Clinical paperComparison of intraosseous versus central venous vascular access in adults under resuscitation in the emergency department with inaccessible peripheral veins☆
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.
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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.