Emergency sternal intraosseous access for warm fresh whole blood transfusion in damage control resuscitation

Red cell haemolysis secondary to intraosseous (IO) blood transfusion in adult patients with major trauma: a systematic review

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.

Effectiveness of intraosseous access during resuscitation: a retrospective cohort study

PURPOSE

During resuscitation in emergency situations, establishing intravascular access is crucial for promptly initiating delivery of fluids, blood, blood products, and medications. In cases of emergency, when intravenous (IV) access proves unsuccessful, intraosseous (IO) access serves as a viable alternative. However, there is a notable lack of information concerning the frequency and efficacy of IO access in acute care settings. This study aims to assess the efficacy of intraosseous (IO) access in acute care settings, especially focusing on children in a level 1 trauma center.

METHODS

This retrospective study included patients with IO access presented in a level 1 trauma center emergency department (ED) between January 2015 and April 2020. Data regarding medication and fluid infusion was documented, and the clinical success rate was calculated.

RESULTS

Of the 109,548 patients that were admitted to the ED, 25,686 IV lines were inserted. Documentation of 188 patients of which 73 (38.8%) children was complete and used for analysis. In these 188 patients, a total of 232 IO accesses were placed. Overall, 182 patients had a functional IO access (204 needles) (88%). In children (age < 18 years) success rate was lower as compared to adults, 71-84% as compared to 94%. However, univariate regression showed no association between the percentage of functional IO access and gender, age, weight, health care location (prehospital and in hospital), anatomical position (tibia as compared to humerus) or type of injury.

CONCLUSION

Intraosseous access demonstrates a high success rate for infusion, independent of gender, age, weight, anatomical positioning, or healthcare setting, with minimal complication rates. Caution is especially warranted for children under the age of six months, since success rate was lower.

When to choose intraosseous access in prehospital trauma care: A registry-based study from the Israel Defense Forces

PURPOSE

Prompt vascular access is crucial for resuscitating bleeding trauma casualties in prehospital settings but achieving peripheral intravenous (PIV) access can be challenging during hemorrhagic shock due to peripheral vessel collapse. Early intraosseous (IO) device use is suggested as an alternative. This study examines injury characteristics and factors linked to IO access requirements.

METHODS

A registry-based cohort study from the Israel Defense Forces Trauma Registry (2010 - 2023) included trauma casualties receiving PIV or IO access prehospital. Casualties who had at least one documented PIV or IO access attempt were included, while those without vascular access were excluded. Casualties requiring both PIV and IO were classified in the IO group. Univariable logistic regression assessed the factors associated with IO access. Results were reported as odds ratios (OR) with 95% confidence intervals (CI), and significant difference was set at p < 0.05.

RESULTS

Of 3462 casualties (86.3% male, the median age: 22 years), 3287 (94.9%) received PIV access and 175 (5.1%) had IO access attempts. In the IO group, 30.3% received freeze-dried plasma and 23.4% received low titer group O whole blood, significantly higher than that in the PIV group. Prehospital mortality was 35.0% in the IO group. Univariable analysis showed significant associations with IO access for increased PIV attempts (OR = 1.69; 95% CI: 1.34 - 2.13) and signs of profound shock (OR = 11.0; 95% CI: 5.5 - 23.3).

CONCLUSION

Profound shock signs are strongly linked to the need for IO access in prehospital settings with each successive PIV attempt increasing the likelihood of requiring IO conversion. IO access often accompanies low titer group O whole blood or freeze-dried plasma administration and higher prehospital mortality, indicating its use in emergent resuscitation situations. Early IO consideration is advised for trauma casualties with profound shock.

Intraosseous access in the resuscitation of patients with trauma: the good, the bad, the future

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.

Low-titer group O whole blood in military ground ambulances: Lessons from the Israel Defense Forces initial experience

BACKGROUND

Cold-stored low-titer group O whole blood (LTOWB) has become increasingly utilised in both prehospital and in-hospital settings for resuscitation of traumatic haemorrhage. However, implementing the use of LTOWB to ground medical teams has been limited due to logistic challenges.

METHODS

In 2022, the Israel Defense Forces (IDF) started using LTOWB in ambulances for the first time in Israel. This report details the initial experience of this rollout and presents a case-series of the first patients treated with LTOWB.

RESULTS

Between January-December 2022, seven trauma patients received LTOWB administered by ground IDF intensive care ambulances after presenting with profound shock. Median time from injury to administration of LTOWB was 35 min. All patients had evidence of severe bleeding upon hospital arrival with six undergoing damage control laparotomy and all but one surviving to discharge.

CONCLUSIONS

The implementation of LTOWB in ground medical units is in its early stages, but continued experience may demonstrate its feasibility, safety, and effectiveness in the prehospital setting. Further research is necessary to fully understand the indications, methodology, and benefits of LTOWB in resuscitating severely injured trauma patients in this setting.

