Insights From a Tertiary Care Intraosseous Insertion Practice Improvement Registry: A 2-Year Descriptive Analysis.

INTRODUCTION: Few practice improvement registries exist that describe opportunities to improve intraosseous (IO) use. The goal of this project was to assess the success rate of the procedure by emergency nurses and identify opportunities to improvement. Secondary goals were to assess success rates based on clinician type, age of patient, and procedural factors. METHODS: Emergency nurses assigned to the resuscitation area of a tertiary care emergency department completed an education module and skill lab on IO placement. Tracking forms were completed whenever IO access was attempted, and the clinical nurse educator collated the forms. RESULTS: Over 2 years, quality improvement forms were submitted for 17 pediatric patients (receiving 23 IO insertions) and 35 adult patients (receiving 40 intraosseous insertions). Prior to an IO attempt, the average number of IV attempts for pediatric and adult patients was 4 (range 0 to 10) and 2 (0 to 5), respectively. Successful pediatric IO insertion rate was 6/15 (40%) for physicians (both residents and attending physicians) and 6/7 (86%) for emergency nurses. Physicians were more likely to perform IO insertions in children <12 months of age and emergency nurses in patients >12 months of age. The leading cause of failed insertions in pediatrics was selecting a needle that was too short: either not reaching the intramedullary canal or quickly becoming dislodged, especially with flushing the IO cannula after insertion. For adult patients, IO insertion success rates for physicians were 13/14 (93%) and 18/20 (90%) for emergency nurses. DISCUSSION: The registry identified opportunities to improve clinical practice on the clinical threshold for IO use in pediatric patients and the appropriate selection of IO cannula.

Use of intra-osseous access in adults: a systematic review.

BACKGROUND: Indications for intra-osseous (IO) infusion are increasing in adults requiring administration of fluids and medications during initial resuscitation. However, this route is rarely used nowadays due to a lack of knowledge and training. We reviewed the current evidence for its use in adults requiring resuscitative procedures, the contraindications of the technique, and modalities for catheter implementation and skill acquisition. METHODS: A PubMed search for all articles published up to December 2015 was performed by using the terms "Intra-osseous" AND "Adult". Additional articles were included by using the "related citations" feature of PubMed or checking references of selected articles. Editorials, comments and case reports were excluded. Abstracts of all the articles that the search yielded were independently screened for eligibility by two authors and included in the analysis after mutual consensus. In total, 84 full-text articles were reviewed and 49 of these were useful for answering the following question "when, how, and for which population should an IO infusion be used in adults" were selected to prepare independent drafts. Once this step had been completed, all authors met, reviewed the drafts together, resolved disagreements by consensus with all the authors, and decided on the final version. RESULTS: IO infusion should be implemented in all critical situations when peripheral venous access is not easily obtainable. Contraindications are few and complications are uncommon, most of the time bound to prolonged use. The IO infusion allows for blood sampling and administration of virtually all types of fluids and medications including vasopressors, with a bioavailability close to the intravenous route. Unfortunately, IO infusion remains underused in adults even though learning the technique is rapid and easy. CONCLUSIONS: Indications for IO infusion use in adults requiring urgent parenteral access and having difficult intravenous access are increasing. Physicians working in emergency departments or intensive care units should learn the procedures for catheter insertion and maintenance, the contraindications of the technique, and the possibilities this access offers.

Intraosseous vascular access for in-hospital emergency use: a systematic clinical review of the literature and analysis.

UNLABELLED: Intraosseous (IO) vascular access is a viable primary alternative in patients requiring emergent vascular access in the hospital emergency department (ED) (eg, resuscitation, shock/septic shock) but is underutilized. OBJECTIVES: This review has 3 objectives: (1) review the evidence supporting the use of IO access; (2) determine the utilization of IO access as described in the literature; and (3) assess the level of specialty society support. METHODS: Electronic and hand searches were undertaken to identify relevant articles. English-language-only articles were identified. The Cochrane Review methodology along with data forms were used to collect and review data. The evidence evaluation process of the international consensus on emergency cardiovascular care was used to assess the evidence. Studies were combined where meta-analyses could be performed. RESULTS: In levels 2 to 5 studies, IO access performed better versus alternative access methods on the end points of time to access and successful access. Complications appeared to be comparable to other venous access methods. Randomized controlled trials are lacking. Newer IO access technologies appear to do a better job of gaining successful access more quickly. Intraosseous access is underutilized in the ED because of lack of awareness, lack of guidelines/indications, proper training, and a lack of proper equipment. CONCLUSIONS: Recommendations/guidelines from physician specialty societies involved in the ED setting are also lacking. Underutilization exists despite recommendations for IO access use from a number of important medical associations peripherally involved in the ED such as the American Academy of Pediatrics. To encourage the IO approach, IO product champions (as both supporter and user) in the ED are needed for prioritizing and assigning IO access use when warranted. In addition, specialty societies directly involved in emergent hospital care should develop clinical guidelines for IO use.

