Intraosseous infusions: A usable technique

doi:10.1016/S0735-6757(86)80014-6

The American Journal of Emergency Medicine

Volume 4, Issue 6, November 1986, Pages 540-542

https://doi.org/10.1016/S0735-6757(86)80014-6 Get rights and content

Intraosseous infusions were widely used in pediatric patients during the 1930s and 1940s. Recent reports have re-introduced this concept and confirmed its safety and ready accessability for fluid and drug administration. However, these reports have not addressed the difficulties encountered during insertion of the intraosseous needle. Spinal needles, standard metal intravenous (IV) needles, and bone marrow biopsy needles have been suggested for intraosseous infusion. These needles were tested for ease of insertion on a pediatric cadaver leg. The site for needle placement was also evaluated during the study. It was found that the 13-gauge Kormed/Jamshidi® disposable bone marrow/aspiration needle was the easiest to insert and did not plug with bone or tissue during insertion. An area proximal to the medial malleolus was found to provide a stable, relatively flat, and easily penetrable location for needle placement. This method was successfully utilized in ten pediatric and five adult patients. Intraosseous needle placement is a safe, rapid method to gain access to the venous circulation. By utilizing these techniques, a stable, usable fluid line can be established in even the most dehydrated pediatric patients.

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Cited by (50)

