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PubMed1992

Intraosseous infusion using the osteoport implant in the caprine tibia.

We evaluated the in vivo animal tolerance to intraosseous infusion via the Osteoport pediatric implant (model 2005PSO, Lifequest Medical, San Antonio, TX, U.S.A.) into the proximal tibia of immature goats and investigated the osseous effects of intermittent and sustained increases in intraosseous pressure (IOP). In group 1 (n = 3) autogenous whole blood was continuously infused (CI) for 5 days at flow rates producing an IOP of 30-45 mm Hg. Group 2 animals (n = 3) underwent a 5-s high-pressure infusion (HPI) of lactated Ringer solution (LRS) producing an IOP of 90-125 mm Hg twice daily for 10 days. In group 3, the Osteoports were left in place 5 (n = 2) or 10 days (n = 2) and evaluated for patency at 72-h intervals. An IOP > 35 mm Hg produced clinical evidence of bone pain. Bone mineral density was significantly increased (p < 0.05) in all implanted tibias (mean 1.04 g/cm2; range 0.87-1.21 g/cm2) compared with controls (mean 0.67 g/cm2; range 0.65-0.71 g/cm2). A nonsignificant increase (+9% to +31%) in periosteal new bone formation occurred in all implanted tibias. In the continuously infused group, there was a significant increase (p < 0.05) in cancellous new bone formation (+483%), percentage eroded bone surface (+143%), and osteoclast covered bone surface (+255%) compared with controls. HPI of LRS did not produce significant bone changes. Seemingly, the Osteoport provided a ready means of intraosseous infusion and may be associated with less complications than current methods of continual vascular access. Bone changes correlated more with the duration than the magnitude of increased intraosseous pressures.

Absorptiometry, Photon↗
PubMed1989

Prehospital intraosseous infusion by emergency medical services personnel: a prospective study.

Intraosseous infusion technique by paramedics in the prehospital setting was prospectively evaluated. Intraosseous access was successfully established in 16 of 17 pediatric patients with cardiopulmonary arrest. There were 13 successful first attempts with intraosseous access established within 1 minute. No significant complications occurred. In this study, the ease of establishing intraosseous access by paramedics in the field is documented.

Allied Health Personnel↗
PubMed1989

Resuscitation of hemorrhage with intraosseous infusion of hypertonic saline/dextran.

We resuscitated unanesthetized bled sheep (bled volume = 1.2-1.7 liters) with 200 ml of hypertonic saline/dextran 70 infused either through a peripheral vein (n = 6) or directly into the red marrow of the sternum (n = 6). Intraosseous infusion of the viscous 7.5% NaCl/6% dextran solution required 2-4 min. Plasma sodium was rapidly increased to the same level in both groups demonstrating equally rapid entry into the vascular space. Both regimens provide rapid and sustained normalization of arterial pressure and cardiac output. No significant differences between the two groups were apparent for any measured variable. Intraosseous infusion of hypertonic resuscitation fluids merits further research to evaluate the safety and efficacy for prehospital treatment of hypovolemia and trauma.

Animals↗
PubMed2003

Long-term effects on tibial growth after intraosseous infusion: a prospective, radiographic analysis.

BACKGROUND: Evaluate, by radiographic analysis, tibial growth after an intraosseous infusion (IOI) in a pediatric population. METHODS: We performed a prospective simple blind study, between January 1, 1994, and July 1, 2001, which included pediatric patients who needed an intraosseous trocar in emergency situations. During the follow-up, roentgenographs were performed. On each radiologic view, different measurements were carried out: anterior and lateral tibial length, anterior and lateral width at 2 diaphyseal levels. We compared the anterior length values to those published in the Anderson et al tables. When only one tibia was punctured, the mean measurements were compared with the control leg measurements using a paired t test. RESULTS: The initial population included 78 patients. Of these 78 subjects, 42 died, 10 families could not be contacted, and one refused to participate. Two children were excluded because they had other conditions that could influence tibial growth. The study included 23 children. The puncture site was the proximal tibia. The mean age was 18.6 months at the time of IOI, the mean time of infusion was 5 hours, and the mean perfused volume was 225 mL. The mean radiologic follow-up time was 29.2 months. When compared with the Anderson et al tables, all the anterior length values were within the 95% confidence interval. For the other measurements, the statistical analysis showed no significant difference between punctured and control legs. CONCLUSION: There is no long-term effect on tibial growth after an IOI when the IO trocar is properly placed.

