Uso de la vía intraósea en emergencias extrahospitalarias / Use of the intraosseous route in outpatient emergencies

En situaciones de emergencia, la canalización de un acceso venoso puede complicarse. En esos casos se utiliza la vía intraósea, al tratarse de un sistema de inserción rápido y seguro y de fácil ejecución. A través de la vía intraósea se consigue el paso de sustancias a la circulación sistémica con la misma rapidez que un acceso venoso periférico. Además, no se colapsa en situaciones de shock. Para su inserción existen distintos dispositivos según la situación clínica del paciente. Con este manuscrito se pretende dar a conocer las ventajas de la punción intraósea en emergencias extrahospitalarias, así como la necesidad de adquirir ciertos conocimientos y el adiestramiento necesario para el uso de esta vía de perfusión. Es una técnica que presenta muchas ventajas en situaciones de emergencia, cada vez más utilizada, pero aún desconocida por gran parte de los profesionales de Enfermería.(AU)

In emergency situations, the insertion of a venous IV line might get complicated. In these cases, the intraosseous route is used, because it is a fast and safe insertion system, and easy to conduct. Through the intraosseous route, the transit of substances to the systemic circulation is achieved with the same speed than with a peripheral venous access. Besides, there is no collapsing in shock situations. There are different devices for its insertion, according to the clinical situation of the patient. The objective of this text is to make public the advantages of intraosseous puncture in outpatient emergencies, as well as the need to acquire certain skills and the training necessary for the use of this perfusion route. This is a technique which offers many advantages in emergency situations and which is increasingly used, but still unknown by a great part of Nursing professionals.(AU)

Análisis de la vía intraósea: Una alternativa para enfermería ante casos urgentes / Analysis of the intraosseous route. an alternative for nursing in emergency cases

Introducción: La vía intraósea es la segunda vía de elección ante la imposibilidad de canalizar una vía intravenosa en situaciones de extrema urgencia. Se consigue de forma rápida y sencilla y requiere pocos segundos para su inserción. Objetivos: Conocer la bibliografía escrita sobre la técnica de inserción intraósea, así como conocer cómo se lleva a cabo y sus ventajas. Compararla con la vía intravenosa. También indagar sobre los conocimientos de los enfermeros de diferentes lugares sobre esta vía. Metodología: Se realiza una revisión bibliográfica sobre la vía intraósea utilizando las bases de datos PubMed, Medline y Buscador Gerión. Los artículos considerados para la inclusión en el estudio se publicaron en los últimos seis años, tanto en inglés como en castellano. Resultados: La vía intraósea se inserta en zona tibial proximal en niños menores de seis años y tibial distal en adultos. Requiere un mínimo de entrenamiento para su inserción y una vigilancia constante para evitar la aparición de complicaciones. Dependiendo de las enfermeras estudiadas se obtienen diferentes resultados según el área en la que trabajan. No existe ninguna diferencia de absorción entre la vía intravenosa e intraósea. Discusión y conslusiones: Los profesionales de emergencias extrahospitalarias son los que obtienen mejores conocimientos y más utilizan esta técnica. El resto debe recibir formación para aumentar su habilidad y considerar la vía intraósea como alternativa a la intravenosa en cualquier situación que pueda presentarse

Introduction: The intraosseous (IO) route is the second route of choice in emergency cases, when inserting a venous catheter is extremely difficult. Venous access through the IO route is achieved easily and quickly, requiring few seconds for insertion. Objectives: To review the available literature on intraosseous insertion technique, to determine how it is best performed, its advantages and to compare it with the use of the intravenous route. Furthermore, to inquire on the knowledge that nurses from different geographical locations and services have on the IO route. Methodology: A bibliographic review on articles discussing the IO route was performed using the following search engines: Pubmed, Medline and Buscador Gerion. Articles published in English and Spanish over the last six years were considered for inclusion. Results: The IO route is inserted in the proximal tibial zone in children younger than six years and in the distal tibial zone in adults. Its insertion requires minimum training and a constant vigilance to avoid complications. Depending on the nurses analyzed, different results were obtained based on their area of work. No absorption difference was found between the intravenous and intraosseous route. Discussion and conclusions: Outpatient emergency professionals are those who have enhanced knowledge and are most skilled in the use of IO technique. The remaining staff should receive training to increase their skills in order to consider the intraosseous route as an alternative to the intravenous route in situations where it might be required

