Elsevier

Resuscitation

Volume 83, Issue 1, January 2012, Pages 40-45
Resuscitation

Clinical paper
Comparison of intraosseous versus central venous vascular access in adults under resuscitation in the emergency department with inaccessible peripheral veins

https://doi.org/10.1016/j.resuscitation.2011.08.017Get rights and content

Abstract

Introduction

Current European Resuscitation Council (ERC) guidelines recommend intraosseous (IO) vascular access, if intravenous (IV) access is not readily available. Because central venous catheterisation (CVC) is an established alternative for in-hospital resuscitation, we compared IO access versus landmark-based CVC in adults with difficult peripheral veins.

Methods

In this prospective observational study we investigated success rates on first attempt and procedure times of IO access versus central venous catheterisation (CVC) in adults (≥18 years of age) with inaccessible peripheral veins under trauma or medical resuscitation in a level I trauma centre emergency department.

Results

Forty consecutive adults under resuscitation were analysed, each receiving IO access and CVC simultaneously. Success rates on first attempt were significantly higher for IO cannulation than CVC (85% versus 60%, p = 0.024) and procedure times were significantly lower for IO access compared to CVC (2.0 versus 8.0 min, p < 0.001). As for complications, failure of IO access was observed in 6 patients, while 2 or more attempts of CVC were necessary in 16 patients. No other relevant complications like infection, bleeding or pneumothorax were observed.

Conclusions

IO vascular access is a reliable bridging method to gain vascular access for in-hospital adult patients under resuscitation with difficult peripheral veins. Moreover, IO access is more efficacious with a higher success rate on first attempt and a lower procedure time compared to landmark-based CVC.

Introduction

Current European Resuscitation Council guidelines for resuscitation recommend intraosseous (IO) route for delivery of drugs, if intravenous access cannot be achieved.1 Peripheral intravenous (IV) access might be difficult, especially in dehydrated patients, those in shock, following chemotherapy, obese, with oedema or IV drug users. Failure rates of IV access in the emergency setting are described around 10–40% and average time needed for peripheral IV catheterisation is reported between 2.5 and 16 min in patients with difficult IV access.2, 3, 4, 5 Delays in establishing vascular access in the field might be followed by additional delay in the emergency department, when reattempting vascular access suspend necessary diagnostic and treatment procedures.

Alternative routes of drug and fluid administration are sublingual, endotracheal, subcutaneous and intramuscular. However, these options are not reasonable in most cases of emergencies and controversial due to unpredictable plasma concentrations along with unknown optimal dose of most drugs.1 Central venous catheterisation (CVC) is an alternative, but it requires the interruption of CPR in the majority of cases and may be associated with risks for the patient, especially in the emergency setting.1, 5

Consequently, a different vascular access technique may be reasonable, at least as a bridging option during ongoing resuscitation efforts. In this context, intraosseous (IO) vascular access of the non-collapsible and highly vasculated intramedullary venous plexus of concellous bone marrow can provide a rapid, safe and easy vascular access to administer drugs, fluids and blood products.11 In infants and children IO approach for emergency vascular access has been widespread adopted for decades already.1 However the role of IO access in adults is much less propagated.12 Only few studies specifically investigate IO access in adults, and most of them were restricted to the prehospital setting or training studies in animal or cadaver models. Own preliminary data of 10 adult patients in the emergency department showed potential benefits of IO access compared to conventional CVC regarding higher success rates and shorter procedure times on first attempt.7

Therefore our goal was to compare the time required to establish IO access versus CVC in adult patients undergoing resuscitation who initially had unsuccessful attempts at peripheral IV access, as well as report on their complication rates.

Section snippets

Study design and setting

This prospective, clinical trial was conducted between November 2007 and May 2009 at the emergency department of an urban level I trauma centre and teaching hospital with approximately 35,000 presentations a year. Our institutional review committee approved this study.

Selection of participants

Based on physiological criteria we approached consecutively all severely injured or critically ill adult patients under resuscitation admitted to our emergency department without at least 1 efficient 18-gauge peripheral IV access.

Results

Forty consecutive adult patients under resuscitation receiving simultaneously IO access and CVC were enrolled into the study, 40 subjects in each intervention group. The follow-up was possible for all 40 patients (Fig. 1).

Discussion

In this trial, we compared success rate on first attempt and necessary procedure time to perform IO vascular access versus CVC in adults under resuscitation in the emergency department lacking peripheral IV access. To our knowledge, this prospectively observational study is the first to compare IO access versus CVC in a real scenario in-hospital setting. We observed that IO cannulation was significantly more successful and faster to gain vascular access when compared to landmark-based CVC,

Conclusions

We found IO vascular access a safe, reliable and rapid option in adults under resuscitation in the emergency department with inaccessible peripheral veins. Compared to landmark-based CVC, IO cannulation was significantly more successful on first attempt and required significantly less time. However, IO access is not a surrogate for CVC and cannot replace it. Complications following IO access are rare, providing correct indication and appropriate handling. Therefore, IO access is worth to be

Conflicts of interest

The authors declare that they have no conflict of interest regarding any financial or personal relationships with the manufacturers or with any other people or organisations that could inappropriately influence or bias their work.

Funding source

The authors declare that they received no funding or any other kind of sponsorship regarding study design, collection, analysis and interpretation of data, writing of the manuscript or decision to submit the manuscript for publication.

Acknowledgment

Daniel Müller supported this study in context of his medical doctoral thesis at the Faculty of Medicine, Ludwig-Maximilians-Universität München, Germany.

References (34)

Cited by (117)

  • Supplies Necessary for Intraosseous Catheter Placement

    2022, Small Animal Critical Care Medicine
  • Vessel health and preservation: Development and validation of a proactive instrument

    2021, Collegian
    Citation Excerpt :

    A panel of vascular access experts developed the tool based on the features of the proactive approach to preserving vessel health highlighted in the literature review by Fiorini et al. (2019). In particular, three dimensions were included: anatomical factors, such as the quality of the veins, conditions, and alterations of the limbs (Fiorini et al., 2019; Weston et al., 2017); patient-related factors and variables already studied as relating to difficulty in positioning a peripheral intravenous cannula, such as age, sex, medical diagnosis, obesity, smoking, previous chemotherapy, comorbidities (Carr et al., 2017; Civetta et al., 2019; Juvin, Blarel, Bruno, & Desmonts, 2003; Leidel et al., 2012; Piredda et al., 2017, 2019; Van Loon et al., 2016; Vezzani et al., 2013), and intravenous plan factors, such as duration and type of infusion therapy and number of blood tests required during hospitalisation (Fiorini et al., 2019; Moureau & Chopra, 2016). Items from existing tools evaluating specific variables related to vessel health and vascular access complications, such as quality of vessel health (Shaw, 2017; Weston et al., 2017), phlebitis and infiltration (Groll et al., 2010) and an oedema scale (Hammad et al., 2018; Hogan, 2007), were included.

  • Impact of intraosseous versus intravenous resuscitation during in-hospital cardiac arrest: A retrospective study

    2021, Resuscitation
    Citation Excerpt :

    Intraosseous (IO) delivery of emergency medications during cardiac arrest provides safe and rapid access when intravenous (IV) injection is not available.1–4

View all citing articles on Scopus

A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2011.08.017.

View full text