Efficacy of intraosseous access for trauma resuscitation: a systematic review and meta-analysis

BACKGROUND

During medical emergencies, intraosseous (IO) access and intravenous (IV) access are methods of administering therapies and medications to patients. Treating patients in emergency medical situations is a highly time sensitive practice; however, research into the optimal access method is limited and existing systematic reviews have only considered out-of-hospital cardiac arrest (OHCA) patients. We focused on severe trauma patients and conducted a systematic review to evaluate the efficacy and efficiency of intraosseous (IO) access compared to intravenous (IV) access for trauma resuscitation in prehospital care.

MATERIALS AND METHOD

PubMed, Web of Science, Cochrane Library, EMBASE, ScienceDirect, banque de données en santé publique and CNKI databases were searched for articles published between January 1, 2000, and January 31, 2023. Adult trauma patients were included, regardless of race, nationality, and region. OHCA patients and other types of patients were excluded. The experimental and control groups received IO and IV access, respectively, in the pre-hospital and emergency departments for salvage. The primary outcome was success rate on first attempt, which was defined as secure needle position in the marrow cavity or a peripheral vein, with normal fluid flow. Secondary outcomes included mean time to resuscitation, mean procedure time, and complications.

RESULTS

Three reviewers independently screened the literature, extracted the data, and assessed the risk of bias in the included studies; meta-analyses were then performed using Review Manager (Version 5.4; Cochrane, Oxford, UK). The success rate on first attempt was significant higher for IO access than for IV access (RR = 1.46, 95% CI [1.16, 1.85], P = 0.001). The mean procedure time was significantly reduced (MD = - 5.67, 95% CI [- 9.26, - 2.07], P = 0.002). There was no significant difference in mean time to resuscitation (MD = - 1.00, 95% CI [- 3.18, 1.17], P = 0.37) and complications (RR = 1.22, 95% CI [0.14, 10.62], P = 0.86) between the IO and IV groups.

CONCLUSION

The success rate on first attempt of IO access was much higher than that of IV access for trauma patients, and the mean procedure time of IO access was significantly less when compared to IV access. Therefore, IO access should be suggested as an urgent vascular access for hypotensive trauma patients, especially those who are under severe shock.

Single Versus Double Anatomic Site Intraosseous Blood Transfusion in a Swine Model of Hemorrhagic Shock

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.

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.

Sternal Intraosseous Devices: Review of the Literature

Introduction

The intraosseous (IO) route is one of the primary means of vascular access in critically ill and injured patients. The most common sites used are the proximal humerus, proximal tibia, and sternum. Sternal IO placement remains an often-overlooked option in emergency and prehospital medicine. Due to the conflicts in Afghanistan and Iraq the use of sternal IOs have increased.

Methods

The authors conducted a limited review, searching PubMed and Google Scholar databases for “sternal IO,” “sternal intraosseous,” and “intraosseous” without specific date limitations. A total of 47 articles were included in this review.

Results

Sternal IOs are currently FDA approved for ages 12 and older. Sternal IO access offers several anatomical, pharmacokinetic, hemodynamic, and logistical advantages over peripheral intravenous and other IO points of access. Sternal IO use carries many of the same risks and limitations as the humeral and tibial sites. Sternal IO gravity flow rates are sufficient for transfusing blood and resuscitation. In addition, studies demonstrated they are safe during active CPR.

Conclusion

The sternal IO route remains underutilized in civilian settings. When considering IO vascular access in adults or older children, medical providers should consider the sternum as the recommended IO access, particularly if the user is a novice with IO devices, increased flow rates are required, the patient has extremity trauma, or administration of a lipid soluble drug is anticipated.

Intravenous vs intraosseous adrenaline administration in cardiac arrest: A protocol for systematic review and meta-analysis

INTRODUCTION

Cardiac arrest refers to the sudden termination of cardiac ejection function due to various causes. Adrenaline is an important component of resuscitation among individuals experiencing cardiac arrest. The adrenaline delivery method chiefly involved intraosseous infusion and intravenous access. However, the impact of different adrenaline delivery methods on cardiac arrest has been unclear in previous research. Thus, the present study aimed to synthesize the available evidence regarding intravenous vs intraosseous adrenaline administration in cardiac arrest.

METHODS AND ANALYSIS

We will search PubMed, EMBASE, Cochrane Library, Wanfang, and China National Knowledge Infrastructure. As per the inclusion criteria, randomized controlled trials (RCTs) on adrenaline administration in cardiac arrest were selected. The primary outcome was prehospital restoration of spontaneous circulation (ROSC); the secondary endpoints were survival, favorable neurological outcome at discharge, and poor neurological outcome at ≥3 mon.We plan to use the Cochrane Collaboration's tool for assessing the bias risk for RCTs. The Grading of Recommendations Assessment, Development and Evaluation approach will grade the certainty of the evidence for all the outcome measures across studies. RevMan 5.3.5 will be used for meta-analysis. If the heterogeneity tests show slight or no statistical heterogeneity, the fixed effects model will be used, in other cases, the random effect model will be used for data synthesis.

RESULTS AND CONCLUSION

This protocol will determine which epinephrine delivery method is the optimal in the management of cardiac arrest. Our findings will help clinicians and health professionals in making accurate clinical decisions about adrenaline administrations in cardiac arrest.

