Emergency alternatives to intravenous access. Intraosseous, intratracheal, sublingual, and other-site drug administration

A Case of Compartment Syndrome Due to Out-of-Hospital Intraosseous Misplacement During Cardiopulmonary Resuscitation

Resuscitation relies heavily on gaining access to the circulatory system. During cardiopulmonary resuscitation (CPR), the biggest, most readily accessible vein that does not impede resuscitation is desired. Intraosseous (IO) access is designated for life-threatening emergencies and is a relatively safe procedure with fewer complications. We describe an intriguing and uncommon consequence of out-of-hospital IO placement: compartment syndrome resulting from the displacement of the IO needle by emergency medical services (EMS) workers in a diabetic woman with hypoglycemia. A few hours later, the patient had swelling, discomfort, and loss of motor and sensory sensations at the IO site, necessitating further examinations. The IO needle had traversed both the anterior and posterior cortices of the tibia and was located in the soft tissues along the posterior portion of the tibia as shown by imaging of the afflicted area. Immediate decompression fasciotomy was performed to preserve the patient's limb.

Intraosseous compared to intravenous drug resuscitation in out-of-hospital cardiac arrest

AIMS

Although the intraosseous (IO) route is increasingly used for vascular access in out-of-hospital cardiac arrest (OHCA), little is known about its comparative effectiveness relative to intravenous (IV) access. We evaluated clinical outcomes following OHCA comparing drug administration via IO versus IV routes.

METHODS

This retrospective cohort study evaluated Emergency Medical Services (EMS)-treated adults with atraumatic OHCA in a large metropolitan EMS system between 9/1/2012-12/31/2014. Access was classified as IO or IV based on the route of first EMS drug administration. Study endpoints were survival to hospital discharge, return of spontaneous circulation (ROSC) and survival to hospital admission.

RESULTS

Among 2164 adults with OHCA, 1800 met eligibility criteria, 1525 of whom were treated via IV and 275 principally via tibial-IO routes. Compared to IV, IO-treated patients were younger, more often women, had unwitnessed OHCA, a non-cardiac aetiology, and presented with non-shockable rhythms. IO versus IV-treated patients were less likely to survive to hospital discharge (14.9% vs 22.8%, p=0.003), achieve ROSC (43.6% vs 55.5%, p<0.001) or be hospitalized (38.5% vs 50.0% p<0.001). In multivariable adjusted analyses, IO treatment was not associated with survival to discharge (odds ratio (OR) (95% confidence interval) 0.81 (0.55, 1.21), p=0.31), but was associated with a lower likelihood of ROSC (OR=0.67 (0.50, 0.88), p=0.004) and survival to hospitalization (OR=0.68 (0.51, 0.91), p=0.009).

CONCLUSION

Though not independently associated with survival to discharge, principally tibial IO versus IV treatment was associated with a lower likelihood of ROSC and hospitalization. How routes of vascular access influence clinical outcomes after OHCA merits additional study.

The versatility of intraosseous vascular access in perioperative medicine: a case series

Intraosseous vascular access is a time-tested procedure that is reemerging in popularity. This is primarily a result of the emphasis on intraosseous access in the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Advanced Cardiac Life Support. Modern intraosseous insertion devices are easy to learn and use, suggesting the possibility of use beyond the resuscitation setting. We present a case series of recent intraosseous insertions for a variety of indications by anesthesiologists at our institution to demonstrate the potential utility of this alternative access technique.

Videos in clinical medicine. Insertion of an intraosseous needle in adults

Intraosseous needle insertion is used as a temporary measure when intravascular access cannot be achieved through peripheral or central venous routes. The intraosseous needle may remain in situ for 72 to 96 hours, but it is best removed within 6 to 12 hours, as soon as an alternative site of intravascular access has been established. The intraosseous route provides fast and reliable vascular access in emergency medical situations. The use of the appropriate technique will ensure that the procedure is performed as safely and effectively as possible.

