Circulation - IV/IO Access

#### INTRAVENOUS (IV) / INTRAOSSEOUS (IO) Access

BMC Infect Dis. 2018 Dec 17;18(1):665

# Acute Tibial osteomyelitis caused by intraosseous access during initial resuscitation: a case report and literature review.

Chalopin T, Lemaignen A, Guillon A, Geffray A, Derot G, Bahuaud O, Agout C, Rosset P, Castellier C, De Pinieux G, Valentin A, Bernard L, Bastides F; Centre De Référence Des Infections Ostéo-Articulaires Du Grand-Ouest (CRIOGO) Study Team.

BACKGROUND: Intra-osseous (IO) access is recommended in cases of pre-hospital emergency or resuscitation when intravascular (IV) route is difficult or impossible. Despite recent improvement in IO devices and increasing indications, it remains rarely used in practice. Various complications have been reported but are uncommon.

CASE PRESENTATION: We report a case of massive acute tibial osteomyelitis in an adult male three months after an IO catheter insertion for emergency drug infusion. We review the literature on association between IO access and acute osteomyelitis in children and adults.

CONCLUSIONS: Emergency-care givers and radiologists should be informed about this infrequent complication in order to make early diagnosis and initiate adequate antibiotic therapy.

Mil Med. 2018 Nov 1;183(11-12):e730-e734

# "Guidewire Intravenous Catheter Systems Do Not Improve First-Pass Success Rates for Peripheral Access When Placed By Army Combat Medics (68W) in a Pre-hospital Setting." A Prospective, Randomized Controlled Trial with Crossover Study Design.

Jin L, Medeck S, Ruley J, Riddle M, Aden J

Introduction: This study was completed to determine if guidewire catheters improve first-pass success and time of placement for peripheral intravenous access. In the military, 21% of casualties from the battlefield arrive to a medical facility in hemorrhagic shock. The importance of successful and timely intravenous placement is crucial in the initial steps of preventing this condition. Multiple studies and reviews have shown that initial first-pass success rates for pre-hospital intravenous placement have been as low as 40%, and an average success rate of 81% when completed by paramedics or similarly skilled personnel. In an attempt to replicate or improve these rates, we proposed to study placement success rates by active duty military combat medics. We hypothesized that there would be no difference in first-pass success rates when using either a standard or guidewire catheter.

Materials and Methods: This study was a prospective, randomized, controlled trial with a crossover study design comparing the Accucath 18-gauge guidewire catheter to the standard 18-gauge peripheral intravenous catheter. The study included 93 1st Cavalry Division Army Combat Medics. Participants were voluntarily enrolled and consented on an individual basis. Each participant paired with a partner of their choice and acted as their own control. All supplies were laid out for the participants with the catheters randomly selected for either arm of the patient. The subjects were allowed to choose which catheter they would be tested on first. Times were recorded for only successful attempts.

Results: The guidewire catheter was not proven to have a higher cannulation rate, achieving only a 44% success rate versus 66% in the standard catheter group, as well as averaging 42 seconds longer to obtain successful cannulation versus the standard catheter. Interestingly, it was observed that the greater the time in service, there was an increased success rate with the guidewire catheter that was not noted with the standard catheter.

Conclusions: There was not a statistically significant improvement in the first-pass success rate of intravenous placement with the use of the guidewire catheter when compared with the standard-issue catheter. With these results, we cannot recommend the guidewire catheter to be used in leu of the standard catheter. Further studies might show improvement if subjects are allotted increased practice and familiarity with the new guidewire device.

Resuscitation. 2019 Jan;134:69-75

# Intraosseous versus intravenous access in patients with out-of-hospital cardiac arrest: Insights from the resuscitation outcomes consortium continuous chest compression trial.

Mody P, Brown S, Kudenchuk P, Chan P, Khera R, Ayers C, Pandey A, Kern K, de Lemos J, Link M, Idris A

AIM: To examine outcomes associated with intraosseous access route attempt for delivery of medications during out-of-hospital cardiac arrest (OHCA) resuscitation.

