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Qasim ZA, Joseph B. Intraosseous access in the resuscitation of patients with trauma: the good, the bad, the future. Trauma Surg Acute Care Open 2024; 9:e001369. [PMID: 38646033 PMCID: PMC11029384 DOI: 10.1136/tsaco-2024-001369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 03/09/2024] [Indexed: 04/23/2024] Open
Abstract
The timely restoration of lost blood in hemorrhaging patients with trauma, especially those who are hemodynamically unstable, is of utmost importance. While intravenous access has traditionally been considered the primary method for vascular access, intraosseous (IO) access is gaining popularity as an alternative for patients with unsuccessful attempts. Previous studies have highlighted the higher success rate and easier training process associated with IO access compared with peripheral intravenous (PIV) and central intravenous access. However, the effectiveness of IO access in the early aggressive resuscitation of patients remains unclear. This review article aims to comprehensively discuss various aspects of IO access, including its advantages and disadvantages, and explore the existing literature on the clinical outcomes of patients with trauma undergoing resuscitation with IO versus intravenous access.
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Affiliation(s)
- Zaffer A Qasim
- Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Bellal Joseph
- Department of Surgery, The University of Arizona College of Medicine Tucson, Tucson, Arizona, USA
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Ellington M, Walker I, Barnard E. Red cell haemolysis secondary to intraosseous (IO) blood transfusion in adult patients with major trauma: a systematic review. BMJ Mil Health 2023:military-2023-002378. [PMID: 37236652 DOI: 10.1136/military-2023-002378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 05/15/2023] [Indexed: 05/28/2023]
Abstract
INTRODUCTION Intraosseous (IO) administration of medications and blood products is accepted practice in major trauma when intravenous access is not immediately available. However, there is a concern that the high infusion pressures required for IO transfusion may increase the risk of red cell haemolysis and its associated complications. The aim of this systematic review is to synthesise the existing evidence describing the risks of red cell haemolysis in IO blood transfusion. METHODS We undertook a systematic search of MEDLINE, CINAHL and EMBASE using the search terms: "intraosseous transfusion" and "haemolysis". Two authors independently screened abstracts, and reviewed full-text articles against the inclusion criteria. Reference lists of included studies were reviewed and a grey literature search undertaken. Studies were assessed for risk of bias. Inclusion criteria were: all human and animal study types that reported novel data on IO-associated red cell haemolysis. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline was used. RESULTS Twenty-three abstracts were identified; n=9 full papers met the inclusion criteria. No further studies were identified from reference lists or grey literature. These papers included: seven large animal translational studies, a prospective and a retrospective human study. The overall risk of bias was high. One animal study with good translatability to adult patients with trauma demonstrated haemolysis. Other animal studies had methodological constraints that limit their human applicability. No haemolysis was observed in low-density flat bones (sternum), whereas haemolysis was reported in long bones (humerus, tibia). IO infusion using a three-way tap was associated with haemolysis. Conversely, pressure bag transfusion was not associated with haemolysis, but this method may result in insufficient flow rates for effective resuscitation. CONCLUSIONS There is a paucity of high-quality evidence surrounding the risks of red cell haemolysis in IO blood transfusion. However, evidence from one study suggests that the likelihood is increased by use of a three-way tap to administer blood transfusion to young adult male patients with trauma. Further research is needed to address this important clinical question. PROSPERO REGISTRATION NUMBER CRD42022318902.
