- Email: [email protected]
Intraosseous infusions in adults
The Journal of Emergency Medicine. Vol
Printed in the USA ??Copyright 0 1989 Pergamon Press plc
7,pp. 587-591, 1989
INTRAOSSEOUS
INFUSIONS
Kenneth V. Iserson,
IN ADULTS
MD, FACEP
Section of Emergency Medicine, Department of Surgery, University of Arizona College of Medicine, Tucson, Anzona Reprint address: Kenneth V. lserson, MD, FACEP, Section of Emergency Medicine, Department of Surgery, University of Arizona College of Medicine, 1501 N. Campbell Avenue, Tucson, AZ 85724
?? Abstract - Intraosseous (IO) access in adults via the distal tibia has never been a widely accepted technique. Yet there have been occasional reports of the successful use of this procedure. This study was done to demonstrate the utility of IO infusions in the adult patient, including those patients in cardiac arrest. ‘Ikrenty-two patients, aged 36 through 84 (mean 65.1 years), who arrived in the emergency department (ED) in cardiac arrest from nonhypovolemic causes and in whom an intravenous line was not established prior to arrival or was found to be inadequate (nonfunctioning or poorly functioning) upon arrival in the ED, had an IO needle (U-gauge KormedlJamshidF, Pharmaseal Division, Baxter Healthcare Corp., Valencia, CA) placed above the medial malleolus. The IO needle was then connected to a standard IV tubing, with a pressure bag or pressure device delivering 300 mm Hg to the solution bag. The resultant flow rate through the IV line ranged from 5 to 12 mllmin. The IO needle was placed and flow established in under one minute in all patients. Temporally related pharmacologic effects were observed after the IO administration of sodium bicarbonate, lidocaine, atropine, and vasopressors. This study shows that 1.0. access can be quickly and easily obtained in adults in the medial supramalleolar position during cardiac arrest. This method of drug administration appears to hold promise as another useful modality for adults and older children during nontraumatic resuscitations.
rary reports of its use in adults (2-4). In 1976, Kwaan utilized intraosseous infusion of contrast material to rapidly demonstrate varicose veins preoperatively (2). In 1977, Valdes reported using intraosseous infusions in 15 adult patients in whom IV therapy was necessary, but venous access could not be achieved. He used a medial malleolar approach in 13 cases, a lateral malleolar approach in two. The fluids administered, without problem, included whole blood, dextran 40, crystalloids, and various medications (3). Nevertheless, recent authors have questioned the effectiveness of applying this technique to older children and adults due to the absence of active marrow in the distal long bones after early childhood (5,6). Early reports of IO infusions in adults, following the method suggested by Josefson (7), used the sternum, which has active bone marrow in adults, for IO access (8-12). This study, using distal tibia1 access was done to demonstrate the utility of IO infusions in the adult patient, including those in cardiac arrest.
MATERIALS
Over a four-year period, adult patients (21 years or older), who arrived in the emergency department (ED) in cardiac arrest from a nonhypovolemic etiology when the author was present, in whom an intravenous (IV) line had not been established prior to arrival or was found to be inadequate (nonfunctioning or poorly functioning) upon arrival in the ED, were included in the study. Five patients were included retrospectively. Flow rates were considered too low using an IO approach to permit hypovolemic patients to be included (4). After arrival in the ED, and while attempts to gain
0 Keywords - Intraosseous; fluid therapy; resuscitation; drug therapy; bone marrow; adult; cardiac arrest
INTRODUCTION
Intravascular access is a vital component of emergency care and resuscitation. The use of lower extremity intraosseous (IO) vascular access has recently been reintroduced and popularized for pediatric resuscitations (1). There have been relatively few contempo-
RECEIVED:~ February1989; ACCEPTED: 9 May 1989
AND METHODS
FINALSUBMISSIONRECENED: lMay1989; 587
0736-4679/89 $3.00 + .OO
588
Kenneth V. lserson
IV access were continuing, an IO needle (13-gauge Kormed/Jamshidi@, Pharmaseal Division, Baxter Healthcare Corporation, Valencia, CA) was placed above the medial malleolus using a method previously described for use in children (Figure 1) (4). This method was used because it had been the easiest and quickest method to consistently gain IO access (4). The needle was introduced just above the midline of the medial malleolus at a 90” angle to the bone. In this position the more anteriorly placed saphenous vein is not compromised. This site was selected because it, unlike the more common proximal tibia1 location, offers a stable, relatively flat location with easy penetrability. The needle was introduced with a downward, pressing and twisting motion, similar to that used when obtaining a bone marrow biopsy (4). The IO needle was connected to a standard IV tubing, with an external pressure bag or pressure device delivering 300 mm Hg to the solution bag (13). Medications were administered through either the needle hub or the attached IV line. The system was run at its highest flow rate (5-12 mL/min) continuously over the span of the 20 to 80 minute resuscitations. Once access was established, there did not appear to be any decrease in flow rate during the resuscitations. The extremity was not elevated (14). The IO needle was left in place at least until a secure, functioning IV line was in use. In most cases, even after IV access had been established, the IO needle was left in place and utilized for some, otherwise incompatible, simultaneous medication administration throughout the resuscitation. Standard American Heart Association Advanced Cardiac Life Support protocols were generally followed (1). As is standard practice, these protocols were altered at the discretion of the lead physician, based on knowledge and the patient’s condition. Blood levels of the IO administered medications were not obtained. Five patients in this series were previously mentioned, although not discussed, in a prior publication on 1.0. infusions (4). There was Institutional Review Board approval for this study.
