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Emergency intraosseous infusions in children
Emergency lntraosseousInfusionsin Children PETER W. GLAESER,
MD, JOSEPH D. LOSEK, MD
Vascular access during advanced life support is essential. Vascular access in the critically ill child can be particularly difficult and often causes unacceptable delay. lntraosseous 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. (Am J Emerg Med
1986;4:34-36) Vascular access is commonly a cause of delay in emergency resuscitation of children. The use of bone marrow as an alternative route of administering resuscitative fluids and medications has not been discussed in the emergency medical literature. The following case presentation illustrates that intraosseous infusion can be a life-saving procedure. CASE REPORT A previously healthy 4-month-old child presented to Milwaukee Children’s Hospital Emergency Department with a one-week history of poor intake, increasing lethargy, and black stools. On examination, he was unresponsive to painful stimuli, had no palpable pulse, and only occasional gasping respirations. Temperature was 32”C, blood pressure was unobtainable by the Doppler method, ECG rhythm strip showed a sinus rate of 50 beats/min, and blood glucose level was 20 mg/dl as determined by chemstrip. He appeared emaciated and was in hypovolemic shock. Cardiopulmonary resuscitation (CPR) was begun. He was intubated orally, ventilated with 100% oxygen, and received one dose (0.1 ml/kg) epinephrine (1: 10,000 and atropine (0.1 mg) endotracheally. There was minimal response in heart rate to this intervention. Multiple attempts were made to obtain venous access without success. Peripheral veins were visible but collapsed, and attempts to use more central veins, including the femoral and jugular vessels, also failed. Fifteen minutes after arrival, an intraosseous line was placed in the left proximal tibia using a 20-gauge spinal needle. The flat surface of the tibia approximately two cen-
From the Department of Pediatrics, Medical College of Wisconsin, and the Emergency Department, Milwaukee Children’s Hospital, Milwaukee, Wisconsin. Manuscript
received July 8, 1985; accepted
September
12, 1985.
Address reprint requests to Dr. Glaeser: Milwaukee Children’s Hospital, 1700 W. Wisconsin Ave., Mail Station 756, Milwaukee, WI 53201. Key Words: Bone marrow,
34
fluid therapy,
infusions,
parenteral.
timeters below the tuberosity was used, as previously described. ‘J Lactated Ringer’s solution (20 ml/kg) was easily infused into the bone marrow over 2-3 minutes by syringe bolus. This was followed by 2 mEq/kg of sodium bicarbonate and 2 ml/kg of 25% glucose in water. Approximately two minutes after completion of the lactated Ringer’s infusion, the patient had a palpable pulse of 108 beats/mitt, and color had improved. Arterial blood gas analysis revealed a pH of 7.60. P co? of 22.9 mm Hg, a PO, of 231.7 mm Hg, a bicarbonate level of 22.5 mEq/l, and an O2 saturation of 99.7%. Ventilation was appropriately adjusted, and an additional 20 ml/ kg of lactated Ringer’s was infused into the bone marrow. Near the completion of the infusion, there were signs of local infiltration, and the intraosseous line was removed. At this time, 33 minutes after arrival, the child’s systolic blood pressure was 100 mm Hg with a heart rate of 132 beatslmin. Physicians in attendance included two pediatric emergency department attending physicians, a pediatric cardiologist, and a pediatric intensivist. Despite volume expansion, intravenous access could not be established by these experienced physicians for an additional hour. The child subsequently was found to have Saltnonella sepsis, which responded to appropriate antibiotic therapy, and he developed no complications related to the use of the intraosseous route. There was no evidence of sequelae related to Gram-negative shock.