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Affiliation(s)
- Matt Ellington
- Anaesthetic Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - I Walker
- Haematology Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Department of Haematology, University of Cambridge, Cambridge, UK
| | - E Barnard
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research and Clinical Innovation), Birmingham, UK
- Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Sulava E, Bianchi W, McEvoy CS, Roszko PJ, Zarow GJ, Gaspary MJ, Natarajan R, Auten JD. Single Versus Double Anatomic Site Intraosseous Blood Transfusion in a Swine Model of Hemorrhagic Shock. J Surg Res 2021; 267:172-181. [PMID: 34153560 DOI: 10.1016/j.jss.2021.04.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 04/05/2021] [Accepted: 04/10/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Blood transfusion via single site intraosseous access is a critical modality when caring for a trauma victim that lacks intravascular access. Flow rates and potential clinical complications when utilizing two sites of intraosseous access are not well known. MATERIALS AND METHODS Anesthetized adult female Yorkshire swine (Sus scrofa; n = 48; 76.7 ± 1.75kg; range 66-90kg) were cannulated and then bled approximately 30% total blood volume. Swine were randomly assigned to treatment groups: single sited humerus, single sited sternum, dual sited humerus or dual sited humerus and sternum. Flow rates, hemolysis, physiologic measurements, biochemical variables, and pulmonary histologic inflammation and occlusion were contrasted between groups. RESULTS Dual sited intraosseous transfusion flow rates (128ml/min, 95% CI 123-132) were double the flow rates of single sites (65ml/min, 95% CI 60-70), P < .0001.Single sited humeral flow rates were greater than sternal flow rates, with respective averages of 74ml/min and 55ml/min, though not reaching statistical significance (P < 0.17). There was no significant elevation of plasma free hemoglobin in any group after transfusion as compared to baseline (P = 0.7). Groups did not significantly differ in vitals or biochemical variables. Most pulmonary specimens had some intraparenchymal fat embolism, however no animals had evidence of occlusive intra-arterial fat embolism. CONCLUSIONS Dual anatomic site, pressure bag driven, intraosseous blood transfusion approximately doubles flow rates without evidence of clinical complications or hemolysis. Further research using a survivability model is needed to characterize long-term complications from pressurized IO transfusions.
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Affiliation(s)
- Eric Sulava
- Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia; Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia.
| | - William Bianchi
- Department of Emergency Medicine, Naval Medical Center San Diego, San Diego, California; Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia
| | - Christian S McEvoy
- Department of General Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia; Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia
| | - Paul J Roszko
- Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia; Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia
| | - Gregory J Zarow
- Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia
| | - Micah J Gaspary
- Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia; Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia
| | - Ramesh Natarajan
- Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia; Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia
| | - Jonathan D Auten
- Department of Emergency Medicine, Naval Medical Center San Diego, San Diego, California; Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia
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Intraosseous access in the resuscitation of trauma patients: a literature review. Eur J Trauma Emerg Surg 2020; 47:47-55. [PMID: 32078703 DOI: 10.1007/s00068-020-01327-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 02/11/2020] [Indexed: 01/21/2023]
Abstract
PURPOSE Intraosseous (IO) catheters continue to be recommended in trauma resuscitation. Their utility has recently been debated due to concerns regarding inadequate flow rates during blood transfusion, and the potential for haemolysis. The objective of this review was to examine the evidence for intraosseous catheters in trauma resuscitation, and to highlight areas for future research. METHODS A PubMed and Embase search for articles published from January 1990 to August 2018 using the terms ("intra-osseous access" or "intraosseous access" or "IO access") AND trauma was performed. Original articles describing the use of an IO catheter in the resuscitation of one or more trauma patients were eligible. Animal, cadaveric studies and those involving healthy volunteers were excluded. RESULTS Nine studies, comprising of 1218 trauma patients and 1432 device insertions, were included. The insertion success rate was 95% and the incidence of complications 0.9%. Flow-rate data and evidence of haemolysis were poorly reported. CONCLUSION Intraosseous catheters have high insertion success rates and a low incidence of complications in trauma patients. Existing evidence suggests that IO transfusion is not associated with haemolysis, however, further studies in humans are needed. There is a paucity of flow rate data for blood transfusion via IO catheters in this population, although much anecdotal evidence advocating their use exists.
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Auten JD, McEvoy CS, Roszko PJ, Polk TM, Kachur RE, Kemp JD, Natarajan R, Zarow GJ. Safety of Pressurized Intraosseous Blood Infusion Strategies in a Swine Model of Hemorrhagic Shock. J Surg Res 2019; 246:190-199. [PMID: 31600648 DOI: 10.1016/j.jss.2019.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 08/09/2019] [Accepted: 09/11/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Current guidelines support intraosseous access for trauma resuscitation when intravenous access is not readily available. However, safety of intraosseous blood transfusions with varying degrees of infusion pressure has not been previously characterized. MATERIALS AND METHODS Adult female Yorkshire swine (Sus scrofa; n = 36; mean (M): 80 kg, 95% CI: 78-82 kg) were cannulated and then bled approximately 30% total blood volume. Swine were randomly assigned to proximal humerus intraosseous blood infusion with either Rapid Infuser, or Pressure Bag, or Push-Pull methods (n = 12 each). Flow rates, infusion pressures, vitals, biochemical variables, and pulmonary and renal tissue pathology were contrasted between groups. RESULTS Flow rates were greater for the Push-Pull strategy than Pressure Bag (96.5 mL/min versus 72.6 mL/min, P = 0.02) or Rapid Infuser (96.5 mL/min versus 60 mL/min, P = 0.002) strategies. The pressures generated during the Push-Pull transfusion (3058 mmHg) were greater than the other strategies (≤360 mmHg). After the observation period, plasma-free hemoglobin levels were higher in the Push-Pull strategy than in the Rapid Infuser (40 mg/dL versus 12 mg/dL, P = 0.02) or Pressure Bag (40 mg/dL versus 12 mg/dL, P = 0.01). Groups did not significantly differ in vitals, biochemical variables, or tissue pathology. CONCLUSIONS Push-Pull conferred the highest flow rates, but with higher infusion pressures and evidence of intravascular hemolysis. Rapid Infuser and Pressure Bag infusions had no increase from baseline in plasma-free hemoglobin. Pressure Bag infusion was noted to confer an advantage in flow rates over Rapid Infuser. Intraosseous blood transfusion with pressure bags can safely bridge toward central access in the early phases of trauma resuscitation.