RESULTS A total of 22 patients, aged 36 through 84 (17 male, 5 female), were included in this study. The mean age was 65.1 years. All had sustained a cardiac arrest from nontraumatic causes. Only three of the patients were reported to have received immediate bystander cardiopulmonary resuscitation (CPR). Most of the patients (n=12) had unsuccessful at-
tempts to establish peripheral IV access prior to arrival at the ED. Others were transported by basic EMT units (n =2), by private vehicle (n = 3), or had an inadequate IV (n=5) on arrival. Intravascular (non-IO) access was ultimately obtained in all patients. The IO needle was placed and flow established in under one minute in all patients. Six needles were placed by individuals who had never used the technique previously. Placement was ascertained by: 1) rigid fixation of needle, 2) flow (under pressure) without progressive edema of surrounding tissues, 3) a loss of resistance upon entering the bone marrow space, or 4) aspiration of bone marrow contents. The last method was the least useful. Bventy patients expired in the ED. ‘Bvo others died in the hospital within 24 hours. There was no evidence of complication from IO access in the two short-term survivors. The observed effects of IO administered medications included a demonstrable change in pH, not accounted for by the respiratory component, in four of seven patients given IO sodium bicarbonate (prior to changes in CPR protocols) during the resuscitation (Table 1). The other three patients who had bicarbonate administered had only a solitary blood gas drawn at variable times during the resuscitation. Following restoration of spontaneous cardiac activity, one patient showed a response to an IO-delivered lidocaine bolus. In two others, bradycardia responded to atropine within one minute. IO-delivered vasopressors raised blood pressure in five patients at points during or after resuscitation when there was spontaneous cardiac activity.
DISCUSSION There are two requirements for an effective medication route during cardiac resuscitations. The first is that it can be quickly placed; the second is that it will deliver medications to the vascular system in an efficient manner. A key element in the resuscitative effort is establishing a route for vascular access. Although many potential routes are available, they can be time-consuming to establish, especially when the operators are inexperienced in the techniques (15- 17). The IO needle has been previously demonstrated to be a rapid, effective method of vascular access in children, via the medial supramalleolar approach (4). It had a higher success rate in the pediatric age group than reported with alternative IO approaches (18,19). Experience suggested that this approach was just as effective in adults (4). One prior series in adult pa-
lntraosseous
589
Infusions in Adults
Figure 1. A 13guage Kormed/Jamshidl@, (Pharmaseal Division, Baxter Healthcare Corp., Valencia, CA) Is placed just above the mldllne of the medlal malleolus at a 90’ angle to the bone. In this position the more anteriorly placed saphenous vein is not compromised. This site offers a stable, relativley fiat locatlon wlth easy penetrability. The needle Is introduced with a downward, pressing and twisting motlon, similar to that used when obtaining a bone marrow biopsy (4) and then connected to a standard IV tubing, with an external pressure bag or pressure device delivering 300 mm Hg to the solution bag (13).
