Comparison of Two Intraosseous Devices: The NIO Versus the EZ-IO by Novice Users-A Randomized Cross Over Trial

Factors associated with failure of intraosseous access in prehospital trauma treatment by military medical personnel

INTRODUCTION

Intraosseous devices have become an alternative to peripheral intravenous (PIV) access. Despite the established success of intraosseous devices in laboratory and simulator studies, there is a lack of data regarding their real-world utilisation in prehospital settings. Therefore, this study aims to evaluate the success rates of intraosseous access in a prehospital military context and identify factors associated with failure.

METHODS

Using the Israel Defense Forces (IDF) Trauma Registry, we retrospectively collected data from 2010 to 2023. The primary outcome was the first pass success rate of intraosseous access, and logistic regression models were applied to identify variables associated with first pass failure.

RESULTS

The study included 172 trauma patients who underwent attempted intraosseous access with 46.5% cases which were classified as military events. The median age was 22 years, and 17.3% were paediatric patients. First pass success was achieved in 67.4% of cases, with a cumulative success rate of 80.8% after multiple attempts. Moreover, significant differences were noted when examining the success rate of the three intraosseous devices used by the IDF teams, with the highest success rate being documented for the NIO Adult versus the EZ-IO or the BIG (81.4%; 76.7%; 62.4%). However, logistic regression analysis revealed that the number of PIV access attempts was the only variable significantly associated with decreased odds of achieving first pass intraosseous access.

CONCLUSION

These findings suggest that intraosseous devices are a viable alternative for establishing vascular access in prehospital military settings. However, success rates were slightly lower than previous reports, potentially due to the severity of injuries in the study cohort. Our analyses revealed a higher number of PIV access attempts correlated with reduced first pass intraosseous success, possibly stemming from caregiver proficiency in obtaining vascular access. Further research is needed to explore additional factors affecting intraosseous access success rates.

Application Times, Placement Accuracy, and User Ratings of Commercially Available Manual and Battery-Powered Intraosseous Catheters in a High Bone Density Cadaveric Swine Model

INTRODUCTION

Intraosseous (IO) infusion, the pressurized injection of fluids into bone through a catheter, is a life-preserving resuscitative technique for treating trauma patients with severe hemorrhage. However, little is known regarding the application times, placement accuracy, and end-user ratings of battery-powered and manual IO access devices. This study was specifically designed to fill these knowledge gaps on six FDA-approved IO access devices.

MATERIALS AND METHODS

Three experienced U.S. Navy Emergency Medicine residents each placed commercially available 15-gauge IO catheters in cadaveric swine (Sus scrofa) proximal humeri and sternums in a randomized prospective experimental design. Devices included the battery-powered EZ-IO Rapid Infuser and the manual Jamshidi IO, PerSys NIO, SAM Manual IO, Tactical Advanced Lifesaving IO Needle (TALON), and PYNG First Access for Shock and Trauma 1 (30 trials per device, 10 per user, 210 total trials). Application times, placement accuracy in medullary (zone 1) and trabecular (zone 2) bone while avoiding cortical (zone 3) bone, and eight subjective user ratings were analyzed using ANOVA and nonparametric statistics at P < .05.

RESULTS

The EZ-IO demonstrated the fastest application times, high rates in avoiding zone 3, and the highest user ratings (P < .0001). The TALON conferred intermediate placement times, highest rates of avoiding zone 3, and second-highest user ratings. The SAM Manual IO and Jamshidi performed poorly, with mixed results for the PerSys NIO and PYNG First Access for Shock and Trauma 1.

CONCLUSIONS

The battery-powered EZ-IO performed best and remains the IO access device of choice. The present findings suggest that the TALON should be considered as a manual backup to the EZ-IO.

Comparison of the NIO and EZIO for Resuscitative Vascular Access in the Emergency Department: A Quasi-Experimental, Before-and-After Study

INTRODUCTION

Intraosseous (IO) needle insertion is a key adjunctive procedure in the care of critically ill and injured patients in a variety of settings, including the battlefield. The NIO is a new, fully disposable, single-piece, IO device with potential practical advantages under austere conditions. We sought to compare the efficacy and safety of the NIO to an established, well-studied device, the EZIO, when used for resuscitative vascular access in the emergency department (ED).

