[Alternatives to the intravenous route in emergency situations]. / Alternatives à la voie intraveineuse en situation d'urgence.

Patients in emergency situations or life distress most often need a intravenous line (IV) to give them the medications they need. The IV route is the preferred route to treat most of the patients in emergency situations out of hospital or in the emergency room but can be very tricky to obtain. Various alternatives have been developed, such as the intraosseous route, particularly useful in cases of venous collapse (shock, cardiorespiratory arrest), the intramuscular route (anaphylaxis, sedation) or the intranasal route (status epilepticus, analgesia). This article reviews the indications, contraindications and pharmacology of these different routes.

Les patients en situation de détresse vitale et d'urgence nécessitent le plus souvent un accès vasculaire veineux, permettant l'administration rapide de thérapeutiques indispensables à la préservation des fonctions vitales. La voie intraveineuse périphérique est l'abord privilégié pour traiter une majorité des patients en situation d'urgence intra ou extrahospitalière, mais elle peut s'avérer complexe à obtenir. Diverses alternatives sont cependant possibles, comme la voie intraosseuse, particulièrement utile en cas de collapsus vasculaire (état de choc, arrêt cardiorespiratoire), la voie intramusculaire (anaphylaxie, sédation) ou encore la voie intranasale (état de mal épileptique, analgésie). Cet article résume les indications, contre-indications et posologies respectives des médicaments susceptibles d'être administrés par ces différentes voies.

Effectiveness of intraosseous access during resuscitation: a retrospective cohort study.

PURPOSE: During resuscitation in emergency situations, establishing intravascular access is crucial for promptly initiating delivery of fluids, blood, blood products, and medications. In cases of emergency, when intravenous (IV) access proves unsuccessful, intraosseous (IO) access serves as a viable alternative. However, there is a notable lack of information concerning the frequency and efficacy of IO access in acute care settings. This study aims to assess the efficacy of intraosseous (IO) access in acute care settings, especially focusing on children in a level 1 trauma center. METHODS: This retrospective study included patients with IO access presented in a level 1 trauma center emergency department (ED) between January 2015 and April 2020. Data regarding medication and fluid infusion was documented, and the clinical success rate was calculated. RESULTS: Of the 109,548 patients that were admitted to the ED, 25,686 IV lines were inserted. Documentation of 188 patients of which 73 (38.8%) children was complete and used for analysis. In these 188 patients, a total of 232 IO accesses were placed. Overall, 182 patients had a functional IO access (204 needles) (88%). In children (age < 18 years) success rate was lower as compared to adults, 71-84% as compared to 94%. However, univariate regression showed no association between the percentage of functional IO access and gender, age, weight, health care location (prehospital and in hospital), anatomical position (tibia as compared to humerus) or type of injury. CONCLUSION: Intraosseous access demonstrates a high success rate for infusion, independent of gender, age, weight, anatomical positioning, or healthcare setting, with minimal complication rates. Caution is especially warranted for children under the age of six months, since success rate was lower.

Selection of the Preferred Puncture Site on Manual Intraosseous Infusion: Proximal Humerus or Proximal Tibia?

Aims/Background Establishing an intraosseous infusion (IO) pathway can rapidly open an urgent route of drug administration for critically ill patients. This study aims to assess different puncture sites on the efficacy of manual intraosseous infusion. Methods Upon applying computed tomography (CT), we compared compact bone thickness and CT values at the same individual's proximal humerus and proximal tibia puncture sites (n = 40). Additionally, cadaveric experiments were used to compare the efficiency of manual puncture at two different insertion sites of the proximal humerus and proximal tibia in the same individual (n = 5). Results The compact bone thickness and CT values at the proximal humerus were significantly lower than those at the proximal tibia. The cadaveric experiments further confirmed that the proximal humerus was superior to the proximal tibia as an insertion site, indicating the proximal humerus is a more suitable insertion site for manual bone marrow puncture needles. Conclusion Selection of the puncture site markedly influences the effectiveness of manual intraosseous infusion, with the proximal humerus potentially offering better puncture efficacy than the proximal tibia.