Intraosseous devices: a randomized controlled trial comparing three intraosseous devices.

INTRODUCTION: Access to the circulation is mandatory for adequate treatment in medical emergency situations. Intraosseous (IO) infusion is a safe, fast, and effective alternative for gaining access to the circulation, if intravenous access fails. In the last decade, the IO method gained renewed interest. New devices have been developed, such as the Bone Injection Gun (BIG) 15G/18G and the First Access for Shock and Trauma 1 (FAST1). OBJECTIVE: To determine which IO needle is preferable for gaining IO access in patients requiring acute administration of fluids or medication in a prehospital setting. METHODS: In this single-blind prospective randomized trial, the IO needles were added to the equipment of the helicopter emergency medical services (HEMS) system. The HEMS nurses received training in proper use of all needles. Children (1-13 years) were randomized to the Jamshidi 15G or the BIG 18G, and adults (>or= 14 years) were randomized to the Jamshidi 15G, the BIG 15G, or the FAST1. All patients requiring acute administration of fluids or medication, without successful insertion of an intravenous (IV) catheter, were included. The IO needles were compared in terms of insertion time, success rate, bone marrow aspiration, adverse events during placement, and user satisfaction. RESULTS: Sixty-five adult and 22 pediatric patients were included. The treatment groups were similar with respect to age, gender, mortality, and trauma mechanism (p >or= 0.05). The median insertion times ranged from 38 seconds for the Jamshidi 15G to 49 seconds for the BIG 15G and 62 seconds for the FAST1 (p = 0.004). The devices did not differ with respect to success rates (adults overall 80% and children overall 86%), complication rates, and user satisfaction. CONCLUSIONS: The Jamshidi 15G needle could be placed significantly faster than the FAST1. The devices had similar success rates, complication rates, and user-friendliness. Intraosseous devices provide a safe, simple, and fast method for gaining access to the circulation in emergency situations.

Intraosseous needles in pediatric cadavers: Rate of malposition.

AIM OF THE STUDY: Intraosseous vascular access is a commonly conducted procedure especially in pediatric resuscitation. Very high success rates for intraosseous (IO) devices are reported. Aim of the study was to describe the rates of malposition of intraosseous needles (ION) in pediatric cadavers via post-mortem computed tomography (PMCT). METHODS: 212 consecutive pediatric cadavers underwent PMCT, of which 38 cadavers had visible ION and were included in the study. They were divided into two subgroups depending on their age (n = 22 infant cadavers (age <1 year) and n = 16 child cadavers (age ≥1 year)). Two independent readers evaluated the number and position of ION. RESULTS: In 22 infant cadavers 34 ION were found. Malposition of at least one ION was visible in 14 subjects (64%), among which 7 cadavers (32%) even had no correctly placed ION, thus being without established vascular access. Overall, 16 of the 34 used ION devices (47%) were in malposition. 23 ION were found in 16 child cadavers. In 8 subjects (50%) at least one ION was malpositioned, among which 3 cadavers (19%) had no correctly placed ION, resulting in a complete absence of vascular access. Overall, 9 of the 23 ION devices (39%) were malpositioned. CONCLUSION: Our study showed relatively high malposition rates for ION devices in pediatric cadavers which was not to be assumed regarding the success rates of 80% and higher in previous literature. This should be clarified by further studies in living patients.

Military Medic Performance with Employment of a Commercial Intraosseous Infusion Device: A Randomized, Crossover Study.