Root damage induced by intraosseous anesthesia–An in vitro investigation

Objectives: The principle of the intraosseous anesthesia (IOA) relies on the perforation of the cortical plate of the bone for direct application of the local anesthetic solution into the underlying cancellous structures. During this procedure, IOA needles might accidentally come in contact with the tooth roots. The aim of the current in vitro study was to examine the consequences of this 'worst case scenario' comparing five commercially available IOA systems. Material and Method: Extracted human roots were randomly perforated using five different IOA systems with a drilling time ≤5s. To simulate normal in vivo conditions, the roots were kept humid during the drilling procedure. Data was statistically evaluated using F-test (SPSS16, SPSS Inc., Chicago, USA) and the significance level was set at p ≤ 0.05. Results: All examined systems resulted in root perforation. Drill fractures occurred in either none 0% (Quicksleeper, Anesto, Intraflow, Stabident) or 100% (X-Tip) of the applications. Excessive heat generation, as evident by combustion odor as well as metal and tooth discoloration, appeared in 30% (Quicksleeper), 40% (Anesto), 60% (Intraflow), 90% (Stabident) and 100% (X-Tip) of all perforations. Cconclusions: Within the limits of in-vitro studies, the results show a potential for irreversible root damage that might be inflicted by an improper use of IOA systems (AU)

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Side effects and complications of intraosseous anesthesia and conventional oral anesthesia

Objective: To analyze the side effects and complications following intraosseous anesthesia (IA), comparing them with those of the conventional oral anesthesia techniques.Material and method: A simple-blind, prospective clinical study was carried out. Each patient underwent two anesthetic techniques: conventional (local infiltration and locoregional anesthetic block) and intraosseous, for respective dental operations. In order to allow comparison of IA versus conventional anesthesia, the two operations were similar and affected the same two teeth in opposite quadrants. Heart rate was recorded in all cases before injection of the anesthetic solution and again 30 seconds after injection. The complications observed after anesthetic administration were recorded.Results: A total of 200 oral anesthetic procedures were carried out in 100 patients. Both IA and conventional anesthesia resulted in a significant increase in heart rate, though the increase was greater with the latter technique. Incidents were infrequent with either anesthetic technique, with no significant differences between them. Regarding the complications, there were significant differences in pain at the injection site, with more intense pain in the case of IA (x2=3.532, p=0.030, Ö2=0.02), while the limitation of oral aperture was more pronounced with conventional anesthesia (x2=5.128, p<0.05, Ö2=0.014). Post-anesthetic biting showed no significant differences (x2=4.082, p=0.121, Ö2=0.009). Conclusions: Both anesthetic techniques significantly increased heart rate, and IA caused comparatively more pain at the injection site, while limited oral aperture was more frequent with conventional anesthesia. Post-anesthetic biting showed no significant differences between the two techniques (AU)

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Intraosseous anesthesia with solution injection controlled by a computerized system versus conventional oral anesthesia: A preliminary study

Objective: To compare a computerized intraosseous anesthesia system with the conventional oral anesthesia techniques, and analyze the latency and duration of the anesthetic effect and patient preference. Design: A simple-blind prospective study was made between March 2007 and May 2008. Each patient was subjected to two anesthetic techniques: conventional and intraosseous using the Quicksleeper(R) system (DHT, Cholet, France). A split-mouth design was adopted in which each patient underwent treatment of a tooth with one of the techniques, and treatment of the homologous contralateral tooth with the other technique. The treatments consisted of restorations, endodontic procedures and simple extractions.Results: The study series comprised 12 females and 18 males with a mean age of 36.8 years. The 30 subjects underwent a total of 60 anesthetic procedures. Intraosseous and conventional oral anesthesia caused discomfort during administration in 46.3% and 32.1% of the patients, respectively. The latency was 7.1±2.23 minutes for the conventional technique and 0.48±0.32 for intraosseous anesthesia - the difference being statistically significant. The depth of the anesthetic effect was sufficient to allow the patients to tolerate the dental treatments. The duration of the anesthetic effect in soft tissues was 199.3 minutes with the conventional technique versus only 1.6 minutes with intraosseous anesthesia - the difference between the two techniques being statistically significant. Most of the patients (69.7%) preferred intraosseous anesthesia. Conclusions: The described intraosseous anesthetic system is effective, with a much shorter latency than the conventional technique, sufficient duration of anesthesia to perform the required dental treatments, and with a much lesser soft tissue anesthetic effect. Most of the patients preferred intraosseous anesthesia (AU)

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Comparative study between manual injection intraosseous anesthesia and conventional oral anesthesia