Systematic overview of intraosseous access versus intravenous delivery for emergency resuscitation: Efficacy and quality of existing evidence.

BACKGROUND: The impact of intraosseous (IO) access on resuscitation outcomes, as compared to intravenous (IV) administration, is subject to ongoing debate. This review aims to provide a comprehensive evaluation of the methodological, reporting, and evidence quality of existing Systematic Reviews/Meta-Analyses (SRs/MAs) on IO use during resuscitation. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a strategic literature search to identify pertinent SRs/MAs published up until May 6th, 2023. After an extensive screening process, 4 SRs/MAs were included for review. We used the A Measurement Tool to Assess Systematic Reviews-2 tool for assessing methodological quality, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist for evaluating reporting quality, and the Grading of Recommendations Assessment, Development, and Evaluation framework for examining the quality of evidence. RESULTS: The assessment revealed high methodological quality across all the included SRs/MAs but showed significant variability in the quality of evidence. The studies offered conflicting findings on the impact of IO access on resuscitation outcomes such as return of spontaneous circulation, survival rates at hospital discharge, and favorable neurological outcomes. Some studies suggested an association of IO access with poorer outcomes, while others indicated no significant difference between IO and IV routes. CONCLUSIONS: Despite the perceived utility of IO access when IV access is unachievable, the impact of IO on survival, return of spontaneous circulation, and neurological outcomes remains ambiguous due to the inconsistency in the existing evidence. This review underscores the critical need for more rigorous and consistent primary research in this area to strengthen clinical guidelines and improve patient outcomes.

Intravenous Versus Intraosseous Use of Tranexamic Acid in Patients With Traumatic Brain Injury.

INTRODUCTION: Tranexamic acid (TXA) is an antifibrinolytic drug that has been demonstrated to reduce head injury-related mortality when given within 2 h of injury in patients with traumatic brain injury and intracranial hemorrhage. It is usually administered via intravenous (IV) access, which can be difficult to obtain in prehospital and austere settings. Intraosseous (IO) access is fast and offers an alternative when IV access proves challenging; however, TXA administration via IO access has never been studied in humans. We sought to determine if the total drug exposure of TXA given in the prehospital setting in patients with moderate or severe brain injury differs based on route of administration. METHODS: We performed a retrospective analysis of prospectively collected data from the prehospital TXA for traumatic brain injury trial (NCT01990768). Participants who received TXA via IO administration were compared to those who received TXA via IV administration and stratified by renal function category based on the Kidney Disease Improving Global Outcomes criteria. The area under the plasma drug concentration-time curve (AUC) was calculated using the trapezoidal rule (Phoenix WinNonlin 8.3, Certara, Princeton NJ) to obtain total drug exposure. The inverse variance method was used to combine observations within strata and calculate mean differences. RESULTS: Of the 966 participants enrolled in the trial, 345 participants received a 2-g TXA prehospital bolus (11 IO, 334 IV); 312 participants received a 1-g TXA prehospital bolus followed by a 1-g TXA infusion in-hospital over 8 h (13 IO, 299 IV). After exclusion because of missing data and extreme estimated AUC, 233 IV and eight IO participants in the 2-g bolus arm and 152 IV and eight IO participants in the 1-g bolus 1-g infusion arm remained. Participants did not differ by age, sex, race, ethnicity, body mass index, serum creatinine, estimated glomerular filtration rate, or clot lysis at 30 min on thromboelastography. No difference in the mean AUCs were observed between IV and IO for either the 2-g bolus group (-2.6 µ g/mL/h [IO] compared to IV, 95% confidence interval: -28.4 to 23.3 µ g/mL/h) or the 1-g bolus/1-g infusion group (-13.0 µ g/mL/h [IO] compared to IV, 95% confidence interval: -236.2 to 210.3 µ g/mL/h). CONCLUSIONS: These preliminary data suggest that the administration of TXA via IO and IV routes may result in similar total drug exposure. Further studies incorporating larger numbers with clinical outcomes are needed to confirm this finding.