Background: Obtaining intraosseous (IO) access remains an invaluable skill in the management and resuscitation of patients on the battlefield. The U.S. Army Combat Medic is currently trained to utilize a sternal IO device (FAST1® Intraosseous Infusion System); however, the Arrow® EZ-IO® Intraosseous Vascular Access System offers unique benefits including ease of use, reload ability, and placement location versatility. Studies have demonstrated high success rates in the operational settings using the EZ-IO® System; however, no prospective studies have been conducted to assess the performance of U.S. Army's conventional Combat Medics using the EZ-IO® System. We hypothesized that EZ-IO® System-naïve medics would have a statistically significant success rate advantage utilizing the proximal tibia approach versus proximal humerus approach. Methods: A total of 77 U.S. Army Medics (Military Occupational Specialty [MOS] 68 W) volunteer participants were recruited to participate in this randomized, crossover study. Participants received a standardized audio-visual-enhanced lecture on EZ-IO® System use without hands-on training and then randomized into two study groups according to which anatomical approach they would attempt first. Results were analyzed to determine participants' first-attempt mean success rates, mean required time to properly place the needle into simulated humeral head and proximal tibial bone models, and mean survey results measuring the participant's subjective assessment of the two approaches to include, along with training and testing experience. The data of those not naïve to the employment of the EZ-IO® System were excluded. Results: The primary outcome measurement of overall mean participant success rate with attempted insertions into proximal tibial and humeral head bone models was 88% and 86%, respectively, demonstrating no statistically significant difference by approach, with no significant learning or design confounding effects (p > 0.05). Secondary outcomes of mean procedural time and subjective comfort and skill benefit were reported. Successful procedure times between the two anatomical approaches demonstrated a statistically significant mean time advantage of 17.1 s (p < 0.05) in proximal tibia IO placement. Overall participant mean subjective comfort level utilizing the EZ-IO® System (0- to 10-point scale with a 0 being not comfortable and a 10 being very comfortable) was 8.2, with no statistically significant difference in comfort discovered when comparing the two approaches. Participants reported a mean subjective score (0-10 scale with a 0 providing no benefit and a 10 providing extreme benefit) of 9.3 when asked how beneficial their newly learned IO system skill was to their overall medical skillset. Conclusions: The overall first-attempt success rates of U.S. Army Combat Medics employing the EZ-IO® System are similar to the success rates of FAST1® device employment and similar to the success of other provider cohorts using the EZ-IO® device. Coupled with perceived benefit of adding the EZ-IO® System to their combat medic skillset, these data warrant further study and consideration for the incorporation of commercial IO systems into U.S. Army Combat Medic initial, sustainment, and pre-combat training and standard issue equipment.

Intraosseous access in the setting of pediatric critical care transport.

OBJECTIVE: To demonstrate safety and efficacy of intraosseous needle placement among health care provider groups in the setting of pediatric critical care transport. DESIGN: Retrospective chart review. SETTING: Pediatric critical care transports to a pediatric intensive care unit. PATIENTS: Children undergoing pediatric critical care transport between January 1, 2000, and March 31, 2002, requiring intraosseous access before arrival to the pediatric intensive care unit. INTERVENTIONS: Intraosseous access placed for emergent vascular access. MEASUREMENTS AND MAIN RESULTS: During the study period, the transport team performed 1,792 transports and identified 47 patients requiring 58 intraosseous placements. These were placed by emergency medical technician-paramedics (18%), referring emergency medicine physicians (42%), and the transport team members (40%). The intraosseous needles were placed with a mean of 1.2 attempts per placement and a first attempt success rate of 78%. Main site of placement was the proximal anterior tibia (95%). Access was maintained for a mean of 5.2 hrs. The intraosseous needle was used for fluids, medications, and laboratory studies. Admitting diagnoses included respiratory distress (28%), cardiopulmonary arrest (26%), neurologic insults (17%), dehydration (15%), sepsis (11%), and other (3%). Ages ranged from 3 wks to 14 yrs (mean 2.2 yrs) and weights from 2.1 to 60 kg (mean 12.3 kg). Complications were noted in seven of 58 (12%), all limited to local edema or infiltration. CONCLUSIONS: Intraosseous placement is frequently needed in the care of critically ill pediatric patients before they reach the pediatric intensive care unit. We have demonstrated that intraosseous needles can be placed safely with similar rates of success when comparing different provider groups. Emergency medical technician-paramedics, emergency medicine physicians, and pediatric critical care transport teams should be familiar with intraosseous placement.