Table 1. Prebicarbonate and Postbicarbonate Arterial pH and pC0, Patient
PH
PC02
Pre Post
6.8 7.2
60 68
Pre Post
7.0 7.4
78 75
Pre Post
6.9 7.1
55 62
Pre Post
6.8 7.1
80 71
1
2
3 4
tients had an 87% success rate with a similar approach-into, rather than just proximal to, the medial malleolus (3). There was no difficulty in placing the IO needle in this series of patients. Even inexperienced operators were able to place the needle with ease and accuracy. In this series, long (8.5 cm), bone marrow biopsy needles were used. However, any sturdy hollow needle with an obturator to prevent blockage by bony material and a standard hub adapter that accommodates a distal IV line can be effective. Some short needles are now being produced specifically for use with this technique. But even if the IO needle can be placed, can it deliver medications in adults? An old radiographic
technique, IO venography, demonstrated the ability of the adult IO space to absorb and deliver medications into the venous system (20). This is despite the change from red to fatty bone marrow that begins in the fourth year of life, and usually affects the tibia and femur between the fifth and seventh years (21). However, except in a limited number of instances, all prior experience and nearly all research into intraosseous infusions have been conducted in pediatric patients or animal models (2-4,7-12,20). It has been shown that direct vascular access, particularly via a central venous line, is effective in delivering medications. The endotracheal route is nearly as good for some, but not all, medications needed during a resuscitative effort. Yet both central lines and endotracheal tubes require skill and time to place, the former having numerous and relatively frequent complications (14). Peripheral lines are not quite as efficacious, and yet they too can be difficult to place in patients in cardiac arrest (1). The relatively low flow rate achieved through the IV line was probably due to the degree of back pressure exerted by the bone marrow contents. When medications were injected directly through the needle, presumably at a much higher pressure than exerted on the IV system, the flow reached 20 to 25 mL/min. One human study in pediatric patients demonstrated an IO flow rate of 3.5 ml/hour with 300 mm Hg external pressure (4). At least one model of IO flow rates in puppies demonstrated flows of 13 ml/hour
590
Kenneth V. lserson
with gravity flow and 29 ml/hour under pressure (22). It is unclear, however, whether this study is relevant to the clinical setting. The effect of medications administered during cardiac resuscitation is variable. It is, therefore, difficult to determine the effectiveness of most medications, including what constitutes a temporally related outcome of epinephrine and atropine. In animal studies, both epinephrine and ephedrine have been shown to be effective in the hypovolemic bovine model through the tibial malleolar route (23). Likewise, in monkeys the IO route of atropine administration has been shown to provide earlier peak levels and significantly higher plasma concentrations than the endotracheal route (24). In this series of patients there was an apparent effect of the sodium bicarbonate administered through the IO route in the four patients in whom a subsequent arterial blood gas was obtained. The only other definite responses to medications administered through the IO route were in patients with, often temporary, cardiac activity. There were no long-term survivors in this group of out-of-hospital cardiac arrest patients. Most of this group did not receive immediate CPR. This mortality rate seems to be little different than that of others in patients who were not resuscitated prior to arrival at the ED using more conventional, and presumably nonlower-extremity vascular access techniques (25,26). The utility and importance of IO access in adults is not confined to cardiac arrests. Its use may be more important in critical care situations when there is difficulty obtaining vascular access by other routes. This may be due to the patient’s anatomy, multiple prior uses of or trauma to the normal vascular access sites, or the inexperience of the clinicians. It could also be
useful in the prehospital setting, as it has been in pediatric patients, when other routes of vascular access are not available (18). In both cases, the route would be especially helpful in delivering medications, such as dopamine, dobutamine, calcium, sodium bicarbonate, hypertonic glucose, succinylcholine, diazpam, dexamethasone, contrast material, insulin, heparin, sulfonamides, penicillin, digitalis, antitoxins, and diazoxide, that are not easily given through the endotracheal or sublingual routes (3,20,27-31). Nearly any noncytotoxic medication, blood, or blood product can be safely delivered through the IO route in adults (7-12). The one restriction on using the IO route is that it is not adequate to serve as a method for rapid fluid replacement. The resistance of the IO space requires that an external pressure device be used on the fluid reservior (bag). Even then, the flow through the IO needle will not be high enough to be effective in volume resuscitations, such as in patients with gastrointestinal bleeding or trauma (3,4,10,22,32). There are very few complications reported with this technique. The most frequent is osteomyelitis. In the 29 studies reported between 1942 and 1954, comprising more than 4,000 pediatric patients, there were 27 cases of osteomyelitis. However, no series of cases since the resurgence of popularity of this technique in 1977 has reported a case (5). Occasionally, an elevated peripheral leukocyte count, sometimes with immature forms is seen for the first 24 to 48 hours after insertion of the needle, but then returns to normal. Essentially, however, the IO technique has proven to be a safe, rapid method for instilling medications in children when alternative methods are not available. It is possible that this technique can also be useful in the adult patient.