DISCUSSION Most of the literature on the intraosseous route of administration of fluid and medication comes from the 1940s. Indeed, the use of this procedure is not new, but does seem to have been forgotten. Numerous studies have confirmed the use of the marrow for reliable and rapid access to the central circulation.3-5 Materials infused into intramedullary sinusoids drain into larger venous channels and into the systemic circulation via the emissary or nutrient veins.? Because the walls of the marrow space are bone, the typical problem of vascular collapse is not encountered. Although bolus epinephrine, atropine. naloxone, lidoCaine and isoproterenol can be given endotracheally, venous access is essential for administration of fluids, glucose, sodium bicarbonate, and calcium. Venous access is especially critical when one considers that cardiac responsiveness to medications and cardioversion is dependent upon blood pH. Children who present in shock typically are severely acidotic and may not respond to other interventions until the pH is corrected. Sites that have been used for intraosseous infusions
GLAESER
include the proximal and distal tibia, the distal femur, and iliac crest. (The iliac crest, however, is inappropriate and potentially dangerous in resuscitation.) The sternum has also been used, but it has inadequate marrow space in children less than 3 years old, is technically difficult when used concurrently with chest compressions, and is complicated by mediastinal puncture.6 Infusion into the proximal or distal tibia has the additional advantage of being physically distant from other resuscitative efforts, and it provides reliable access, even in neonates. Needles ranging from the standard steel butterfly needle to specialized trephine needles have been used for this procedure. Spinal and standard bone-marrow needles provide a stylet that prevents the needle from being plugged by bone and are easily available in most emergency department settings. Blood, colloids, crystalloids, antibiotics, digitalis, antisera, heparin, insulin, anesthetic agents, catecholamines, calcium gluconate, sodium bicarbonate, D,,, and contrast media have been infused into bone ma~ow~3-5.7-10
Complications of intraosseous infusion that have been reported include osteomyelitis, local cellulitis and abscess, subperiosteal infiltration or hematoma, subcutaneous infiltration, sepsis, and leakage from multiple puncture sites. 6-12 Embolization of fat and bone fragments is of theoretical concern, but to date there have been no reports of this.12,i3 In general, significant infectious complications have been rare and may not be applicable to the present standard of care. Osteomyelitis seems the most serious and prevalent complication reported in the literature. Most reports of osteomyelitis come from an era when routine cultures and broad-spectrum antibiotics were not used. In 1947, Heinild reported that all previous cases of osteomyelitis occurred in patients who had received continuous intraosseous infusions over a minimum of hours, most having received infusions for days.7 The incidence of osteomyelitis under these conditions was approximately 3% of the cumulative 300 cases. In Heinild’s own study, of 944 cases in which a needle was placed for a bolus infusion, using isotonic solutions including sodium bicarbonate, there were no cases of osteomyelitis.7 Heinild did report three cases of osteomyelitis in 23 patients given 32 infusions of D,, or concentrated serum. From these results, as well as sporadic reports of osteomyelitis after the intraosseous administration of concentrated serum or contrast media, it was concluded that the risk of osteomyelitis complicating intraosseous infusion was increased with infusion of hypertonic solutions or continuous infusions. Current literature continues to cite these results as reasons for not using hypertonic solution.’ Sodium bicarbonate and glucose are rou-
AND LOSEK W EMERGENCY
INTRAOSSEOUS
INFUSIONS
tinely given in hypertonic solutions and are essential in pediatric resuscitations. A recent case report by Berg’ supports the “avoidance of hypertonic solutions,” and conveniently sidesteps the issue of sodium bicarbonate therapy in that intravenous access was obtained and sodium bicarbonate was given prior to using intraosseous catecholamines. In the present case, sodium bicarbonate and 25% glucose in water were utilized in an already septic child without development of infectious complications. Currently, there seems to be a reluctance to use the intraosseous route for emergency venous access. Reasons for this are hardly new, having been enuciated by Quilligan and TurkelI in their 1946 review: “The methods of bone marrow infusion have not been accepted enthusiastically by pediatricians. This may be because indications for its use are rare when cases are handled by physicians who have become proficient in the care of infants and children.” In a recent editorial, Orlowski’5 points out, as does the present report, “that catastrophes occur even in controlled environments.” Regardless of the level of skill, there are times when venous access requires multiple attempts and, more importantly, consumes precious time. The use of intraosseous infusions should not infer a lack of expertise. As with any procedure, risk versus benefit must dictate its use. If the use of intraosseous infusions is limited to emergent situations, there is no doubt the potential benefit far outweighs the risk. Although the administration of hypertonic solutions by the intraosseous route requires further controlled studies to evaluate efficacy and relationship to development of osteomyelitis, the use of such agents by no means should be contraindicated under emergent conditions. Because intraosseous placement allows safe, rapid, reliable access to the venous circulation away from the focus of resuscitative activity, its use should be considered early in the resuscitation until vascular access can be obtained.