METHODS: Using data from the Continuous Chest Compression trial, we examined rates of survival to hospital discharge, sustained return of spontaneous circulation (ROSC), and survival with favorable neurological function among patients with intraosseous and intravenous access attempts after adjusting for age, sex, initial rhythm, bystander cardiopulmonary resuscitation, public location, witnessed status, EMS response and trial randomization cluster.

RESULTS: Among 19,731 patients, intraosseous access was attempted in 3068 patients and intravenous access in 16,663 patients respectively. Patients in whom intraosseous access was attempted were younger, more often female, and had marginally faster times to initial access and to initial drug administration. Unadjusted outcomes were significantly lower in patients with attempted intraosseous access compared with intravenous access: (4.6% vs. 5.7%, p = 0.01) for survival to discharge, (17.9% vs. 23.5%, p < 0.001) for sustained ROSC and (2.8% vs. 4.2%, p < 0.001) for survival with favorable neurological function. After adjustment, there were no differences in hospital survival (OR, 0.88, 95% CI 0.72-1.09, p = 0.24) or survival with favorable neurological function (OR, 0.87, 95% CI 0.67-1.12, p = 0.29) in patients with intraosseous access attempt (vs. intravenous access). However, intraosseous access continued to associate with lower rates of sustained ROSC (OR, 0.80, 95% CI 0.71 - 0.89, p < 0.001).

CONCLUSIONS: Among patients with OHCA, intraosseous access attempt was associated with worse ROSC rates but no difference in survival. Further studies are necessary to elucidate the optimal access route among OHCA patients.

BMJ Open. 2019 Apr 2;9(4):e022278

# Factors associated with peripheral intravenous cannulation first-time insertion success in the emergency department. A multicentre prospective cohort analysis of patient, clinician and product characteristics.

Carr P, Rippey J, Cooke M, Trevenen M, Higgins N, Foale A, Rickard C

OBJECTIVES: This study aimed to identify the incidence of and factors associated with peripheral intravenous catheter/cannula (PIVC) first time insertion success (FTIS) in the emergency department (ED).

DESIGN: Prospective cohort study.

SETTING: Two tertiary EDs in Western Australia.

PARTICIPANTS: 879 ED patients.

PRIMARY OUTCOME: To identify factors affecting FTIS using univariate and multivariate logistic regression modelling. We created four models: patient factors only; clinician factors only; products and technology factors only and all factors model. We assessed each model's performance using area under the receiver operating characteristic curve.

RESULTS: A total of 1201 PIVCs were inserted in 879 patients. The mean age was 60.3 (SD 22) years with slightly more females (52%). The FTIS rate was 73%, with 128 (15%) requiring a second attempt and 83 (9%) requiring three or more attempts. A small percentage (3%) had no recorded number of subsequent attempts. FTIS was related to the following patient factors: age (for a 1-year increase in age: OR 0.99, 95% CI 0.983 to 0.998; p=0.0097); and target vein palpability: (always palpable vs never palpable: OR 3.53 95% CI 1.64 to 7.60; only palpable with tourniquet vs never palpable: OR 2.20, 95% CI 1.06 to 4.57; p=0.0014). Clinician factors related to FTIS include: clinicians with greater confidence (p<0.0001) and insertion experience (301-1000 vs <301: OR 1.54, 95% CI 1.02 to 2.34; >1000 vs <301: OR 2.07, 95% CI 1.41 to 3.04; p=0.0011). The final all factors model combining patient factors; clinician factors and product and technology factors has greater discriminative ability than specific factors models. It has a sensitivity of 74.26%, specificity of 57.69%, positive predictive value of 82.87% and negative predictive value of 44.85%.

CONCLUSION: A clinical decision, matching patients who have no palpable veins and are older, with clinicians with greater confidence and experience, will likely improve FTIS.