REFERENCES 1. American Heart Association. Textbook of advanced cardiac life support. Dallas, Texas: American Heart Association; 1987. 2. Kwaan JHM, Jones RN, Connolly JE. Simplified technique for the management of refractory varicose ulcers. Surgery. 1976;80:743-7. 3. Valdes MM. Intraosseous fluid administration in emergencies. Lancet. 1977;1:1235-6. 4. Iserson KV, Criss E. Intraosseous infusions: a useable technique. Am J Emerg Med. 1986;4:540-2. 5. Brillman JC. Intraosseous infusion for emergent intravascular access. Topics in Emerg Med. 1988;10:75-80. 6. Hoelzer ME Recent advances in intravenous therapy. Emerg Med Clin N Am. 1986;4:487-500. 7. Josefson A. A new method of treatment-intraossal injections. Acta Medica Scandinavica. 1934;81:550-64. 8. Tocantins LM, O’Neill JF. Infusion of blood and other fluids into the circulation via the bone marrow. Proc Sot Exp Biol and Med. 1940;45:782-3.
9. Tocantins LM, O’Neill JF. Infusion of blood and other fluids into the general circulation via the bone marrow. Surg Gynecol Obstet. 1941;73:281-7. 10. Tocantins LM, O’Neill JF, Price AH. Infusions of blood and other fluids via the bone marrow in traumatic shock and other forms of peripheral circulatory failure. Ann Surg. 1941;114: 1085-92. 11. Papper EM. The bone marrow route for injecting fluids and drugs into the general circulation. Anesthesiology. 1942;3:30713. 12. Doud EA, Tysell JE. Massive intramedullary infusions. JAMA. 1942;120:1212-13. 13. Iserson KV, Reeter AK, Woods W, Criss E. Pressurization of IV bags: a new configuration and evaluation for use. J Emerg Med. 1985;3:89-92. 14. Kaye W, Bircher NC. Access for drug administration during cardiopulmonary resuscitation. Crit Care Med. 1988;16:179-82. 15. Kanter RK, Zimmerman JJ, Strauss RH, Stoechel KA. Pediatric emergency intravenous access. AJDC. 1986;140:132-34.
lntraosseous
Infusions in Adults
16. Rossetti V, Thompson BM, Aprahamian C, Darin JC, Mateer JR. Difficulty and delay in intravenous access in pediatric arrests (abstract). Ann Emerg Med. 1984;13:406. 17. Iserson KV, Criss E. Pediatric venous cutdowns. Ped Emerg Care. 1986;2:231-4. 18. Smith RJ, Keseg DP, Manley LK, Standeford T. Intraosseous infusions by prehospital personnel in critically ill pediatric patients. Ann Emerg Med. 1988;17:491-5. 19. Rosetti VA, Thompson BM, Miller J, Mateer JR, Aprahamian C. Intraosseous infusion: an alternative route of pediatric intravascular access. Ann Emerg Med. 1985;14:885-8. 20. Begg AC. Intraosseous venography of the lower limb and pelvis. Br J Rad. 1954;27:318-24. 21. Tocantins LM, G’Neill JF. Complications of intra-osseous therapy. Ann Surg. 1945;122:266-77. 22. Hodge D, Delgado-Paredes C, Fleisher G. Intraosseous infusion flow rates in hypovolemic “pediatric” dogs. 1987;16:3057. 23. Shoor PM, Berryhill RE, Benumof JL. Intraosseous infusion: pressure-flow relationship and pharmacokinetics. J Trauma. 1979;19:772-4. 24. Prete MR, Hannan CJ, Burkle FM. Plasma atropine concentrations via intravenous, endotracheal, and intraosseous ad-
591
ministration. Am J Emerg Med. 1987;5:101-4. 25. Guzy PM, Pearce ML, Greenfield S. The survival benefit of bystander cardiopulmonary resuscitation in a paramedicserved metropolitan area. Am J Public Health. 1983;73:7669. 26. Vertesi L, Wilson L, Glick N. Cardiac arrest: comparison of paramedic and conventional ambulance services. Can Med Assot J. 1983;128:809-13. 27. Berg RA. Emergency infusion of catecholamines into bone marrow. Am J Dis Child. 1984;138:810-11. 28. McNamara RM, Spivey WH, Unger HD, Malone DR. Emergency applications of intraosseous infusion. J Emerg Med. 1987;5:97-101. 29. Macht DI. Absorption of drugs through the bone marrow. Proc Sot Exp Biol Med. 1941;47:299-305. 30. Tarrow AB, ‘Ihrkel H, Thompson MS. Infusions via the bone marrow and biopsy of the bone and bone marrow. Anesthesiology. 1952;13:501-9. 3 1. Heinild S, Sondergaard T, Thdvad F. Bone marrow infusions in childhood: experiences from a thousand infusions. J Pediatr. 1947;30:400-11. 32. Arbeiter HI, Greengard J. Tibia1 bone marrow infusions in infancy. J Ped. 1944;25:1-12.