METHODS

Retrospective, single-center, quasi-experimental, before-and-after, observational cohort study performed at an urban, tertiary-care hospital ED among adult patients receiving IO access during resuscitation. The before/NIO period lasted from July 1, 2019, to May 31, 2020, and the EZIO/after period from June 1, 2020, to April 30, 2021. Patient demographics, prehospital treatment, ED presentation, characteristics and results of IO insertion(s), potential procedure-associated adverse events, and ED and hospital outcomes were abstracted from the medical record. The primary outcome, rate of first-pass success (FPS), was compared between the NIO and EZIO periods using multivariable regression after adjustment for potential confounding factors.

RESULTS

We enrolled 63 total patients/66 limbs (mean age 61 ± 18, 51% female), 34 patients/35 limbs during the NIO period and 29 patients/31 limbs during the EZIO period. The most common reason for IO insertion was cardiac arrest (40/63, 63%), followed by respiratory failure, trauma, and sepsis. The majority of IO insertions were performed at the proximal tibia (58/66, 88%) by senior emergency medicine residents or faculty. The overall rate of FPS was 53/66 (80%), 24/35 (69%) with the NIO compared to 29/31 (94%) with the EZIO. After multivariable modeling, the odds of FPS with the NIO vs. the EZIO was 0.19 (95% CI, 0.01-1.5, P = .16). Procedure-related adverse events were infrequent in both groups. In-hospital mortality was 45/63 (71%).

CONCLUSIONS

We found that the NIO device was associated with a lower-than-expected rate of FPS compared to the EZIO device, although not significantly different after adjusting for between-group imbalances and considering limitations in the study design. Further, prospective research into the efficacy and safety of the NIO is needed before clinical use can be encouraged.

Pediatric Intraosseous Access Performed by Emergency Department Nurses Using Semiautomatic Devices: A Randomized Crossover Simulation Study

BACKGROUND

No study has examined the performance of emergency department (ED) nurses in establishing intraosseous access (IO) access. This study aimed to evaluate ED nurses' success rate in establishing pediatric IO access using semiautomatic devices.

METHODS

A randomized crossover simulation study was conducted. The success rates of ED nurses were compared with those of paramedics with similar years of experience. The study instruments were the new spring-loaded injector (NIO) and the battery power drill (EZ-IO). Uncooked piglets' bones were used as the study model. All attempts were filmed by a video camera. Successful placement was defined as the visualization of flow from the marrow cavity. Participants recorded their ranking of the "ease of use" of each device.

RESULTS

No differences in 1-attempt success rate was found between nurses and paramedics (27/34 [79.4%] vs 25/30 [83.3%], P = 0.68). Nurses and paramedics had similar success rates with the 2 semiautomatic IO devices (12/17 vs 12/15 with the spring-loaded injector, P = 0.69, and 15/17 vs 13/15 with the battery power drill, P = 0.9). The number of failed attempts and the causes for failure were equally distributed between nurses and paramedics. Median ease-of-use Likert-scale scores of the spring-loaded injector and the battery power drill were 4 (interquartile range [IQR] = 3-4) and 5 (IQR = 5-5) (P < 0.04) for the nurses and 5 (IQR = 4-5) and 5 (IQR = 4-5) (P = 0.44) for the paramedics, respectively.

CONCLUSIONS

Emergency department nurses and paramedics had a similarly high insertion success rates on a pediatric bone model. This pilot study suggests that ED nurses can successfully perform this procedure.

Intraosseous vascular access in emergency and trauma settings: a comparison of the most universally used intraosseous devices

Introduction: Obtaining successful vascular access is an essential component of the emergency and trauma setting. The modern practice of medicine advocates IO access for patients in a critical condition, especially when IV access is problematic or unobtainable. Various medical devices allowing for IO access have been coined and used in the management of critical patients.Areas covered: This study aims to review the literature regarding different intraosseous devices used to obtain vascular access (Bone Injection Gun (BIG), EZ-IO, NIO, Jamshidi, and First Access for Shock and Trauma (FAST-1) and discuss their clinical and experimental role in the emergency and trauma settings.Expert opinion: The development of medical technology contributes to an increasing number of intraosseous devices facilitating vascular access in challenging scenarios, including cardiopulmonary resuscitation, anaphylactic, or hypovolemic shock. Each of these devices provides an effective route for fluid resuscitation, drug delivery, laboratory evaluation, and shortening the timeframe for established vascular access, provided that the person obtaining the access is acquainted with the use of the device.