REFERENCES 1. Berg RA. Emergency infusion of catecholamines into bone marrow. Am J Dis Child 1984;138:810-811. 2. Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine. Philadelphia: W. B. Saunders Co., 1985. 3. Tocantins LM. Rapid absorption of substances injected into the bone marrow. Proc Sot Exp Biol Med 1940;45:292298. 4. Tocantins LM, O’Neill JF, Jones HW. Infusions of blood and other fluids via the bone marrow. JAMA 1941;117:12291234. 5. Macht DI. Studies on intraosseous injection of epinephrine. Am J Physiol 1943;138:269-272. 6. Tocantins LM, O’Neill JF. Complications of intraosseous therapy. Ann Surg 1945;122:266-277. 7. Heinild S, Sondergaard J, Tuvdad F. Bone marrow infusions
3.5
AMERICAN
8.
9. 10.
11.
36
JOURNAL
OF EMERGENCY
MEDICINE
n Volume 4, Number 1 n January
in childhood: Experiences from a thousand infusions. J Pediatr 1947;30:400-411. Tarrow AB, Turkel H, Thompson MS. Infusions via the bone marrow and biopsy of the bone and bone marrow. Anesthesiology 1952;13:501-509. Valdes MM. lntraosseous fluid administration in emergencies. Lancet 1977;1:1235-1236. Shoor PM, Berryhill RE, Benumof JL. lntraosseous infusion: Pressure flow relationship and pharmacokinetics. J Trauma 1979;19:772-774. Landon JF, Hammond JW. Bone marrow infusion with two
12.
13. 14. 15.
1986
cases of localized osteomyelitis. Arch Pediatr 1944; 111:611-616. Wile UJ, Schamberg IL. Pulmonary fat embolism following infusions via bone marrow. J Invest Dermatol 1942;5:173177. Pediatric Forum. Emergency bone marrow infusions. Am J Dis Child 1985;139:438-439. Quilligan JJ, Turkel H. Bone marrow infusion and its complications. Am J Dis Child 1946;71:457-465. Orlowski JP. My kingdom for an IV line (editorial). Am J Dis Child 1984;138:803.
MD, JOSEPH D. LOSEK, MD
Vascular access during advanced life support is essential. Vascular access in the critically ill child can be particularly difficult and often causes unacceptable delay. lntraosseous 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. (Am J Emerg Med
1986;4:34-36) Vascular access is commonly a cause of delay in emergency resuscitation of children. The use of bone marrow as an alternative route of administering resuscitative fluids and medications has not been discussed in the emergency medical literature. The following case presentation illustrates that intraosseous infusion can be a life-saving procedure. CASE REPORT A previously healthy 4-month-old child presented to Milwaukee Children’s Hospital Emergency Department with a one-week history of poor intake, increasing lethargy, and black stools. On examination, he was unresponsive to painful stimuli, had no palpable pulse, and only occasional gasping respirations. Temperature was 32”C, blood pressure was unobtainable by the Doppler method, ECG rhythm strip showed a sinus rate of 50 beats/min, and blood glucose level was 20 mg/dl as determined by chemstrip. He appeared emaciated and was in hypovolemic shock. Cardiopulmonary resuscitation (CPR) was begun. He was intubated orally, ventilated with 100% oxygen, and received one dose (0.1 ml/kg) epinephrine (1: 10,000 and atropine (0.1 mg) endotracheally. There was minimal response in heart rate to this intervention. Multiple attempts were made to obtain venous access without success. Peripheral veins were visible but collapsed, and attempts to use more central veins, including the femoral and jugular vessels, also failed. Fifteen minutes after arrival, an intraosseous line was placed in the left proximal tibia using a 20-gauge spinal needle. The flat surface of the tibia approximately two cen-
From the Department of Pediatrics, Medical College of Wisconsin, and the Emergency Department, Milwaukee Children’s Hospital, Milwaukee, Wisconsin. Manuscript
received July 8, 1985; accepted
September
12, 1985.
