[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.

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.

A Prospective Comparison of Standard Technique, Doppler Ultrasonography, and Pressure Waveform Analysis for Confirming Intraosseous Catheter Placement.

Purpose: Intraosseous (IO) catheters allow healthcare workers to rapidly administer fluids and medications to critically ill patients when intravenous access is inadequate or unable to be obtained. An improperly placed IO catheter can lead to delays in care, as well as serious complications such as limb necrosis. Methods: In this single-center, prospective, observational study, we compared 2 established methods of confirming proper IO catheter placement to a novel pressure waveform analysis technique in which the IO catheter is attached to a standard pressure transducer. Attaching a pressure transducer to a properly placed IO catheter produces a pulsatile waveform. Misplacement of the IO catheter produces a flatline waveform. Results: Of 42 IO catheters, 8 (19%) were incorrectly placed per the waveform analysis technique. Compared to the pressure waveform analysis technique, the standard method and the power Doppler method incorrectly classified 4/8 (50%) and 5/8 (62.5%) of the misplaced catheters, respectively. The standard method had a higher positive predictive value for detecting incorrectly placed IO catheters than the power Doppler method (100% vs 63%, respectively). Blinded reviewers demonstrated better agreement using the pressure waveform analysis technique than using power Doppler (k = 0.77 vs k = 0.58, respectively). Conclusion: The standard and power Doppler ultrasonography techniques identify incorrectly placed IO catheters sub-optimally. The pressure waveform analysis technique is more accurate than the standard of care and has superior interrater agreement compared to the ultrasound method of confirmation. With more than 500 000 IO catheters placed in the United States each year, this novel technique may improve overall IO safety. Trial Registration Number: NCT03908879.

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

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

Intraosseous line insertion for the primary health care physician.

Early rapid access to the vascular system is essential in emergencies and is lifesaving. In this article, we will provide information on the common sites used, the equipment that is required, the indications and contraindications for intraosseous line insertion, how to correctly and safely do the procedure, medication that can be administered, post insertion line management and possible complications. This is a lifesaving procedure and primary healthcare physicians should acquire this skill.

Efficacy of intraosseous access for trauma resuscitation: a systematic review and meta-analysis.

BACKGROUND: During medical emergencies, intraosseous (IO) access and intravenous (IV) access are methods of administering therapies and medications to patients. Treating patients in emergency medical situations is a highly time sensitive practice; however, research into the optimal access method is limited and existing systematic reviews have only considered out-of-hospital cardiac arrest (OHCA) patients. We focused on severe trauma patients and conducted a systematic review to evaluate the efficacy and efficiency of intraosseous (IO) access compared to intravenous (IV) access for trauma resuscitation in prehospital care. MATERIALS AND METHOD: PubMed, Web of Science, Cochrane Library, EMBASE, ScienceDirect, banque de données en santé publique and CNKI databases were searched for articles published between January 1, 2000, and January 31, 2023. Adult trauma patients were included, regardless of race, nationality, and region. OHCA patients and other types of patients were excluded. The experimental and control groups received IO and IV access, respectively, in the pre-hospital and emergency departments for salvage. The primary outcome was success rate on first attempt, which was defined as secure needle position in the marrow cavity or a peripheral vein, with normal fluid flow. Secondary outcomes included mean time to resuscitation, mean procedure time, and complications. RESULTS: Three reviewers independently screened the literature, extracted the data, and assessed the risk of bias in the included studies; meta-analyses were then performed using Review Manager (Version 5.4; Cochrane, Oxford, UK). The success rate on first attempt was significant higher for IO access than for IV access (RR = 1.46, 95% CI [1.16, 1.85], P = 0.001). The mean procedure time was significantly reduced (MD = - 5.67, 95% CI [- 9.26, - 2.07], P = 0.002). There was no significant difference in mean time to resuscitation (MD = - 1.00, 95% CI [- 3.18, 1.17], P = 0.37) and complications (RR = 1.22, 95% CI [0.14, 10.62], P = 0.86) between the IO and IV groups. CONCLUSION: The success rate on first attempt of IO access was much higher than that of IV access for trauma patients, and the mean procedure time of IO access was significantly less when compared to IV access. Therefore, IO access should be suggested as an urgent vascular access for hypotensive trauma patients, especially those who are under severe shock.

