Intraosseous infusion
Encyclopedia
Intraosseous infusion is the process of injection
directly into the marrow
of a bone. This technique is used in emergency
situations to provide fluids and medication when intravenous access
is not available or not feasible.
In 1936, Tocantins and O'Neill found that when they injected 5 mL of saline into a long bone of a rabbit, only 2 mL were recovered at the distal end. They reasoned that the saline had been absorbed into the systemic circulation
. Subsequent tests confirming absorption included injecting dye into the marrow cavity. Within 10 seconds, the dye reached the heart. A procedure of sternum injection was developed and subsequently used by paramedics in World War II
.
Widespread use of IO by military medics also was reported during World War II. More than 4,000 cases of IO use during the war were documented and the U.S. military considered IO infusion a standard practice in the treatment of seriously wounded soldiers.
However, the practice of IO infusion did not carry over into civilian use following the war and was not rediscovered until 1984, when an American pediatrician, James Orlowski, MD, observed medics using IO access during a cholera
epidemic in India. His editorial, "My Kingdom for an Intravenous Line," advocated the use of IO infusion in pediatric patients and it became a standard of practice for pediatric patients in the late 1980s.
Until very recently, however, a reliable, safe and easy method to access the intraosseous space in adults proved elusive, and this area of medicine and its opportunities remained unexplored. In the mid-2000s, technological advances in the field made the use of IO easier and safer for practitioners.
is used as it lies just under the skin and can easily be palpated and located. The anterior aspect of the femur
, the superior iliac crest and the head of the humerus
are other sites that can be used.
This route of fluid and medication administration is an alternative one to the preferred intravascular route when the latter cannot be established in a timely manner. When intravascular access cannot be obtained intraosseous access is usually the next approach. It can be maintained for 24–48 hours, after which another route of access should be obtained.
Although intravascular access is still the preferred method for medication delivery in the prehospital area, advances in IO access (such as the F.A.S.T.1 and the EZ-IO system) for adults has caused many systems to re-think their preferred secondary access route. In Massachusetts, for example, IO is now a preferred administration over endotracheal
(ET) drug administration. In fact, the American Heart Association
no longer recommends using the endotracheal tube for resuscitation
drugs since the efficacy is unclear. Paramedic
s may perform intraosseous infusion in a cardiac arrest patient if no vein is clearly visible. The IO is becoming more and more common in emergency medical services
(EMS) systems around the world.
Furthermore, any medication that can be introduced via IV can be introduced via IO. Because of this, adult IO systems (most of which use a mechanical or powered adjunct to place the catheter) have become more common across the United States in the prehospital setting. Intraosseous access has roughly the same absorption rate as IV access, and (unlike ET administration) allows for fluid resuscitation as well as high-volume drugs such as sodium bicarbonate
to be administered in the setting of a cardiac arrest when IV access is unavailable. Endotracheal administration allows only specific drugs that have relatively low toxicity to lung
tissue, and must be restricted to relatively low volumes to avoid drowning the patient.
Due to the rapid advance and adoption of superior intraosseous access technology, IO access has now become the preferred method of establishing vascular access for patients in whom traditional access is difficult or impossible. This includes patients experiencing cardiac arrest, major trauma, airway compromise, severe dehydration and shock. IO is also an alternative route for patients who typically have poor peripheral vasculature or challenging vascular access such as diabetics, renal patients, burn victims, IV drug users, obese patients, dehydrated patients, the very young or elderly patients, and others. Many EMS services and hospitals are now using IO as their first line solution for vascular access in both adult and pediatric cardiac arrest victims, enabling administration of lifesaving drugs much earlier than previously possible with traditional peripheral IV placement.
There have been at least two studies comparing the EZ-IO and the BIG. Another paper compared the EZ-IO with the COOK IO needle. These three papers all found a minor preference for the EZ-IO. Another study compared the Jamshidi 15G, the BIG 15G, and the FAST1, finding median insertion times of 38, 49 and 62 seconds respectively (p = 0.004).
The EZ-IO is used by 90 percent of US advanced life support ambulances and over half of US Emergency Departments, as well as the US Military, and is available in over 50 countries worldwide. The EZ-IO is FDA-cleared for use on adult and pediatric patients in medically necessary instances, including difficult vascular access situations, as well as resuscitation and shock. The EZ-IO can be inserted in the proximal tibia, proximal humerus and the distal tibia.
Pyng's FAST1 and FASTx is inserted into the manubrium (upper sternum)http://www.pyng.com.
guideline cited two randomized controlled trials, one of 60 children and one of electively cannulated hematology/oncology patients. In addition, uncontrolled studies have been performed, one of which reported 72% to 87% rates of successful insertion.