Address reprint requests to Dr. Glaeser: Milwaukee Children’s Hospital, 1700 W. Wisconsin Ave., Mail Station 756, Milwaukee, WI 53201. Key Words: Bone marrow,
34
fluid therapy,
infusions,
parenteral.
timeters below the tuberosity was used, as previously described. ‘J Lactated Ringer’s solution (20 ml/kg) was easily infused into the bone marrow over 2-3 minutes by syringe bolus. This was followed by 2 mEq/kg of sodium bicarbonate and 2 ml/kg of 25% glucose in water. Approximately two minutes after completion of the lactated Ringer’s infusion, the patient had a palpable pulse of 108 beats/mitt, and color had improved. Arterial blood gas analysis revealed a pH of 7.60. P co? of 22.9 mm Hg, a PO, of 231.7 mm Hg, a bicarbonate level of 22.5 mEq/l, and an O2 saturation of 99.7%. Ventilation was appropriately adjusted, and an additional 20 ml/ kg of lactated Ringer’s was infused into the bone marrow. Near the completion of the infusion, there were signs of local infiltration, and the intraosseous line was removed. At this time, 33 minutes after arrival, the child’s systolic blood pressure was 100 mm Hg with a heart rate of 132 beatslmin. Physicians in attendance included two pediatric emergency department attending physicians, a pediatric cardiologist, and a pediatric intensivist. Despite volume expansion, intravenous access could not be established by these experienced physicians for an additional hour. The child subsequently was found to have Saltnonella sepsis, which responded to appropriate antibiotic therapy, and he developed no complications related to the use of the intraosseous route. There was no evidence of sequelae related to Gram-negative shock.
DISCUSSION Most of the literature on the intraosseous route of administration of fluid and medication comes from the 1940s. Indeed, the use of this procedure is not new, but does seem to have been forgotten. Numerous studies have confirmed the use of the marrow for reliable and rapid access to the central circulation.3-5 Materials infused into intramedullary sinusoids drain into larger venous channels and into the systemic circulation via the emissary or nutrient veins.? Because the walls of the marrow space are bone, the typical problem of vascular collapse is not encountered. Although bolus epinephrine, atropine. naloxone, lidoCaine and isoproterenol can be given endotracheally, venous access is essential for administration of fluids, glucose, sodium bicarbonate, and calcium. Venous access is especially critical when one considers that cardiac responsiveness to medications and cardioversion is dependent upon blood pH. Children who present in shock typically are severely acidotic and may not respond to other interventions until the pH is corrected. Sites that have been used for intraosseous infusions
GLAESER
include the proximal and distal tibia, the distal femur, and iliac crest. (The iliac crest, however, is inappropriate and potentially dangerous in resuscitation.) The sternum has also been used, but it has inadequate marrow space in children less than 3 years old, is technically difficult when used concurrently with chest compressions, and is complicated by mediastinal puncture.6 Infusion into the proximal or distal tibia has the additional advantage of being physically distant from other resuscitative efforts, and it provides reliable access, even in neonates. Needles ranging from the standard steel butterfly needle to specialized trephine needles have been used for this procedure. Spinal and standard bone-marrow needles provide a stylet that prevents the needle from being plugged by bone and are easily available in most emergency department settings. Blood, colloids, crystalloids, antibiotics, digitalis, antisera, heparin, insulin, anesthetic agents, catecholamines, calcium gluconate, sodium bicarbonate, D,,, and contrast media have been infused into bone ma~ow~3-5.7-10
Complications of intraosseous infusion that have been reported include osteomyelitis, local cellulitis and abscess, subperiosteal infiltration or hematoma, subcutaneous infiltration, sepsis, and leakage from multiple puncture sites. 