The utilisation of intraosseous infusion in the resuscitation of paediatric major trauma patients

Intraosseous lines are a reliable and rapid tool for obtaining vascular access in emergency situations, particularly in children. Their use is recommended when intravenous access cannot be easily secured and there is a need for fluid or pharmacological resuscitation. Training in this technique is included in the Advanced Trauma Life Support (ATLS) and Advanced Paediatric Life Support course (APLS) provider courses. The objective of this study is to analyse the national use of intraosseous lines in paediatric trauma in England and Wales. Data has been collected from the Trauma Audit and Research Network (TARN) group longitudinally over 14 years from 1988 to 2002. From 23,489 paediatric trauma cases, intraosseous lines were used in only 129 patients. Compared with the remainder of the paediatric data, we found that these were the younger (1-6 years), more severely injured patients (higher ISS, lower GCS, higher head, thorax, and abdominal AIS). The mortality of these patients was high at 64% compared with 4% overall. IO line use was greater in general than in Paediatric hospitals, perhaps due to good intravenous access skills in paediatric centres. We recommend that intraosseous line use should be a skill available to everybody involved in paediatric trauma resuscitation, particularly those who may not have refined paediatric intravenous cannulation skills.     

Oxygen debt criteria quantify the effectiveness of early partial resuscitation after hypovolemic hemorrhagic shock

BACKGROUND: The effectiveness of partial resuscitation after hypovolemic hemorrhagic shock with deferment of full resuscitation is critical to successful hypotensive resuscitation. METHODS: To quantitatively address this issue, 40 canines were bled under anesthesia to a mean oxygen debt (O(2)D) of 104 +/- 7.6 mL/kg over 60 minutes (mortality, 40%). Animals surviving the shock were then immediately resuscitated with 0%, 8.4%, 15%, 30%, or 120% (full resuscitation) of shed volume as 5% albumin and held for 2 hours postshock, when the remaining portion of full resuscitation volume was given. Animals were followed for 7 days postshock with hepatic and renal function studies, and then, under anesthesia, cardiac output and organ biopsy specimens were taken before the animals were killed. RESULTS: By 2 hours postshock, 0% immediate resuscitation had an O(2)D increase of 80 mL/kg above end of shock, but O(2)D at 8.4% immediate resuscitation decreased -30 mL/kg, 15% immediate resuscitation fell -65 mL/kg, 30% immediate resuscitation decreased -80 mL/kg below end of shock, and O(2)D with 120% full resuscitation fell to preshock levels. All decreases in O(2)D were significantly (p < 0.05) below end of shock, but both 15% and 30% immediate resuscitation exceeded the 8.4% immediate resuscitation rate (p < 0.05) throughout the resuscitation, and 120% full resuscitation exceeded these (p < 0.05). The immediate resuscitation O(2)D response correlated significantly (p < 0.001) with base deficit and lactate, but blood pressure was not a significant discriminator. Seven-day biopsies showed return of bowel mucosa but a pattern of cellular injury in heart, liver, and kidney that improved from 8.4% < 15% < 30 < 120% immediate resuscitation. CONCLUSION: The data suggest that, compared with 120% postshock immediate resuscitation, 8.4% and 15% immediate resuscitation give poorer results, with 30% immediate resuscitation showing mild, transient, but acceptable changes in organ function allowing for a 2-hour delay until full resuscitation, with complete 7-day recovery. Base deficit and lactate, but not blood pressure, are significant indices of O(2)D.     

