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Intraosseous infusion, a mode of peripheral access largely abandoned in the 1940s and 1950s, is becoming increasingly popular in the setting of pediatric crisis. While complications are rare when the procedure is properly performed, the risk of osteomyelitis increases with prolonged infusions. We present a case of bilateral osteomyelitis secondary to intraosseous infusion.
Fluids, medications, and blood products can be rapidly administered via intraosseous infusion under emergency conditions, particularly to pediatric patients aged from 0 to 2 years. A five-month-old infant who had been hospitalized with a diagnosis of sepsis developed swelling and hyperemia at the infusion site 10 days after an intraosseous infusion in the right proximal tibia. Physical examination showed a serous discharge from a fistula on the anteromedial side of the right proximal cruris. Plain radiographs demonstrated periosteal reaction in the right tibia and osteolytic areas in the proximal metaphysis. With a diagnosis of acute osteomyelitis, drainage and medullary irrigation were performed and parenteral antibiotic treatment was initiated. Cultures from the surgical site yielded Candida albicans, upon which fluconazole (8 mg/kg) treatment was administered for four weeks. A complete clinical and radiographic improvement was observed at the end of a 12-month follow-up.
A program to instruct ground and aeromedical prehospital emergency medical system providers in the intraosseous infusion technique was developed and implemented. Paramedics and flight nurses received training through lectures and performance of the procedure in several animal models. The records of attempts on 15 patients who subsequently received intraosseous infusions were then reviewed. An intraosseous infusion was successful in 12 of 15 attempts (80%), and all needles were placed in less than 30 seconds. Drugs administered included phenobarbitol, phenytoin, atropine, epinephrine, sodium bicarbonate, isoproterenol, and pancuronium. Observed complications were limited to minimal subcutaneous infiltration in three cases and slow infusion in another. No serious sequelae were noted, but most patients did not survive and the ability of this study to detect sequelae may be limited. These data suggest that intraosseous infusion is a safe and reliable technique in the prehospital setting. Research is needed to study this technique in more detail.
Intraosseous infusion has become an increasingly popular technique for vascular access in critically ill or injured children. Continuing acceptance of this procedure by physicians and possibly by prehospital personnel may lead to inadvertent placement through the immature growth plate. In our study, we intentionally penetrated the epiphyseal plate with the intraosseous needle and infused fluids in order to observe what complications, if any, might arise from this procedure. Twenty pigs 3 to 4 weeks old had a bone marrow aspiration needle introduced into the medullary cavity through the tibial epiphysis under fluoroscopic visualization. Sodium bicarbonate at 2 mEq/kg (n = 10) or 0.9 normal saline at 2 mL/kg (n = 10) was infused through the intraosseous needle. Radiographs of the involved growth plates were taken at two months and six months after infusion. No growth disturbances or growth plate abnormalities were detected clinically or radiographically through the rapid growth phase of the porcine tibia. Therefore, we believe that intraosseous infusion is a safe method of alternative vascular access associated with no significant growth defects despite injury to the developing growth plate from placement and infusion.
This study was designed to determine whether the success rate in establishing intraosseous infusion (IOI) varied with four different types of needles--standard hypodermic, spinal, bone marrow, and Turkel intraosseous infusion needle. Twenty-four second-year residents from various specialties, without prior training or experience in the technique, participated in the study. Each participant attempted to establish an intraosseous infusion in a randomly assigned limb of an anesthetized piglet, using each needle in a randomly assigned order. The overall success rate was 67.7%. Success ratios varied between needles: hypodermic 54%, spinal 75%, bone marrow 75%, and Turkel 67%. Utilizing Cochran's Q-test, there was no statistical difference in success rates between needle types. However, in cases where the resident was successful with all four needles, the average time to successful infusion was significantly less for bone marrow needles.
