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Intraosseous infusion using the bone injection gun in the prehospital setting

2008; Elsevier BV; Volume: 80; Issue: 3 Linguagem: Inglês

10.1016/j.resuscitation.2008.11.006

1873-1570

Jean David, Pierre-Yves Dubien, Olivier Capel, Olivier Peguet, Pierre‐Yves Gueugniaud,

Injury Epidemiology and Prevention

The development of new devices has increased the options available for vascular access through the intraosseous (IO) route, particularly for adult patients.1Brenner T. Bernhard M. Helm M. Doll S. Volkl A. Ganion N. et al.Comparison of two intraosseous infusion systems for adult emergency medical use.Resuscitation. 2008; 78: 314-319Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar, 2Cooper B.R. Mahoney P.F. Hodgetts T.J. Mellor A. Intra-osseous access (EZ-IO) for resuscitation: UK military combat experience.J R Army Med Corps. 2007; 153: 314-316Crossref PubMed Scopus (74) Google Scholar, 3Schwartz D. Amir A. Dichter R. Figenberg Z. The use of a powered device for intraosseous drug and fluid administration in a national EMS: a 4-year experience.J Trauma. 2008; 64: 650-654Crossref PubMed Scopus (47) Google Scholar If it is difficult or impossible to establish peripheral venous access in the prehospital setting, IO access should be considered as an alternative to a central venous line.When two attempts at peripheral line insertion failed in adults patients in our mobile intensive care unit (SAMU system),4Adnet F. Lapostolle F. International EMS systems: France.Resuscitation. 2004; 63: 7-9Abstract Full Text Full Text PDF PubMed Scopus (186) Google Scholar senior emergency physicians were allowed to insert an IO catheter in the left or right proximal tibia (Bone Injection Gun, WaisMed Ltd., West Hempstead, New York, USA). If IO access failed, a central venous catheter was inserted. From January 1, 2005 to December 31, 2006, in the prehospital setting, IO needle placement was attempted in 11 patients (mean age: 55 year) but was successful only in 5 patients (right/left tibia: 0/5; aetiology: 2 trauma, 2 cardiac arrest, 1 seizure). In the 6 failed attempts (right/left tibia: 3/3; aetiology: 2 trauma, 1 cardiac arrest, 1 hip fracture, 1 ascites/portal hypertension), the needle was not securely placed in the bone and no flow was achieved (3 patients), there was extravasation (2 patients, Figure 1), and in one case, infusion was painful despite injection of IO lidocaine.The IO approach is said to be a very fast, simple infusion technique that can be used successfully even by inexperienced personnel, yet we observed a very high rate of IO insertion failure (55 %) by trained emergency physicians. Previous studies reported better results but were mainly done in children.5Horton M.A. Beamer C. Powered intraosseous insertion provides safe and effective vascular access for pediatric emergency patients.Pediatr Emerg Care. 2008; 24: 347-350Crossref PubMed Scopus (100) Google Scholar Only a few studies have been done in adults 1Brenner T. Bernhard M. Helm M. Doll S. Volkl A. Ganion N. et al.Comparison of two intraosseous infusion systems for adult emergency medical use.Resuscitation. 2008; 78: 314-319Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar, 2Cooper B.R. Mahoney P.F. Hodgetts T.J. Mellor A. Intra-osseous access (EZ-IO) for resuscitation: UK military combat experience.J R Army Med Corps. 2007; 153: 314-316Crossref PubMed Scopus (74) Google Scholar, 3Schwartz D. Amir A. Dichter R. Figenberg Z. The use of a powered device for intraosseous drug and fluid administration in a national EMS: a 4-year experience.J Trauma. 2008; 64: 650-654Crossref PubMed Scopus (47) Google Scholar and only one has used the bone injection gun in living humans.3Schwartz D. Amir A. Dichter R. Figenberg Z. The use of a powered device for intraosseous drug and fluid administration in a national EMS: a 4-year experience.J Trauma. 2008; 64: 650-654Crossref PubMed Scopus (47) Google Scholar In this study, the authors reported a success rate of 91% after one attempt.3Schwartz D. Amir A. Dichter R. Figenberg Z. The use of a powered device for intraosseous drug and fluid administration in a national EMS: a 4-year experience.J Trauma. 2008; 64: 650-654Crossref PubMed Scopus (47) Google Scholar Our high failure rate was caused mainly by the inability to control the path of the catheter with the bone injection gun. This resulted in either failure to insert the catheter through the outer layer of the bone into the marrow space, or to complete transfixion of the bone (Figure 1). In contrast, no comparable problems seem to be observed when other devices such as the EZ-IO needle (Vidacare, San Antonio, USA) are used.1Brenner T. Bernhard M. Helm M. Doll S. Volkl A. Ganion N. et al.Comparison of two intraosseous infusion systems for adult emergency medical use.Resuscitation. 2008; 78: 314-319Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar, 2Cooper B.R. Mahoney P.F. Hodgetts T.J. Mellor A. Intra-osseous access (EZ-IO) for resuscitation: UK military combat experience.J R Army Med Corps. 