Comparison of two intraosseous access devices in adult patients under resuscitation in the emergency department: A prospective, randomized study

Introduction

Current guidelines recommend intraosseous (IO) vascular access in adults if peripheral venous access is unavailable. Most available data derive from children, animal models, cadaver studies or the prehospital setting. Therefore we compared two different IO access devices in adults under resuscitation in the hospital setting.

Patients and methods

This prospective, randomized clinical study compared two different IO access devices in adults (≥18 years of age) under trauma or medical resuscitation admitted to our emergency department with impossible peripheral venous access. Each adult was randomized to either spring-loaded BIG Bone Injection Gun or battery-powered EZ-IO. Outcome measures included success rates on first attempt, procedure times and complications.

Results

Forty consecutive adults under resuscitation were enrolled. Twenty patients received the BIG, another twenty patients the EZ-IO. Over all success rate on first attempt was 85% and mean procedure time 2.0 min ± 0.9. Comparing the two devices, success rate on first attempt was 80% for the BIG versus 90% for the EZ-IO and mean procedure time was 2.2 min ± 1.0 for the BIG versus 1.8 min ± 0.9 for the EZ-IO. The differences between both IO devices were not statistically significant. No other relevant complications like infection, extravasation or bleeding were observed.

Conclusions

IO vascular access was a reliable and safe method to gain rapid vascular access for in-hospital adult emergency patients under resuscitation. Further studies are necessary regarding comparative effectiveness of different IO devices.     

Insights From a Tertiary Care Intraosseous Insertion Practice Improvement Registry: A 2-Year Descriptive Analysis

Introduction

Few practice improvement registries exist that describe opportunities to improve intraosseous (IO) use. The goal of this project was to assess the success rate of the procedure by emergency nurses and identify opportunities to improvement. Secondary goals were to assess success rates based on clinician type, age of patient, and procedural factors.

Comparison of intraosseous versus central venous vascular access in adults under resuscitation in the emergency department with inaccessible peripheral veins

Introduction

Current European Resuscitation Council (ERC) guidelines recommend intraosseous (IO) vascular access, if intravenous (IV) access is not readily available. Because central venous catheterisation (CVC) is an established alternative for in-hospital resuscitation, we compared IO access versus landmark-based CVC in adults with difficult peripheral veins.

Methods

In this prospective observational study we investigated success rates on first attempt and procedure times of IO access versus central venous catheterisation (CVC) in adults (≥18 years of age) with inaccessible peripheral veins under trauma or medical resuscitation in a level I trauma centre emergency department.

Results

Forty consecutive adults under resuscitation were analysed, each receiving IO access and CVC simultaneously. Success rates on first attempt were significantly higher for IO cannulation than CVC (85% versus 60%, p = 0.024) and procedure times were significantly lower for IO access compared to CVC (2.0 versus 8.0 min, p < 0.001). As for complications, failure of IO access was observed in 6 patients, while 2 or more attempts of CVC were necessary in 16 patients. No other relevant complications like infection, bleeding or pneumothorax were observed.

Conclusions

IO vascular access is a reliable bridging method to gain vascular access for in-hospital adult patients under resuscitation with difficult peripheral veins. Moreover, IO access is more efficacious with a higher success rate on first attempt and a lower procedure time compared to landmark-based CVC.     

Confirmation of intraosseous cannula placement based on pressure measured at the cannula during squeezing the extremity in a piglet model

Aim of the study

We sought to assess the reliability of the method using the pressure measured at the intraosseous (IO) cannula while squeezing the involved limb (P_squeezing) in determining the position of the IO needle and to compare its performance with that of the traditional confirmation method.

Methods

Eighty limbs of twenty domestic swine were assigned to one of three conditions regarding the position of the IO needle; correct placement (n = 40), incorrect placement in which the IO needle was placed into the subcutaneous space without entering the bone (incorrect-subcutaneous placement, n = 20), or incorrect placement in which the IO needle passed entirely through the bone (incorrect-penetrating placement, n = 20). A blinded investigator randomly identified the position of the needle by the traditional method or test method using P_squeezing. If P_squeezing was 80 mmHg or higher, the IO cannula was regarded as incorrectly placed.