Age Determination by Skeleton↗
PubMed1997

Fat embolism with the use of intraosseous infusion during cardiopulmonary resuscitation.

The objective of this prospective study was to assess the incidence and magnitude of fat emboli after cardiopulmonary resuscitation and intraosseous infusions. An animal laboratory at a university center was used to study 33 mixed-breed piglets. The piglets underwent hypoxic cardiac arrest followed by chest compressions and mechanical ventilation for a minimum of 30 minutes. The animals were divided in groups: group 1 (n = 5), which had no intraosseous cannulas, group 2 (n = 6), which had intraosseous cannulas with infusion, groups 3 (n = 6), 4 (n = 6), and 5 (n = 8), which had intraosseous cannulas with infusion of epinephrine, normal saline, and sodium bicarbonate respectively, and group 6 (n = 2), which was a sham group with no intraosseous cannulas and no cardiopulmonary resuscitation. At cessation of cardiopulmonary resuscitation, representative lung samples were collected from upper and lower lobes of each lung and observed for fat globules and bone marrow elements. Fat globules were seen in the peribronchial blood vessels and intravascular areas throughout all lung fields of groups 1 through 5. There was no difference in appearance or distribution of fat globules among the 5 treatment groups. Analysis of variance showed no statistical significance (P < 0.05) within or among groups 1 through 5. The use of the intraosseous cannula for infusion of emergency drugs and fluids did not increase the magnitude of fat embolization over cardiopulmonary resuscitation alone in this animal model. The benefits of using this procedure in critically ill children as a means of rapid vascular access for resuscitation is well established. However, the risk of fat embolism in this population needs further study.

Analysis of Variance↗
PubMed1990

Blasts in peripheral blood with intraosseous infusion.

Two children who died of apparent Sudden Infant Death syndrome (SIDS) were found to have immature white blood cells, including blasts, in their peripheral blood. No cause for marrow elements in peripheral blood was found. The blood was sampled proximal to an intraosseous infusion, which may have displaced the marrow elements into the venous circulation. Physicians should be aware that patients receiving intraosseous infusions may have immature white blood cells in the peripheral circulation in the absence of malignant, infectious, or infiltrative disease of the marrow.

Bone Marrow↗
PubMed1989

Implementation of intraosseous infusion technique by aeromedical transport programs.

Aeromedical transport program implementation of intraosseous infusion (IOI) was ascertained by telephone survey. One hundred thirty-three programs were polled: 69.2% had never utilized IOI nor were considering its use; 13.5% had previously utilized IOI; 15.8% had not yet implemented IOI but had been in-serviced on the technique; and 1.5% were considering implementation. Of 39 programs previously in-serviced or presently utilizing the procedure, seven restricted IOI insertion to physicians while 32 permitted placement by nurses or paramedics. Half of the programs would pursue IOI immediately after a 5-minute trial of peripheral line placement in preference to cutdown or central venous line attempts. About 50 IOI were performed by aeromedical transport personnel in 1986. Rate of successful insertion was approximately 80%. Complications were few and minor. This survey demonstrates that the simple, safe technique of IOI is being grossly under-utilized and warrants further consideration.

Aircraft↗
PubMed1993

[Intraosseous infusions in pediatric life-threatening emergencies].

As the bone marrow is a vascular tissue which cannot collapse, it may be used as a vascular access to treat life-threatening emergencies especially in children. Two cases reported here underline the value of this life-saving procedure. Both children were 9 months old, and were admitted for severe dehydration, having lost 15 and 10% of body weight respectively. All attempts to set up an intravenous infusion in a peripheral vein failed in both. The fontanelles were closed, and the central veins (internal jugular and subclavian veins) easily accessible, however collapsed. Intraosseous infusion was decided as a last ditch procedure. A 15-gauge Mallarmé's trocar was inserted at the proximal end of the tibia. In both children, this allowed rehydration to be carried out, and, in the second child, anticonvulsive and antibiotic therapy to be started. The intraosseous line was replaced, in the first child, at the third hour, by a conventional infusion line, set up by denudation, and in the second one, by a subclavian line. This technique has few contra-indications, and the complication rate is low. However, this technique should remain limited to a few indications only.

Dehydration↗
PubMed1986

Intraosseous infusions in the emergency department.