Printed in the USA ??Copyright 0 1989 Pergamon Press plc
7,pp. 587-591, 1989
INTRAOSSEOUS
INFUSIONS
Kenneth V. Iserson,
IN ADULTS
MD, FACEP
Section of Emergency Medicine, Department of Surgery, University of Arizona College of Medicine, Tucson, Anzona Reprint address: Kenneth V. lserson, MD, FACEP, Section of Emergency Medicine, Department of Surgery, University of Arizona College of Medicine, 1501 N. Campbell Avenue, Tucson, AZ 85724
?? Abstract - Intraosseous (IO) access in adults via the distal tibia has never been a widely accepted technique. Yet there have been occasional reports of the successful use of this procedure. This study was done to demonstrate the utility of IO infusions in the adult patient, including those patients in cardiac arrest. ‘Ikrenty-two patients, aged 36 through 84 (mean 65.1 years), who arrived in the emergency department (ED) in cardiac arrest from nonhypovolemic causes and in whom an intravenous line was not established prior to arrival or was found to be inadequate (nonfunctioning or poorly functioning) upon arrival in the ED, had an IO needle (U-gauge KormedlJamshidF, Pharmaseal Division, Baxter Healthcare Corp., Valencia, CA) placed above the medial malleolus. The IO needle was then connected to a standard IV tubing, with a pressure bag or pressure device delivering 300 mm Hg to the solution bag. The resultant flow rate through the IV line ranged from 5 to 12 mllmin. The IO needle was placed and flow established in under one minute in all patients. Temporally related pharmacologic effects were observed after the IO administration of sodium bicarbonate, lidocaine, atropine, and vasopressors. This study shows that 1.0. access can be quickly and easily obtained in adults in the medial supramalleolar position during cardiac arrest. This method of drug administration appears to hold promise as another useful modality for adults and older children during nontraumatic resuscitations.
rary reports of its use in adults (2-4). In 1976, Kwaan utilized intraosseous infusion of contrast material to rapidly demonstrate varicose veins preoperatively (2). In 1977, Valdes reported using intraosseous infusions in 15 adult patients in whom IV therapy was necessary, but venous access could not be achieved. He used a medial malleolar approach in 13 cases, a lateral malleolar approach in two. The fluids administered, without problem, included whole blood, dextran 40, crystalloids, and various medications (3). Nevertheless, recent authors have questioned the effectiveness of applying this technique to older children and adults due to the absence of active marrow in the distal long bones after early childhood (5,6). Early reports of IO infusions in adults, following the method suggested by Josefson (7), used the sternum, which has active bone marrow in adults, for IO access (8-12). This study, using distal tibia1 access was done to demonstrate the utility of IO infusions in the adult patient, including those in cardiac arrest.