Mil Med. 2019 Mar 1;184(Suppl 1):322-325

# IV DripAssist: An Innovative Way to Monitor Intravenous Infusions Away From an Outlet?

Couperus K, Kmiecik K, Kang C

Intravenous (IV) administration of fluids and medications are a significant part of patient treatment. In austere environments, typical methods of counting drops from gravity drips or infusion pumps both have limitations such as accuracy, weight, and need for power. The DripAssist device calculates drip rates by counting drops in IV tubing drip chambers and may provide a useful patient safety monitor adjunct. The protocol was IRB approved, prospective, and designed as a pilot study involving 28 Madigan Army Medical Center Emergency Department personnel. After a brief didactic introduction to the device for clinical staff with no prior experience using the device, participants were timed setting three normal saline infusions at rates of 250 mL/h, 125 mL/h and 83 mL/h with 15gtt/mL tubing. Participants filled out a survey on perceived ease of use and utility of the device compared to pumps and manual counting. Most participants felt the DripAssist device was easy to understand and set up, but nurses and physician assistants were more likely than medics to perceive a benefit versus IV pumps or gravity drips. The DripAssist device may offer a safe, low-weight, functional tool which could improve care in a variety of resource-limited environments. However, additional studies using the device during actual field exercises would be beneficial.

Mil Med. 2019 Mar 1;184(Suppl 1):329-334

# Reduced Complications of Supraclavicular Approach in Simulated Central Venous Access: Applicability to Military Medicine.

Sappenfield J, Grek S, Cooper L, Lizdas D, Lampotang S

In a study with 76 anesthesia providers on a mixed reality simulator, central venous access via the supraclavicular approach to the subclavian vein, without ultrasonography required less attempts compared to the infraclavicular approach. Participants had shorter times to venous access and larger improvements in confidence. Results from this simulation-based study indicate that the supraclavicular approach may deserve consideration as an alternative approach for central venous access in deployed military environments. The use of ultrasonography during the supraclavicular approach to the subclavian vein is also described which may improve its safety profile. This technique could be more appropriate in scenarios when central venous access is preferred over intraosseous access for patients being transported to another location for further care.

Clin Pract Cases Emerg Med. 2018 Sep 5;2(4):323-325

# FascIOtomy: Ultrasound Evaluation of an Intraosseous Needle Causing Compartment Syndrome.

Abramson T, Alreshaid L, Kang T, Mailhot T, Omer T

Intraosseous (IO) needles are used in critically ill patients when it is not possible to quickly obtain venous access. While they allow for immediate access, IO infusions are associated with complications including fractures, infections, and compartment syndrome. We present a case where point-of-care ultrasound was used to quickly identify a malfunctioning IO needle that resulted in compartment syndrome of the lower extremity.

J Spec Oper Med. Spring 2019;19(1):52-55.

# The Prehospital Trauma Registry Experience With Intraosseous Access.

Schauer SG, Naylor JF, April MD, Fisher AD, Cunningham CW, Fernandez JRD, Shreve BP, Bebarta VS.

BACKGROUND: Peripheral intravenous (IV) cannulation is often difficult to obtain in a patient with hemorrhagic shock, delaying the appropriate resuscitation of critically ill patients. Intraosseous (IO) access is an alternative method. To date, few data exist on use of this procedure by ground forces in Afghanistan. Here, we compare patient characteristics and concomitant interventions among patients undergoing IO access versus those undergoing IV access only.

METHODS: We obtained data from the Prehospital Trauma Registry (PHTR). When possible, patients were linked to the Department of Defense Trauma Registry for outcome data. To develop the cohorts, we searched for all patients with documented IO or IV access placement. Those with both IO and IV access documented were placed in the IO group.

RESULTS: Of the 705 available patients in the PHTR, we identified 55 patients (7.8% of the population) in the IO group and 432 (61.3%) in the IV group. Among patients with documentation of access location, the most common location was the tibia (64.3%; n = 18). Compared with patients with IV access, those who underwent IO access had higher urgent evacuation rates (90.9% versus 72.4%; p = .01) and air evacuation rates (58.2% versus 14.8%; p < .01). The IO cohort had significantly higher rates of interventions for hypothermia, chest seals, chest tubes, needle decompressions, and tourniquets, but a significantly lower rate of analgesic administration (ρ ≤ .05).

CONCLUSION: Within the registry, IO placement was relatively low (<10%) and used in casualties who received several other life-saving interventions at a higher rate than casualties who had IV access. Incidentally, lower proportions of analgesia administration were detected in the IO group compared with the IV group, despite higher intervention rates.

