Intraosseous infusions: an important but forgotten method of vascular access

Pharmacokinetic longitudinal studies of antibiotics administered via a permanent intraosseous device in micropigs

BACKGROUND

In critically ill children, intraosseous (IO) administration of a medicine provides an alternate vascular access route when IV access is not readily available. We investigated the short and long-term efficacy and safety of a totally intraosseously implantable device.

PROCEDURE

This study was undertaken in micropigs (i) to compare serum levels achieved by equal bolus dosages of two antibiotics (amikacin and vancomycin) administered through an intratibial needle, an intraosseous implantable device and central IV routes to determine whether standard parenteral dosing guidelines for antibiotics may be applied without modification for IO injection, and (ii) to show the efficiency of the implantable device over a prolonged period, as a permanent access to intraosseous space.

RESULTS

The area under the plasma concentration time curves were similar for IV, intratibial and through the intraosseous implantable device, for intermittent administrations of amikacin and vancomycin, over a period of 6 months. However, vancomycin did not reach therapeutic levels via both IO routes. We did not find any alteration of amikacin and vancomycin pharmacokinetics over a period of 6 months using the implantable device. No complication occurred.

CONCLUSIONS

Long-term administration of antibiotics through a totally implantable intraosseous device is feasible and safe in micropigs. Although the procedure seems promising, additional studies of the continuous infusion of chemotherapeutic agents, blood products and antimicrobial solutions are needed prior to use in humans.

Intraosseous infusion and pulmonary fat embolism

OBJECTIVES: To determine the incidence of pulmonary fat embolism after the intraosseous (IO) infusion of normal saline and drugs and to determine whether pulmonary capillary blood is a predictor of lung fat embolism. DESIGN: A randomized, prospective, animal study. SETTING: Animal research laboratory of a university hospital. SUBJECTS: Twenty-eight mixed breed piglets (average weight 30.9 kg). Interventions and Methods: Animals were anesthetized, intubated, mechanically ventilated, and instrumented. IO needles were placed in the tibial bone. Animals were assigned to one of four groups: Group 1 received fluid (20 mL/kg) under 300 mm Hg pressure (n = 6); group 2 received fluid (20 mL/kg) at free flow under gravity (n = 6); group 3 received 100 mL of fluid over 20 mins (n = 8); and group 4 received 100 mL of fluid over 7 mins (n = 8). MEASUREMENTS AND MAIN RESULTS: Buffy coat samples were obtained from pulmonary arterial catheter in the occluded position at baseline, after IO needle placement, and at the end of infusion. Lung specimens (both upper and lower lobes) were obtained at the end of the infusion. Specimens were stained with oil red O and graded for fat emboli by a pathologist blinded to experimental conditions. Fat emboli (one to three emboli per high power field) were found in about 30% of the lung specimens. The difference in number of fat emboli between groups was not statistically significant. Buffy coat stains yielded fat emboli, which were distributed sporadically in all groups. CONCLUSION: Fat embolism is common; however, the method of IO fluid administration does not influence the number of emboli. Our study therefore implies that the risk of fat embolization is of concern, but its clinical relevance is unclear. Until the clinical significance of pulmonary fat emboli and the prevalence of fat emboli syndrome are delineated more precisely, the IO route is an effective but not necessarily safe route for delivery of fluids and drugs.

Bilateral osteomyelitis due to intraosseous infusion: case report and review of the English-language literature

Intraosseous infusion, a mode of peripheral access largely abandoned in the 1940s and 1950s, is becoming increasingly popular in the setting of pediatric crisis. While complications are rare when the procedure is properly performed, the risk of osteomyelitis increases with prolonged infusions. We present a case of bilateral osteomyelitis secondary to intraosseous infusion.