For most emergency physicians and pediatricians, the frustrations encountered when obtaining intravenous access in infants involved in traumatic or medical emergencies are well known. Although it is rare that parenteral access is absolutely unobtainable in a pediatric patient, minutes and sometimes hours are often lost as futile attempts are made to cannulate a collapsed vein of such a patient. Many alternatives to such a crisis situation, including the intratracheal, intracardiac, and sublingual routes of administration, have been proposed and efficaciously used. Disadvantages to these alternatives, however, include the inability to administer volume-expanding colloids or crystalloids, and a relatively narrow spectrum of useful medications. One relatively safe, well-proven, and technically easy method for giving replacement fluids, blood products, and numerous resuscitative drugs is infusion by the intraosseous route. Although not recommended as a replacement for current modes of intravascular access, we feel it has definite utility in selected situations and warrants the awareness of emergency physicians. The value, historical aspects, technique, and complications of this procedure are discussed.

Child↗
PubMed1988

Pediatric intraosseous infusions: impact on vascular access time.

A 1-year retrospective chart review was performed to evaluate the effect of intraosseous infusions (IO) on the time required to establish vascular access in pediatric patients requiring immediate vascular access for resuscitation. Eighty-one patients were identified, including 29 pulseless and non-breathing and 52 noncardiopulmonary arrest children, who required intravenous fluids or medication for resuscitation. Comparing the results with a previous review, the IO method effectively reduced the time needed to establish vascular access in the arrested group when standard techniques failed, particularly in the child less than 2 years old. The IO method was not used effectively in the non-arrest group, as evidenced by a significantly greater mean time required to establish vascular access. There were no significant complications related to the IO procedure. Nine (50%) of the patients receiving IO fluids or medication had clinical and/or laboratory evidence that these substances reached the central circulation. Early use of IO infusion in the resuscitation is recommended for not only the arrested patient, but also the critical nonarrested patient requiring immediate vascular access.

Bone Marrow↗
PubMed2002

Hypertonic saline: intraosseous infusion causes myonecrosis in a dehydrated swine model of uncontrolled hemorrhagic shock.

BACKGROUND: The Institute of Medicine has recommended intraosseous (IO) infusion of 7.5% hypertonic saline (HTS) for combat casualties in shock. We tested the safety and efficacy of this recommendation in a long-term survival model of uncontrolled hemorrhagic shock using dehydrated swine. METHODS: Fourteen dehydrated Yorkshire swine had placement of a 12G needle in the right anterior tibia under isoflurane anesthesia. Uncontrolled hemorrhage was induced via left iliac artery and vein injury. Animals were kept in shock for 2 hours and then resuscitated over 2 hours with 5 mL/kg of 7.5% HTS given either as 10 small boluses (group I, n = 4) or two large boluses (group II, n = 6) to compare the physiologic response and blood loss. Control animals (group III, n = 4) received an equal volume of 0.9% saline IO and additional intravenous saline to equalize the salt load in all groups. RESULTS: The three groups had similar physiologic responses, with no increase in blood loss following HTS resuscitation. However, between the second and fifth postresuscitation days, the 7.5% HTS resuscitated animals developed soft tissue necrosis or bone marrow necrosis of the right hind leg (group I, 100%; group II, 66.6%; group III, 0%). CONCLUSION: HTS resuscitation effectively restored hemodynamic stability in dehydrated swine without increased bleeding from an uncontrolled vascular injury. However, IO infusion of HTS in this model was associated with a very high rate of local complications. Further investigations should be undertaken before IO use of 7.5% HTS in humans.

Animals↗
PubMed1987

Emergency applications of intraosseous infusion.

Vascular access is an important step in the care of the critically ill child but can be very difficult and time consuming. Recently, intraosseous infusion has experienced a resurgence as a rapid alternative to venous cannulation. Several cases illustrate the usefulness of this technique in the emergency department. Included are the first reports of the use of intraosseous diazepam and succinylcholine.

Ampicillin↗
PubMed1992

The effects of intraosseous infusion on the growth plate in a nestling rabbit model.

