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PubMed1992

Intraosseous infusion of resuscitative fluids and drugs: long-term effect on linear bone growth in pigs.

We studied the effects of intraosseous (IO) infusion of a standard fluid bolus and resuscitative drugs on long-term bone growth and epiphyseal closure in the "pediatric" swine model. Eighteen weanling pigs were randomly assigned to six groups as follows: three animals received two normal saline boluses, 20 mL/kg IO over 20 minutes; three received sodium bicarbonate, 1 mEq/kg IO; three received a 10% sodium bicarbonate infusion IO at maintenance rate over 1 hour; three received epinephrine 1:10,000, 0.1 mL/kg IO; three received an epinephrine infusion IO at 1 microgram/kg/min for 1 hour; and three received a dopamine infusion IO at 10 micrograms/kg/min for 1 hour. All infusions were given in the left hindleg; the right hindleg was used as a control. Lateral radiographs of the hind extremities were obtained at the beginning of the study and at 1 and 3 months after infusion. Linear radiographic measurements of the infused and control tibias were compared. At 6 months after infusion, the tibias were harvested, measured directly, and radiographed to determine the degree of epiphyseal closure. Analysis of variance for the first 3 months' data yielded a nonsignificant time-by-treatment interaction (P = .84) and a nonsignificant main effect for time (P = .22). Separate analysis of the direct measurements taken at 6 months revealed no difference in growth between experimental and control tibias. In addition, no radiographic difference in epiphyseal closure was noted between the two groups at the conclusion of the study, nor were any structural defects discovered. Intraosseous infusion of fluids and resuscitative drugs does not adversely affect subsequent bone growth and development in the swine model.

Animals↗

PubMed1995

Intraosseous infusion of a small volume of hyperosmotic fluid increases mean arterial pressure and lessens the catecholamine response in pigs with haemorrhagic shock.

OBJECTIVE: To measure the plasma catecholamine concentrations during an episode of haemorrhagic shock treated by intraosseous infusion of a small volume of hyperosmotic fluid in a standardised porcine model. DESIGN: Randomised open study. SETTING: University hospital, Norway. MATERIAL: 14 piglets. INTERVENTION: Two groups of piglets (n=7 each) were anaesthetised with ketamine and bled to a mean arterial pressure of 40 mm Hg. After 30 minutes the animals were randomised to receive 100 ml of either hyperosmotic (2.4 mo/l) or iso-osmotic (0.29 mo/l) fluid (equal volumes of glucose and sodium chloride) into the tibial bone marrow. MAIN OUTCOME MEASURES: Short term (70 minutes) observation of changes in haemodynamic, biochemical and hormonal variables. RESULTS: The hyperosmotic infusion significantly improved the circulation (mean arterial pressure and cardiac index) compared with the iso-osmotic infusion (p < 0.05). The increased plasma catecholamine concentrations returned to the reference ranges 20 minutes after the hyperosmotic infusion, and were significantly different (p < 0.05) from the catecholamine concentrations observed in the iso-osmotic treatment group. CONCLUSION: Intraosseous hyperosmotic resuscitation increases the circulatory performance and reduces the plasma catecholamine concentrations during haemorrhagic shock in pigs.

Animals↗

PubMed1986

Emergency intraosseous infusions in children.

Vascular access during advanced life support is essential. Vascular access in the critically ill child can be particularly difficult and often causes unacceptable delay. Intraosseous infusion provides safe, rapid, reliable access to the venous circulation. A case is presented illustrating the value of familiarity with this procedure. Use of the bone marrow for emergency administration of fluids and medications should be considered early in resuscitation until vascular access is obtained.

Bicarbonates↗

PubMed1985

Intraosseous infusion: an alternative route of pediatric intravascular access.

Substantial difficulties can be encountered when establishing rapid intravascular access in critically ill children. The historic technique of tibial intraosseous infusion is presented as an alternate intravenous route in children less than 3 years old. Review of the literature reveals this technique to be a rapid, reliable method with an acceptably low complication rate. Substances absorbed through the marrow, flow rates, technical difficulties, and complications are discussed.

Absorption↗

PubMed1988

Intraosseous infusion of muscle relaxants.

This case report presents the resuscitation of a 6 1/2-month-old child with elevated intracranial pressure, seizure activity, and a presumptive diagnosis of shaken child syndrome. It is unique in the usage of an intraosseous infusion line for the administration of muscle relaxants and anesthetic agents to aid in an atraumatic intubation in this head-injured child. This is an original report of the usage of the intraosseous line for the administration of succinylcholine chloride, atracurium besylate, and thiopental sodium.