Vascular Access in Resuscitation

Intraosseous vascular access is a time-tested procedure which has been incorporated into the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation. Intravenous access is often difficult to achieve in shock patients, and central line placement can be time consuming. Intraosseous vascular access, however, can be achieved quickly with minimal disruption of chest compressions. Newer insertion devices are easy to use, making the intraosseous route an attractive alternative for venous access during a resuscitation event. It is critical that anesthesiologists, who are often at the forefront of patient resuscitation, understand how to properly use this potentially life-saving procedure.

Successful cardiopulmonary resuscitation following cardiopulmonary arrest in a geriatric chinchilla

OBJECTIVE

To describe the successful application of CPR in a geriatric chinchilla employing basic and advanced life support measures during cardiopulmonary arrest (CPA).

CASE SUMMARY

A 13-year-old female intact chinchilla presented to a general and multispecialty referral hospital for a dental procedure. During recovery from anesthesia the patient suffered CPA and CPR was initiated. Noninvasive positive pressure mask ventilation was initiated and external chest compressions were performed. An 18-Ga needle was introduced into the medullary cavity of the right humerus as an intraosseous catheter and provided access for administration of drugs and fluids. After return of spontaneous circulation was noted mannitol was administered via the intraosseous catheter to alleviate suspected increased intracranial pressure. Clinical improvement was noted shortly after administration. Monitoring during the recovery period showed a normal sinus cardiac rhythm and a SpO₂ of 100% while on supplemental oxygen. Neurologic function continued to improve over the following hours. Oxygen therapy was provided via an oxygen cage, and administration of antimicirobials, gastrointestinal protectants, and nutritional supplementation were part of the post resuscitation care. Oxygen therapy was discontinued after 24 hours, during which time normal behaviors were observed and neurologic status was considered appropriate. The patient was discharged 48 hours after CPA.

NEW OR UNIQUE INFORMATION PROVIDED

Published reports from clinical practice on the outcomes of CPR for exotic small mammals are limited. This report details the successful outcome of the use of combined basic and advanced life support measures for the provision of CPR in a chinchilla. This report also highlights the utility of an intraosseous catheter for administration of drugs and fluids novel to this species during resuscitation and recovery. To the authors' knowledge this is the first published report of successful CPR following CPA in a geriatric chinchilla.

Intraosseous devices for intravascular access in adult trauma patients

Three intraosseous devices have been approved by the Food and Drug Administration for use in adult trauma patients when intravenous access cannot be obtained. Sites of insertion are the sternum (FAST1), proximal tibia and humerus (Big Injection Gun), and proximal and distal tibia and humerus (EZ-IO). Insertion generally requires less than 1 minute, and flow rates up to 125 mL/min can be achieved. The devices are used for emergency resuscitation and should be removed within 24 hours of insertion or as soon as practical after peripheral or central intravenous access has been achieved. Contraindications include fractures or other trauma at the insertion site, prosthetic joints near the site, previous attempts to insert an intra osseous device at the same site, osteoporosis or other bone abnormalities, infections at the proposed site, and inability to identify pertinent insertion landmarks. Primary complications are extravasation of medications and fluids into the soft tissue, fractures caused by the insertion, and osteomyelitis.

[Intraosseous infusion in the pediatric emergency medical service. Analysis of emergency medical missions 1990-2009]

BACKGROUND

Timely establishment of venous access in infants and toddlers during emergency medical care can be a particularly challenging task. Alternative routes for drug and fluid administration, such as endobronchial, intramuscular, central venous or venous cut-down do not offer reliable solutions. Intraosseous infusion (IOI) has become established as an effective alternative intravascular access for rapid and efficient drug delivery. IOI was introduced in our local emergency medical service (EMS) in 1993 and was assigned a high priority in international guidelines for pediatric emergency medical care in 2000 and 2005. The aim of this study was to review the impact of the introduction of IOI on drug administration routes during prehospital emergency treatment of critically ill or severely injured pediatric patients (NACA index V-VII) in our tertiary medical care centre over a period of 20 years.