STUDY OBJECTIVE: The objective of this study was to test the hypothesis that saline or bicarbonate infusion does not damage the growth plate in a nestling rabbit model. SETTING: Animal laboratory. DESIGN: In this prospective study, 22 tibias from nestling rabbits were randomized into control, puncture-only, physiologic saline, or bicarbonate infusion groups and killed three and five days after treatment for evaluation of injury. MEASUREMENTS: Bone injury was evaluated by microradiograph and by decalcified and undecalcified histology. RESULTS: Radiographs demonstrated loss of trabecular (ie, calcified) bone after infusion of both saline and bicarbonate solutions. Although no histologic damage to the cell lines of the growth plate was seen, newly formed bone trabeculae were seen in both infusion groups, suggesting injury and repair at sites of infusion. These findings were absent in control and puncture-only groups. No histologic or radiographic differences were seen between saline and bicarbonate infusions. CONCLUSION: The nestling rabbit provides a good animal model for evaluating the effects of intraosseous infusion on growing long bones and cartilage. Saline and bicarbonate infusions did not damage morphologically the metaphyseal growth plate but did cause loss of bone trabeculae that support the growth plate. The injury appeared to be repaired rapidly in these nestling rabbits.

Animals↗
PubMed1991

Intraosseous infusion for resuscitation.

An 11 week old infant who had a cardiac arrest secondary to gastrointestinal haemorrhage and was successfully treated using intraosseous infusion is reported. The child was discharged with no apparent neurological deficit.

Bone Marrow↗
PubMed1990

Comparison of serum phenobarbital levels after single versus multiple attempts at intraosseous infusion.

Serum drug levels from a single intraosseous attempt in nontraumatized bone have proven comparable to levels from IV drug infusions. However, in the clinical situation, inexperienced personnel may make multiple intraosseous attempts, which could allow significant extravasation from multiple intramedullary entrance sites. Serum drug levels arising from multiple intraosseous attempts in traumatized bone were compared with those arising from single intraosseous attempts in nontraumatized bone. We administered phenobarbital to 24 dogs randomly divided into single- (11) and multiple-attempt (13) groups. In the multiple-attempt group, we created three intramedullary insertion sites in a linear fashion and infused through only the central site. In the single-attempt group, only a single infusion site was created. Phenobarbital then was infused into the intramedullary space, and central venous phenobarbital samples were collected at one-, three-, six-, and ten-minute intervals. The single-attempt group attained significantly higher serum phenobarbital levels at each interval compared with the multiple-attempt group (P less than .0001). Therefore, to be an effective mode of therapy, it is critical to achieve single-attempt intraosseous needle placement for intraosseous infusion.

Animals↗
PubMed1994

Intraosseous infusion: success of a standardized regional training program for prehospital advanced life support providers.

STUDY OBJECTIVE: To evaluate a standardized training program in intraosseous (IO) infusion for prehospital providers. DESIGN: Prospective multicenter 24-month study. SETTING: IO infusions were performed by prehospital providers from eight advanced life support units serving 14 hospitals within nine counties. PARTICIPANTS: Field advanced life support providers (paramedics and registered nurses). INTERVENTIONS: All providers participated in a one-hour standardized training session and supervised hands-on simulation. Providers completed a data sheet on all IO infusions performed. Data sheets were collected and summarized. RESULTS: One hundred thirty-four prehospital providers completed the training session and were approved to perform the procedure. Fifteen patients requiring IO infusion were encountered during the study period. Thirteen (87%) had IO infusion completed successfully. Clinical indications included 11 patients in cardiac arrest, two trauma resuscitations, one seizure, and one toxic ingestion. Patient ages ranged from 1 to 24 months. Seven patients were initially resuscitated. Four survived to hospital discharge. Procedural complications included one incidence of local fluid extravasation and one IO line that became dislodged en route. There were no complications at time of discharge in the four survivors. All procedures were performed in less than two minutes. CONCLUSION: A one-hour standardized training session was successfully used to train prehospital providers in the procedure of IO infusion. IO infusion then was implemented into their clinical practice with a satisfactory success rate and few complications.

Child, Preschool↗
PubMed1990

Adoption of intraosseous infusion technique for prehospital pediatric emergency care.

A telephone survey was conducted, contacting 51 designated state EMS offices, to determine the extent of use of intraosseous (IO) infusions in prehospital pediatric emergency care nationally and to identify common means of promoting IO adoption, training EMS personnel, and monitoring intraosseous field use. Less than half of the respondents reported actual prehospital use of IO infusions in pediatric patients, and an additional third indicated that they were unaware of any future plans for introducing the technique into EMS practice. This study's documentation of the current limited prehospital use of intraosseous infusions indicates a need for concerted efforts to promote broad adoption and continued evaluation of the IO technique in prehospital pediatric emergency care. Suggestions to enhance adoption include increased utilization of existing successful IO teaching approaches, development of national EMS standards regarding intraosseous infusions, active involvement of EMS regulatory agencies for widespread practice changes, and consistent quality assurance activities.

Bone and Bones↗