PEG-Hemoglobin as a resuscitation solution in the treatment of hypovolemic shock in the anesthetized rat

This study was designed to determine the advantages of using the hemoglobin-based oxygen carrier, polyethylene glycol conjugated bovine hemoglobin (PEG-Hb), as an additive to Ringer's lactate solution (RLS) for the treatment of acute hemorrhage in anesthetized female rats. Different compositions of PEG-Hb and RLS were administered intravenously in a paradigm that provided 30 ml/kg of resuscitation fluid following an episode of 15 min of hypotension. Hypotension was achieved by the removal of blood (1 ml/min) from the femoral vein until the mean arterial pressure was lowered to or below 50 mmHg and subsequently maintained until resuscitation. Short-term cardiovascular assessment showed that resuscitation fluids containing PEG-Hb resulted in higher mean arterial pressure, aortic blood flow, renal blood flow, and less dramatic shifts in arterial base excess and respiratory blood gases than plain RLS. The long-term survival experiment showed lower lactate dehydrogenase, alkaline phosphatase, and serum glutamic pyruvic transaminase levels in most groups resuscitated with solutions containing PEG-Hb, but no differences in survival (100%) were observed. The data suggest that the addition of PEG-Hb to RLS improves its resuscitative effects. Specifically, a solution of 50% RLS:50% PEG-Hb appeared to have the most favorable cardiovascular and metabolic effects in this anesthetized rat hypovolemic shock resuscitation model. Presumably, the improved effects seen with the addition of PEG-Hb were due to its innate plasma expansion and oxygen-delivery capabilities.     

Intraosseous infusion of fluids in the initial management of hypovolemic shock in young subjects

Immediate aggressive fluid resuscitation of a child with life-threatening hemorrhagic shock provides the difference between life and death. Obtaining venous access in the hypovolemic child sometimes is difficult and time consuming. In order to evaluate the benefit of prehospital administration of intraosseous fluids into the tibial bone marrow as a method of gaining quick access to the systemic circulation and in resuscitating victims from severe hypovolemic shock, 13 puppies weighing 4.6 to 10 kg were subjected to progressive, controlled exsanguination until their mean arterial pressure (MAP) was 20% or less of their baseline MAP for 5 minutes (maxishock). Then an 18-gauge intraosseous needle was inserted into the tibial bone marrow and lactated Ringer's solution was infused at 300 mm Hg of pressure until a volume three times the blood loss had been administered. The MAP, central venous pressure, arterial blood gases, hematocrit, serum lactate, and urine output were recorded at 10, 20, 30, 45, 60, 90, and 120 minutes after the onset of maxishock. At the end of the experiment the left lung of each animal was sent to the pathology department to investigate the possibility of bone marrow emboli. The results were compared with a group of control dogs with maxishock and no treatment, and a group of dogs with maxishock treated with a canine military antishock trousers inflated to 50 to 55 mm Hg and no fluids. The average needle insertion time was 16 seconds; the rate of infusion of fluids varied from a maximum of 25.7 mL/min to a minimum of 4.5 mL/min, with a mean of 10.6 mL/min.(ABSTRACT TRUNCATED AT 250 WORDS)     

Treatment of hemorrhagic shock with intraosseous or intravenous infusion of hypertonic saline dextran solution.

The efficacy of intravenous or intraosseous infusion of 250 ml of 7.5% NaCl and 6% dextran 60 (H/H) was compared with intravenous Ringer's lactate (RL) for the initial treatment of patients with hemorrhagic shock due to upper gastrointestinal bleeding. 49 patients were randomly assigned to receive either H/H (n = 26) or RL (n = 23). In the first 16 patients with H/H and in all RL patients, solutions were infused by the intravenous route, while the intraosseous route through sternal puncture was chosen for the last 10 H/H subjects. H/H patients were analyzed together since no differences were noticed between the routes of infusion. The H/H group also received 2.3 +/- 0.7 liters of intravenous crystalloid solutions in the first hour and 4.4 +/- 0.1 liters in the 24-hour period, while RL received 3.3 +/- 0.7 and 7.3 +/- 2.4 liters, respectively. Blood pressure (BP) increased during the first 15 min in the H/H group (from 61 +/- 17/30 +/- 12 to 85 +/- 30/48 +/- 14 mm Hg) and thereafter, while remaining unchanged in the RL group (from 75 +/- 18/40 +/- 12 to 75 +/- 17/40 +/- 14 mm Hg; p less than 0.05). The differences between groups were significant throughout 24 h. Urine output and improvement of the Glasgow Coma Score were also higher in H/H patients than in the control group (p less than 0.05). There were 5 deaths in RL group and 1 in the H/H group. Sternal of peripheral vein infusion of 250 ml of 7.5% NaCl/6% dextran 60 is an effective initial treatment of hemorrhagic shock.     