METHODS

Pediatric prehospital emergency medical protocols from 1990 to 2009 were analyzed with respect to the administration routes for fluids and medications in severely injured or critically ill children with NACA severity scores V-VII. The frequency and mode of vascular access during prehospital treatment including IOI, endobronchial administration, central venous catheterization (CVC) and intramuscular administration as well as prehospital treatment and transportation without vascular access were analyzed. Two groups were compared: the introduction phase of IOI between 1990 and 1999 and the phase of growing IOI routine after introducing guidelines and regular staff IOI technique training between 2000 and 2009. Demographic data and drug administration routes in the two different time periods were analyzed using the Mann-Whitney-u test and t-test or χ(2)-test, respectively. A p-value <0.05 was regarded as significant.

RESULTS

A total of 5,279 pediatric prehospital emergency charts were analyzed and 401 patients (7.6%) were scored as NACA V-VII. At the emergency scene 299 patients (75%) received a peripheral intravenous access, 3 (0.7%) a central venous line access, 77 (19%) an intraosseous needle and in 22 (5.4%) no vascular or intraosseous access was used during the course of prehospital treatment (NACA VII - 13 patients, NACA VI - 2 patients, NACA V - 7 patients). Of the NACA VII patients 3 were transported under continuous cardiopulmonary resuscitation without vascular access. After 2002 all patients with NACA index VII were treated with vascular or intraosseous access. In 48 patients (12%) at least initial medication was given by the endobronchial or alternative route but within the last 3 years endobronchial drug administration was no longer reported. Thus, in 124 critically ill patients (31%) routine peripheral venous access could not be established initially or until the end of treatment (77 times IOI, 22 times no access over the course of treatment, 3 times CVC and 22 times initial endobronchial followed by peripheral venous access). Over the reviewed period the use of IOI increased significantly (p<0.001), while the incidence of lacking vascular access (p<0.05) and alternative drug administration routes (p<0.001) continuously decreased.

CONCLUSION

The IOI technique has not only been assigned a high priority in the guidelines for pediatric emergency care of critically ill children with difficult or failed venous access but has also significantly influenced current prehospital care. The introduction of the IOI technique in our prehospital pediatric emergency system has markedly reduced the number of critically ill or severely injured pediatric patients without vascular access or with less reliable alternative administration routes in the last 20 years.

Intraosseous drug administration in children and adults during cardiopulmonary resuscitation

OBJECTIVE

To review and assess the available literature on the use of intraosseous (IO) drug administration during cardiopulmonary resuscitation, addressing the benefits and risks of using this method of drug delivery in children and adults.

DATA SOURCES

The MEDLINE (1950-July 2007) database was searched for pertinent abstracts, using the key term intraosseous infusions. Additional references were obtained from the bibliographies of the articles reviewed. Manufacturer Web sites were used to obtain information about IO insertion devices.

STUDY SELECTION AND DATA EXTRACTION

All available English-language clinical trials, retrospective studies, and review articles describing IO drug administration were reviewed. Studies conducted in animal models to evaluate the effectiveness and safety of IO drug administration were also included.

DATA SYNTHESIS

IO access uses the highly vascularized bone marrow to deliver fluids and medications during cardiopulmonary resuscitation. This route, developed in the 1940s, has been revived in the past decade as a means of achieving rapid vascular access when intravenous access cannot be obtained. The primary advantage of IO access is the high success rate (approximately 80%). Most trained providers can place an IO line within 1-2 minutes. A number of small-scale studies and retrospective reviews have established the usefulness of this route for the delivery of many commonly used resuscitation drugs. In addition, animal models have demonstrated rapid drug delivery to the systemic circulation. While all resuscitation drugs can be given by the IO route, administration of ceftriaxone, chloramphenicol, phenytoin, tobramycin, and vancomycin may result in lower peak serum concentrations. The most common adverse effect seen with IO use, extravasation, has been reported in 12% of patients. Compartment syndrome, osteomyelitis, and tibial fracture are rare, but have also been reported.