Sternal Morphologic Characteristics of U.S. Military Males by Computed Tomography: Implications for Intraosseous Access.

INTRODUCTION: Sternal intraosseous (IO) access has advantages over humeral and tibial access for fluid resuscitation in military medical settings due to superior flow rates and pharmacokinetics. However, the morphology of the young adult manubrial cortical and medullary bone as it relates to IO catheter tips of currently available FDA-approved IO access devices is unclear. MATERIALS AND METHODS: Computed tomography manubrium images of active duty service members (N = 93) aged 18 to 30 were assessed by radiologists, including manubrial height, width, and cortical thickness, as well as total thickness and medullary thickness at the thickest (superior) and thinnest (inferior) parts of the manubrium. Inference regarding medullary or cortical IO catheter tip placement rates were made for FAST1 (5.5 mm catheter depth) and TALON (4.5 mm catheter depth) sternal IO devices. Data were analyzed using ANOVA, non-parametric, and correlational statistics at P < 0.05. RESULTS: As inferred from case-specific CT-derived manubrium dimensions and maximal catheter tip penetration depths, both FAST1 and TALON would be placed in the target medullary space on 100% of opportunities if properly applied in the superior manubrium and on 99% of opportunities if properly applied in the inferior manubrium. Age was not significantly related to IO-relevant manubrial dimensions. CONCLUSIONS: Present findings suggest that both FAST1 and TALON sternal IO catheter tips can be successfully placed into the target medullary bone with high accuracy in male military members aged 18 to 30 who require rapid resuscitation.

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

AIM: While intravenous (IV) vascular access for out-of-hospital cardiac arrest (OHCA) resuscitation is standard, humeral-intraosseous (IO) access is commonly used, despite few supporting data. We investigated the association between IV vs. humeral-IO and outcomes. METHODS: We utilized BC Cardiac Arrest Registry data, including adult OHCA where the first-attempted intra-arrest vascular access route performed by advanced life support (ALS)-trained paramedics was IV or humeral-IO. We fit a propensity-score adjusted model with inverse probability treatment weighting to estimate the association between IV vs. humeral-IO routes and favorable neurological outcomes (CPC 1-2) and survival at hospital discharge. We repeated models within subgroups defined by initial cardiac rhythm. RESULTS: We included 2,112 cases; the first-attempted route was IV (n = 1,575) or humeral-IO (n = 537). Time intervals from ALS-paramedic on-scene arrival to vascular access (6.6 vs. 6.9 min) and epinephrine administration (9.0 vs. 9.3 min) were similar between IV and IO groups, respectively. Among IV and humeral-IO groups, 98 (6.2%) and 20 (3.7%) had favorable neurological outcomes. Compared to humeral-IO, an IV-first approach was associated with improved hospital-discharge favorable neurological outcomes (AOR 1.7; 95% CI 1.1-2.7) and survival (AOR 1.5; 95% CI 1.0-2.3). Among shockable rhythm cases, an IV-first approach was associated with improved favorable neurological outcomes (AOR 4.2; 95% CI 2.1-8.2), but not among non-shockable rhythm cases (AOR 0.73; 95% CI 0.39-1.4). CONCLUSION: An IV-first approach, compared to humeral-IO, for intra-arrest resuscitation was associated with an improved odds of favorable neurological outcomes and survival to hospital discharge. This association was seen among an initial shockable rhythm, but not non-shockable rhythm, subgroups.

"Intraosseous administration of tenecteplase for thrombolysis of an acute ischemic stroke".