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

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

EMS Use and Success Rates of Intraosseous Infusion for Pediatric Resuscitations: A Large Regional Health System Experience.

OBJECTIVE: Access of intraosseous (IO) compartments is a commonly used technique that is an invaluable asset in emergency resuscitation. Prehospital IO success rates using semi-automatic insertion devices vary between 70 and 100% of pediatric patients. There are limited data on time to insertion and duration of IO function in the prehospital setting. Recent studies limited to the pediatric emergency department (PED) setting have also suggested that IOs may be less successful in the infant population. We explored the use of IO access for pediatric resuscitation, encompassing the prehospital and pediatric emergency department (PED) settings. METHODS: This is a retrospective review of emergency medical services (EMS) patient care reports and PED data of patients aged 0-17 years old and transported by regional ground EMS agencies in Southwestern Ontario, Canada from 2012 to 2019. Mean and median time to first insertion and IO function (from insertion to IO failure, IV access, transfer to ICU, or death) were calculated. RESULTS: Successful prehospital IO access was achieved in 83.7% of patients. The median time required to achieve IO access was 4 min (IQR 3-7) and mean duration of IO function was 27.6 min (SD: 14.8). Patients less than 1 year old had fewer functional IOs (25.9% vs. 75.0%), more insertion attempts (2 vs. 1), and shorter duration of IO function (18.8 vs. 32.2 mins) than the older age group (p < 0.05). CONCLUSIONS: This is the first study to provide time to IO access and IO duration in the prehospital setting, and the first prehospital evidence to suggest inferior IO function in infants <1 year old, compared to other ages. This highlights unique challenges for infants that have implications for the PED, interfacility transport, and critical care settings.

Can Non-Physician Providers Use Ultrasound to Aid in Establishing Peripheral IV Access in Patients Who are Difficult to Cannulate? A Scoping Review.

INTRODUCTION: Non-physician performed point-of-care ultrasound (POCUS) is emerging as a diagnostic adjunct with the potential to enhance current practice. The scope of POCUS utility is broad and well-established in-hospital, yet limited research has occurred in the out-of-hospital environment. Many physician-based studies expound the value of POCUS in the acute setting as a therapeutic and diagnostic tool. This study utilized a scoping review methodology to map the literature pertaining to non-physician use of POCUS to improve success of peripheral intravenous access (PIVA), especially in patients predicted to be difficult to cannulate. METHODS: Ovid MEDLINE, CINAHL Plus, EMBASE, and PubMed were searched from January 1, 1990 through April 15, 2021. A thorough search of the grey literature and reference lists of relevant articles was also performed to identify additional studies. Articles were included if they examined non-physician utilization of ultrasound-guided PIVA (USGPIVA) for patients anticipated to be difficult to cannulate. RESULTS: A total of 158 articles were identified. A total of 16 articles met the inclusion criteria. The majority of participants had varied experience with ultrasound, making accurate comparison difficult. Training and education were non-standardized, as was the approach to determining difficult intravenous access (DIVA). Despite this, the majority of the studies demonstrated high first attempt and overall success rates for PIVA performed by non-physicians. CONCLUSION: Non-physician USGPIVA appears to be a superior method for PIVA when difficulty is anticipated. Additional benefits include reduced requirement for central venous catheter (CVC) or intraosseous (IO) needle placement. Paramedics, nurses, and emergency department (ED) technicians are able to achieve competence in this skill with relatively little training. Further research is required to explore the utility of this practice in the out-of-hospital environment.

[Demystifying the intraosseous infusion technique]. / Tous les secrets de l'accès vasculaire intra-osseux.

Intraosseous infusion provides a safe and effective access to the vascular system that allows for administration of urgent therapies in both adults and children. It has few contraindications and complications are rare. The needle is most commonly inserted in the proximal tibia or anterior humerus. Different devices are available but those with a traditional drill are the most widespread. The intraosseous infusion procedure is easy and the learning curve is short, making it the best alternative when traditional intravenous access is not possible or delayed.