6-12 Embolization of fat and bone fragments is of theoretical concern, but to date there have been no reports of this.12,i3 In general, significant infectious complications have been rare and may not be applicable to the present standard of care. Osteomyelitis seems the most serious and prevalent complication reported in the literature. Most reports of osteomyelitis come from an era when routine cultures and broad-spectrum antibiotics were not used. In 1947, Heinild reported that all previous cases of osteomyelitis occurred in patients who had received continuous intraosseous infusions over a minimum of hours, most having received infusions for days.7 The incidence of osteomyelitis under these conditions was approximately 3% of the cumulative 300 cases. In Heinild’s own study, of 944 cases in which a needle was placed for a bolus infusion, using isotonic solutions including sodium bicarbonate, there were no cases of osteomyelitis.7 Heinild did report three cases of osteomyelitis in 23 patients given 32 infusions of D,, or concentrated serum. From these results, as well as sporadic reports of osteomyelitis after the intraosseous administration of concentrated serum or contrast media, it was concluded that the risk of osteomyelitis complicating intraosseous infusion was increased with infusion of hypertonic solutions or continuous infusions. Current literature continues to cite these results as reasons for not using hypertonic solution.’ Sodium bicarbonate and glucose are rou-
AND LOSEK W EMERGENCY
INTRAOSSEOUS
INFUSIONS
tinely given in hypertonic solutions and are essential in pediatric resuscitations. A recent case report by Berg’ supports the “avoidance of hypertonic solutions,” and conveniently sidesteps the issue of sodium bicarbonate therapy in that intravenous access was obtained and sodium bicarbonate was given prior to using intraosseous catecholamines. In the present case, sodium bicarbonate and 25% glucose in water were utilized in an already septic child without development of infectious complications. Currently, there seems to be a reluctance to use the intraosseous route for emergency venous access. Reasons for this are hardly new, having been enuciated by Quilligan and TurkelI in their 1946 review: “The methods of bone marrow infusion have not been accepted enthusiastically by pediatricians. This may be because indications for its use are rare when cases are handled by physicians who have become proficient in the care of infants and children.” In a recent editorial, Orlowski’5 points out, as does the present report, “that catastrophes occur even in controlled environments.” Regardless of the level of skill, there are times when venous access requires multiple attempts and, more importantly, consumes precious time. The use of intraosseous infusions should not infer a lack of expertise. As with any procedure, risk versus benefit must dictate its use. If the use of intraosseous infusions is limited to emergent situations, there is no doubt the potential benefit far outweighs the risk. Although the administration of hypertonic solutions by the intraosseous route requires further controlled studies to evaluate efficacy and relationship to development of osteomyelitis, the use of such agents by no means should be contraindicated under emergent conditions. Because intraosseous placement allows safe, rapid, reliable access to the venous circulation away from the focus of resuscitative activity, its use should be considered early in the resuscitation until vascular access can be obtained.
REFERENCES 1. Berg RA. Emergency infusion of catecholamines into bone marrow. Am J Dis Child 1984;138:810-811. 2. Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine. Philadelphia: W. B. Saunders Co., 1985. 3. Tocantins LM. Rapid absorption of substances injected into the bone marrow. Proc Sot Exp Biol Med 1940;45:292298. 4. Tocantins LM, O’Neill JF, Jones HW. Infusions of blood and other fluids via the bone marrow. JAMA 1941;117:12291234. 5. Macht DI. Studies on intraosseous injection of epinephrine. Am J Physiol 1943;138:269-272. 6. Tocantins LM, O’Neill JF. Complications of intraosseous therapy. Ann Surg 1945;122:266-277. 7. Heinild S, Sondergaard J, Tuvdad F. Bone marrow infusions
3.5
AMERICAN
8.
9. 10.
11.
36
JOURNAL
OF EMERGENCY
MEDICINE
n Volume 4, Number 1 n January
in childhood: Experiences from a thousand infusions. J Pediatr 1947;30:400-411. Tarrow AB, Turkel H, Thompson MS. Infusions via the bone marrow and biopsy of the bone and bone marrow. Anesthesiology 1952;13:501-509. Valdes MM. lntraosseous fluid administration in emergencies. Lancet 1977;1:1235-1236. Shoor PM, Berryhill RE, Benumof JL. lntraosseous infusion: Pressure flow relationship and pharmacokinetics. J Trauma 1979;19:772-774. Landon JF, Hammond JW. Bone marrow infusion with two
12.
13. 14. 15.
1986
cases of localized osteomyelitis. Arch Pediatr 1944; 111:611-616. Wile UJ, Schamberg IL. Pulmonary fat embolism following infusions via bone marrow. J Invest Dermatol 1942;5:173177. Pediatric Forum. Emergency bone marrow infusions. Am J Dis Child 1985;139:438-439. Quilligan JJ, Turkel H. Bone marrow infusion and its complications. Am J Dis Child 1946;71:457-465. Orlowski JP. My kingdom for an IV line (editorial). Am J Dis Child 1984;138:803.