Scand J Trauma Resusc Emerg Med. 2019 Feb 13;27(1):15

# Comparison of two different intraosseous access methods in a physician-staffed helicopter emergency medical service - a quality assurance study.

Sørgjerd R, Sunde G, Heltne J

BACKGROUND: Intravenous access in critically ill and injured patients can be difficult or impossible in the field. Intraosseous access is a well-established alternative to achieve access to a noncollapsible vascular network. We wanted to compare the use of a sternal and tibial/humeral intraosseous device in a physician-staffed helicopter emergency medical service.

METHODS: The helicopter emergency medical service in Bergen, Norway, is equipped with two different intraosseous devices, the EZ-IO and FAST-Responder. We compared insertion time, insertion sites, flow, indication for intraosseous access, and complications between the tibial/humeral and sternal techniques.

RESULTS: In 49 patients, 53 intraosseous insertions were made. The overall intraosseous rate was 1.5% (53 insertions in 3600 patients treated). The main patient categories were cardiac arrest and trauma. Overall, 93.9% of the insertions were successful on the first attempt. The median insertion time using EZ-IO was 15 s compared to 20 s using FAST-Responder. Insertion complications registered using the EZ-IO included extravasation, aspiration failure and insertion time > 30 s. Using FAST-Responder, there were reported complications such as user failure (12.5%) and insertion time > 30 s (12.5%). Regarding the flow, we found that 35.1% of the EZ-IO insertions experienced poor flow and needed a pressure bag. With FAST-Responder, the flow was reported as very good or good in 85.7%, and no insertions had poor flow.

CONCLUSION: Intraosseous access seems to be a reliable rescue technique in our helicopter emergency medical service, with high insertion success rates. EZ-IO was a more rapid method in gaining vascular access compared to FAST-Responder. However, FAST-Responder may be a better method when high-flow infusion is needed. Few complications were registered with both techniques in our service.

Acta Anaesthesiol Scand. 2019 Jul 10;Epub ahead of print

# Point-of-care analyses of blood samples from intraosseous access in pre-hospital critical care.

Jousi M, Björkman J, Nurmi J

BACKGROUND: Intraosseous (IO) access is used for fluid and medication administration in emergency situations when difficulties with vascular access are encountered. IO access would be readily available to take samples for point-of-care (POC) analysis, but there is scarce evidence about the reliability of POC analysis of IO samples among emergency patients. The aim of this study was to evaluate the feasibility and reliability of POC analysis of IO samples in critically ill pre-hospital patients.

METHODS: We performed a prospective, observational study in 35 critically ill pre-hospital patients. After inserting a humeral IO needle, we immediately drew an IO sample. We compared the results to an arterial sample drawn from the same patient within 5 (blood gases) or 15 (other parameters) minutes. Samples were analysed with an i-STAT® POC analyser for blood gases, acid-base balance, electrolytes, glucose and haemoglobin. The agreement between each patient's IO and arterial samples was analysed using the Bland-Altman method. The results were compared to responses about acceptable bias on a questionnaire sent to 16 experienced emergency physicians.

RESULTS: The analysis was successful for 23 patients (70%). Higher age was associated with failed analyses. The average bias was acceptable for base excess, pH, standard bicarbonate, glucose, ionized calcium and sodium. IO potassium values were systematically higher than arterial values. IO haemoglobin values had widely varying agreement.

CONCLUSION: When vascular access is challenging, IO access can be used for emergency POC analyses to help guide clinical decision-making. However, the limitations of IO POC analyses must be carefully considered.

AANA J. 2019 Feb;87(1):65-70.

# Management of Gravity Intravenous Infusions in an Austere Environment Using the DripAssist Infusion Rate Monitor.

Buonora M

The US Army's 541st Forward Surgical Team (FST) deployed in support of Operation Inherent Resolve- Syria in 2017. Throughout the deployment the 541st FST provided surgical and anesthesia services to US, coalition, and partner forces in numerous austere environments. Following an enemy attack, the FST received multiple casualties and provided a total of 7 critical medication infusions to 3 patients without the aid of electronic-controlled intravenous (IV) infusion pumps or syringes for 10 hours while the wounded soldiers waited for evacuation to a higher level of care. The team administered propofol, norepinephrine, tranexamic acid, and ketamine by individual gravity infusions relying solely on counting drops. An infusion rate monitor (DripAssist, Shift Labs Inc) was used to assist in initial IV rate setup and maintenance. The medics and nurses of the 541st FST found that the infusion rate monitor improved the speed of setting the IV infusion rate, drop counting accuracy, and the team's ability to monitor the continuous delivery of gravity IV infusions.