CONCLUSIONS

IO administration is a safe and effective method for delivering drugs during cardiopulmonary resuscitation. It should be considered whenever intravenous access cannot be rapidly obtained.

[Vascular access in emergency paediatric anaesthesia]

There is very little literature to guide the young practitioner in caring for a child that needs emergency surgery and has difficult venous access. Questionnaires were sent to 89 members of the Swiss Paediatric Anaesthesia Society and to the heads of Anaesthesia Departments of Swiss teaching hospitals. Two typical case records were presented, both of which were characterised by the fact that 2-3 peripheral venous cannulation attempts were unsuccessful. Case A: a young child with a fracture of the radius and case B an infant with upper gastrointestinal ileus. The anaesthetists were then questioned regarding their preferences for optimal treatment. The majority would proceed with further attempts and, if these still failed, intramuscular or inhalational induction of anaesthesia was suggested as a reasonable choice for case A. However, for case B, a femoral venous or intraosseous access to the venous system was judged to be the safest method. On the basis of our inquiry and a literature search, a priority list was developed to suggest the best possible techniques for vascular access and alternative anaesthesia induction techniques for emergency paediatric procedures.

Methylene blue attenuates lung injury after mesenteric artery clamping/unclamping

BACKGROUND

This controlled, experimental study was designed to assess the effects of intratracheal and intravenous methylene blue on reperfusion lung injury following superior mesenteric artery clamping/unclamping.

MATERIALS AND METHODS

Superior mesenteric arteries of 144 anaesthetized adult male Wistar rats (n = 12/group) were clamped for 1 h. Ten minutes before unclamping, methylene blue or its vehicle was administered intratracheally or intravenously, followed by a 3 h-respiratory assessment and postexperimental assessment of survival.

RESULTS

Intravenous 3 and 9 mg kg(-1) but not higher methylene blue doses, and intratracheal 6-mg kg(-1) but not lower doses, significantly (P < 0.05) reduced the 100% increase in plateau pressure, 30% reduction in PO(2)/FiO(2), fourfold augmented bronchoalveolar lavage-retrieved volume and the increased polymorphonuclear leukocytes/bronchoalveolar cells' ratio associated with unclamping of the superior mesenteric artery. Lung tissue polymorphonuclear leukocytes count, total xanthine oxidase activity and wet-to-dry-weight ratio were also normal in these dose-treated groups. These effective regimens were also associated with longer animal survival.

CONCLUSIONS

Intratracheal methylene blue mitigates lung reperfusion injury following superior mesenteric artery clamping/unclamping at a similar magnitude as an intravenous regimen. This finding is a novel potential use of methylene blue in vivo.

Long-term effects on tibial growth after intraosseous infusion: a prospective, radiographic analysis

BACKGROUND

Evaluate, by radiographic analysis, tibial growth after an intraosseous infusion (IOI) in a pediatric population.

METHODS

We performed a prospective simple blind study, between January 1, 1994, and July 1, 2001, which included pediatric patients who needed an intraosseous trocar in emergency situations. During the follow-up, roentgenographs were performed. On each radiologic view, different measurements were carried out: anterior and lateral tibial length, anterior and lateral width at 2 diaphyseal levels. We compared the anterior length values to those published in the Anderson et al tables. When only one tibia was punctured, the mean measurements were compared with the control leg measurements using a paired t test.