INTRO: Current guidelines for acute ischemic stroke recommend timely administration of intravascular thrombolytic therapy to promote functional and neurologic outcomes. Tenecteplase is an emerging off-label therapy for this indication and being utilized by various institutions due to its simpler administration strategy. In emergent situations in which intravenous access cannot be obtained, intraosseous access is a viable option for medication administration. However, there has been minimal published cases to support the efficacy and safety of intraosseous administration of tenecteplase for acute ischemic stroke. CASE: We describe the case of a 51-year-old woman who developed acute ischemic stroke within our institution. Due to difficulty achieving intravenous access and time-dependent efficacy of thrombolytic therapy, the decision was made to administer tenecteplase by the intraosseous route. Stroke symptoms improved within 48 hours following administration without complication. CONCLUSION: Intraosseous administration of tenecteplase may be considered for treatment of acute ischemic stroke if intravenous access is unattainable.

Intraosseous versus intravenous vascular access in upper extremity among adults with out-of-hospital cardiac arrest: cluster randomised clinical trial (VICTOR trial).

OBJECTIVE: To compare the effectiveness of intraosseous versus intravenous vascular access in the treatment of adult patients with out-of-hospital cardiac arrest. DESIGN: Cluster randomised controlled trial. SETTING: The VICTOR (Venous Injection Compared To intraOsseous injection during resuscitation of patients with out-of-hospital cardiac arrest) trial involved emergency medical service agencies with all four advanced life support ambulance teams in Taipei City, Taiwan. The enrolment period spanned 6 July 2020 to 30 June 2023 and was temporarily suspended between 20 May 2021 and 31 July 2021 owing to the covid-19 pandemic. PARTICIPANTS: Adult (age 20-80 years) patients with non-traumatic out-of-hospital cardiac arrest. INTERVENTIONS: Biweekly randomised clusters of four participating advanced life support ambulance teams were assigned to insert either intravenous or intraosseous access. MAIN OUTCOME MEASURES: The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation, sustained return of spontaneous circulation (≥2 hours), and survival with favourable neurological outcomes (cerebral performance category score ≤2) at hospital discharge. RESULTS: Among 1771 enrolled patients, 1732 (741 in the intraosseous group and 991 in the intravenous group) were included in the primary analysis (median age 65.0 years; 1234 (71.2%) men). In the intraosseous group, 79 (10.7%) patients were discharged alive, compared with 102 (10.3%) patients in the intravenous group (odds ratio 1.04, 95% confidence interval 0.76 to 1.42; P=0.81). The odds ratio of intraosseous versus intravenous access was 1.23 (0.89 to 1.69; P=0.21) for pre-hospital return of spontaneous circulation, 0.92 (0.75 to 1.13; P=0.44) for sustained return of spontaneous circulation, and 1.17 (0.82 to 1.66; P=0.39) for survival with favourable neurological outcomes. CONCLUSIONS: Among adults with non-traumatic out-of-hospital cardiac arrest, initial attempts to establish vascular access through the intraosseous route did not result in different outcomes compared with intravenous access in terms of the proportion of patients surviving to hospital discharge, pre-hospital return of spontaneous circulation, sustained return of spontaneous circulation, and favourable neurological outcomes. TRIAL REGISTRATION: NCT04135547ClinicalTrials.gov NCT04135547.

Prehospital transfusion of labile blood product using intraosseous perfusion with multi-lumen extender: Why not?

BACKGROUND: French prehospital military medical teams are provided with labile blood products to effectively address hemorrhagic shock. In combat environment, standard good medical practice may limit efficacy of therapeutic goals regarding damage control resuscitation. STUDY DESIGN AND METHODS: We present here a case report describing the management of a soldier heavily wounded during a helicopter forward medical evacuation in Sahel region. RESULTS: We report the challenge encountered by medical team using only a humeral intraosseous route available due to severity of lesions and challenging environment. In this configuration, multi-lumen extender enabled transfusion of two units of packed red blood cells and two units of plasma, and analgesia while limiting manipulation and dislodgment of the fragile intraosseous route. This situation, outside of usual good medical practice, raises issues of hemolysis, physicochemical compability of drugs and blood products, and consequences on flow rate reduction. DISCUSSION: With this case, we emphasize the benefit of multi-lumen extender associated with intraosseous route for early management of heavy casualties in harsh prehospital environment. Literature suggests that hemolysis and physicochemical compability should remain limited. The main issue of this setting consists of flow reduction and can be addressed by prioritizing humeral route, and using counter pressure cuffs, until a second peripheral or central line is available and management can resume without the need for multi-lumen extender.