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Affiliation(s)
- Jonathan D Auten
- Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia; Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia.
| | - Christian S McEvoy
- Department of General Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia; Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia
| | - Paul J Roszko
- Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia; Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia
| | - Travis M Polk
- Department of General Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia; Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia
| | - Ryan E Kachur
- Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia; Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia
| | - Jean D Kemp
- Department of Pathology, Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Ramesh Natarajan
- Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia; Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia
| | - Greg J Zarow
- Naval Medical Center Portsmouth, Combat Trauma Research Group, Clinical Investigation Department, Portsmouth, Virginia
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Emergency sternal intraosseous access for warm fresh whole blood transfusion in damage control resuscitation. J Trauma Acute Care Surg 2019; 84:S120-S124. [PMID: 29462086 DOI: 10.1097/ta.0000000000001850] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Intraosseous (IO) vascular access is increasingly used as an emergency tool for achieving access to the systemic circulation in critically ill patients. The role of IO transfusion of blood in damage control resuscitation is however questionable due to possible inadequate flow rate and hemolysis. Some experts claim that IO transfusion is contraindicated. In this study, we have challenged this statement by looking at flow rates of autologous fresh whole blood reinfusion and hemolysis using two of the commonly used Food and Drug Administration-approved and Conformité Européenne (CE)-marked sternal needles. Additionally, the success rate of sternal access between the two devices is evaluated. METHODS Volunteer professional military personnel, were enrolled prospectively in a nonrandomized observational study design. We collected 450 mL of autologous whole blood from each participant. Participants were divided into the following three groups of 10: Tactically Advanced Lifesaving IO Needle (T.A.L.O.N.) IO, FAST1 IO, and intravenous group. The reinfusion was done by gravity only. Blood sampling was performed before blood collection and 30 minutes after reinfusion. Investigation of hemolysis was performed by measurements of haptoglobin and lactate dehydrogenase. Success rate was evaluated by correct aspiration of bone marrow. RESULTS Median reinfusion rate was 46.2 mL/min in the FAST1 group, 32.4 mL/min in the T.A.L.O.N. group, and 74.1 mL/min in the intravenous group. Blood samples from all participants were within normal ranges. There was no statistically significant difference in haptoglobin and lactate dehydrogenase between the groups. In the FAST1 group, 1 (9%) of 11 procedures failed. In the T.A.L.O.N. group, 4 (29%) of 14 procedures failed. CONCLUSION Although preferable, achieving peripheral venous access in the bleeding patient is a major problem. Our findings suggest that fresh whole-blood transfusion through the IO route is safe, reliable, and provide sufficient flow for resuscitation. LEVEL OF EVIDENCE Therapeutic/Care management study, level III.