Objective: To compare intraosseous anesthesia (IA) with the conventional oral anesthesia techniques. Materials and methods: A simple-blind, prospective clinical study was carried out. Each patient underwent two anesthetic techniques: conventional (local infiltration and loco regional anesthetic block) and intraosseous, for respective dental operations. In order to allow comparison of IA versus conventional anesthesia, the two operations were similar and affected the same two teeth in opposite quadrants. Results: A total of 200 oral anesthetic procedures were carried out in 100 patients. The mean patient age was28.6±9.92 years. Fifty-five vestibular infiltrations and 45 mandibular blocks were performed. All patients were also subjected to IA. The type of intervention (conservative or endodontic) exerted no significant influence (p=0.58 and p=0.62, respectively). The latency period was 8.52±2.44 minutes for the conventional techniques and 0.89±0.73minutes for IA - the difference being statistically significant (p<0.05). Regarding patient anesthesia sensation, the infiltrative techniques lasted a maximum of one hour, the inferior alveolar nerve blocks lasted between 1-3 hours, and IA lasted only 2.5 minutes - the differences being statistically significant (p≤0.0000, Phi=0.29). Anesthetic success was recorded in 89% of the conventional procedures and in 78% of the IA. Most patients preferred IA(61%) (p=0.0032).Conclusions: The two anesthetic procedures have been compared for latency, duration of anesthetic effect, anesthetic success rate and patient preference. Intraosseous anesthesia has been shown to be a technique to be taken into account when planning conservative and endodontic treatments (AU)

A prospective, randomized, triple-blind comparison of articaine and bupivacaine for maxillary infiltrations

Objectives: To compare the clinical anesthetic efficacy of 0.5% bupivacaine and 4% articaine (both with 1:200.000adrenaline) for anterior maxillary infiltration in healthy volunteers. Material and methods: A triple-blind split-mouth randomized clinical trial was carried out in 20 volunteers. A supraperiosteal buccal injection of 0.9 ml of either solution at the apex of the lateral incisor was done in 2 appointments separated 2 weeks apart. The following outcome variables were measured: latency time, anesthetic efficacy(dental pulp, keratinized gingiva, alveolar mucosa and upper lip mucosa and tissue) and the duration of anesthetic effect. Hemodynamic parameters were monitored during the procedure. Results: Latency time recorded was similar for both anesthetic solutions (p>0.05). No statistically significant differences were found in terms of anesthetic efficacy for dental pulp, keratinized gingiva or alveolar mucosa. Articaine had a significant higher proportion of successful anesthesia at 10 minutes after infiltration in lip mucosa and lip skin (p=0.039). The duration of anesthesia was 336 minutes for bupivacaine and 167 minutes for articaine. (p<0.001). No significant hemodynamic alterations were noted during the procedure. Conclusions: Articaine and bupivacaine exhibited similar anesthetic efficacy for maxillary infiltrations. The duration of anesthesia was longer with the bupivacaine solution, but lip anesthesia was better with articaine (AU)

La vía intraósea en situaciones de emergencia: análisis en el medio extrahospitalario / Intraosseous access in prehospital emergency care

Objetivo: Evaluar la efectividad del dispositivo EZ-IO® para canalizar una vía intraósea en situaciones de emergencia extrahospitalaria. Como objetivos específicos se ha monitorizado el tiempo de canalización de la cavidad medular y determinado la presencia y número de complicaciones en el acceso intraóseo. Método: Estudio descriptivo, observacional y prospectivo realizado en el periodo de enero 2008 a diciembre 2010 en el Área Metropolitana de Barcelona. Se incluyeron aquellos pacientes con inestabilidad hemodinámica o parada cardiorrespiratoria (PCR) a los que no fue posible canalizar una vía venosa periférica en 90’’ o bien tras tres intentos. Se excluyeron todos los pacientes con buen acceso venoso o que no se estaban en situación crítica. En todos los casos la punción intraósea se realizó con el dispositivo EZIO®. Las zonas de abordaje fueron la tibia y el húmero. Resultados: Se incluyeron 49 pacientes: la mitad varones (67,3%) y con edades entre 4 meses y 86 años (media: 49,3, desviación estándar: 25,9). El 77,6% de pacientes se encontraban en PCR (77,6%). El tiempo invertido en canalizar la vía intraósea fue inferiora 10” en el 44,9%, y las complicaciones durante su inserción fueron escasas. Conclusión: La rapidez en tener un acceso vascular unido a la baja presencia de complicaciones convierte la vía intraósea EZ-IO® en una excelente alternativa para la administración de fármacos y/o sueroterapia tanto en el enfermo crítico como en aquél que se encuentra en PCR en el medio extrahospitalario (AU)