MATERIALS
Over a four-year period, adult patients (21 years or older), who arrived in the emergency department (ED) in cardiac arrest from a nonhypovolemic etiology when the author was present, in whom an intravenous (IV) line had not been established prior to arrival or was found to be inadequate (nonfunctioning or poorly functioning) upon arrival in the ED, were included in the study. Five patients were included retrospectively. Flow rates were considered too low using an IO approach to permit hypovolemic patients to be included (4). After arrival in the ED, and while attempts to gain
0 Keywords - Intraosseous; fluid therapy; resuscitation; drug therapy; bone marrow; adult; cardiac arrest
INTRODUCTION
Intravascular access is a vital component of emergency care and resuscitation. The use of lower extremity intraosseous (IO) vascular access has recently been reintroduced and popularized for pediatric resuscitations (1). There have been relatively few contempo-
RECEIVED:~ February1989; ACCEPTED: 9 May 1989
AND METHODS
FINALSUBMISSIONRECENED: lMay1989; 587
0736-4679/89 $3.00 + .OO
588
Kenneth V. lserson
IV access were continuing, an IO needle (13-gauge Kormed/Jamshidi@, Pharmaseal Division, Baxter Healthcare Corporation, Valencia, CA) was placed above the medial malleolus using a method previously described for use in children (Figure 1) (4). This method was used because it had been the easiest and quickest method to consistently gain IO access (4). The needle was introduced just above the midline of the medial malleolus at a 90” angle to the bone. In this position the more anteriorly placed saphenous vein is not compromised. This site was selected because it, unlike the more common proximal tibia1 location, offers a stable, relatively flat location with easy penetrability. The needle was introduced with a downward, pressing and twisting motion, similar to that used when obtaining a bone marrow biopsy (4). The IO needle was connected to a standard IV tubing, with an external pressure bag or pressure device delivering 300 mm Hg to the solution bag (13). Medications were administered through either the needle hub or the attached IV line. The system was run at its highest flow rate (5-12 mL/min) continuously over the span of the 20 to 80 minute resuscitations. Once access was established, there did not appear to be any decrease in flow rate during the resuscitations. The extremity was not elevated (14). The IO needle was left in place at least until a secure, functioning IV line was in use. In most cases, even after IV access had been established, the IO needle was left in place and utilized for some, otherwise incompatible, simultaneous medication administration throughout the resuscitation. Standard American Heart Association Advanced Cardiac Life Support protocols were generally followed (1). As is standard practice, these protocols were altered at the discretion of the lead physician, based on knowledge and the patient’s condition. Blood levels of the IO administered medications were not obtained. Five patients in this series were previously mentioned, although not discussed, in a prior publication on 1.0. infusions (4). There was Institutional Review Board approval for this study.
RESULTS A total of 22 patients, aged 36 through 84 (17 male, 5 female), were included in this study. The mean age was 65.1 years. All had sustained a cardiac arrest from nontraumatic causes. Only three of the patients were reported to have received immediate bystander cardiopulmonary resuscitation (CPR). Most of the patients (n=12) had unsuccessful at-
tempts to establish peripheral IV access prior to arrival at the ED. Others were transported by basic EMT units (n =2), by private vehicle (n = 3), or had an inadequate IV (n=5) on arrival. Intravascular (non-IO) access was ultimately obtained in all patients. The IO needle was placed and flow established in under one minute in all patients. Six needles were placed by individuals who had never used the technique previously. Placement was ascertained by: 1) rigid fixation of needle, 2) flow (under pressure) without progressive edema of surrounding tissues, 3) a loss of resistance upon entering the bone marrow space, or 4) aspiration of bone marrow contents. The last method was the least useful. Bventy patients expired in the ED. ‘Bvo others died in the hospital within 24 hours. There was no evidence of complication from IO access in the two short-term survivors. The observed effects of IO administered medications included a demonstrable change in pH, not accounted for by the respiratory component, in four of seven patients given IO sodium bicarbonate (prior to changes in CPR protocols) during the resuscitation (Table 1). The other three patients who had bicarbonate administered had only a solitary blood gas drawn at variable times during the resuscitation. Following restoration of spontaneous cardiac activity, one patient showed a response to an IO-delivered lidocaine bolus. In two others, bradycardia responded to atropine within one minute. IO-delivered vasopressors raised blood pressure in five patients at points during or after resuscitation when there was spontaneous cardiac activity.