Use of intraosseous infusion in the pediatric trauma patient.

Intraosseous infusions (IO) are frequently used for gaining rapid vascular access in critically ill children. Few studies exist evaluating the efficacy of this procedure in the injured child. The objective of this study was to describe one pediatric institution's experience with the procedure of IO in young trauma victims. This study evaluated indications, insertion sites, complications, infused pharmacological agents, age, injury severity, and outcome. Fifteen patients received IO placement for cardiopulmonary arrest, seven for hypovolemic shock, and five for neurological compromise. Patient ages ranged from 3 months to 10 years (mean, 2.9 years). Twenty-nine IO lines were attempted in the tibia and three in the femur. Four of 32 attempts were unsuccessful. Of 32 attempts at IO placement (5 patients received multiple attempts), 15 were started in the prehospital setting and 17 in the emergency department. Multiple resuscitation medications as well as large colloid, crystalloid, and blood boluses were successfully infused. Seven of the 27 patients survived without observed IO-related complications. This study supports the use of IO infusion by prehospital as well as hospital personnel in the initial resuscitation of critically injured children. IO has a been established as a rapid, safe, and simple method of obtaining short term vascular access in both critically ill and injured children. This route deserves primary consideration as an alternate route for fluid resuscitation in pediatric trauma patients regardless of age. IO should be placed without delay when venous access is not rapidly obtainable.(ABSTRACT TRUNCATED AT 250 WORDS)

Variability in intraosseous pressure induced by saline flush of an intraosseous cannula by multiple practitioners.

Intraosseous cannulation is an accepted means to achieve vascular access when peripheral venous access is not available. It is common practice to flush the intraosseous cannula with saline prior to establishing infusions. The objective of this study was to evaluate changes in intraosseous pressure during the flush procedure and to assess the variability of pressure changes induced by different practitioners. Two intraosseous cannulas were placed in an isolated cadaveric femur collected from a swine. Intraosseous pressure and the rate of change in pressure were recorded continuously during a series of saline flushes into a distal femoral intraosseous cannula by 21 members of the veterinary research staff at the authors' institution. Median peak intraosseous pressures exceeded 600 mmHg, and an inverse relationship was noted between peak intraosseous pressure and the duration of flush. Bone marrow fat emboli were grossly evident in flush effluents and their presence was confirmed by microscopic examination. Until the practitioners were informed of the pressure changes induced by the intraosseous cannula flush, few had appreciated the magnitude of the pressures that they had generated, suggesting that an instrumented intraosseous flush preparation like the one used in this study may prove useful as a training tool for flush procedures.

Comparison of three intraosseous access techniques in cats.

OBJECTIVE: To compare the placement feasibility and amount of bone trauma induced by 3 intraosseous (IO) access techniques in cats: an automatic impact penetration device (A), an automatic rotary insertion device (B), and a manual IO needle (C). DESIGN: Prospective ex vivo study. SETTING: University. ANIMALS: Eighteen adult mixed breed feline cadavers. INTERVENTIONS: Cadavers provided 72 total IO insertion locations divided equally between the right and left humerus and tibia. The 3 IO techniques were randomly allocated to these locations. Time to successful insertion, ease of insertion, and success rate were recorded. Each insertion site was analyzed for the number of bone fragments and defect diameter by computed tomography. MEASUREMENTS AND MAIN RESULTS: Device B had lower time of insertion (P=0.01) compared with devices A and C. Device B had better ease of insertion scores (P<0.01) compared with devices A and C. No differences were detected between insertion sites (tibia versus humerus). No differences in the number of bone fragments, defect diameter, or success rate were detected among devices (P=0.06, 0.31, and 0.14, respectively). CONCLUSIONS: All 3 IO access methods evaluated yield acceptable results. Device B is significantly faster and easier to place in cat cadavers when compared with other methods.

The role of the registered nurse in the insertion of intraosseous access devices.

As a leader in infusion therapy, the Infusion Nurses Society convened a national task force of experts to examine the practice of registered nurses (RNs) placing intraosseous access devices. It is the position of the Infusion Nurses Society that a qualified RN, who is proficient in infusion therapy and who has been appropriately trained for the procedure, may insert, maintain, and remove intraosseous access devices.

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

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