Le cathétérisme intra-osseux permet un accès vasculaire rapide, facile, sûr et efficace pour l'administration de thérapeutiques urgentes, chez l'enfant comme chez l'adulte. Il présente peu de contre-indications et ses complications sont rares. Les sites d'implantation privilégiés sont les abords tibial proximal et huméral chez l'adulte. Différents systèmes de cathétérisme sont disponibles ; les plus répandus et probablement les plus simples d'utilisation sont maintenant motorisés. La technique d'utilisation de ces cathéters est facilement acquise après une courte formation. Ils représentent la première alternative à l'accès veineux périphérique dans la gestion des urgences vitales lorsque celui-ci n'est pas disponible.

THE SHORT- AND LONG-TERM IMPACTS OF INTRAOSSEOUS CATHETERIZATION TRAINING ON MEDICAL STAFF'S READINESS TO STABILIZE CRITICAL PATIENTS AT THE PEDIATRIC EMERGENCY DEPARTMENT.

The introduction of intraosseous injection methodology is very important in critically ill patients, with whom peripheral venous catheterization is impossible and there is not enough time to access a central vein due to a life-threatening condition of the patient. To carry out the relevant methodology in Georgia, for the first time in 2016 and then in 2017, the USA Mayo Clinic Emergency Care Physicians held trainings in Intraosseous Catheterization, which included both theoretical (indications, contraindications, complications, etc.) and practical trainings (techniques for using a special tool on manikin bone).A team of emergency physicians from two Pediatric Clinics of Georgia was later selected to undergo the above-mentioned training (theoretical and practical). Both teams were tested before and after the training. The results were compared. For two years, a certain number of physicians performed appropriate manipulation in patients. The aim of our further study was to determine whether physicians possessed theoretical and practical skills two years after training. Doctors were divided into two groups: those who performed this manipulation during this period and those who did not. The results of the testing ahve shown the need for periodic intraosseous catheterization training so that physicians who have not practiced this manipulation would not lose the relevant skills and perform this manipulation safely when needed.

Distal femur versus humeral or tibial IO, access in adult out of hospital cardiac resuscitation.

BACKGROUND: Intraosseous (IO) vascular access is a well-established method for fluid and drug administration in the critically ill. The Food and Drug Administration has approved adult IO access at the proximal humerus, proximal tibia, and the sternum; all three sites have significant limitations. The Distal Femur is away from the chest, with high flow rates. The objective of this study was to evaluate the distal femur site during resuscitation of adult out-of-hospital cardiac arrest. METHODS: A retrospective analysis of adult out of hospital cardiac arrest patients treated by the San Antonio Fire Department. IO access was obtained by first-responders (paramedics or EMT-basic) or EMS paramedics. All resuscitation attempts from 2017 to 2018 data were analyzed. The protocol did not dictate the preference of IO site. The primary measure: number of OHCA patients in each subgroup: IO femur, IO humerus, IO tibia. Secondary measures: paramedic or basic operator, dislodgement rate, and total fluid infused. RESULTS: There were 2,198 patients meeting inclusion criteria: 888 femur, 696 humerus, 432 tibia. Distal femur increased 2.5 times in the 2018 cohort compared to the 2017 cohort, with a corresponding decrease in humerus (factor of 0.29). Proximal tibia remained unchanged. Dislodgement rates and total infusion (ml) remained unchanged. CONCLUSIONS: The distal femur IO was feasible and associated with similar measured performance parameters as other IO sites in adult OHCA for both advanced and basic life support personnel.

Pre-hospital intraosseous use in children: Indications and success rate.