Injection (medicine)
An injection is an infusion method of putting fluid into the body, usually with a hollow needle and a syringe which is pierced through the skin to a sufficient depth for the material to be forced into the body...
directly into the marrow
Bone marrow
Bone marrow is the flexible tissue found in the interior of bones. In humans, bone marrow in large bones produces new blood cells. On average, bone marrow constitutes 4% of the total body mass of humans; in adults weighing 65 kg , bone marrow accounts for approximately 2.6 kg...
of a bone. This technique is used in emergency
Medical emergency
A medical emergency is an injury or illness that is acute and poses an immediate risk to a person's life or long term health. These emergencies may require assistance from another person, who should ideally be suitably qualified to do so, although some of these emergencies can be dealt with by the...
situations to provide fluids and medication when intravenous access
Intravenous therapy
Intravenous therapy or IV therapy is the infusion of liquid substances directly into a vein. The word intravenous simply means "within a vein". Therapies administered intravenously are often called specialty pharmaceuticals...
is not available or not feasible.
History
The intraosseous space was first discovered as a non-collapsible vein in 1922 when C.K. Drinker MD, of Harvard University, examined the circulation of the sternum and confirmed that fluids infused into the bone marrow were quickly absorbed into the central circulation, providing an opportunity for vascular access when traditional methods fail.In 1936, Tocantins and O'Neill found that when they injected 5 mL of saline into a long bone of a rabbit, only 2 mL were recovered at the distal end. They reasoned that the saline had been absorbed into the systemic circulation
Systemic circulation
Systemic circulation is the part of the cardiovascular system which carries oxygenated blood away from the heart to the body, and returns deoxygenated blood back to the heart. This physiologic theory of circulation was first described by William Harvey...
. Subsequent tests confirming absorption included injecting dye into the marrow cavity. Within 10 seconds, the dye reached the heart. A procedure of sternum injection was developed and subsequently used by paramedics in World War II
World War II
World War II, or the Second World War , was a global conflict lasting from 1939 to 1945, involving most of the world's nations—including all of the great powers—eventually forming two opposing military alliances: the Allies and the Axis...
.
Widespread use of IO by military medics also was reported during World War II. More than 4,000 cases of IO use during the war were documented and the U.S. military considered IO infusion a standard practice in the treatment of seriously wounded soldiers.
However, the practice of IO infusion did not carry over into civilian use following the war and was not rediscovered until 1984, when an American pediatrician, James Orlowski, MD, observed medics using IO access during a cholera
Cholera
Cholera is an infection of the small intestine that is caused by the bacterium Vibrio cholerae. The main symptoms are profuse watery diarrhea and vomiting. Transmission occurs primarily by drinking or eating water or food that has been contaminated by the diarrhea of an infected person or the feces...
epidemic in India. His editorial, "My Kingdom for an Intravenous Line," advocated the use of IO infusion in pediatric patients and it became a standard of practice for pediatric patients in the late 1980s.
Until very recently, however, a reliable, safe and easy method to access the intraosseous space in adults proved elusive, and this area of medicine and its opportunities remained unexplored. In the mid-2000s, technological advances in the field made the use of IO easier and safer for practitioners.
Procedure
The needle is injected through the bone's hard cortex and into the soft marrow interior which allows immediate access to the vascular system. An IO infusion can be used on adult or pediatric patients when traditional methods of vascular access are difficult or impossible. Often the antero-medial aspect of the tibiaTibia
The tibia , shinbone, or shankbone is the larger and stronger of the two bones in the leg below the knee in vertebrates , and connects the knee with the ankle bones....
is used as it lies just under the skin and can easily be palpated and located. The anterior aspect of the femur
Femur
The femur , or thigh bone, is the most proximal bone of the leg in tetrapod vertebrates capable of walking or jumping, such as most land mammals, birds, many reptiles such as lizards, and amphibians such as frogs. In vertebrates with four legs such as dogs and horses, the femur is found only in...
, the superior iliac crest and the head of the humerus
Humerus
The humerus is a long bone in the arm or forelimb that runs from the shoulder to the elbow....
are other sites that can be used.
This route of fluid and medication administration is an alternative one to the preferred intravascular route when the latter cannot be established in a timely manner. When intravascular access cannot be obtained intraosseous access is usually the next approach. It can be maintained for 24–48 hours, after which another route of access should be obtained.
Although intravascular access is still the preferred method for medication delivery in the prehospital area, advances in IO access (such as the F.A.S.T.1 and the EZ-IO system) for adults has caused many systems to re-think their preferred secondary access route. In Massachusetts, for example, IO is now a preferred administration over endotracheal
Tracheal intubation
Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic or rubber tube into the trachea to maintain an open airway or to serve as a conduit through which to administer certain drugs...