Intraosseous infusions are becoming more popular in critical care and emergency room settings in pediatric patients. Spinal needles are introduced in metaphyseal bone to establish intravenous (i.v.) access when standard i.v. routes are not accessible. An experimental rabbit model was constructed to simulate intraosseous infusion in human infants to determine effects on the physis and growth rate of the infused bone. Twenty immature rabbits were infused with saline, bicarbonate, or dopamine solutions. Rabbits were killed and tibias harvested at 24 h and 3 weeks, and gross and histologic sections were examined. No growth disturbance occurred in any of the infused tibias. Gross and microscopic changes were confined to metaphyseal bone and had completely resolved after 3 weeks. There was no evidence of physeal injury.
Two examples of resuscitation of a scalded child by intraosseous infusion, following failed peripheral venous cannulation, are presented. The technique of intraosseous infusion is reviewed and it is concluded that this technique provides a valuable second-line technique for establishing emergency venous access in children. It is quick, reliable and enables the rapid infusion of intravenous fluids and drugs into the systemic venous system. Complications are rare but can be serious and close observation of the infusion site is advisable.
STUDY OBJECTIVE: To evaluate the ability of emergency medical technician-paramedic (EMT-P) units to become and remain proficient in the performance of the intraosseous infusion procedure. DESIGN AND SETTING: Descriptive nonrandomized trial open to all patients meeting protocol criteria over a five-year period; prehospital urban and suburban area with a population of 951,000. PARTICIPANTS: One hundred fifty-two consecutive patients (age range, newborn to 102 years) who had intraosseous infusion line placement attempted by EMT-Ps. INTERVENTION: Jamshidi sternal intraosseous infusion needle placed in the proximal tibia bone marrow in patients requiring emergency vascular access for fluid and/or medication administration. RESULTS: EMT-Ps performed 165 attempts on 152 patients with a five-year success rate of 76% per patient and 70% per attempt. Success rates per patient age group were 78%, 0 to 11 months; 85%, 1 to 2 years; 67%, 3 to 9 years; and 50%, 10 years or older. Success rates were significantly higher in children 3 years old compared with children and adults 3 or more years old (P = .04). Proficiency was maintained over the five-year study period. Infiltration was the most common complication, occurring in 14 patients (12%). Errors in landmark identification and needle bending were the most frequent identifiable causes for unsuccessful attempts. Evidence of clinical response to fluid or medication infused was noted in 28 patients (24%). CONCLUSION: EMT-P units can successfully perform the intraosseous infusion line procedure in patients of all ages. Proficiency is maintained over time despite its infrequent use by individual EMT-Ps.
STUDY OBJECTIVE: To evaluate clinical and cellular changes of bone through the rapid growth phase of development after intraosseous infusion of hypertonic or isotonic solutions at slow or fast infusion rates in a pig model. METHODS: This was a prospective, randomized, partially blinded, comparative study using a porcine model in an urban teaching hospital laboratory with further development in a local farm environment. Sixty pigs weighing 12 to 30 kg were anesthetized and endotracheally intubated, and a no. 15 Jamshidi bone marrow needle was inserted into a front forelimb. Hypertonic (mannitol) or isotonic (saline) solutions of 8 mL/kg were infused through the intraosseous site at a rapid or slow infusion rate. Animals were observed for approximately 6 months, after which they were killed and the front forelimbs harvested for gross pathologic and histologic evaluation. RESULTS: No clinical complications were noted in any of the animal groups. No substantial histologic differences were found between the hypertonic and isotonic groups. Although gross pathologic lesions were found in 32% of the hypertonic groups and in fewer than 5% of the isotonic groups, this difference was not statistically significant. Equal bone changes were found in the slow- and rapid-infusion groups. CONCLUSION: The rate of intraosseous infusion and the osmolarity of the infused fluid did not appear to be related to any gross pathologic or histologic cellular or marrow changes or to any clinical complications in animal development in this study.
