Recommendations for the Use of Intraosseous Vascular Access for Emergent and Nonemergent Situations in Various Health Care Settings: A Consensus Paper

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.

A pilot study comparing bone marrow aspirates and venous blood for emergency point-of-care blood parameters in healthy dogs

OBJECTIVE

To compare intravenous and intraosseous blood aspirates using point-of-care diagnostic equipment available in veterinary hospitals.

DESIGN

Prospective study.

SETTING

Private referral hospital.

ANIMALS

Dogs undergoing a tibial plateau leveling osteotomy or extracapsular anterior cruciate ligament stabilization procedure were enrolled.

METHODS

Under general anesthesia, simultaneous 0.5 mL intravenous and intraosseous blood samples were collected from the jugular vein and proximal tibia, respectively. Samples were evaluated in duplicate within 10 minutes of collection and averaged for each of the following parameters: blood urea nitrogen (BUN), glucose, packed cell volume, total plasma protein (TPP), plasma lactate, sodium, potassium, chloride, urea, glucose, pH, anion gap, pO_2, and pCO₂ . Normalcy was tested with Kolmogorov-Smirnov test. A Student's t-test and Bland-Altman plot were used to compare intravenous and intraosseous samples.

RESULTS

Twelve dogs were recruited into the study. There were statistically significant differences between intravenous and intraosseous samples for sodium (P = 0.0216), chloride (P = 0.0225), BUN (P = 0.014), and potassium (P < 0.0001), respectively. No significant differences were detected for the other parameters evaluated.

DISCUSSION

The intraosseous space provides an easily accessible, noncollapsible alternative for assessing blood parameters. Omitting potassium, the statistically significant differences noted between sites was not felt to be clinically significant. Although statistically insignificant, the large difference in hematocrit values indicates that the samples should not be used interchangeably.

CONCLUSION

Intraosseous aspirates, excluding potassium and hematocrit, appear to be a reliable alternative for assessing most point-of-care analytes in healthy dogs, although a larger sample size should be investigated. The application of these data in shock patients is unknown.

Should nurses be trained to use ultrasound for intravenous access to patients with difficult veins?

Peripheral venous access is the most common invasive procedure performed on patients in the UK and is traditionally the responsibility of nursing staff. In an emergency, intravenous therapy can be lifesaving. Approximately 11% of adults have difficult venous access and are often subjected to repeated failed attempts, resulting in delayed diagnosis and treatment. Eventually, rescue methods are used by a doctor, but this increases demand on their time and the workflow of emergency departments. This article explores whether training nurses to obtain venous access using ultrasound would have a positive effect on doctors' workload and benefit adult patients with difficult veins. Research indicates that nurses can successfully use ultrasound to reduce the number of attempts, time to access and patient discomfort, and can prevent the insertion of unnecessary central lines. Ultrasound training programmes for nurses demonstrate benefits for patients and clinicians.

Vascular access through the intraosseous route in pediatric emergencies

Obtaining venous access in critically ill children is an essential procedure to restore blood volume and administer drugs during pediatric emergencies. The first option for vascular access is through a peripheral vein puncture. If this route cannot be used or if a prolonged period of access is necessary, then the intraosseous route is an effective option for rapid and safe venous access. The present work is a descriptive and exploratory literature review. The study's aim was to describe the techniques, professional responsibilities, and care related to obtaining venous access via the intraosseous route in pediatric emergencies. We selected 22 articles (published between 2000 and 2011) that were available in the Latin American and Caribbean Health Sciences (LILACS) and MEDLINE databases and the SciELO electronic library, in addition to the current protocol of cardiopulmonary resuscitation from the American Heart Association (2010). After the literature search, data were pooled and grouped into the following categories of analysis: historical aspects and physiological principles; indications, benefits, and contraindications; professional assignments; technical principles; care during the access; and possible complications. The results of the present study revealed that the intraosseous route is considered the main secondary option for vascular access during the emergency response because the technique is quick and easily executed, presents several non-collapsible puncture sites, and enables the rapid and effective administration of drugs and fluid replacement.

Ultrasound first, second, and last for vascular access

Vascular access is the most commonly performed invasive procedure in medicine. For more than 20 years, ultrasound has been shown to improve the success and decrease complications of central venous access; however, it is still not universally used for this procedure. Ultrasound may also be used to facilitate difficult peripheral vascular access, potentially avoiding other more invasive procedures such as central or intraosseus vascular access. This article reviews some of the indications and evidence for ultrasound-guided vascular access, provides tips for successful ultrasound guidance, and discusses barriers to adoption.

Barriers and facilitators to intraosseous access in adult resuscitations when peripheral intravenous access is not achievable

OBJECTIVES

Studies suggest that intraosseous (IO) access is underutilized in adult resuscitations, despite recommendations from advanced trauma and cardiac life support guidelines. The objective was to determine factors associated with IO access use by physicians during adult resuscitations when intravenous (IV) access is not immediately achievable.

METHODS

This study was an online survey among physicians purposefully recruited from various clinical care areas at three teaching hospitals. Questions were generated from the qualitative results of 20 iterative interviews, verified for internal validity, and piloted. The interview guide was based on the constructs of the Theory of Planned Behavior (TPB), which elicits salient attitudes, social influences, and control beliefs that potentially influence intention to use IO access. Recruitment took place in September 2012 until reaching more than 100% of the required sample size (n = 200). Internal consistency was measured using Cronbach's alpha, and the effect of TPB constructs and specific beliefs were assessed with regression analyses.

RESULTS

For the 205 respondents, the mean age was 35 years (range = 20 to 66 years), and 53.3% were male. Participants' departmental affiliations were 50.3% emergency medicine (EM), 16.9% internal medicine, 14.9% anesthesia, 10.8% general surgery, and 7.2% critical care. Residents comprised 60.7% of the sample, and 39.3% were attending physicians. Median intention to use IO access when IV is not immediately achievable was 4.67 (interquartile range [IQR] = 4 to 5) out of 5 (5 highest) and predicted by the following TPB constructs: attitudes (AdjCoefficients = 0.504; 95% confidence interval [CI] = 0.334 to 0.673), social influences (AdjCoefficients = 0.285; 95% CI = 0.172 to 0.398), and control beliefs (AdjCoefficients 0.217; 95% CI = 0.113 to 0.320). Physicians were more likely to use IO access if they believed that it provided rapid vascular access for delivering large volumes of fluids, could prevent delays in care, and was associated with a low complication rate. Conversely, the perception that nurses are not familiar or supportive of IO access and a lack of physician confidence regarding the appropriate indications for IO access were barriers to use.

CONCLUSIONS

These data are an important step in the knowledge-to-action process, as they identify specific factors associated with physician use of IO access. Interventions addressing these actionable facilitators and barriers are likely to have a positive effect on increasing the appropriate physician use of this potentially life-saving technique in adult patients requiring emergent vascular access.

Citation classics from Indian pediatrics

Scientific papers are often assessed by the number of citations they receive in subsequent years. We retrieved the most cited articles published in Indian Pediatrics by counting the number of citations on Google scholar. 17 scientific papers received more than 50 citations; all except one were research articles. The maximum number of most cited articles (six each) were related to neonatology and infectious diseases. Most of these articles made significant impact in formulation of guidelines and/or change in practice and policy.