Accidental Falls↗

PubMed1985

Intraosseous infusions: a review.

Intravenous access is critical in infants and children with severe shock or cardiac arrest. However, it is in these clinic situations that venous access may be most difficult. The technique of intraosseous infusion may provide a useful alternative to intravenous access in the initial phases of resuscitation. The method of insertion, indications, contraindications, and complications are reviewed.

Adult↗

PubMed1989

Iatrogenic bilateral tibial fractures after intraosseous infusion attempts in a 3-month-old infant.

A 3-month-old girl presented to the emergency department with a clinical picture compatible with sepsis. When peripheral IV cannulation could not be attained, intraosseous (IO) access was attempted unsuccessfully in both tibias as well as in the right femur. The child was subsequently treated for S pneumoniae meningitis. Three days after discharge and 14 days after initial presentation, the family noticed swelling of the child's right leg. Radiographs revealed healing fractures of both proximal tibias. This case represents a previously unreported complication of intraosseous infusions and underscores the need for the use of proper technique and equipment.

Bone and Bones↗

PubMed1990

Pediatric intraosseous infusion.

Venous access in the infant and child is always challenging. The hypotensive child who is deteriorating needs rapid volume expansion and medications. Vascular collapse and previous venous cut-downs can preclude easy cannulation of vessels. Intraosseous infusion of fluids and drugs can be readily performed. The technique is easily mastered and there are few complications.

Catheterization, Peripheral↗

PubMed2005

The utilisation of intraosseous infusion in the resuscitation of paediatric major trauma patients.

Intraosseous lines are a reliable and rapid tool for obtaining vascular access in emergency situations, particularly in children. Their use is recommended when intravenous access cannot be easily secured and there is a need for fluid or pharmacological resuscitation. Training in this technique is included in the Advanced Trauma Life Support (ATLS) and Advanced Paediatric Life Support course (APLS) provider courses. The objective of this study is to analyse the national use of intraosseous lines in paediatric trauma in England and Wales. Data has been collected from the Trauma Audit and Research Network (TARN) group longitudinally over 14 years from 1988 to 2002. From 23,489 paediatric trauma cases, intraosseous lines were used in only 129 patients. Compared with the remainder of the paediatric data, we found that these were the younger (1-6 years), more severely injured patients (higher ISS, lower GCS, higher head, thorax, and abdominal AIS). The mortality of these patients was high at 64% compared with 4% overall. IO line use was greater in general than in Paediatric hospitals, perhaps due to good intravenous access skills in paediatric centres. We recommend that intraosseous line use should be a skill available to everybody involved in paediatric trauma resuscitation, particularly those who may not have refined paediatric intravenous cannulation skills.

Age Distribution↗

PubMedDate not supplied

Treatment of dogs in hemorrhagic shock by intraosseous infusion of hypertonic saline and dextran.

Under isoflurane anesthesia, 50% of the calculated blood volume was removed from 11 dogs. After 30 minutes, five dogs were treated with hypertonic saline and dextran (HSD) (5 mL/kg) followed by isotonic saline solution (2 mL/kg) intraosseously. Six dogs (controls) received isotonic saline (7 mL/kg) intraosseously. All treatments were administered through the medullary cavity of the tibia over a 30-minute period. Cardiac output, mean arterial pressure, central venous pressure, packed cell volume, total protein, and blood gases were monitored for 4 hours. Cardiac output, mean arterial pressure, and circulating volume (indicated by packed cell volume and total protein) were significantly improved after administration of HSD. We conclude that intraosseous infusion of HSD is efficacious in treating hemorrhagic shock and believe the technique may prove to be useful in clinical situations when intravenous lines cannot be established rapidly.

Animals↗

PubMed1987

Intraosseous infusion flow rates in hypovolemic "pediatric" dogs.

We tested a 20-gauge, 2 1/2-inch spinal needle and a 13-gauge, 3 1/2-inch bone marrow needle with Ringer's lactate delivered by gravity and 300 mm Hg pressure in vitro and in hypovolemic puppies to ascertain in vivo intraosseous flow rates and to determine the effects of catheter size and anatomic factors on flow rate. In vitro flow was significantly faster than in vivo flow (P = .001). In vivo, mean flow rates were 11 mL/min for the 20-gauge needle and 13 mL/min for the 13-gauge needle by gravity. The mean flows by 300 mm Hg pressure for the same needles were 24 mL/min and 29 mL/min. While the in vivo flow rates were significantly greater for the 13-gauge versus the 20-gauge needle, the differences were not clinically significant (2 mL/min difference by gravity and 5 mL/min difference by pressure). The clinically comparable in vivo rates for the two needles tested indicated that the rates are dependent on flow through the bone marrow rather than the size of the needle. The data suggest that while intraosseous infusion is a rapid technique for gaining vascular access, the flow rates achieved may not be sufficient for the definitive treatment of severe hypovolemic or hemorrhagic shock alone.

