remain, especially concerning the risk of bone marrow and fat emboli to the lungs. We examined autopsy pulmonary specimens on two children who had received intraosseous infusions during resuscitation attempts and found an average of 0.23 to 0.71 bone marrow and fat emboli per mm2 of lung. We studied normotensive dogs with intraosseous infusions of emergency drugs and solutions into the distal femur. Three dogs were studied with each of the following emergency drugs or solutions: controls with normal saline (0.9% NaCl), epinephrine 0.01 mg/kg, NaHCO3 1 mEq/kg, CaCl 10 mg/kg, atropine 0.01 mg/kg, hydroxyethyl starch 6% in normal saline 10 mL/kg, 50% dextrose in water 0.25 g/kg, and lidocaine 1 mg/kg. Four hours after infusion, the animals were killed, and representative sections of the lung were examined with oil red-0 and hematoxylin and eosin stains for the presence of fat and bone marrow emboli. Fat and bone marrow emboli were found in all lung sections, varying from 0.11 to 4.48 emboli/mm2 lung (mean, 0.91 emboli/mm2 lung) for the emergency drugs and solutions and 0.06 to 0.53 emboli/mm2 (mean, 0.29 emboli/mm2 lung) for the controls. Analysis of variance revealed no significant difference (P = .07) in mean number of fat and bone marrow emboli per square millimeter of lung among the emergency drugs and compared with controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Prehospital Intraosseous Infusion by Emergency Medical Services Personnel: A Prospective Study

Intraosseous infusion technique by paramedics in the prehospital setting was prospectively evaluated. Intraosseous access was successfully established in 16 of 17 pediatric patients with cardiopulmonary arrest. There were 13 successful first attempts with intraosseous access established within 1 minute. No significant complications occurred. In this study, the ease of establishing intraosseous access by paramedics in the field is documented.

Implementation of intraosseous infusion technique by aeromedical transport programs.

Aeromedical transport program implementation of intraosseous infusion (IOI) was ascertained by telephone survey. One hundred thirty-three programs were polled: 69.2% had never utilized IOI nor were considering its use; 13.5% had previously utilized IOI; 15.8% had not yet implemented IOI but had been in-serviced on the technique; and 1.5% were considering implementation. Of 39 programs previously in-serviced or presently utilizing the procedure, seven restricted IOI insertion to physicians while 32 permitted placement by nurses or paramedics. Half of the programs would pursue IOI immediately after a 5-minute trial of peripheral line placement in preference to cutdown or central venous line attempts. About 50 IOI were performed by aeromedical transport personnel in 1986. Rate of successful insertion was approximately 80%. Complications were few and minor. This survey demonstrates that the simple, safe technique of IOI is being grossly under-utilized and warrants further consideration.

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 infusions by prehospital personnel in critically ill pediatric patients.

A program to instruct ground and aeromedical prehospital emergency medical system providers in the intraosseous infusion technique was developed and implemented. Paramedics and flight nurses received training through lectures and performance of the procedure in several animal models. The records of attempts on 15 patients who subsequently received intraosseous infusions were then reviewed. An intraosseous infusion was successful in 12 of 15 attempts (80%), and all needles were placed in less than 30 seconds. Drugs administered included phenobarbitol, phenytoin, atropine, epinephrine, sodium bicarbonate, isoproterenol, and pancuronium. Observed complications were limited to minimal subcutaneous infiltration in three cases and slow infusion in another. No serious sequelae were noted, but most patients did not survive and the ability of this study to detect sequelae may be limited. These data suggest that intraosseous infusion is a safe and reliable technique in the prehospital setting. Research is needed to study this technique in more detail.

Intraosseous infusions: a review.

Intravenous access is critical in infants and children with severe shock or cardiac arrest. However, it is in these clinic situations that venous access may be most difficult. The technique of intraosseous infusion may provide a useful alternative to intravenous access in the initial phases of resuscitation. The method of insertion, indications, contraindications, and complications are reviewed.