DISCUSSION There are two requirements for an effective medication route during cardiac resuscitations. The first is that it can be quickly placed; the second is that it will deliver medications to the vascular system in an efficient manner. A key element in the resuscitative effort is establishing a route for vascular access. Although many potential routes are available, they can be time-consuming to establish, especially when the operators are inexperienced in the techniques (15- 17). The IO needle has been previously demonstrated to be a rapid, effective method of vascular access in children, via the medial supramalleolar approach (4). It had a higher success rate in the pediatric age group than reported with alternative IO approaches (18,19). Experience suggested that this approach was just as effective in adults (4). One prior series in adult pa-
lntraosseous
589
Infusions in Adults
Figure 1. A 13guage Kormed/Jamshidl@, (Pharmaseal Division, Baxter Healthcare Corp., Valencia, CA) Is placed just above the mldllne of the medlal malleolus at a 90’ angle to the bone. In this position the more anteriorly placed saphenous vein is not compromised. This site offers a stable, relativley fiat locatlon wlth easy penetrability. The needle Is introduced with a downward, pressing and twisting motlon, similar to that used when obtaining a bone marrow biopsy (4) and then connected to a standard IV tubing, with an external pressure bag or pressure device delivering 300 mm Hg to the solution bag (13).
Table 1. Prebicarbonate and Postbicarbonate Arterial pH and pC0, Patient
PH
PC02
Pre Post
6.8 7.2
60 68
Pre Post
7.0 7.4
78 75
Pre Post
6.9 7.1
55 62
Pre Post
6.8 7.1
80 71
1
2
3 4
tients had an 87% success rate with a similar approach-into, rather than just proximal to, the medial malleolus (3). There was no difficulty in placing the IO needle in this series of patients. Even inexperienced operators were able to place the needle with ease and accuracy. In this series, long (8.5 cm), bone marrow biopsy needles were used. However, any sturdy hollow needle with an obturator to prevent blockage by bony material and a standard hub adapter that accommodates a distal IV line can be effective. Some short needles are now being produced specifically for use with this technique. But even if the IO needle can be placed, can it deliver medications in adults? An old radiographic
technique, IO venography, demonstrated the ability of the adult IO space to absorb and deliver medications into the venous system (20). This is despite the change from red to fatty bone marrow that begins in the fourth year of life, and usually affects the tibia and femur between the fifth and seventh years (21). However, except in a limited number of instances, all prior experience and nearly all research into intraosseous infusions have been conducted in pediatric patients or animal models (2-4,7-12,20). It has been shown that direct vascular access, particularly via a central venous line, is effective in delivering medications. The endotracheal route is nearly as good for some, but not all, medications needed during a resuscitative effort. Yet both central lines and endotracheal tubes require skill and time to place, the former having numerous and relatively frequent complications (14). Peripheral lines are not quite as efficacious, and yet they too can be difficult to place in patients in cardiac arrest (1). The relatively low flow rate achieved through the IV line was probably due to the degree of back pressure exerted by the bone marrow contents. When medications were injected directly through the needle, presumably at a much higher pressure than exerted on the IV system, the flow reached 20 to 25 mL/min. One human study in pediatric patients demonstrated an IO flow rate of 3.5 ml/hour with 300 mm Hg external pressure (4). At least one model of IO flow rates in puppies demonstrated flows of 13 ml/hour
590
Kenneth V. lserson
with gravity flow and 29 ml/hour under pressure (22). It is unclear, however, whether this study is relevant to the clinical setting. The effect of medications administered during cardiac resuscitation is variable. It is, therefore, difficult to determine the effectiveness of most medications, including what constitutes a temporally related outcome of epinephrine and atropine. In animal studies, both epinephrine and ephedrine have been shown to be effective in the hypovolemic bovine model through the tibial malleolar route (23). Likewise, in monkeys the IO route of atropine administration has been shown to provide earlier peak levels and significantly higher plasma concentrations than the endotracheal route (24). In this series of patients there was an apparent effect of the sodium bicarbonate administered through the IO route in the four patients in whom a subsequent arterial blood gas was obtained. The only other definite responses to medications