Einsatz der intraossären Infusion im pädiatrischen Notarztdienst

Zusammenfassung

Hintergrund

Ziel der Studie war es, den Einfluss der Einführung des intraossären Zugangs (IOZ) auf die Art der Medikamentenapplikation im Rahmen der Primärversorgung schwer kranker oder verletzter Kinder [National-Advisory-Committee-for-Aeronautics- (NACA-)Index V–VII] in einem zentrumgebundenen Kindernotarztdienst zu evaluieren.

Methode

Hinsichtlich des Vorhandenseins und der Art des Gefäßzugangs im Rahmen der Primärversorgung wurden 5279 pädiatrische Kindernotarztprotokolle aus den Jahren 1990–2009 retrospektiv analysiert. Von primärem Interesse waren die Häufigkeit der IOZ-Anlage, die Häufigkeit alternativer Applikationswege für Medikamente sowie Primärversorgungen ohne Gefäßzugang.

Ergebnisse

Als NACA-Index V–VII wurden 401 Patienten (7,6%) klassifiziert. Am Einsatzort wurde 299-mal (75%) eine periphere Venenverweilkanüle (PVK) und 3-mal (0,7%) ein zentraler Venenkatheter (ZVK) angelegt. In 77 Fällen (19%) wurde eine intraossäre Nadel (IOZ) gesetzt. Bei 22 Patienten (5,4%) konnte bis zur Klinikeinlieferung kein Gefäßzugang angelegt werden. Bei 48 Patienten (12%) wurden Medikamente endobronchial oder alternativ appliziert. Im Beobachtungszeitraum kam der IOZ stetig häufiger zum Einsatz; dagegen wurden fehlende oder alternative Applikationswege seltener. Innerhalb der letzten 3 Jahre wurde keine endobronchiale Medikamentengabe mehr berichtet.

Schlussfolgerung

Die Einführung der intraossären Infusionstechnik in der präklinischen Kindernotfallmedizin hat die Zahl kritisch kranker oder schwer verletzter Kinder ohne Gefäßzugang oder mit unzuverlässigen alternativen Medikamentenapplikationswegen in den letzten 20 Jahren deutlich reduziert.

Abstract

Background

Timely establishment of venous access in infants and toddlers during emergency medical care can be a particularly challenging task. Alternative routes for drug and fluid administration, such as endobronchial, intramuscular, central venous or venous cut-down do not offer reliable solutions. Intraosseous infusion (IOI) has become established as an effective alternative intravascular access for rapid and efficient drug delivery. IOI was introduced in our local emergency medical service (EMS) in 1993 and was assigned a high priority in international guidelines for pediatric emergency medical care in 2000 and 2005. The aim of this study was to review the impact of the introduction of IOI on drug administration routes during prehospital emergency treatment of critically ill or severely injured pediatric patients (NACA index V–VII) in our tertiary medical care centre over a period of 20 years.

Methods

Pediatric prehospital emergency medical protocols from 1990 to 2009 were analyzed with respect to the administration routes for fluids and medications in severely injured or critically ill children with NACA severity scores V–VII. The frequency and mode of vascular access during prehospital treatment including IOI, endobronchial administration, central venous catheterization (CVC) and intramuscular administration as well as prehospital treatment and transportation without vascular access were analyzed. Two groups were compared: the introduction phase of IOI between 1990 and 1999 and the phase of growing IOI routine after introducing guidelines and regular staff IOI technique training between 2000 and 2009. Demographic data and drug administration routes in the two different time periods were analyzed using the Mann-Whitney-u test and t-test or χ²-test, respectively. A p-value <0.05 was regarded as significant.

Results

A total of 5,279 pediatric prehospital emergency charts were analyzed and 401 patients (7.6%) were scored as NACA V–VII. At the emergency scene 299 patients (75%) received a peripheral intravenous access, 3 (0.7%) a central venous line access, 77 (19%) an intraosseous needle and in 22 (5.4%) no vascular or intraosseous access was used during the course of prehospital treatment (NACA VII – 13 patients, NACA VI – 2 patients, NACA V – 7 patients). Of the NACA VII patients 3 were transported under continuous cardiopulmonary resuscitation without vascular access. After 2002 all patients with NACA index VII were treated with vascular or intraosseous access. In 48 patients (12%) at least initial medication was given by the endobronchial or alternative route but within the last 3 years endobronchial drug administration was no longer reported. Thus, in 124 critically ill patients (31%) routine peripheral venous access could not be established initially or until the end of treatment (77 times IOI, 22 times no access over the course of treatment, 3 times CVC and 22 times initial endobronchial followed by peripheral venous access). Over the reviewed period the use of IOI increased significantly (p<0.001), while the incidence of lacking vascular access (p<0.05) and alternative drug administration routes (p<0.001) continuously decreased.

Conclusion

The IOI technique has not only been assigned a high priority in the guidelines for pediatric emergency care of critically ill children with difficult or failed venous access but has also significantly influenced current prehospital care. The introduction of the IOI technique in our prehospital pediatric emergency system has markedly reduced the number of critically ill or severely injured pediatric patients without vascular access or with less reliable alternative administration routes in the last 20 years.