Evaluation of a new pediatric intraosseous needle insertion device for low-resource settings

Background and PurposeThe Near Needle Holder (NNH) (Near Manufacturing, Camrose, Alberta, Canada) is a reusable tool to introduce a standard hollow needle for pediatric intraosseous (IO) infusion. We compared the NNH to the Cook Dieckmann (Cook Critical Care, Bloomington, IN) manual IO needle in a simulation setting.MethodsStudy subjects were 32 physicians, nurses, and medical students participating in a trauma course in Guyana. After watching a training video and practicing under supervision, subjects were observed inserting each device into a pediatric leg model using a randomized crossover design. Outcome measures were time to successful insertion, technical complications, ease of use, and safety of each device.ResultsThe mean time for IO insertion (32 ± 13 seconds) was similar for both devices (P = .92). Subjects rated the NNH device equivalent in ease of use to the Cook IO needle but slightly lower in perceived safety to the user.ConclusionsAfter training, all subjects successfully inserted the NNH IO device in a simulation environment, and most rated it as easy to use and safe. The NNH is a significant advance because IO needles are often not available in emergency departments in developing countries. Further studies are needed to evaluate clinical effectiveness of the NNH.     

Elevation in compartment pressure following hypovolemic shock and fluid resuscitation: a canine model

We induced hemorrhagic shock in seven dogs and then resuscitated them with intravenous (IV) lactated ringers. We then monitored anterior leg compartment pressures via a slit catheter during both bleeding and reperfusion. These values were compared with controls that received IV fluids without being bled. Compartment pressures in resuscitated dogs rose well above control values. These values were statistically significant when compared to controls via the paired student t test (P < .01). This model demonstrates that sufficient swelling occurs to significantly elevate compartment pressures, even in the absence of local trauma. While this elevation may not be sufficient enough to cause a compartment syndrome, it reinforces the notion that extremities that have experienced ischemia and reperfusion are at an increased risk for developing compartment syndrome.     

失血性休克兔容量治疗的合理方案

目的探讨失血性休克兔容量治疗的合理方案。方法采用正交实验设计确立实验因素为输液种类(A)、输液剂量(B)和输液时机(C);实验水平数为三水平,A1、A2、A3分别为6%羟乙基淀粉、生理盐水、林格氏液,B1、B2、B3输液剂量分别为5、10、20 ml/kg,C1、C2、C3分别为休克前、代偿期、失代偿期。应用L9(34)正交表。27只健康新西兰大白兔,经颈内静脉缓慢放血(5-6 ml/min),直至MAP下降30%,建立失血性休克模型。根据正交表顺序进行实验。输液后由颈内静脉注入伊文思蓝,3 h后处死兔。测定肺组织含水率、伊文思蓝含量,并观察肺组织学改变。结果输液种类是影响失血性休克兔肺毛细血管渗漏的主要因素,其次为输液剂量,再次为输液时机。直观分析结果表明最优输液方案为A1B3C2。肺组织病理学结果显示,A1B3C2组肺损伤最轻,其它由轻到重依次为A1B2C2、A3B3C2、A1B3C3、A3B2C1、、A2B2C3、含B1的三组,A2B3C1肺损伤最重。结论失血性休克兔6%HES 20 ml/kg于休克代偿期输入产生效果最好。     