Objective: To assess the effectiveness of the EZ-IO device for intraosseous catheter insertion in the prehospital emergency setting in terms of time needed to insert the catheter into the bone marrow and the presence and number of complications. Methods: Prospective observational study of patients treated between January 2008 and December 2010 in the metropolitan area of Barcelona, Spain. We included patients with hemodynamic instability or in cardiorespiratory arrest in whom venous access could not be achieved within 90 minutes or after 3 attempts. Patients with good venous accessor who were not in critical condition were excluded. In all cases the intraosseous puncture was performed with the EZ-IO in the tibia or the humerus. Results: Forty-nine patients were included. More than half (67.3%) were male; ages ranged from 4 months to 86 years(mean [SD] 49.29 [25.89] years). Most patients were in cardiorespiratory arrest (77.6%). The bone marrow could be accessed within 10 minutes in 44.9% of the patients and few complications occurred during insertion. Conclusion: Rapid vascular access and a low complication rate make EZ-IO placement of an intraosseous catheter anexcellent for choice for injecting drugs or fluids when patients are in cardiorespiratory arrest or other critical conditions in the prehospital setting (AU)

El acceso intraóseo para fluidoterapia en situación de combate. Experiencia de la sanidad militar española en Afganistán / Intraosseous access for fluid therapy in combat situations: use by Spanish military medical staff in Afghanistan

Objetivos: Se expone la experiencia de de la Sanidad Militar española en el uso de dispositivos de punción intraósea para fluidoterapia en una zona de combate. Pacientes y método: Estudio descriptivo de una serie de 25 pacientes. El número de agujas empleadas fue de 30. Los sujetos de estudio fueron aquellos pacientes con lesión por de arma de fuego, por explosión de artefactos explosivos o politraumatizados, atendidos por médicos militares españoles en la región oeste de Afganistán (Herat) entre marzo de 2007 y Junio de 2008. Resultados: La técnica se realizó en 19 pacientes en medio prehospitalario. A los 6 restantes les fue realizada la técnica en el hospital militar español (ROLE 2). Todos los pacientes eran varones, con una media de edad de 26 años (DE 2,3), la mayoría pertenecían al Ejército Nacional afgano (64%), presentaron heridas por artefacto explosivo (68%) y el lugar de lesión predominante fueron los miembros inferiores (56%). Se consiguió una vía permeable en el 76% de los casos. En el ROLE 2 la técnica obtuvo éxito en el 100% de los casos. El primer lugar de elección elegido fue la tuberosidad tibial anterior. La vía intraósea fue empleada para la perfusión de fluidos y medicamentos. No se encontraron complicaciones secundarias a la inserción de la aguja. Sin embargo, 5 pacientes presentaron dolor. Conclusión: Basándose en nuestra experiencia, el empleo del acceso intraóseo como alternativa al venoso, puede ser recomendable para el tratamiento del paciente traumático atendido en el ámbito militar (AU)

Objectives: To describe the Spanish military medical staff’s experience with the use of intraosseous lines for fluid therapy in a combat zone. Patients and methods: Descriptive study of 25 patients (30 needles). The patients were injured by firearms or explosive devices, or had multiple injuries, and were attended by Spanish military physicians in western Afghanistan (Herat) between March 2007 and June 2008. Results: The bone puncture was performed on 19 patients in prehospital settings. The remaining 6 patients underwent the procedure in the Spanish military hospital. All patients were men; the mean (SD) age was 26 (2.3) years. Most belonged to the Afghan National Army (64%) and had injuries caused by explosive devices (68%). The largest percentage of injuries involved the lower limbs (56%). A line could be inserted in 76% of the cases (100% at the military hospital). The first-choice site of puncture was the anterior tibial tuberosity. Fluids and medications were successfully administered through the intraosseous lines. No complications occurred during needle insertion, but 5 patients reported pain. Conclusion: Our experience suggests that intraosseous access can provide an alternative to venous access for treating trauma patients in combat zones (AU)

La vía intraósea en situaciones de emergencia: revisión bibliográfica / Intraosseus infusion in emergency situations: bibliographic review