The technique of intraosseous infusion is a life-saving emergency alternative when IV access is impossible or will be critically delayed. Concerns about its safety remain, especially concerning the risk of bone marrow and fat emboli to the lungs. We examined autopsy pulmonary specimens on two children who had received intraosseous infusions during resuscitation attempts and found an average of 0.23 to 0.71 bone marrow and fat emboli per mm2 of lung. We studied normotensive dogs with intraosseous infusions of emergency drugs and solutions into the distal femur. Three dogs were studied with each of the following emergency drugs or solutions: controls with normal saline (0.9% NaCl), epinephrine 0.01 mg/kg, NaHCO3 1 mEq/kg, CaCl 10 mg/kg, atropine 0.01 mg/kg, hydroxyethyl starch 6% in normal saline 10 mL/kg, 50% dextrose in water 0.25 g/kg, and lidocaine 1 mg/kg. Four hours after infusion, the animals were killed, and representative sections of the lung were examined with oil red-0 and hematoxylin and eosin stains for the presence of fat and bone marrow emboli. Fat and bone marrow emboli were found in all lung sections, varying from 0.11 to 4.48 emboli/mm2 lung (mean, 0.91 emboli/mm2 lung) for the emergency drugs and solutions and 0.06 to 0.53 emboli/mm2 (mean, 0.29 emboli/mm2 lung) for the controls. Analysis of variance revealed no significant difference (P = .07) in mean number of fat and bone marrow emboli per square millimeter of lung among the emergency drugs and compared with controls.(ABSTRACT TRUNCATED AT 250 WORDS)
We attempted a clavicular approach to intraosseous infusion (clavicular IO) as a new procedure in adults, and compared the flow rates of subclavian venous infusion, and clavicular, iliac and tibial IO. Furthermore, we observed enhanced roentgenograms of each IO by contrast media. As a result, clavicular IO indicated 11.9 +/- 0.68 mL/kg/hr (mean +/- SD, n = 29), iliac IO 32.2 +/- 4.48 (n = 21), tibial IO 18.9 +/- 1.28 (n = 15), and subclavian venous infusion 15.2 +/- 1.48 (n = 15). There were no statistically significant differences between subclavian venous infusion and clavicular IO. In roentgenograms, the contrast media entered the inferior vena cava from iliac IO, and via the femoral vein by tibial IO. The superior vena cava was enhanced through the subclavian vein in clavicular IO. No complications such as fractures or transclavicular penetrations by the IO needle occurred. In conclusion, clavicular IO may be an alternative infusion technique to provide the fluids into the subclavian vein in adults.
Intraosseous infusion is an outmoded technique that is gaining new prominence in the field of emergency medicine. Although not recommended as a replacement for conventional modes of intravascular access, this alternative provides rapid venous access during life-threatening emergencies. A review of the literature indicates that the intraosseous route provides relatively safe, rapid, and reliable access to the systemic venous circulation and is associated with an acceptably low complication rate. This article offers a brief historical overview of this technique and discusses insertion methods, clinical applications, and nursing management of pediatric intraosseous infusion.
In traumatically injured or medically unstable pediatric patients requiring resuscitation, gaining intravenous access often is frustrating for the physician and agonizing for the patient. Even when cardiopulmonary resuscitation is performed by trained professionals, cardiac arrests in children in the prehospital setting have a mortality of 79% to 100%. Immediate vascular access such as that obtained by intraosseous infusion improves survival. The intraosseous infusion technique uses the medullary cavity in the tibia as a "noncollapsible vein" for parenteral infusion. It is indicated in a child in shock or cardiac arrest when two attempts to access peripheral vasculature have failed or when more than 2 minutes have elapsed in the attempt to gain access. Epinephrine, bicarbonate, calcium, lidocaine, and volume expanders can be infused via the intraosseous route. Complications rarely occur. The technique described here is gaining acceptance in both prehospital and emergency department settings.