Animals↗

PubMed1990

Emergency intraosseous infusion in severely burned children.

Severely burned patients require rapid administration of large volumes of isotonic fluids. Obtaining adequate intravenous (IV) access in children with greater than 70% total body surface area burns may be difficult, time-consuming, and sometimes impossible. This report describes the use of intraosseous infusion technique as a life-saving means of establishing IV access in two severely burned children.

Bone and Bones↗

PubMed1991

Skin necrosis complicating intraosseous infusion.

Bone marrow infusion is currently recommended as a useful technique for rapidly obtaining vascular access in critically ill children. Minor complications occur frequently, but serious complications of this technique are uncommon. We describe two patients with local skin necrosis complicating intraosseous infusion. To minimize the complications of this technique, we recommend placement verification before fluid infusion, careful monitoring for infiltration, and prompt removal after venous access is obtained.

Bone Marrow↗

PubMed1993

Intraosseous infusion of prostaglandin E2 in the caprine tibia.

We evaluated the effects of intraosseously administered prostaglandin E2 (PGE2) within the proximal metaphysis of the goat (caprine) tibia under intraosseous normotensive and hypertensive conditions. PGE2 was administered at 0.5 or 1.0 mg (1 ml vol) twice daily for 10 days via an Osteoport which had been surgically implanted within the proximal tibial metaphysis. Intraosseous hypertension was produced when venous outflow obstruction (VOO) was created by ligation of the popliteal vein, which drained the proximal tibia, and occlusion of the diaphyseal medullary space distally with bone cement. After VOO, the intraosseous pressure measured at the metaphysis increased significantly (p < 0.05) from a baseline mean of 14.9 +/- 4.2 mm Hg to 28.6 +/- 5.3 mm Hg. Serum radioimmunoassays indicated that VOO prolonged the venous drainage of PGE2 from the tibia after an infusion. Static histomorphometric analysis indicated a marked dose-dependent increase in new bone formation in all PGE2 groups at 30 days after the PGE2 infusion. Significant (p < 0.05) formation of new bone occurred, primarily at the subperiosteal and endocortical surfaces, and moderately increased the marrow cavity of cancellous new bone as compared with the VOO-only group and the controls. Bone remodeling indices were also increased by PGE2. The PGE2 infusion, combined with VOO, produced significantly more new bone formation than the PGE2 infusion alone. Intensive marrow fibrosis was associated with the active bone remodeling.

Animals↗

PubMed2000

Intraosseous infusion devices: a comparison for potential use in special operations.

OBJECTIVE: To determine which intraosseous (IO) devices were easy to learn to use, easy to use once the skill was obtained, and appropriate for the Special Operations environment. METHODS: Thirty-one Navy SEAL corpsmen, Air Force pararescuemen, Army Special Forces, and Ranger medics, in a prospective, randomly assigned, cross-over study, tested four commercially available, Food and Drug Administration-cleared IO devices. The systems included the injection models First Access for Shock and Trauma (FAST, Pyng Medical) and Bone Injection Gun (Wais Medical, Kress USA Corporation) and the hand-driven threaded-needle SurFast (Cook Critical Care) and straight-needle Jamshidi needle (Baxter) models. The Special Operations medical care providers received a lecture regarding IO use, viewed videotapes of the injection models, and practiced with demonstration units in the classroom. Each participant then entered the cadaver lab where all four of the IO devices were placed in randomly assigned order. A poststudy questionnaire was then completed. The FAST was placed in the sternum, whereas the other units were placed in either medial proximal or distal medial tibia. Each participant was assessed for time, number of attempts, and success. The presence of marrow, extravasation, quality of flow, and security of needle were evaluated in combination to help determine success. RESULTS: All four devices were believed to be easy to learn as well as easy to place. FAST was successful in 29 of 30 insertions (94%) with a placement time of 114 +/- 36 (mean +/- SD) seconds. The Bone Injection Gun was similarly successful (29 of 31 insertions, 94%) with a mean placement time of 70 +/- 33 seconds. This time was statistically significantly faster (p < 0.05) than that with FAST, but not with the other devices. Thirty of 31 SurFast placements (97%) were successful, on average taking 88 +/- 33 seconds to place. The Jamshidi needle also had 30 of 31 successful placements (97%) at an average 90 +/- 59 seconds. No one device was rated by the participants as significantly better than the others; however, the Bone Injection Gun did have 65% of participants rate it as first or second (closest was Jamshidi needle at 52%). CONCLUSION: These IO devices were easy to teach and learn as well as easy to use. Insertion times compared favorably with peripheral intravenous catheter placement in the face of hemorrhage. All four devices can be appropriately used in the Special Operations environment and are reasonable alternatives when intravenous access cannot be gained. Although no device was rated higher than the others, particular features are desirable (low weight/size, simplicity, reusability, secure, clean, well protected).