Results

P_squeezing was higher in incorrect placements (176.0 mmHg (130.0–195.0)) compared with that in correct placements (27.0 mmHg (20.0–34.0)) (p < 0.001). The test method correctly identified all 40 placements, but the traditional method was incorrect for one (5%) of 20 correct placements (p = 1.000) and 7 (35%) of 20 incorrect placements (p = 0.008). In incorrect placements, false positive results occurred mainly in incorrect-penetrating placements.

Conclusion

We suggest that the method using the pressure measured at the IO cannula can be used when there is uncertainty about the position of the IO cannula after determination using traditional methods.     

Analysis of intraosseous blood samples using an EPOC point of care analyzer during resuscitation

Background

In the early phases of resuscitation in a critically ill patient, especially those in cardiac arrest, intravenous (IV) access can be difficult to obtain. Intraosseous (IO) access is often used in these critical situations to allow medication administration. When no IV access is available, it is difficult to obtain blood for point of care analysis, yet this information can be crucial in directing the resuscitation. We hypothesized that IO samples may be used with a point of care device to obtain useful information when seconds really do matter.

Intravenous vs. intraosseous access and return of spontaneous circulation during out of hospital cardiac arrest

Introduction

Guidelines endorse intravenous (IV) and intraosseous (IO) medication administration for cardiac arrest treatment. Limited clinical evidence supports this recommendation. A multiagency, retrospective study was performed to determine the association between parenteral access type and return of spontaneous circulation (ROSC) in out of hospital cardiac arrest.

EZ-IO intraosseous device implementation in a pre-hospital emergency service: A prospective study and review of the literature

Introduction

Intraosseous access is increasingly recognised as an effective alternative vascular access to peripheral venous access. We aimed to prospectively study the patients receiving prehospital intraosseous access with the EZ-IO^®, and to compare our results with those of the available literature.

Methods

Every patient who required an intraosseous access with the EZ-IO from January 1st, 2009 to December 31st, 2011 was included. The main data collected were: age, sex, indication for intraosseous access, localisation of insertion, success rate, drugs and fluids administered, and complications. All published studies concerning the EZ-IO device were systematically searched and reviewed for comparison.

Results

Fifty-eight patients representing 60 EZ-IO procedures were included. Mean age was 47 years (range 0.5–91), and the success rate was 90%. The main indications were cardiorespiratory arrest (74%), major trauma (12%), and shock (5%). The anterior tibia was the main route. The main drugs administered were adrenaline (epinephrine), atropine and amiodarone. No complications were reported. We identified 30 heterogeneous studies representing 1603 EZ-IO insertions. The patients’ characteristics and success rate were similar to our study. Complications were reported in 13 cases (1.3%).

Conclusion

The EZ-IO provides an effective way to achieve vascular access in the pre-hospital setting. Our results were similar to the cumulative results of all studies involving the use of the EZ-IO, and that can be used for comparison for further studies.     

Comparison of intraosseous access and central venous catheterization in Chinese adult emergency patients: A prospective,multicenter, and randomized study

BACKGROUND: It is challenging to establish peripheral intravenous access in adult critically patients. This study aims to compare the success rate of the first attempt, procedure time, operator satisfaction with the used devices, pain score, and complications between intraosseous (IO) access and central venous catheterization (CVC) in critically ill Chinese patients.     

经骨髓输液在抢救创伤失血性休克中的临床研究

目的研究经骨髓输液在抢救创伤失血性休克过程中的可行性和有效性,探讨急诊抢救输液的新方法。方法选择创伤失血性休克268例,随机分为经骨髓输液和经静脉输液两组。静脉穿刺困难的立即行经骨髓穿刺输液,对照组经静脉常规穿刺置管输液。结果两组输液后在血压回升的时间和输液的速度上差异无统计学意义(P>0·05),但在建立输液通道所用的时间上,经骨髓输液组较静脉输液组明显缩短。结论在抢救创伤失血性休克中,经骨髓输液是静脉穿刺困难患者的替代方法,不但安全、迅速、有效,而且便于在院前急救和基层医院开展。     

Update on point of care ultrasound in the care of the critically ill patient

One of the most exciting developments to come to the aid of the critically ill patient in recent years is not new at all, but rather has been repackaged and evolved to a level where point-of-care use by critical care physicians has been made possible. Critical care or point-of-care ultrasound dates back more than twenty years, but has come to prominence in the last 5 years and is spreading quickly. Multiple critical care societies have taken up ultrasound policy and training and one organization has been formed that concentrates only on point-of-care ultrasound in critical settings and interventions. The amount of literature generated on the topic is increasing rapidly and hardly a major clinical journal exists that has not published ultrasound related topics.     