Ann Vasc Surg. 2019 Oct 30;Epub ahead of print

# Compartment Syndrome of the Leg after Intraosseous (IO) Needle Insertion.

Kibrik P, Alsheekh A, Rajaee S, Marks N, Hingorani A, Ascher E

Intraosseous (IO) needles are used in patients who are critically ill when it is not possible to obtain venous access. While IO allows for immediate access, IO infusions are associated with complications including fractures, infections, and compartment syndrome. We present a case of an 87-year-old man who developed lower extremity compartment syndrome after receiving an IO needle insertion and had to be treated surgically with fasciotomy to correct the problem.

J Spec Oper Med. Spring 2019;19(1):52-55.

# The Prehospital Trauma Registry Experience With Intraosseous Access.

Schauer SG, Naylor JF, April MD, Fisher AD, Cunningham CW, Fernandez JRD, Shreve BP, Bebarta VS.

BACKGROUND: Peripheral intravenous (IV) cannulation is often difficult to obtain in a patient with hemorrhagic shock, delaying the appropriate resuscitation of critically ill patients. Intraosseous (IO) access is an alternative method. To date, few data exist on use of this procedure by ground forces in Afghanistan. Here, we compare patient characteristics and concomitant interventions among patients undergoing IO access versus those undergoing IV access only.

METHODS: We obtained data from the Prehospital Trauma Registry (PHTR). When possible, patients were linked to the Department of Defense Trauma Registry for outcome data. To develop the cohorts, we searched for all patients with documented IO or IV access placement. Those with both IO and IV access documented were placed in the IO group.

RESULTS: Of the 705 available patients in the PHTR, we identified 55 patients (7.8% of the population) in the IO group and 432 (61.3%) in the IV group. Among patients with documentation of access location, the most common location was the tibia (64.3%; n = 18). Compared with patients with IV access, those who underwent IO access had higher urgent evacuation rates (90.9% versus 72.4%; p = .01) and air evacuation rates (58.2% versus 14.8%; p < .01). The IO cohort had significantly higher rates of interventions for hypothermia, chest seals, chest tubes, needle decompressions, and tourniquets, but a significantly lower rate of analgesic administration (ρ ≤ .05).

CONCLUSION: Within the registry, IO placement was relatively low (<10%) and used in casualties who received several other life-saving interventions at a higher rate than casualties who had IV access. Incidentally, lower proportions of analgesia administration were detected in the IO group compared with the IV group, despite higher intervention rates.

AANA J. 2017 Aug;85(4):256-260.

# Comparison of Flow Dynamics of Peripherally and Centrally Inserted Intravenous Catheters Using a Rapid Infusion System (ThermaCor 1200).

Wrenn E, Wohlers R, Montgomery M, Cobb H, Condra J, Tharpe S, Patil N

The inability to rapidly administer warm intravenous fluids and blood products can potentially threaten a patient's safety and well-being in many clinical settings. Large-bore intravenous catheters and rapid infusion systems are often used in situations where rapid blood loss and massive blood transfusion may be expected. This study examined the maximum flow rate and infusion pressure of various peripherally and centrally inserted intravenous catheters using a rapid infusion system (ThermaCor 1200 Rapid Infusion System, Smisson-Cartledge Biomedical). Nine different peripheral and central catheters or lumens were studied using 500 mL of 0.9% sodium chloride and 250 mL of hetastarch. Ten trials were performed. The maximum flow rates and infusion pressures were noted. Data were analyzed using the analysis of variance and the Tukey Studentized Range test. Statistically significant greater flow rates were noted with both 0.9% sodium chloride and hetastarch in most of the peripherally inserted catheters compared with the centrally inserted catheters. These results suggest that use of this infusion system with peripherally inserted catheters may be more effective in achieving higher maximum flow rates than with centrally inserted catheters.