OBJECTIVE: Intraosseous (IO) needle insertion is an effective method to obtain circulatory access in unwell children. METHODS: We conducted a 12-month retrospective record review of children aged less than 18 years who had a recorded IO attempt by Ambulance Victoria paramedics. RESULTS: Sixty-five children underwent IO attempt during pre-hospital care, 60 had IO outcome recorded and were included. 58/60 (96.7%) children had IO successfully placed, 35 were aged <5 years. Cardiorespiratory arrest (39/58, 67.2%) and status epilepticus (11/58, 19%) were the most common indications. CONCLUSION: While IO placement is uncommonly performed pre-hospital, in critical situations there is a high success rate.

Sternal Intraosseous Devices: Review of the Literature.

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

A multicenter phase II study of intrabone single-unit cord blood transplantation without antithymocyte globulin.

To overcome the delayed or failed engraftment after unrelated cord blood transplantation (CBT), we conducted a multicenter phase II study of intrabone single-unit CBT without antithymocyte globulin (ATG) for adult patients with hematological malignancies (UMIN-CTR, UMIN000020997). Sixty-four patients received an intrabone injection of unwashed (n = 61) or washed (n = 3) cord blood after local anesthesia. All injection-related adverse events were mild and resolved spontaneously. Sixty-two patients were evaluable for the efficacy of intrabone CBT of serological HLA-A, -B, and -DR ≥ 4/6 matched cord blood with a median number of 2.57 × 107/kg cryopreserved total nucleated cells. The probability of survival with neutrophil engraftment on day 28 was 77.4% (95% confidence interval, 67.0-85.8%), which exceeded the threshold value. The cumulative incidences of neutrophils ≥ 0.5 × 109/L on day 60 was 80.6% (68.2-88.6%), with a median time to recovery of 21 days after transplantation. The cumulative incidences of platelets ≥ 20 × 109/L and platelets ≥ 50 × 109/L on day 100 were 75.8% (62.6-84.9%) and 72.6% (59.4-82.1%), respectively, with median time to platelets ≥ 20 × 109/L and platelets ≥ 50 × 109/L of 38 and 45 days after transplantation, respectively. The cumulative incidences of grade II-IV and III-IV acute graft-versus-host disease were 29.0% and 6.5%, respectively. All responded to steroid therapy, and secondary treatments were not required. The present study suggests the efficacy of intrabone single-unit CBT without ATG in terms of early engraftment and controllable acute graft-versus-host disease.

Intravenous vs intraosseous adrenaline administration in cardiac arrest: A protocol for systematic review and meta-analysis.

INTRODUCTION: Cardiac arrest refers to the sudden termination of cardiac ejection function due to various causes. Adrenaline is an important component of resuscitation among individuals experiencing cardiac arrest. The adrenaline delivery method chiefly involved intraosseous infusion and intravenous access. However, the impact of different adrenaline delivery methods on cardiac arrest has been unclear in previous research. Thus, the present study aimed to synthesize the available evidence regarding intravenous vs intraosseous adrenaline administration in cardiac arrest. METHODS AND ANALYSIS: We will search PubMed, EMBASE, Cochrane Library, Wanfang, and China National Knowledge Infrastructure. As per the inclusion criteria, randomized controlled trials (RCTs) on adrenaline administration in cardiac arrest were selected. The primary outcome was prehospital restoration of spontaneous circulation (ROSC); the secondary endpoints were survival, favorable neurological outcome at discharge, and poor neurological outcome at ≥3 mon.We plan to use the Cochrane Collaboration's tool for assessing the bias risk for RCTs. The Grading of Recommendations Assessment, Development and Evaluation approach will grade the certainty of the evidence for all the outcome measures across studies. RevMan 5.3.5 will be used for meta-analysis. If the heterogeneity tests show slight or no statistical heterogeneity, the fixed effects model will be used, in other cases, the random effect model will be used for data synthesis. RESULTS AND CONCLUSION: This protocol will determine which epinephrine delivery method is the optimal in the management of cardiac arrest. Our findings will help clinicians and health professionals in making accurate clinical decisions about adrenaline administrations in cardiac arrest. ETHICS AND DISSEMINATION: Ethical approval was not required because this study was planned as a secondary analysis. The results will be disseminated in peer-reviewed publications, journals, and academic. INPLASY REGISTRATION NUMBER: INPLASY202090100 (DOI:10.37766/inplasy2020.9.0100).