大鼠自体内瘘模型制备及内瘘狭窄的实验研究

目的吻合口内膜增生可导致自体动静脉内瘘失功,本研究拟在设计大鼠模型研究其进程及机制。方法SPF级wistar大鼠,行右颈总动脉-颈内静脉端端吻合,术后14,28天处死,取近吻合口静脉、动脉组织,行HE染色,弹力、胶原纤维的双重组合染色,PCNA、TGF—β1、NF—kB免疫组化。结果内瘘吻合术后14天近吻合口静脉端见明显的内膜增生,呈息肉样增生,其中平滑肌细胞增生活跃,大量胶原纤维沉积,28天管腔明显狭窄。特殊染色见术后14、28天近吻合口静脉内弹力层不连续。PCNA、NF—kB在近吻合口静脉壁中膜和外膜高表达,在14天达到一个高峰,在28天观察期内仍持续高表达。TGF—β1在外膜基质高表达。结论大鼠右侧颈总动脉-颈内静脉端端吻合可模拟内瘘局部血流动力学的影响,短期内可见明显内膜增生等病理表现,是一种合适的自体动静脉内瘘动物模型,显示TGF-β1,NF—kB参与了内瘘内膜增生病理过程。     

Assuring quality in laboratory testing at the point of care

The science of laboratory medicine has undergone much change during recent years. Despite more recent emphasis on quality improvement, there has not been sufficient attention paid to effective quality management of new approaches to laboratory testing such as point of care testing. It is important that appropriate resources be allocated to quality management, so that waste is minimized and that resources which are expended may be demonstrated to affect the quality of patient care in a positive way. Older quality management tools such as process quality control and proficiency testing are vital to the success of point of care testing programs, however, new ways of looking at the use of these tools are required. Newer approaches such as electronic quality control of point of care devices and an expanded role of total quality management strategies will enhance rather than supplant the more traditional quality improvement mechanisms.     

肾肿瘤血管的实验研究

目的 研究肾肿瘤血管的形态分布,为肾肿瘤影像诊断和治疗提供依据.方法 22例肾肿瘤,术后肾脏切除标本制作血L管铸犁,使用大体及电子显微镜观察肿瘤血管的形态特征.结果 肾脏肿瘤血管铸型显示肿瘤血管增多、增粗、受压、移位;肿瘤内部血管丰富,且存在动一静脉瘘.结论 肾细胞癌大部分为多血供肿瘤,肿瘤区血管较止常组织发生了明显变化,有自己独特的表现.     

Reconstruction-plasty of iatrogenic choledochal stenoses using human pericardium. An experimental study in the domestic pig]

The effect of human pericardial patch plastic for reconstruction of iatrogenic common bile duct stenosis was investigated in experiments performed in pigs. All patches (n = 8) were overgrown with immature biliary epithelium detectable on light and electron microscopy within 6 weeks. No restenosis nor any fistula developed during this observation period. Liver function tests, especially bilirubin, were not suitable parameters for the detection of biliary obstruction (preoperative value 0.38 +/- 0.09 mg/dl; 1 week after subtotal stenosis 3.36 +/- 1.53 mg/dl; 2 weeks after subtotal stenosis 1.49 +/- 0.62 mg/dl; 3 weeks after subtotal stenosis 0.50 +/- 0.27 mg/dl; 6 weeks after pericardial patch plastic 0.33 +/- 0.05 mg/dl, mean +/- SD. Ultrasonographic measurement of the common bile duct diameter was the diagnostic method of choice. Preoperative dimension 4.5 +/- 0.5 mm; 1 week after subtotal stenosis 8.5 +/- 2.0 mm; 2 weeks after subtotal stenosis 10.5 +/- 1.8 mm; 3 weeks after subtotal stenosis 14.0 +/- 3.6 mm; 6 weeks after pericardial patch plastic 9.0 +/- 1.6 mm, mean +/- SD.     

Analysis of bloodgas,electrolytes and glucose from intraosseous samples using an i-STAT point-of-care analyser

Background

Intraosseous access is used in emergency medicine as an alternative when intravenous access is difficult to obtain. Intraosseous samples can be used for laboratory testing to guide treatment. Many laboratories are reluctant to analyse intraosseous samples, as they frequently block conventional laboratory equipment. We aimed to evaluate the feasibility and accuracy of analysis of intraosseous samples using an i-STAT^® point-of-care analyser.