[Intraosseous vancomycin in total knee arthroplasty]. / Vancomicina intraósea en artroplastía total de rodilla.

INTRODUCTION: intravenous antibiotic prophylaxis has significantly reduced the incidence of periprosthetic joint infection (PJI) in knee surgeries. However, for patients colonized with methicillin-resistant Staphylococcus aureus (MRSA) or those at risk of colonization, prophylaxis should include vancomycin. Intraosseous (IO) administration of vancomycin could enhance its effectiveness in total knee arthroplasty (TKA). MATERIAL AND METHODS: a retrospective review was conducted, including 143 patients at risk of PJI scheduled for TKA who received IO vancomycin along with intravenous (IV) cefazolin, referred to as group I (GI), between May 2021 and December 2022. The occurrence of complications in the first three postoperative months was evaluated. Results were compared with 140 patients without risk factors who received standard IV prophylaxis, designated as group II (GII). RESULTS: in GI, 500 mg of IO vancomycin was administered, injected into the proximal tibia, in addition to standard IV prophylaxis. In GII, patients received only IV cefazolin. The incidence of complications was 1.64% in GI and 1.4% in GII. The PJI rate at 90 postoperative days was 0.69% in GI and 0.71% in GII. CONCLUSIONS: IO vancomycin administration, along with standard IV prophylaxis, provides a safe and effective alternative for patients at risk of MRSA colonization. This approach minimizes complications associated with IV vancomycin use and addresses logistical challenges of timely administration.

INTRODUCCIÓN: la profilaxis antibiótica intravenosa ha reducido significativamente la incidencia de infección articular periprotésica (IAP) en cirugías de rodilla. No obstante, para pacientes colonizados con Staphylococcus aureus resistente a meticilina (SARM) o aquellos con riesgo de colonización, la profilaxis debe incluir vancomicina. La administración intraósea de vancomicina podría potenciar su efectividad en la artroplastía total de rodilla. MATERIAL Y MÉTODOS: se realizó una revisión retrospectiva que incluyó a 143 pacientes en riesgo de IAP programados para artroplastía total de rodilla que recibieron vancomicina intraósea junto a cefazolina intravenosa (IV), a quienes denominamos grupo I (GI), entre mayo de 2021 y diciembre de 2022. Se evaluó la aparición de complicaciones en los primeros tres meses postoperatorios. Los resultados se compararon con 140 pacientes sin factores de riesgo que recibieron profilaxis intravenosa estándar, denominados grupo II (GII). RESULTADOS: en el GI, se administraron 500 mg de vancomicina intraósea, inyectados en la tibia proximal, además de la profilaxis intravenosa estándar. En el GII, los pacientes recibieron sólo cefazolina intravenosa. La incidencia de complicaciones fue de 1.64% en el GI y de 1.4% en el GII. La tasa de IAP a los 90 días postoperatorios fue de 0.69% en el GI y de 0.71% en el GII. CONCLUSIONES: la administración de vancomicina intraósea, junto con la profilaxis intravenosa estándar, ofrece una alternativa segura y eficaz para pacientes con riesgo de colonización por SARM. Este enfoque minimiza las complicaciones asociadas con el uso intravenoso de vancomicina y soluciona los desafíos logísticos de la administración oportuna.

Low Risk of Periprosthetic Joint Infection After Aseptic Revision Total Knee Arthroplasty With Intraosseous Vancomycin.