Evaluation of the NIO and T.A.L.O.N Intraosseous Devices as Placed by U.S. Army Conventional Force Combat Medics-A Randomized Crossover Study

INTRODUCTION

In recent U.S. Military conflicts, hemorrhage remains the leading cause of preventable death with 30%-40% mortality rates. Management consists of effective bleeding control and rapid resuscitation with blood products. Rapid and accurate circulatory access is crucial in battlefield trauma management. This study evaluates the insertion success rate and time to successfully insert the NIO automatic intraosseous (IO) device and the Tactical Advanced Lifesaving IO Needle (TALON) manual IO device. The primary outcome is successful first attempt insertion. Secondary outcomes are the time taken for the successful insertion, user-reported "ease of use" for both devices, and user-reported device preference.

MATERIALS AND METHODS

This is a prospective randomized crossover study comparing the NIO and TALON devices. As they are often the frontline health care providers, combat medics (68W) were recruited to participate in this study. They were randomized into two cohorts based on the IO device and location they would start first. Each medic performed a total of four IO cannulations on the proximal tibia and the humeral head of cadaveric human models.

RESULTS

Sixty medics participated in the study, performing a total of 240 IO insertions, 120 with NIO (60 at the proximal tibia and 60 at the humeral head) and 120 with TALON (60 at the proximal tibia and 60 at the humeral head). The first attempt success rate was 89.2% for the NIO and 83.3% for the TALON, P = .19. The time to successful first attempt insertion for the NIO [M = 24.71 seconds, SD = 4.72] and the TALON, [M = 24.70 seconds, SD = 4.74] were similar, P = .98. The differences between the success of device insertion and time to successful insertion did not achieve statistical significance. The "ease of use" score (5-point Likert Scale) for the NIO [M = 4.73] and the TALON, [M = 4.11], demonstrated a significant difference, P < .001. Ninety percent [n = 54] of the combat medics preferred the NIO versus only 10% [n = 6] preferred TALON.

CONCLUSIONS

Our findings indicate that the overall insertion success rate and time to successful insertion were similar between NIO automatic IO device and the TALON manual IO device. In our study, Army combat medics learned how to use both devices rapidly but felt the NIO automatic IO device easier to use and overwhelmingly preferred this device.

Checking the basis of intraosseous access-Radiological study on tibial dimensions in the pediatric population

BACKGROUND

Malposition of intraosseous needles in pediatric patients is frequently reported. Incorrect needle length and penetration depth related to the puncture site and level are possible causes.

AIMS

Aim of this study was to analyze anatomic dimensions of the proximal tibia in the pediatric population with respect to intraosseous needle placement and needle tip position.

METHODS

Plain lower leg radiographs of children aged from birth to 16 years of age were analyzed. Pretibial tissue layer, cortical bone thickness, and the diameter of the medullary cavity were measured at two different puncture levels. Data were analyzed as descriptive statistics and by polynomial regression plots and set in context to commonly used EZ-IO^® needle lengths of 15 and 25 mm.

RESULTS

Radiographs from 190 patients (104 boys/86 girls) were included. When fully inserted to skin level, up to 10.5% of needles do not reach medullary cavity at one and 18.5% at two patient's fingerbreadths distal to tibial tuberosity. The opposite cortical wall is touched or penetrated in 16% and 25%, respectively. Up to 96% of too deep needle tip positions occur in children younger than 24 months, as do too superficial tip positions in 59%.

CONCLUSIONS

Puncture level and needle length have a great influence on potential needle tip positions. Infants and toddlers are at highest risk for malpositioning. Due to relevant growth-related differences in tibial anatomy, an age-related and well-reflected approach is crucial to successfully establish intraosseous access.