Insulin infusion via an intraosseous needle in diabetic ketoacidosis

We report the successful management of a five-year-old child with severe diabetic ketoacidosis with dehydration, who received his initial resuscitative fluids and a continuous infusion of insulin via an intraosseous needle. The patient had presented to a remote community hospital and intravenous access could not be gained. The correction of hyperglycaemia and metabolic acidaemia was achieved at a rate comparable to intravenous therapy. No complications were observed. Although intraosseous access is well described in paediatric resuscitation guidelines, it is not mentioned in International Diabetes Society guidelines for the management of diabetic ketoacidosis. Alternatives to intravenous administration of insulin delivery recommended in such guidelines, such as the subcutaneous or intramuscular routes, may be less appropriate than the intraosseous route. This route can also allow resuscitation fluids and other drugs to be reliably administered in children with diabetic ketoacidosis and severe dehydration where intravenous access can not be attained. We suggest that the potential role of intraosseous access, when intravenous access can not be obtained, should be considered when management guidelines for paediatric diabetic ketoacidosis with dehydration are reviewed.     

Hypertonic saline: intraosseous infusion causes myonecrosis in a dehydrated swine model of uncontrolled hemorrhagic shock.

BACKGROUND: The Institute of Medicine has recommended intraosseous (IO) infusion of 7.5% hypertonic saline (HTS) for combat casualties in shock. We tested the safety and efficacy of this recommendation in a long-term survival model of uncontrolled hemorrhagic shock using dehydrated swine. METHODS: Fourteen dehydrated Yorkshire swine had placement of a 12G needle in the right anterior tibia under isoflurane anesthesia. Uncontrolled hemorrhage was induced via left iliac artery and vein injury. Animals were kept in shock for 2 hours and then resuscitated over 2 hours with 5 mL/kg of 7.5% HTS given either as 10 small boluses (group I, n = 4) or two large boluses (group II, n = 6) to compare the physiologic response and blood loss. Control animals (group III, n = 4) received an equal volume of 0.9% saline IO and additional intravenous saline to equalize the salt load in all groups. RESULTS: The three groups had similar physiologic responses, with no increase in blood loss following HTS resuscitation. However, between the second and fifth postresuscitation days, the 7.5% HTS resuscitated animals developed soft tissue necrosis or bone marrow necrosis of the right hind leg (group I, 100%; group II, 66.6%; group III, 0%). CONCLUSION: HTS resuscitation effectively restored hemodynamic stability in dehydrated swine without increased bleeding from an uncontrolled vascular injury. However, IO infusion of HTS in this model was associated with a very high rate of local complications. Further investigations should be undertaken before IO use of 7.5% HTS in humans.     

Significance of hypocalcemia following hypovolemic shock

Changes in calcium levels during and after resuscitation from severe shock were studied in 22 seriously injured patients who received an average of 21 blood transfusions and 26 mEq supplemental calcium. Total serum proteins (TSP), serum albumin (SA), total calcium (TC), and ionized calcium (CA++), were studied intraoperatively after the tenth transfusion and postoperatively at 5 hours, 15 hours, day 2, day 4, and during convalescence (day 25). The intraoperative TSP fell to 3.7 gm%; the TC and Ca++ fell to 7.2 mg% and 1.4 mEq/L. The TSP and SA remained low throughout day 4 (4.8 and 2.6 gm%); the TC was also low on day 4 (7.5 mg%), whereas the Ca++ rose to normal (2.1 mEq/L) by day 2. The severity of hypocalcemia paralleled the hypoproteinemia, the number of transfusions given during resuscitation, and the duration of shock; paradoxically, hypocalcemia correlated inversely with Ca++ supplementation of blood transfusions during resuscitation, suggesting increased extravascular Ca++ flux with more severe shock. Further studies in comparably injured patients are needed to identify the concomitant responses of the calcium homeostatic factors such as parathormone in order to help identify the optimal role of calcium manipulation during resuscitation from hypovolemic shock.     

Anaphylactic shock during excision of an intraosseous Echinococcus granulosus cyst

During the excision of a cystic tumor of the left proximal thigh under general anesthesia a severe anaphylactic shock was observed in a patient. This severe allergic reaction was due to the puncture of an Echinococcus granulosus hydatid during the preparation of a bone-plate covering the bony cyst of the left thigh.