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Bäckman S, Ångerman-Haasmaa S, Jousi M, Siitonen S, Salmela K. ABO and D typing and alloantibody screening in marrow samples: relevance to intraosseous blood transfusion. Transfusion 2018; 58:1372-1376. [DOI: 10.1111/trf.14557] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 01/05/2018] [Accepted: 01/22/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Sari Bäckman
- Meilahti Hospital Blood Bank, Department of Clinical Chemistry, Helsinki University Hospital Laboratory (HUSLAB), and the Department of Emergency Medicine and Services; Helsinki University Hospital; Helsinki Finland
| | - Susanne Ångerman-Haasmaa
- Meilahti Hospital Blood Bank, Department of Clinical Chemistry, Helsinki University Hospital Laboratory (HUSLAB), and the Department of Emergency Medicine and Services; Helsinki University Hospital; Helsinki Finland
| | - Milla Jousi
- Meilahti Hospital Blood Bank, Department of Clinical Chemistry, Helsinki University Hospital Laboratory (HUSLAB), and the Department of Emergency Medicine and Services; Helsinki University Hospital; Helsinki Finland
| | - Sanna Siitonen
- Meilahti Hospital Blood Bank, Department of Clinical Chemistry, Helsinki University Hospital Laboratory (HUSLAB), and the Department of Emergency Medicine and Services; Helsinki University Hospital; Helsinki Finland
| | - Katja Salmela
- Meilahti Hospital Blood Bank, Department of Clinical Chemistry, Helsinki University Hospital Laboratory (HUSLAB), and the Department of Emergency Medicine and Services; Helsinki University Hospital; Helsinki Finland
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Anson JA, Sinz EH, Swick JT. The versatility of intraosseous vascular access in perioperative medicine: a case series. J Clin Anesth 2014; 27:63-7. [PMID: 25547826 DOI: 10.1016/j.jclinane.2014.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 09/08/2014] [Accepted: 10/02/2014] [Indexed: 01/01/2023]
Abstract
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.
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Affiliation(s)
- Jonathan A Anson
- Penn State Milton S. Hershey Medical Center, 500 University Drive, Mail Code H187, PO Box 850, Hershey, PA 17033-0850, USA.
| | - Elizabeth H Sinz
- Department of Anesthesia, Penn State Milton S. Hershey Medical Center, 500 University Drive, PO Box 850, Hershey, PA 17033-0850, USA
| | - John T Swick
- Department of Anesthesia, Penn State Milton S. Hershey Medical Center, 500 University Drive, PO Box 850, Hershey, PA 17033-0850, USA
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Abstract
Abstract
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.
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What is the evidence of utility for intraosseous blood transfusion in damage-control resuscitation? J Trauma Acute Care Surg 2014; 75:904-6. [PMID: 24158214 DOI: 10.1097/ta.0b013e3182a85f71] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Intraosseous Transfusion With Liposome-Encapsulated Hemoglobin Improves Mouse Survival After Hypohemoglobinemic Shock Without Scavenging Nitric Oxide. Shock 2011; 35:45-52. [DOI: 10.1097/shk.0b013e3181e46e93] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Plewa MC, King RW, Fenn-Buderer N, Gretzinger K, Renuart D, Cruz R. Hematologic safety of intraosseous blood transfusion in a swine model of pediatric hemorrhagic hypovolemia. Acad Emerg Med 1995; 2:799-809. [PMID: 7584767 DOI: 10.1111/j.1553-2712.1995.tb03275.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To assess the risk of hemolysis, disseminated intravascular coagulation (DIC), or fat embolism syndrome (FES) with pressurized intraosseous (IO) blood transfusion following hemorrhage. METHODS A controlled, repeated-measures, randomized animal study with blinded pathologic evaluations was conducted. Sixteen pentobarbital-anesthetized, instrumented immature swine underwent a 20-mL/kg hemorrhage into citrate-phosphate-dextrose bags, then received autologous blood transfusion via a 16-ga i.v. catheter (eight), or via a 15-ga IO needle in the proximal tibia (eight) under maximal manual pressure using a 30-mL syringe. At baseline and at one hour and 48 hours posttransfusion, blood samples were assayed for hemoglobin (Hb), schistocytes, free Hb in plasma, bilirubin, lactate dehydrogenase, platelets, fibrinogen, and alveolar-arteriolar O2 gradient. Lung sections were examined for inflammation after hematoxylin/eosin stain, and for fat emboli after oil red-O-stain. Kidney sections were examined for inflammation using hematoxylin/eosin stain. RESULTS Though the IO transfusion rate of 21 +/- 6 mL/min was slower than the i.v. rate of 35 +/- 5 mL/min (p = 0.0012), all the animals returned to baseline blood pressure within 15 minutes and survived. The presence of schistocytes and mildly elevated free Hb in plasma was noted in both groups at baseline and each time period, and was presumed to be due to sampling from the arterial catheter. All other laboratory values remained within normal limits and without intergroup differences at any time period. No fat embolus was noted, and all lung and kidney specimens were free of inflammation. CONCLUSIONS In this model, pressurized IO blood transfusion appears to be hematologically safe, i.e., without risk of appreciable hemolysis, DIC, or FES.
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Affiliation(s)
- M C Plewa
- Emergency Medicine Residency Program, St. Vincent Medical Center, Toledo Hospital, OH 43608-2691, USA
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