administered through the IO route were in patients with, often temporary, cardiac activity. There were no long-term survivors in this group of out-of-hospital cardiac arrest patients. Most of this group did not receive immediate CPR. This mortality rate seems to be little different than that of others in patients who were not resuscitated prior to arrival at the ED using more conventional, and presumably nonlower-extremity vascular access techniques (25,26). The utility and importance of IO access in adults is not confined to cardiac arrests. Its use may be more important in critical care situations when there is difficulty obtaining vascular access by other routes. This may be due to the patient’s anatomy, multiple prior uses of or trauma to the normal vascular access sites, or the inexperience of the clinicians. It could also be
useful in the prehospital setting, as it has been in pediatric patients, when other routes of vascular access are not available (18). In both cases, the route would be especially helpful in delivering medications, such as dopamine, dobutamine, calcium, sodium bicarbonate, hypertonic glucose, succinylcholine, diazpam, dexamethasone, contrast material, insulin, heparin, sulfonamides, penicillin, digitalis, antitoxins, and diazoxide, that are not easily given through the endotracheal or sublingual routes (3,20,27-31). Nearly any noncytotoxic medication, blood, or blood product can be safely delivered through the IO route in adults (7-12). The one restriction on using the IO route is that it is not adequate to serve as a method for rapid fluid replacement. The resistance of the IO space requires that an external pressure device be used on the fluid reservior (bag). Even then, the flow through the IO needle will not be high enough to be effective in volume resuscitations, such as in patients with gastrointestinal bleeding or trauma (3,4,10,22,32). There are very few complications reported with this technique. The most frequent is osteomyelitis. In the 29 studies reported between 1942 and 1954, comprising more than 4,000 pediatric patients, there were 27 cases of osteomyelitis. However, no series of cases since the resurgence of popularity of this technique in 1977 has reported a case (5). Occasionally, an elevated peripheral leukocyte count, sometimes with immature forms is seen for the first 24 to 48 hours after insertion of the needle, but then returns to normal. Essentially, however, the IO technique has proven to be a safe, rapid method for instilling medications in children when alternative methods are not available. It is possible that this technique can also be useful in the adult patient.
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9. Tocantins LM, O’Neill JF. Infusion of blood and other fluids into the general circulation via the bone marrow. Surg Gynecol Obstet. 1941;73:281-7. 10. Tocantins LM, O’Neill JF, Price AH. Infusions of blood and other fluids via the bone marrow in traumatic shock and other forms of peripheral circulatory failure. Ann Surg. 1941;114: 1085-92. 11. Papper EM. The bone marrow route for injecting fluids and drugs into the general circulation. Anesthesiology. 1942;3:30713. 12. Doud EA, Tysell JE. Massive intramedullary infusions. JAMA. 1942;120:1212-13. 13. Iserson KV, Reeter AK, Woods W, Criss E. Pressurization of IV bags: a new configuration and evaluation for use. J Emerg Med. 1985;3:89-92. 14. Kaye W, Bircher NC. Access for drug administration during cardiopulmonary resuscitation. Crit Care Med. 1988;16:179-82. 15. Kanter RK, Zimmerman JJ, Strauss RH, Stoechel KA. Pediatric emergency intravenous access. AJDC. 1986;140:132-34.
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16. Rossetti V, Thompson BM, Aprahamian C, Darin JC, Mateer JR. Difficulty and delay in intravenous access in pediatric arrests (abstract). Ann Emerg Med. 1984;13:406. 17. Iserson KV, Criss E. Pediatric venous cutdowns. Ped Emerg Care. 1986;2:231-4. 18. Smith RJ, Keseg DP, Manley LK, Standeford T. Intraosseous infusions by prehospital personnel in critically ill pediatric patients. Ann Emerg Med. 1988;17:491-5. 19. Rosetti VA, Thompson BM, Miller J, Mateer JR, Aprahamian C. Intraosseous infusion: an alternative route of pediatric intravascular access. Ann Emerg Med. 1985;14:885-8. 20. Begg AC. Intraosseous venography of the lower limb and pelvis. Br J Rad. 1954;27:318-24. 21. Tocantins LM, G’Neill JF. Complications of intra-osseous therapy. Ann Surg. 1945;122:266-77. 22. Hodge D, Delgado-Paredes C, Fleisher G. Intraosseous infusion flow rates in hypovolemic “pediatric” dogs. 1987;16:3057. 23. Shoor PM, Berryhill RE, Benumof JL. Intraosseous infusion: pressure-flow relationship and pharmacokinetics. J Trauma. 1979;19:772-4. 24. Prete MR, Hannan CJ, Burkle FM. Plasma atropine concentrations via intravenous, endotracheal, and intraosseous ad-
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