RESULTS

The initial population included 78 patients. Of these 78 subjects, 42 died, 10 families could not be contacted, and one refused to participate. Two children were excluded because they had other conditions that could influence tibial growth. The study included 23 children. The puncture site was the proximal tibia. The mean age was 18.6 months at the time of IOI, the mean time of infusion was 5 hours, and the mean perfused volume was 225 mL. The mean radiologic follow-up time was 29.2 months. When compared with the Anderson et al tables, all the anterior length values were within the 95% confidence interval. For the other measurements, the statistical analysis showed no significant difference between punctured and control legs.

CONCLUSION

There is no long-term effect on tibial growth after an IOI when the IO trocar is properly placed.

Endobronchial adrenaline: should it be reconsidered? Dose response and haemodynamic effect in dogs

BACKGROUND

Tracheal drug administration is a route for drug delivery during cardiopulmonary resuscitation when intravenous access is not immediately available. However, tracheal adrenaline (epinephrine) injection has been recently shown to be associated with detrimental decrease in blood pressure. This was attributed to exaggerated early beta2 mediated effects unopposed by alpha-adrenergic vasoconstriction. We hypothesized that endobronchial adrenaline administration is associated with better drug absorption, which may abolish the deleterious drop of blood pressure associated with tracheal drug administration.

OBJECTIVE

To determine haemodynamic variables after endobronchial adrenaline administration in a non-arrest canine model.

DESIGN

Prospective, randomized, laboratory study.

METHODS

Adrenaline (0.02, 0.05, 0.1 mg/kg) diluted with normal saline was injected into the bronchial tree of five anaesthetized dogs. Injection of 10-ml saline served as control. Heart rate, blood pressure and arterial blood gases were monitored for 60 min after drug instillation. The protocol was repeated after 1 week.

RESULTS

Adrenaline at a dose of 0.02 mg/kg produced only a minor initial decrease in diastolic (from 90 +/- 5 to 78 +/- 3 mmHg, P=0.05), and mean blood pressure (from 107 +/- 4 to 100 +/- 3 mmHg, P=0.05), in all dogs. This effect lasted less then 30 s following the drug administration. In contrast, higher adrenaline doses (0.05 and 0.1 mg/kg) produced an immediate increase in diastolic (from 90 +/- 5 to 120 +/- 7 mmHg; and from 90 +/- 5 to 170 +/- 6 mmHg, respectively), and mean blood pressure (from 107 +/- 4 to 155 +/- 10 mmHg; and from 107 +/- 4 to 219 +/- 6 mmHg, respectively). All adrenaline doses resulted in an immediate increase in systolic blood pressure and pulse. Endobronchial administration of saline (control) affected none of the haemodynamic variables.

CONCLUSIONS

In a non-arrest model, endobronchial adrenaline administration, as opposed to the effect of tracheal adrenaline, produced only a minor decrease in diastolic and mean blood pressure. We suggest that endobronchial adrenaline administration should be investigated further in a CPR low-flow model when maintaining adequate diastolic pressure may be crucial for survival.

The use of the corpus cavernosum for the administration of phenobarbital: an experimental study in dogs

Status epilepticus (SE) is classically defined as a generalized tonic-clonic seizure lasting longer than 30 min. Prolonged seizure activity can be resulted in irreversible cerebral injury. In addition, the existence evidence suggests that the longer the duration of the seizure activity is less likely to be controlled. The intravenous (IV) access is frequently difficult during SE, especially in infants and neonates. On the other hand, it has been demonstrated that high volumes of fluid can be injected into the corpora cavernosa. In this study, phenobarbital (PB) was administered to dogs using both IV and intracavernous (IC) routes with a dose of 20 mg/kg. The time period required to establish the IC route was less than 5 s. The levels of PB in the blood were measured and all results were compared. There was no statistically significant difference between the IV and IC administration with regard of the blood PB levels. Within 48 h of the experiment, none of animals demonstrated any evidence of infection or disability. Our findings suggest that the IC route may be an alternative route for the administration of PB when venous access is not immediately available or if it is not possible to achieve.