Allied Health Personnel↗

PubMed1994

[Heart arrest: septic and hypovolemic shock--intraosseous infusion technique].

Cardiorespiratory arrests in infants are most often caused by generalized hypoxia. This leads to the well-known fact that the outcome of arrests in the pediatric age group is poor. On the other hand we have the chance to recognize the ongoing hypoxia at early stages. Prevention of this dangerous situation is the aim of treatment. Clinical manifestations of shock states in children differ considerably from those seen in adult patients. Causes and treatment of hypovolemic and septic shock and the technique of intraosseous puncture and infusion are described in detail.

Child, Preschool↗

PubMed1996

Intraosseous infusion of prostaglandin E2 prevents disuse-induced bone loss in the tibia.

We investigated whether intraosseous injection of prostaglandin E2 would preserve tibial bone mass in the skeletally unloaded limb of a large animal model. Skeletal unloading of one rear limb was produced by unilateral Achilles tenectomy in the goat. Prostaglandin E2 was injected at 0.5 or 1.0 mg (1 ml of volume) twice daily, beginning on day 7 and continuing for 10 days, through an implant that had been surgically placed in the proximal tibial metaphysis. Thirty-five days after surgery, the tibiae were harvested for measurement of static and dynamic bone parameters and mechanical characteristics using transmission ultrasound. Prostaglandin E2 produced a dose-dependent increase in the formation of woven new bone at all bone envelopes. The 1.0 mg dosage prevented and partially reversed the effects of skeletal unloading and added new bone (p < 0.05) compared with the unloaded tibiae. Because prostaglandin E2 increased both bone formation and resorption and the new bone produced was primarily woven bone, the material properties of the tibiae infused with prostaglandin E2 did not increase significantly during the study compared with the unloaded and weight-bearing tibiae.

Animals↗

PubMed2001

Intraosseous infusion and pulmonary fat embolism.

OBJECTIVES: To determine the incidence of pulmonary fat embolism after the intraosseous (IO) infusion of normal saline and drugs and to determine whether pulmonary capillary blood is a predictor of lung fat embolism. DESIGN: A randomized, prospective, animal study. SETTING: Animal research laboratory of a university hospital. SUBJECTS: Twenty-eight mixed breed piglets (average weight 30.9 kg). Interventions and Methods: Animals were anesthetized, intubated, mechanically ventilated, and instrumented. IO needles were placed in the tibial bone. Animals were assigned to one of four groups: Group 1 received fluid (20 mL/kg) under 300 mm Hg pressure (n = 6); group 2 received fluid (20 mL/kg) at free flow under gravity (n = 6); group 3 received 100 mL of fluid over 20 mins (n = 8); and group 4 received 100 mL of fluid over 7 mins (n = 8). MEASUREMENTS AND MAIN RESULTS: Buffy coat samples were obtained from pulmonary arterial catheter in the occluded position at baseline, after IO needle placement, and at the end of infusion. Lung specimens (both upper and lower lobes) were obtained at the end of the infusion. Specimens were stained with oil red O and graded for fat emboli by a pathologist blinded to experimental conditions. Fat emboli (one to three emboli per high power field) were found in about 30% of the lung specimens. The difference in number of fat emboli between groups was not statistically significant. Buffy coat stains yielded fat emboli, which were distributed sporadically in all groups. CONCLUSION: Fat embolism is common; however, the method of IO fluid administration does not influence the number of emboli. Our study therefore implies that the risk of fat embolization is of concern, but its clinical relevance is unclear. Until the clinical significance of pulmonary fat emboli and the prevalence of fat emboli syndrome are delineated more precisely, the IO route is an effective but not necessarily safe route for delivery of fluids and drugs.

Journal Article↗