BACKGROUND: Aseptic revisions are the most common reason for revision total knee arthroplasty (rTKA). Previous literature reports early periprosthetic joint infection (PJI) rates after aseptic rTKA to range from 3 to 9.4%. Intraosseous (IO) regional administration of vancomycin has previously been shown to produce high local tissue concentrations in primary and rTKA. However, no data exist on the effect of prophylactic IO vancomycin on early PJI rates in the setting of aseptic rTKA. The aim of this study was to determine the following: (1) what is the rate of early PJI during the first year after surgery in aseptic rTKA performed with IO vancomycin; and (2) how does this compare to previously published PJI rates after rTKA. METHODS: A consecutive series of 117 cases were included in this study who underwent rTKA between January 2016 and March 2022 by 1 of 2 fellowship-trained adult reconstruction surgeons and received IO vancomycin at the time of surgery in addition to standard intravenous antibiotic prophylaxis. Rates of PJI at 3 months, 1 year, and the final follow-up were evaluated and compared to prior literature. RESULTS: Follow-up at 3 months was available for 116 of the 117 rTKAs, with 1 lost to follow-up. The rate of PJI was 0% at 3 months postoperatively. Follow-up at 1 year was obtained for 113 of the 117 rTKAs, and the PJI rate remained 0%. The rate of PJI at the final follow-up of ≥ 1 year was 0.88% (95% confidence interval: -0.84 to 2.61). Previous literature reports PJI rates in aseptic rTKA to range from 3 to 9.4%. CONCLUSIONS: Dual prophylactic antibiotics with IO vancomycin in conjunction with intravenous cephalosporins or clindamycin were associated with a substantial reduction in early PJI compared to prior published literature. These data supplement the early evidence about the potential clinical benefits of IO vancomycin for infection prevention in high-risk cases. LEVEL OF EVIDENCE: Level III, therapeutic study.

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

Introduction: 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. Aim: This study aimed to determine the incidence and epidemiology use of IO vascular access in SES 061 La Rioja during the year 2022. Matherial and methods: 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. Results: 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. Discussion: IO vascular access provides a suitable route for out-of-hospital stabilization of critically ill patients when peripheral vascular access is difficult or impossible.

A comparison between intraosseous and intravenous access in patients with out-of-hospital cardiac arrest: A retrospective cohort study.

INTRODUCTION: The optimal vascular access for patients with out-of-hospital cardiac arrest (OHCA) remains controversial. Increasing evidence supports intraosseous (IO) access due to faster medication administration and higher first-attempt success rates compared to intravenous (IV) access. However, the impact on patient outcomes has been inconclusive. METHODS: This retrospective cohort study in Taoyuan City, Taiwan, from January 1, 2019, to December 31, 2022, included patients aged ≥18 years with non-traumatic OHCA resuscitated by emergency medical technician paramedics (EMT-Ps) with either IVs or IOs for final vascular access. The exclusion criteria were cardiac arrest en route to the hospital and resuscitation during the coronavirus pandemic (from May 1, 2022, to October 31, 2022). The primary and secondary outcomes were sustained ROSC (≥2 h) and cerebral performance category (CPC) 1-2, respectively. Univariate logistic regression was used to estimate the odds ratios (ORs) and 95% confidence intervals (CI) for the primary analysis. Multivariable logistic regression was employed, with variables selected based on a p-value of <0.05 in the univariate analysis. The survival benefits of different insertion sites and subgroups like general ambulance teams (with a composition that includes fewer EMT-Ps and limited experience in using IO access) were also analyzed. RESULTS: A total of 2003 patients were enrolled; 1602 received IV access and 401 IO access. The median patient age was 70 years, and most were male (66.6%). Compared to patients receiving IV access, the adjusted odds ratios (aORs) for primary and secondary outcomes in patients with IOs were 0.83 (95% confidence interval [CI], 0.61-1.11; p = 0.20) and 0.96 (95% CI, 0.39-2.40; p = 0.93), respectively. Different insertion sites showed no outcome differences. In the subgroups of females and patients resuscitated by general ambulance teams, the aORs for sustained ROSC were 0.55 (95% CI, 0.33-0.92; p = 0.02) and 0.62 (95% CI, 0.41-0.94; p = 0.02), respectively. CONCLUSIONS: For patients with OHCA resuscitated by EMT-Ps, IO access was comparable to IV access regarding patient outcomes. However, in females and patients resuscitated by general ambulance teams, IV access might be favorable.