Methylene blue in preventing hemodynamic and metabolic derangement following superior mesenteric artery clamping/unclamping: an intratracheal vs. intraperitoneal dose-response study

Intestinal ischemia-reperfusion affects hemodynamics. We studied intratracheal vs. intraperitoneal methylene blue (MB) attenuation of hemodynamic and metabolic deterioration following superior mesenteric artery (SMA) clamping/unclamping. Murine SMAs (5/group) were clamped for 1 h. MB (2, 6, 20, or 60 mg/kg [MB-2, MB-6, MB-20, and MB-60]) was administered intraperitoneally or intratracheally 10 min before unclamping. Observation continued for another 3 h. Circulating xanthine oxidase and base deficit levels doubled among ischemia non-treated and ischemia MB-2- and MB-60-treated groups, blood pressure decreased by 50%, and heart rate increased by 35%, compared to controls (non-clamped/unclamped and non-MB-treated rats, P < 0.01). These three ischemia groups needed 3-fold the amount of fluid to maintain systolic pressure > or =60 mmHg than controls (P < 0.01). Only the MB-6 and MB-20 intraperitoneal and intratracheal regimens similarly afforded hemodynamic stability in ischemic animals; base deficit and resuscitation volumes normalized as well. No drug regimen affected heart rate. We concluded that intraperitoneal and intratracheal MB at specific doses prevented systemic derangement following SMA clamping/unclamping.

Intracavernous application of diazepam: an alternative route of the seizure treatment--an experimental study in rabbits

BACKGROUND

There is a general need to terminate seizures as soon as possible using anticonvulsant drugs via an intravenous (i.v.) route, but it is often difficult to achieve a secure i.v. line during the seizure, especially in children. However, it has been demonstrated that high volumes of fluid can be injected into the corpora cavernosa. The purpose of this study was to evaluate the absorption properties of diazepam (DZ) after intracavernous (i.c.) administration and whether therapeutically significant plasma concentrations can be obtained or not.

METHODS

Diazepam was administered to rabbits using both the i.v. and i.c route with a dose of 1 mg/kg. Blood samples were collected from the saphenous vein for a time period of 30 min. The levels of DZ in the blood were analyzed by high performance liquid chromatography and their blood profiles were obtained and compared.

RESULTS

The insertions of the needle using this method were successful in all cases. The average time of inserting the needle was less than 5 s. There was no statistically significant difference between the i.v. and i.c. administration with regard of the blood DZ levels. Within 48 h after the experiment, none of the animals demonstrated any evidence of infection or disability.

CONCLUSION

Our results demonstrated that commercially available parenteral DZ can be absorbed rapidly by the i.c. route in rabbits. Further studies are needed on the feasibility of this method before it is evaluated in humans.

[Retrospective study of 32 cases of intraosseous perfusion]

BACKGROUND

We studied all intraosseous infusions performed between 1994 and 1997 by the pediatric intensive care unit and by the pre-hospital emergency medical staff in the Hôpital d'Enfants, Toulouse, France.

POPULATION AND METHODS

We report 32 cases of intraosseous infusions in 30 children aged 2 weeks to 9 years.

RESULTS

In our population, such a technique has been used in about 60% of all cardiopulmonary arrest, drowning or traffic accident cases. Intraosseous infusion was successful in all cases, on the first attempt in more than 80% of cases. Nine children recovered without any sequelae. No major complications have been observed.

CONCLUSIONS

Intraosseous infusion is safe, rapid and effective. It is an essential alternative route in pediatric resuscitation when no other venous access can be performed quickly. An effort must be made on behalf of its diffusion and teaching.

[Intraosseous infusion in children]

OBJECTIVE

To assess the benefits and drawbacks of intraosseous infusion (IOI) for emergency therapy in children.

STUDY DESIGN

Retrospective, non comparative study of IOI carried out between January 1994 and June 1998.

PATIENTS

Forty-one children requiring without delay IOI either in the emergency medical ambulance or the emergency admission and intensive therapy units.