Methods

Intravenous and intraosseous samples of twenty children presenting for scheduled diagnostic bone marrow aspiration were analysed using an i-STAT^® point-of-care analyser. Sample types were compared using Bland Altman plots and by calculating intraclass correlation coefficients and coefficients of variance.

Results

The handheld i-STAT^®point-of-care analyser proved suitable for analysing intraosseous samples without technical difficulties.Differences between venous and intraosseous samples were clinically acceptable for pH, base excess, sodium, ionised calcium and glucose in these haemodynamically stable patients. The intraclass correlation coefficient was excellent (>0.8) for comparison of intraosseous and intravenous base excess, and moderate (around 0.6) for bicarbonate, sodium and glucose.The coefficient of variance of intraosseous samples was smaller than that of venous samples for most variables.

Conclusion

Analysis of intraosseous samples with a bedside, single-use cartridge-based analyser is feasible and avoids the problem of bone marrow contents damaging conventional laboratory equipment. In an emergency situation point-of-care analysis of intraosseous aspirates may be a useful guide to treatment.     

Analysis of blood glucose measurements using capillary and arterial blood samples in intensive care patients

Objective To analyse agreement between two methods for blood glucose measurement in intensive care patients: capillary blood using a reagent strip and glucometer with arterial blood using a blood gas analyser.Design and setting Prospective, single-centre, observational study in a 12-bed tertiary referral intensive care unit.Measurements Blood glucose levels were measured in consecutive patients using simultaneous measurements of capillary blood samples using glucometry and from a multi-electrode arterial blood gas analyser. An a priori subgroup of patients with tissue hypoperfusion was identified (defined as systolic blood pressure <90 mmHg or vasopressor dependency). A total of 493 paired measurements were obtained; 75 of these were from patients with systemic hypoperfusion.Results Overall, the mean difference (bias) was 0.12 mmol/l (2.15 mg/dl) and precision 0.77 mmol/l (13.8 mg/dl); 95% limits of agreement were –0.14 and 1.66 mmol/l (–2.5 and 29.8 mg/dl). In patients with systemic hypoperfusion the bias was 0.24 mmol/l (4.0 mg/dl) and precision 0.9 mmol/l (16.2 mg/dl); 95% limits of agreement –2.05 and 1.58 mmol/l (36.8 and 28.4 mg/dl).Conclusions In a general population of intensive care patients, there is statistical agreement between blood glucose measured from capillary blood glucometry and arterial blood gas analysis. However, in patients with systemic hypoperfusion, the accuracy of agreement between these two measurement techniques may be such that that biochemical hypoglycaemia (<2.5 mmol/l, 44.9 mg/dl) may go undetected if used interchangeably.     

An evaluation of bag-valve-mask ventilation using an ergonomically designed facemask among novice users: A simulation-based pilot study

Purpose

We sought to compare the ability of novice operators to provide artificial ventilation using a standard facemask and a new ergonomically designed facemask. Whether or not proper technique was used was also assessed.

Methods

Thirty-two allied-health students used both masks in random crossover fashion to ventilate an airway trainer. Breaths were delivered by a mechanical ventilator and exhaled tidal volume was recorded for each of 12 breaths for each participant for each mask. The effect of each mask during ventilation over time was assessed using repeated-measures ANOVA. Assessment of mask technique among participants and association between mask type and hand repositioning were analyzed using the Wilcoxon-Rank Sum Test and McNemar's paired proportions test, respectively.

Results

The tidal volume achieved when participants used the ergonomic mask was higher than when participants used the standard mask by the fourth breath (361 ± 104 mL vs. 264 ± 163 mL; Bonferroni adjusted p-value = 0.040) and increased over time. The repeated-measures ANOVA showed that the ergonomic mask consistently resulted in higher tidal volumes than the standard mask regardless of rescuer's gender. Over time the standard mask resulted in a linear decrease in tidal volume of −10 mL/breath (estimated difference in decay of 10 mL/breath versus the ergonomic mask; p < 0.001).

Conclusion

Novice airway operators were better able to provide facemask ventilation using an ergonomically designed mask than with a traditional facemask. We conclude that better hand position facilitating improved mask seal and less operator fatigue account for our findings.