(ET) drug administration. In fact, the American Heart Association
American Heart Association
The American Heart Association is a non-profit organization in the United States that fosters appropriate cardiac care in an effort to reduce disability and deaths caused by cardiovascular disease and stroke. It is headquartered in Dallas, Texas...
no longer recommends using the endotracheal tube for resuscitation
Cardiopulmonary resuscitation
Cardiopulmonary resuscitation is an emergency procedure which is performed in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person in cardiac arrest. It is indicated in those who are unresponsive...
drugs since the efficacy is unclear. Paramedic
Paramedic
A paramedic is a healthcare professional that works in emergency medical situations. Paramedics provide advanced levels of care for medical emergencies and trauma. The majority of paramedics are based in the field in ambulances, emergency response vehicles, or in specialist mobile units such as...
s may perform intraosseous infusion in a cardiac arrest patient if no vein is clearly visible. The IO is becoming more and more common in emergency medical services
Emergency medical services
Emergency medical services are a type of emergency service dedicated to providing out-of-hospital acute medical care and/or transport to definitive care, to patients with illnesses and injuries which the patient, or the medical practitioner, believes constitutes a medical emergency...
(EMS) systems around the world.
Furthermore, any medication that can be introduced via IV can be introduced via IO. Because of this, adult IO systems (most of which use a mechanical or powered adjunct to place the catheter) have become more common across the United States in the prehospital setting. Intraosseous access has roughly the same absorption rate as IV access, and (unlike ET administration) allows for fluid resuscitation as well as high-volume drugs such as sodium bicarbonate
Sodium bicarbonate
Sodium bicarbonate or sodium hydrogen carbonate is the chemical compound with the formula Na HCO3. Sodium bicarbonate is a white solid that is crystalline but often appears as a fine powder. It has a slightly salty, alkaline taste resembling that of washing soda . The natural mineral form is...
to be administered in the setting of a cardiac arrest when IV access is unavailable. Endotracheal administration allows only specific drugs that have relatively low toxicity to lung
Lung
The lung is the essential respiration organ in many air-breathing animals, including most tetrapods, a few fish and a few snails. In mammals and the more complex life forms, the two lungs are located near the backbone on either side of the heart...
tissue, and must be restricted to relatively low volumes to avoid drowning the patient.
Due to the rapid advance and adoption of superior intraosseous access technology, IO access has now become the preferred method of establishing vascular access for patients in whom traditional access is difficult or impossible. This includes patients experiencing cardiac arrest, major trauma, airway compromise, severe dehydration and shock. IO is also an alternative route for patients who typically have poor peripheral vasculature or challenging vascular access such as diabetics, renal patients, burn victims, IV drug users, obese patients, dehydrated patients, the very young or elderly patients, and others. Many EMS services and hospitals are now using IO as their first line solution for vascular access in both adult and pediatric cardiac arrest victims, enabling administration of lifesaving drugs much earlier than previously possible with traditional peripheral IV placement.
IO Devices
There are several FDA approved IO devices including Vidacare's battery-powered EZ-IO and Pyng's hand-powered FAST1 and FASTx. Other devices include the spring-loaded WaisMed's BIG Bone Injection Gun (BIG), the COOK IO needle, and the Jamshidi 15G.There have been at least two studies comparing the EZ-IO and the BIG. Another paper compared the EZ-IO with the COOK IO needle. These three papers all found a minor preference for the EZ-IO. Another study compared the Jamshidi 15G, the BIG 15G, and the FAST1, finding median insertion times of 38, 49 and 62 seconds respectively (p = 0.004).
The EZ-IO is used by 90 percent of US advanced life support ambulances and over half of US Emergency Departments, as well as the US Military, and is available in over 50 countries worldwide. The EZ-IO is FDA-cleared for use on adult and pediatric patients in medically necessary instances, including difficult vascular access situations, as well as resuscitation and shock. The EZ-IO can be inserted in the proximal tibia, proximal humerus and the distal tibia.
Pyng's FAST1 and FASTx is inserted into the manubrium (upper sternum)http://www.pyng.com.
Effectiveness
This American Heart AssociationAmerican Heart Association
The American Heart Association is a non-profit organization in the United States that fosters appropriate cardiac care in an effort to reduce disability and deaths caused by cardiovascular disease and stroke. It is headquartered in Dallas, Texas...
guideline cited two randomized controlled trials, one of 60 children and one of electively cannulated hematology/oncology patients. In addition, uncontrolled studies have been performed, one of which reported 72% to 87% rates of successful insertion.