METHODS

The tibia was punctured by paediatricians either with Mallarmé's trocars in 1994 or Cook Critical Care trocars from 1995 on.

RESULTS

Overall, 46 IOI have been carried out in 41 children with a median age of 18 months (range: 8 days-9 years). The main indications for IOI were the management of near drowning, road traffic accidents and cardiopulmonary resuscitation. Complications included one articular puncture and nine subcutaneous extravasations, requiring the puncture of the other limb in five cases.

CONCLUSION

IOI is an easy technique for vascular access. It is indicated in emergency cases when, after a delay of five minutes, other techniques have failed.

[Use of the intraosseous route in a premature infant]

BACKGROUND

The intraosseous route (IOR) is a rehabilitated vascular access in emergency situations. Its indications and duration are defined, although the age limit at which it is usable is not clearly established.

CASE REPORT

A 34-week-old preterm neonate, without infection, receiving gastric gavage, developed, at 8 days of life, a severe septic shock requiring ventilatory support and emergency volume expansion via a subclavian catheter. During the chest X-ray to check its position, the catheter was unfortunately pulled out. The child presented an acute desaturation with bradycardia, requiring bag ventilation and endotracheal epinephrine. The umbilical vein being unusable, an intraosseous access (20 G, distal hole, Cook) was performed at the upper tibial level to continue resuscitation and left in place for 14 hours to infuse antibiotics, inotropic support, blood products and colloids. Blood cultures grew Klebsiella pneumoniae. After a severe initial phase, course was favorable with normal examination at 3 years without complication of the IOR.

DISCUSSION

To our knowledge, it is the youngest child in whom IOR was performed. For neonates and especially preterms, the site of puncture is just below the tibial superior tuberosity, otherwise there is a risk of fracture of the diaphysis. This risk justifies the control of the IOR by X-ray. The place of the IOR among emergency vascular accesses in neonates, seems to us to be reserved to situations when umbilical vein is unusable.

CONCLUSION

Although no study compared IOR to superior longitudinal sinus access, we suggest to reserve the sinus access only when IOR has failed, because of its potential cerebral complications.

Intraosseous infusion in an emergency situation: a case report

An 18-month-old boy who had cardiopulmonary arrest secondary to penicillin anaphylaxis was successfully resuscitated by intraosseous administration of emergency resuscitative medications because peripheral vascular access was impossible. He was discharged 2 weeks later in a satisfactory clinical condition.

Bone marrow infusion in adults

OBJECTIVE

To asses the feasibility and success rate of vascular access through intraosseous infusions in adults, in elective and emergency situations using a novel, automatic device, the bone injection gun.

DESIGN

A prospective, nonrandomized trial.

MATERIALS AND METHODS

Two groups of patients were prospectively selected over an 11-month period. Group 1: Adult patients with recent closed long bone fractures, who underwent orthopedic surgery to upper and lower limbs and needed regional anesthesia. Group 2: Adult patients who required emergency or semiemergency vascular access, in whom intravenous central or peripheral cannulation could not be established within a reasonable period of time.

MAIN RESULTS

Fifty adult patients, aged 27 through 78 years, underwent the procedure, which was universally successful. In group 1, n = 31 patients; in group 2 (n = 19), 12 patients had multiple injuries, and seven underwent emergency resuscitation. In 76% of the cases, the needle was inserted into the area of the tibial tuberosity; in the reminder of the cases, the needle was inserted at the distal end of the radial bone and into the lateral or the medial malleolus. The success rate for an adequate insertion was 100% in this group of patients. No complications from the procedure were observed in this series.

CONCLUSIONS

This study emphasizes the importance and feasibility of the intraosseous route for infusion of fluids and medications in emergency situations in adults. The use of an impact, high speed automatic needle insertion device provides a higher success rate of vascular access via the intraosseal route in adult patients.