Objetivo: Análisis de la documentación científica sobre la vía intraósea (IO) en situaciones de emergencia. Métodos: Revisión de la literatura médica para la evaluación de la antigüedad y distribución de los trabajos según el sujeto a estudio; zonas de acceso IO; sistemas de infusión IO; flujos; tiempos de inserción; indicaciones y complicaciones de los sistemas IO. Resultados: Se revisaron 201 trabajos (1057 accesos IO) desde 1945 hasta 2006 (humanos 82; animales 55; cadáveres y/o maniquíes 23; revisiones o comentarios 41). Documentamos: Accesos en tuberosidad tibial 501; epífisis/metáfisis 106; clavícula 64; esternón 62; cresta ilíaca 51; maléolos 24; fémur 3; calcáneo 1. Tiempos inserción: inferior a 60 segundos 240; de 60 a 120 segundos 106; superior a 120 segundos 12. Agujas y sistemas IO: aguja de Jamshidi 261; sistema B.I.G. 145; aguja de Cook 100; sistema F.A.S.T.1 50; agujas intramusculares y punción lumbar 35; palomillas 22. Los flujos varían de 25 a 100 ml/minuto en función del calibre del catéter y presión de infusión. La extravasación (14 casos), el síndrome compartimental (7 casos) y la osteomielitis (5 casos) son las complicaciones más frecuentes recogidas. Conclusión: La vía IO es un acceso venoso rápido, temporal, de fácil aprendizaje y colocación y de escasas complicaciones. El estudio sistematizado de esta técnica, mejoraría la evidencia científica existente sobre la infusión IO (AU)

Objectives: Analysis of the scientific documents about the intraosseous (IO) infusion in emergency situations. Methods: Review of the medical literature for the evaluation of the studies, IO access areas, IO infusion systems, flows, insertion times, recommendations and complications of the IO systems. Results: 201 studies (1057 IO access) have been reviewed from 1945 to 2006 (humans n=82; animals n=55; cadaver and skill lab n=23; reviews or comments n=41). We document: Accesses in tibial tuberosity n=51; epiphysis/metaphysis n=106; clavicula n=64; sternum n=62; iliac crest n=51; malleolus n=24; femur n=3; calcaneum n=1. Insertion times: below 60 seconds n=240; from 60 to 120 seconds n=106; above 120 seconds n=12. Needles and IO systems: Jamshidi needle n=261; B.I.G. system n=145; Cook needle n=100; F.A.S.T. 1 system n=50; intramuscular needles and/or lumbar puncture n=35; butterfly needle n=22. Flows vary from 25 to 100 ml/minute according to the catheter calibre and the infusion pressure. The extravasation (n=14), compartment syndrome (n=7) and osteomyelitis (n=5) are the most prevalent complications gathered. Conclusion: IO access is quick, temporal, easy to learn and to place with few complications. The systematized study of this device could make the scientific evidence about IO better (AU)

Una alternativa a la vía venosa difícil / An alternative to the difficult venous path

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La vía intraósea y enfermería / The intra bone passage and nursing

Se confirma la utilidad de la vía intraósea como acceso vascular de emergencia cuando la instauración de la vía venosa periférica y/o central se hace difícil o imposible en la atención a pacientes críticos, como otra técnica más de Enfermería en la atención al paciente crítico. De la bibliografía revisada se deduce que el acceso vascular intraóseo constituye una vía de acceso rápida, fácil y eficaz al sistema vascular, sobre todo en los niños menores de 6 años. La utilidad de la vía intraósea está justificada cuando se tarda más de 90 segundos o tras tres intentos fallidos de canalización venosa periférica en pacientes críticos o inestables. Las zonas anatómicas más adecuadas de punción en niños son la porción proximal y distal de la tibia y el fémur distal. Permite la administración de líquidos y fármacos igual que la vía venosa periférica. Tanto las complicaciones como las contraindicaciones son escasas (AU)

La vía intraósea. Cuando las venas han desaparecido / The intraosseal route. When the veins have disappeared

El objetivo de este estudio es mostrar la utilidad de la vía intraósea como acceso vascular de emergencia, especialmente en niños, cuando el acceso vascular a través de vías periféricas o centrales se hace difícil o imposible. De la bibliografía revisada se deduce que la vía intraósea constituye una vía de acceso rápida, fácil y eficaz al sistema vascular, sobre todo en los niños menores de 6 años. Su utilidad está indicada cuando, en situaciones de extrema urgencia, se tarda mucho en canalizar una vía periférica o central y la vida del niño está en peligro. La zona más adecuada para su inserción es la porción proximal y porción distal de la tibia y la porción distal del fémur. Permite la administración de líquidos, electrólitos y fármacos comparable a la vía venosa. Las complicaciones son escasas, siendo la más grave el síndrome compartimental. Además de ser una vía alternativa para la perfusión de sustancias y fármacos en el torrente circulatorio, sirve como lugar de acceso al sistema vascular para la toma de muestras con fines de estudios de laboratorio. Se concluye que la vía intraósea constituye una vía de acceso al sistema vascular fácil, rápida y segura. Las complicaciones suelen ser raras y las contraindicaciones escasas (AU)