OBJECTIVE: A postal survey was conducted to gain an overview of current opinion and practice relating to intraosseous infusion in adult resuscitation in accident and emergency (A&E) departments in the UK and to use the results to generate debate in light of published and personal experience. METHODS: Questionnaires were sent to 559 departments listed in the 1996 British Association for Accident and Emergency Medicine directory. Three hundred and thirty two (59%) were returned and the 157 (28%) consultant led departments with more than 30,000 new patient attendances per year were examined. RESULTS: Seventy four per cent of respondents were aware that intraosseous infusion could be used in adult resuscitation, while only seven per cent used the technique. All (100%) were involved with training their medical staff and 11% said they taught the technique for use in adults. The majority of respondents were accredited in at least one of the adult resuscitation training courses. CONCLUSIONS: Numerous references appear in the literature relating to intraosseous infusion in adult resuscitation and represent a wealth of experience. The technique is taught and used in our department in contrast with the results of this survey, which demonstrate that it is infrequently taught and used in UK A&E departments. The more widespread teaching of this technique for adult use is recommended.
Intraosseous infusion is a technique used for the administration of fluids to a hemodynamically shocked child in whom attempts to access the vascular system have been unsuccessful. Although few complications are seen, injury to the epiphyseal growth plate during the performance of this technique remains a serious problem. This study investigates the relationship between the site of insertion of the intraosseous needle and the epiphyseal growth plate, and the ease of needle insertion into various locations of the tibia in newborn infants. Fourteen newborn infant cadavers (28 tibias in total) were dissected after placement of four needles: 1). through the tibial tuberosity (Site A); 2). 10 mm distal to the tibial tuberosity (Site B); 3). 20 mm distal to the tibial tuberosity (Site C) and; 4). 10 mm proximal to the tibial tuberosity (Site D). Distances from the distal end of the epiphyseal growth plate were measured. A high number of needle placements at Site A were inserted into the epiphyseal growth plate. Most placements at Site B were between 10 and 16 mm from the epiphyseal growth plate on the right side and between 10 and 15 mm on the left side, and all were inserted without difficulty. Although far from the epiphyseal growth plate, most placements at Site C were very difficult to insert because of the thick cortical bone. All placements at Site D entered the epiphysis or the epiphysis and joint space of the knee. An insertion site of at least 10 mm distal to the tibial tuberosity is therefore recommended to avoid epiphyseal growth plate injury and ensure ease of insertion.
OBJECTIVE: To assess the benefits and drawbacks of intraosseous infusion (IOI) for emergency therapy in children. STUDY DESIGN: Retrospective, non comparative study of IOI carried out between January 1994 and June 1998. PATIENTS: Forty-one children requiring without delay IOI either in the emergency medical ambulance or the emergency admission and intensive therapy units. METHODS: The tibia was punctured by paediatricians either with Mallarmé's trocars in 1994 or Cook Critical Care trocars from 1995 on. RESULTS: Overall, 46 IOI have been carried out in 41 children with a median age of 18 months (range: 8 days-9 years). The main indications for IOI were the management of near drowning, road traffic accidents and cardiopulmonary resuscitation. Complications included one articular puncture and nine subcutaneous extravasations, requiring the puncture of the other limb in five cases. CONCLUSION: IOI is an easy technique for vascular access. It is indicated in emergency cases when, after a delay of five minutes, other techniques have failed.
To reduce the emergency treatment time of shock victims, resuscitation fluids can be infused into a patient via their sternum rather than through a peripheral vein. Successful use of this method requires manual infusion because available medical equipment is not capable of infusing the preferred resuscitation fluids into the sternum at the required flow rates. This article describes the process and results of the design of a high pressure infusion system specifically intended for automating emergency sternal infusions. Infusion requirements for the human sternum were clearly defined, and were followed by the development and evaluation of many infusion system ideas, including numerous commercially available pump designs. The options were narrowed down to five schemes that were studied in depth. Finally, two schemes were picked, a compressed gas bag-within-a-bag design and a peristaltic design.
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