2007; 153: 314-316Crossref PubMed Scopus (74) Google Scholar, 5Horton M.A. Beamer C. Powered intraosseous insertion provides safe and effective vascular access for pediatric emergency patients.Pediatr Emerg Care. 2008; 24: 347-350Crossref PubMed Scopus (100) Google Scholar Although IO infusion is becoming a very interesting alternative to IV access in the emergency setting, additional studies are needed to determine the best technique to be used by physicians.Conflict of interest statementNone. The development of new devices has increased the options available for vascular access through the intraosseous (IO) route, particularly for adult patients.1Brenner T. Bernhard M. Helm M. Doll S. Volkl A. Ganion N. et al.Comparison of two intraosseous infusion systems for adult emergency medical use.Resuscitation. 2008; 78: 314-319Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar, 2Cooper B.R. Mahoney P.F. Hodgetts T.J. Mellor A. Intra-osseous access (EZ-IO) for resuscitation: UK military combat experience.J R Army Med Corps. 2007; 153: 314-316Crossref PubMed Scopus (74) Google Scholar, 3Schwartz D. Amir A. Dichter R. Figenberg Z. The use of a powered device for intraosseous drug and fluid administration in a national EMS: a 4-year experience.J Trauma. 2008; 64: 650-654Crossref PubMed Scopus (47) Google Scholar If it is difficult or impossible to establish peripheral venous access in the prehospital setting, IO access should be considered as an alternative to a central venous line. When two attempts at peripheral line insertion failed in adults patients in our mobile intensive care unit (SAMU system),4Adnet F. Lapostolle F. International EMS systems: France.Resuscitation. 2004; 63: 7-9Abstract Full Text Full Text PDF PubMed Scopus (186) Google Scholar senior emergency physicians were allowed to insert an IO catheter in the left or right proximal tibia (Bone Injection Gun, WaisMed Ltd., West Hempstead, New York, USA). If IO access failed, a central venous catheter was inserted. From January 1, 2005 to December 31, 2006, in the prehospital setting, IO needle placement was attempted in 11 patients (mean age: 55 year) but was successful only in 5 patients (right/left tibia: 0/5; aetiology: 2 trauma, 2 cardiac arrest, 1 seizure). In the 6 failed attempts (right/left tibia: 3/3; aetiology: 2 trauma, 1 cardiac arrest, 1 hip fracture, 1 ascites/portal hypertension), the needle was not securely placed in the bone and no flow was achieved (3 patients), there was extravasation (2 patients, Figure 1), and in one case, infusion was painful despite injection of IO lidocaine. The IO approach is said to be a very fast, simple infusion technique that can be used successfully even by inexperienced personnel, yet we observed a very high rate of IO insertion failure (55 %) by trained emergency physicians. Previous studies reported better results but were mainly done in children.5Horton M.A. Beamer C. Powered intraosseous insertion provides safe and effective vascular access for pediatric emergency patients.Pediatr Emerg Care. 2008; 24: 347-350Crossref PubMed Scopus (100) Google Scholar Only a few studies have been done in adults 1Brenner T. Bernhard M. Helm M. Doll S. Volkl A. Ganion N. et al.Comparison of two intraosseous infusion systems for adult emergency medical use.Resuscitation. 2008; 78: 314-319Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar, 2Cooper B.R. Mahoney P.F. Hodgetts T.J. Mellor A. Intra-osseous access (EZ-IO) for resuscitation: UK military combat experience.J R Army Med Corps. 2007; 153: 314-316Crossref PubMed Scopus (74) Google Scholar, 3Schwartz D. Amir A. Dichter R. Figenberg Z. The use of a powered device for intraosseous drug and fluid administration in a national EMS: a 4-year experience.J Trauma. 2008; 64: 650-654Crossref PubMed Scopus (47) Google Scholar and only one has used the bone injection gun in living humans.3Schwartz D. Amir A. Dichter R. Figenberg Z. The use of a powered device for intraosseous drug and fluid administration in a national EMS: a 4-year experience.J Trauma. 2008; 64: 650-654Crossref PubMed Scopus (47) Google Scholar In this study, the authors reported a success rate of 91% after one attempt.3Schwartz D. Amir A. Dichter R. Figenberg Z. The use of a powered device for intraosseous drug and fluid administration in a national EMS: a 4-year experience.J Trauma. 2008; 64: 650-654Crossref PubMed Scopus (47) Google Scholar Our high failure rate was caused mainly by the inability to control the path of the catheter with the bone injection gun. This resulted in either failure to insert the catheter through the outer layer of the bone into the marrow space, or to complete transfixion of the bone (Figure 1). In contrast, no comparable problems seem to be observed when other devices such as the EZ-IO needle (Vidacare, San Antonio, USA) are used.1Brenner T. Bernhard M. Helm M. Doll S. Volkl A. Ganion N. et al.Comparison of two intraosseous infusion systems for adult emergency medical use.Resuscitation. 2008; 78: 314-319Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar, 2Cooper B.R. Mahoney P.F. Hodgetts T.J. Mellor A. Intra-osseous access (EZ-IO) for resuscitation: UK military combat experience.J R Army Med Corps. 2007; 153: 314-316Crossref PubMed Scopus (74) Google Scholar, 5Horton M.A. Beamer C. Powered intraosseous insertion provides safe and effective vascular access for pediatric emergency patients.Pediatr Emerg Care. 2008; 24: 347-350Crossref PubMed Scopus (100) Google Scholar Although IO infusion is becoming a very interesting alternative to IV access in the emergency setting, additional studies are needed to determine the best technique to be used by physicians. Conflict of interest statementNone. None.