Extracorporeal shockwave therapy combined with multiple drilling and intramedullary drug injection for treating early-stage Femur Head Necrosis: Protocol for a randomized controlled trial.

BACKGROUND: Early diagnosis and treatment of the osteonecrosis of the femoral head (ONFH), a refractory disease, is imperative to prevent femoral head collapse; however, the existing solutions remain controversial. This study assessed the safety and efficacy of extracorporeal shock wave therapy (ESWT) combined with multiple drilling and intramedullary drug injection, a novel cocktail therapy, as a randomized controlled trial (RCT) model to postulate an alternative therapy for patients with early-stage ONFH. METHODS: Femoral head necrosis patients aged 20 to 60 years with stage ARCO I-II were recruited. One hundred twenty eligible participants were randomized into four groups in a 1:1:1:1 ratio: extracorporeal shock wave therapy combined with multiple drilling and intramedullary drug injection (group EMI), extracorporeal shock wave therapy (group E), multiple drilling combined with intramedullary drug injection (group MI), and multiple drilling ("positive" control group; group M). The primary outcomes included effective rate, subchondral collapse rate of the femoral head, lesion size, and grade of bone marrow edema. Secondary outcomes included the Harris Hip Score and the visual analog scale. All outcomes were measured at the screening visit (baseline) and at the planned time intervals during treatment and follow-up, and the efficacy was statistically analyzed according to the intention-to-treat sub-populations and per-protocol sub-populations. OBJECTIVES: To examine the clinical efficacy of ESWT combined with multiple drilling and intramedullary drug injection to provide a safe and more effective method for treating early-stage ONFH. TRIAL REGISTRATION NUMBER: ChiCTR1900020888; Pre-results.

Prehospital use of peripheral intravenous catheters and intraosseous devices: An integrative literature review of current practices and issues.

INTRODUCTION: Peripheral intravenous catheters and intraosseous devices have been widely used in the prehospital setting for a considerable period. Changes in technology and guidelines have led to an increase in situations where use of these devices in a prehospital setting is recommended. Despite being commonplace they are not without risk of harm to the patient. STUDY OBJECTIVE: To examine critically the research-based literature related to incidence of insertion of peripheral intravenous catheters and intraosseous devices, the use of these vascular access devices and to determine which health professionals insert them, most commonly, in the prehospital setting. METHODS: An integrative review was undertaken using material retrieved following a systematic search of research literature databases, grey literature and secondary sources written in English. No date limit was applied to the search and the searching was undertaken until September 2019. Articles specifically addressing peripheral intravenous catheter and intraosseous device use in the prehospital setting were selected. RESULTS: The search resulted in 20 articles being included in the review, 17 related to peripheral intravenous catheters and three for intraosseous devices. All articles related to observational studies across a variety of services and settings. CONCLUSION: The role of vascular access in the prehospital setting continues to be significant, particularly for patients who are critically unwell. This review identified that differences in service structure, geography and the patient's condition all impact on the insertion and use of these vascular access devices. Despite this there are limited data reported that can allow prehospital clinicians and services to benchmark their practice.

USE OF INTRAOSSEOUS ACCESS IN PEDIATRIC EMERGENCY CARE IN GEORGIA.

Intraosseous Access (IO) has obtained an increasingly valued place in emergency medical care cases when peripheral access venous access in not possible. This has also been demonstrated in pediatric settings. The method though has never been applied in Georgia, let alone pediatric emergencies. Therefor we conducted the study to access opportunities for IO use introduction in pediatric emergency care in Georgia. A quasi experimental study was conducted with 24 patients undergoing IO and further 40 receiving central venous access for their condition management. A number of parameters were monitored and reported. Additionally, a pre- and post-test was used to assess the specially trained medical personnel. The study groups outcomes were described, while personal assessment was analyzed. The study demonstrates that with proper training and in certain indications, the internationally approved method can be safely used in Georgian healthcare settings, including pediatric emergency management. The method should be included into the Georgian patient management guidelines, provided proper training is delivered to the personnel.