[Intraosseous vascular access - step by step]. / Intraossärer Zugang ­ Schritt für Schritt.

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.

Intraosseous Versus Intravenous Vancomycin in Tourniquetless Primary Total Knee Arthroplasty: A Randomized Trial.

BACKGROUND: Intraosseous (IO) administration of vancomycin at the time of total knee arthroplasty (TKA) has been shown to be safer and more effective than intravenous (IV) administration at preventing early periprosthetic joint infection. Previous studies have relied on tourniquet inflation to enhance local tissue concentrations and mitigate systemic release. METHODS: A single-blinded, randomized clinical trial was performed on 20 patients (10 IV, 10 IO) undergoing primary TKA. The control (IV) group received weight-dosed vancomycin approximately 1 hour prior to the incision and weight-dosed cefazolin immediately prior to the incision. The interventional (IO) group received weight-dosed cefazolin immediately prior to the incision and 500 mg of vancomycin delivered via the IO technique at the time of the incision. Systemic samples for vancomycin levels were taken prior to the incision and at closure. During the procedure, tissue samples were taken from the distal femur, proximal tibia, and suprapatellar synovium. There were no differences in patient demographics or changes in serum creatinine from preoperative to postoperatively between groups. RESULTS: Significant differences in systemic vancomycin levels (ug/mL) were found at the start of the case (IV = 27.9 ± 4.9 versus IO = 0 ± 0, P = .0004) and at the end of the case (IV = 19.6 ± 2.6 versus IO = 7.8 ± 1.0, P = .001). No significant differences were seen in the average vancomycin concentration in the distal femur (IV = 61.0 ± 16.0 versus IO = 66.2 ± 12.3, P = .80), proximal tibia (IV = 52.8 ± 13.5 versus IO = 57.1 ± 17.0, P = .84), or suprapatellar synovial tissue (IV = 10.7 ± 5.3 versus IO = 9.0 ± 3.3, P = .80). There were no complications associated with vancomycin administration in either group. CONCLUSIONS: This study demonstrates the utility of IO vancomycin in tourniquetless TKA with similar local tissue and significantly lower systemic concentrations than IV administration. LEVEL OF EVIDENCE: Level 1 therapeutic randomized trial.

Biodistribution and Safety of Human Multi-Chimeric Cells After Systemic Intraosseous and Intravenous Administration in the Experimental Mouse Model.

Cellular therapies provide promising options for inducing tolerance in transplantation of solid organs, bone marrow, and vascularized composite allografts. However, novel tolerance-inducing protocols remain limited, despite extensive research. We previously introduced and characterized a human multi-chimeric cell (HMCC) line, created through ex vivo fusion of human umbilical cord blood (UCB) cells derived from three unrelated donors. In this study, we assessed in vivo biodistribution and safety of HMCCs in the NOD.Cg-PrkdcscidIl2rgtm1Wjl/SzJ NOD scid gamma (NSG) mouse model. Twenty-four NSG mice were randomly assigned to four groups (n = 6/group) and received intraosseous (IO.) or intravenous (IV.) injections of 0.6 × 106 donor UCB cells or fused HMCC: Group 1-UCB (IO.), Group 2-UCB (IV.), Group 3-HMCC (IO.), and Group 4-HMCC (IV.). Hematopoietic phenotype maintenance and presence of human leukocyte antigens (HLA), class I antigens, in the selected lymphoid and nonlymphoid organs were assessed by flow cytometry. Weekly evaluation and magnetic resonance imaging (MRI) assessed HMCC safety. Comparative analysis of delivery routes revealed significant differences in HLA class I percentages for IO.: 1.83% ± 0.79%, versus IV. delivery: 0.04% ± 0.01%, P < 0.01, and hematopoietic stem cell marker percentages of CD3 (IO.: 1.41% ± 0.04%, vs. IV.: 0.07% ± 0.01%, P < 0.05) and CD4 (IO.: 2.74% ± 0.31%, vs. IV.: 0.59% ± 0.11%, P < 0.01). Biodistribution analysis after IO. delivery confirmed HMCC presence in lymphoid organs and negligible presence in nonlymphoid organs, except for lung (IO.: 0.19% ± 0.06%, vs. IV.: 6.33% ± 0.56%, P < 0.0001). No evidence of tumorigenesis was observed by MRI at 90 days following IO. and IV. administration of HMCC. This study confirmed biodistribution and safety of HMCC therapy in the NSG mouse model, both following IO. and IV. administration. However, IO. delivery route confirmed higher efficacy of engraftment and safety profile, introducing HMCCs as a novel cell-based therapeutic approach with promising clinical applications in solid organ, bone marrow, and vascularized composite allotransplantation transplantation.