Anatomical investigations on intraosseous access in stillborns – Comparison of different devices and techniques
2018, Resuscitation
Citation Excerpt :
However, neonates were not analysed separately. Regarding anatomical considerations, there are only limited studies with respect to neonatal tibial anatomy [19–21]. However, these studies did not refer to the need of intraosseous access in this special group of patients.
Intraosseous (IO)-access plays an alternative route during resuscitation. Our study was performed to investigate the successful rate of IO-access in preterm and term stillborns using different devices and techniques.
The cadavers used were legal donations. 16 stillborns, median: 29.2 weeks (IQR 27.2–38.4) were investigated. Two different needles (a: Butterfly needle, 21G, Venofix^® Fa.Braun; b: Arrow^®EZ-IO^®15G, Teleflex, Dublin, Ireland) were used. Needles were inserted i: manually, using a Butterfly needle; ii: manually, using EZ-IO^® needle or iii: using a battery-powered semi-automatic drill (Arrow^®EZ-IO^®). Spectral-CT's were performed. The diameter of the corticalis was determined from the CT-images. Successful hit rates with 95% confidence intervals (CI) and odds ratios between the three methods were estimated using a generalised linear mixed model (GLMM).
Estimated success rate was 61.1% (95%CI:39.7%–78.9%) for the Butterfly needle, 43.0% (95%CI:23.4%–65.0%) for hand-twisted EZ-IO^® screwing and 39.7% (95%CI:24.1–57.7%) for the semi-automatic drill (Arrow^®EZ-IO^®), all referring to an average diameter of the corticalis of 1.2 mm. The odds of a correct position were 2.4 times higher (95%CI:0.8–7.6) when using the Butterfly needle than with the drill. In contrast, the odds of correct positioning when inserting the needle by hand were not significantly different from using the drill (odds ratio 1.1, 95%CI: 0.4–3.3). Neither of these effects nor the diameter of the corticalis with an odds ratio near one were significant in the model. Median diameter of the bone marrow cavity was 4.0 mm [IQR 3.3–4.7].
Intraosseous access for premature and neonatal infants could be best achieved by using a manually twisted Butterfly needle.
Evaluation of the sternal intraosseous route as alternative emergency vascular access for the dental office: A manikin and cadaver model pilot study
2013, Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Citation Excerpt :
At least 130 individuals in both groups using the respective systems would be needed to achieve an adequate power (>0.8) to state inequality of these independent groups at a P value of .05 using the Fisher exact test. It is assumed that the intraosseous access is an alternative to the intravascular route.2,3,8-16 Published success rates of a sternal intraosseous access range between 74% and 80%.17,18
To evaluate 2 sternal intraosseous access devices as alternatives to emergency intravenous access for dentists, using a manikin and a cadaver model.
A group of 37 students performed a sternal intraosseous access on a manikin using a Vidacare kit including a puncture template and a prepuncture skin incision. Five months later, 9 of the students used the Vidacare and 8 used an Illinois needle (without template and incision) on adult human cadavers. India ink was injected as a tracer.
Shorter times were recorded on cadavers compared with manikins in both systems. One Vidacare puncture ended subcutaneously. Two Illinois needle punctures perforated the sternum, one with intense mediastinal ink traces. Vidacare punctures took longer compared with Illinois needle punctures (medians, 32 vs 12 seconds; P = .0002).
Template use to identify the sternal puncture position, combined with additional prepuncture skin incision, may be more efficient and less predisposed to severe complications for dentists' emergency use.
The efficiency of intraosseous human growth hormone administration: A feasibility pilot study in a rabbit model
2013, American Journal of Emergency Medicine
Citation Excerpt :
The intraosseous (IO) route has been found to be clinically efficacious in both children and adults for the administration of fluid boluses and blood transfusions [1] as well as various pharmaceuticals, such as cardiac resuscitation drugs, anticonvulsants, adjunctive anesthesia medications [2,3] and human albumin [4]. It is considered as an alternative to the intravenous (IV) route [5], especially during resuscitation, as the bone marrow drains directly into the venous system. Its use for delivery of medications and fluids was first described by Drinker and Doan in 1922 [6,7].
The use of protein- and peptide-based drugs in the treatment of disease has significantly increased in recent years. However, their chemical and physical properties make them unsuitable for simple oral delivery.
The objective of this proof-of-concept study was to examine the feasibility of protein administered via intraosseous (IO) injection. Human growth hormone (GH), a 22-kd protein, served as the model protein.
An indwelling IO needle and intravenous (IV) line were placed in four New Zealand white male rabbits, and 50, 100, 200, or 400 μg/kg of GH were injected. Blood samples were taken at different time points and analyzed for GH concentration. There were no significant pharmacokinetic differences between the IO and IV routes. For the 400 μg/kg dose, the area under the serum GH concentration time curve was 100.55 ± 46.7 μg/min*mL with IV administration and 84.6 ± 34 μg/min*mL for IO (P = .73 compared to the IV route), C_max measured 11.2 ± 5 μg/L and T_max 0.9 ± 0.7 minutes. For the 200 μg/kg dose, the area under the curve was 68.5 ± 16.7 μg/min*mL with IV administration, and 85.1 ± 1.5 μg/min*mL (P = .39) for IO, C_max measured 8.13 ± 2.44 μg/L and T_max 1.92 ± 1.06 minutes.
The findings confirm that a large protein (22 kd) can be administered via IO injection, reaching blood levels comparable to IV injection. Further studies with a larger number of animals are required to evaluate the pharmacokinetics and pharmacodynamics of high-molecular-weight proteins injected by the IO route.
The use of intraosseous infusions in the operating room
2008, Journal of Clinical Anesthesia
Citation Excerpt :
Several studies have evaluated the performance of the different types of needles and devices available for IO access. Using a pediatric cadaver leg, Iserson and Criss [11] assessed the ease of use of various needles including 13-, 18-, and 20-gauge spinal needles, as well as standard metal IV needles. The 13-g Kormed/Jamshidi (American Pharmaseal Laboratories, Glendale, CA) disposable bone marrow aspiration needle was the easiest to insert, it did not become plugged with tissue during insertion, and it was consistently placed successfully on the first attempt.
The use of an intraosseous (IO) infusion during the anesthetic care of an 8-month-old, 5.4-kg infant with cyanotic congenital heart disease (CHD) is presented. Previous vascular access had resulted in thrombotic occlusion of the upper and lower venous systems. When intravenous access could not be achieved, an IO needle was placed and IO access was used during the surgical procedure. The role of the IO route in the perioperative period is discussed and its adverse effect profile is reviewed.
Comparison of two intraosseous infusion systems for adult emergency medical use
2008, Resuscitation
The current guidelines of the European Resuscitation Council (ERC) stipulate that an intraosseous access should be placed if establishing a peripheral venous access for cardiopulmonary resuscitation (CPR) would involve delays. The aim of this study was therefore to compare a manual intraosseous infusion technique (MAN-IO) and a semi-automatic intraosseous infusion system (EZ-IO) using adult human cadavers as a model.
After receiving verbal instruction and giving their written informed consent, the participants of the study were randomized into two groups (group I: MAN-IO, and group II: EZ-IO). In addition to the demographic data, the following were evaluated: (1) Number of attempts required to successfully place the infusion, (2) Insertion time, (3) Occurrence of technical complications and (4) User friendliness.
Evaluation protocols from 84 study participants could be evaluated (MAN-IO: n = 39 vs. EZ-IO: n = 45). No significant differences were seen in the study participants’ characteristics. Insertion times (MW ± S.D.) of the respective successful attempts were comparable (MAN-IO: 33 ± 28 s vs. EZ-IO: 32 ± 11 s). When using the EZ-IO, the access was successfully established significantly more often on the first attempt (MAN-IO: 79.5% vs. EZ-IO: 97.8%; p < 0.01). The EZ-IO was also found to have more advantages in terms of technical complications (MAN-IO: 15.4% vs. EZ-IO: 0.0%; p < 0.01) and user friendliness (school grading system: MAN-IO: 1.9 ± 0.7 vs. EZ-IO: 1.2 ± 0.4; p < 0.01).
In an adult human cadaver model, the semi-automatic system was proven to be more effective. The EZ-IO gave more successful results, was associated with fewer technical complications, and is user friendlier.
Resuscitation science of pediatrics
2001, Annals of Emergency Medicine

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Intraosseous infusions: A usable technique

Ann Emerg Med

Lancet

Bone marrow infusions: Intratibial and intravenous routes compared

B Med J

Intraosseous infusions (letter)

South Med J