ETHICS AND DISSEMINATION

Ethical approval was not required because this study was planned as a secondary analysis. The results will be disseminated in peer-reviewed publications, journals, and academic.

INPLASY REGISTRATION NUMBER

INPLASY202090100 (DOI:10.37766/inplasy2020.9.0100).

Intraosseous transfusion of hemoglobin vesicles in the treatment of hemorrhagic shock with collapsed vessels in a rabbit model

BACKGROUNDS

Intravenous transfusion sometimes encounters difficulty under prehospital conditions when peripheral vessels are collapsed and inaccessible. We investigated whether the cellular type hemoglobin-based oxygen carriers (Hemoglobin Vesicles: HbVs) allow intraosseous administration into blood circulation for the resuscitation of rabbits with severe hemorrhagic shock.

STUDY DESIGN AND METHODS

New Zealand white rabbits (2.5 kg average) were set in severe hemorrhagic shock [mean arterial pressure (MAP): 21 ± 2 mm Hg, Hb 5.1 ± 0.8 g/dL]. Immediately thereafter, 12 mL/kg of HbVs, 5% human serum albumin (HSA), autologous whole blood (WB), stored red blood cells (RBCs) or 36 mL/kg of Lactated Ringer's (LR) were intraosseously transfused, followed by an additional intraosseous transfusion with 8 mL/kg of HSA (following HbV, HSA or stored RBC transfusion), or WB or 24 mL/kg of LR (following LR transfusion), respectively.

RESULTS

Intraosseous transfusion of HbVs increased MAP (48 ± 9 mm Hg) and improved hypohemoglobinemia (7.1 ± 0.6 g/dL) as well as WB or RBC transfusion. In contrast, neither HSA nor LR improved hemodynamics or Hb levels. Seven out of 10 rabbits receiving HbVs survived for 24 hours, while only one out of 10 rabbits receiving LR survived (WB and RBC; 100% survivals, HSA; 30% survival).

CONCLUSIONS

Intraosseous infusion of HbVs might be an effective initial treatment to maintain hemodynamics during acute hemorrhagic shock. This approach could be used in emergency situations in which access to peripheral vessels is difficult.

Intraosseous access in the resuscitation of trauma patients: a literature review

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.

Fresh Low Titer O Whole Blood Transfusion in the Austere Medical Environment

Massive hemorrhage is an immediate threat to life. The military developed the Tactical Combat Casualty Care guidelines to address the management of acute trauma, including administration of blood products. The guidelines have been expanded to include low titer O whole blood, which is in limited use by the military. This proposal describes how the transfusion of fresh whole blood might be applied to the remote civilian environment. In doing so, this life-saving intervention may be brought to the austere medical environment, allowing critically hemorrhaging patients to survive to reach definitive medical care.

Safety of Pressurized Intraosseous Blood Infusion Strategies in a Swine Model of Hemorrhagic Shock

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.

Conducting fresh whole blood transfusion training

Fresh whole blood is the optimal resuscitation fluid for casualties in hemorrhagic shock according to the Committee on Tactical Combat Casualty Care and has demonstrated to improve outcomes in severely wounded patients. Like all medical interventions, fresh whole blood transfusions are not without risks, but similarly can be mitigated through increased training to develop provider knowledge and proficiency. To date, no literature has been published regarding the proper technique to conduct fresh whole blood transfusion training. This article provides a structured foundation to establish a standardized fresh whole blood transfusion training program to increase skill and preparedness for fresh whole blood protocol implementation. Using these techniques in a training environment, providers will be able to provide optimal resuscitation in hemorrhagic shock in austere environments.

Comparison of ROTEM parameters from venous and intraosseous blood

Rotational thromboelastometry is recommended to guide haemostatic therapy in trauma-related coagulopathy. In the case of unsuccessful venepuncture, intraosseous access allows immediate administration of drugs and volume replacement. Feasibility of rotational thromboelastometry from intraosseous blood has not yet been investigated in humans. We performed rotational thromboelastometry and standard coagulation assays from intraosseous and intravenous blood samples in 19 volunteers and 4 patients undergoing general anaesthesia. Intraosseous access was performed either at the tibial bone or the proximal humerus. We observed visible clotting in the majority of the intraosseous samples. Only 13% of the probes allowed realization of rotational thromboelastometry. ROTEM parameters are reported as follows: shorter median clotting time (CT) in EXTEM, INTEM, and APTEM (53 vs. 68 s; 140 vs. 154 s; 54 vs. 62.5 s) and smaller median maximal clot firmness (MCF) in EXTEM and APTEM (56 vs. 63 mm; 55 vs. 62 mm) in intraosseous samples. We found no relevant differences in median MCF values in FIBTEM and INTEM (12 vs. 13 mm; 60 vs. 59 mm). Given the difficulties we faced during IO blood sampling in a study setting, we advise against ROTEM measurements out of IO blood for guidance of procoagulant therapy in emergency situations.