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

INTRODUCTION: 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. AIM: We aim to determine how IOVA was integrated into management of vascular access during out-of-hospital cardiac arrest (OHCA) resuscitation. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Retrospective Comparison of Upper and Lower Extremity Intraosseous Access During Out-of-Hospital Cardiac Arrest Resuscitation.

OBJECTIVE: Intraosseous (IO) access is frequently utilized during the resuscitation of out-of-hospital cardiac arrest (OHCA) patients. Due to proximity to the heart and differential flow rates, the anatomical site of IO access may impact patient outcomes. Using a large dataset, we aimed to compare the outcomes of OHCA patients who received upper or lower extremity IO access during resuscitation. METHODS: The ESO Data Collaborative public use research datasets were used for this retrospective study. All adult (≥18 years of age) OHCA patients with successful IO access in an upper or lower extremity were evaluated for inclusion. Patients were excluded if they had intravenous (IV) access prior to IO access, or if they had a Do Not Resuscitate order documented. Our primary outcome was return of spontaneous circulation (ROSC). Secondary outcomes included survival to discharge and survival to discharge to home. Mixed-effects multivariable logistic regression models adjusted for age, sex, etiology, witnessed status, pre-first responder cardiopulmonary resuscitation (CPR), initial electrocardiogram (ECG) rhythm, location [private/residential, public, or assisted living/institutional], and response time in addition to the primary airway management strategy (endotracheal intubation, supraglottic device, surgical airway, no advanced airway) were used to compare the outcomes of patients with upper extremity IO access to the outcomes of patients with lower extremity IO access. RESULTS: After application of exclusion criteria, 155,884 patients who received IO access during resuscitation remained (76% lower extremity, 24% upper extremity). Upper extremity IO access was associated with greater adjusted odds of ROSC (1.11 [1.08, 1.15]), and this finding was consistent across multiple patient subgroups. Secondary analyses suggested that upper extremity access was associated with increased survival to discharge (1.18 [1.00, 1.39]) and survival to discharge to home (1.23 [1.02, 1.48]) in comparison to lower extremity IO access. CONCLUSION: In this large prehospital dataset, upper extremity IO access was associated with a small increase in the odds of ROSC in comparison to lower extremity IO access. These data support the need for prospective investigation of the ideal IO access site during OHCA resuscitation.

Umbilical vein catheterisation for the family physician working in primary health care.

This is part of a series of articles on vascular access in emergencies. The other two articles were on intra osseous lines and central venous lines. These are critical lifesaving emergency skills for the primary care professional. In this article, we will provide an overview of umbilical vein catheterisation highlighting its importance, the indications, contraindications, techniques, complications and nursing considerations. By familiarising healthcare providers with this procedure, we hope to enhance their knowledge and skills, ultimately leading to improved outcomes in the neonatal population.