When considering use of IO devices in the pediatric population, bone marrow biopsy needles for manual insertion are available in 16- and 18-gauge sizes for various size infants and children, whereas the EZ-IO and B.I.G. devices also provide needles of appropriate size and depth for use in the pediatric population. This is not true for the sternal access device, FAST1, which is currently available only in an adult size with a pediatric device in the development phase (personal communication with PYNG medical representative).
Calkins et al.31 compared 4 different systems for IO placement including the FAST1, the B.I.G., a hand-driven threaded-needle SurFast (SF, Cook Critical Care), and the straight Jamshidi needle (Baxter Allegiance, McGaw Park, IL). They found that all 4 systems were easy to learn to use and provided secure access. The B.I.G. was successful in 29 of 31 insertions with a placement time of 70 ± 33 s. The SurFast was successful in 30 of 31 insertions with a placement time of 88 ± 33 s but had the highest extravasation rate. The Jamshidi needle was also successful in 30 of 31 placements with a placement time of 90 ± 59 s. However, the flow was noted to be slow in 7 of the 30 successful placements. The FAST1 was successful in 29 of 31 insertions; however, the mean placement time was significantly longer than the other 3 devices (114 ± 36 s).
When comparing the traditional manual method using a Jamshidi needle with the automatic B.I.G., there was a faster time to placement of the IO device in the B.I.G. group (16.91 vs 11.93 s).32 Although statistically different, both devices were placed in a timely fashion and with similar ease-of-use ratings among the Emergency Medical Technician students and practicing paramedics. Similar results were reported by Brenner et al.33 when comparing manual IO infusion devices versus the EZ-IO in adult human cadavers. Although insertion times were similar, access was achieved more successfully on the first attempt when using the EZ-IO (97.8% vs 79.5%). User ease was scored higher in the automatic device and there were fewer technical complications when compared with the manual technique (0% in EZ-IO group vs 15.4% with the manual device). When compared with the results of Calkins et al., insertion times for both of these comparison studies were considerably shorter.
In adult trauma patients, insertion success rates were compared between the FAST1 and EZ-IO devices.34 This field trial included a training session with hands-on instruction for emergency service personnel before the use of the 2 devices. The field trial of the FAST1 occurred first, followed by the trial for the EZ-IO device. There was immediate feedback regarding the use of the devices upon insertion in the field. One hundred seventy-eight insertions were evenly divided between the FAST1 and EZ-IO. The success rate of device insertion was 64 of 89 (72%) with the FAST1 and 78 of 89 (87%) with the EZ-IO, although there was no difference between the 2 devices with respect to first attempt success rate. Provider comfort was similar for each model and there was no difference in device effectiveness with regard to infusion. Failures for each model were attributed to excessive tissue over the insertion site, inability to infuse, and fluid extravasation around the insertion site. These failures led the study personnel to recommend a device with a longer needle for the bariatric population. In addition, with the FAST1, there were problems with the catheter dislodging or breaking that were best avoided when proper technique with linear alignment of the elbow and wrist occurred during insertion to avoid torque. Difficulties with the EZ-IO included loss of drill power with insertion, most likely caused by the drill being pushed against the bone with too much force to allow the drill to have adequate rotation speed to penetrate the bone. The majority of the providers also thought that the drill was underpowered, a problem that can be alleviated by using a lithium ion battery pack rather than regular AA batteries.
REPORTS OF INTRAOPERATIVE AND IN-HOSPITAL IO USE
Although used most frequently in prehospital or emergency room scenarios, IO access has been anecdotally reported in both the inpatient and intraoperative care of pediatric patients. Harte et al.11 used IO access in an 11-mo-old girl who had presented with multiple organ injuries secondary to a motor vehicle accident. During the course of a lengthy stay in the pediatric intensive care unit (ICU), she had multiple peripheral venipunctures, bilateral femoral and brachial central venous catheters, bilateral saphenous vein cutdowns, and a right internal jugular venous line. Although she was eventually transferred out of the ICU, a cardiopulmonary arrest occurred, requiring reestablishment of vascular access. When attempts to reestablish peripheral and central venous access failed, bilateral tibial IO catheters were placed and used for successful resuscitation with the administration of sodium bicarbonate, calcium chloride, epinephrine, and dopamine.
Similar success was reported by Lake and Emmerson35 with the use of IO access in an inpatient, former preterm infant of 25 wk gestation who had been hospitalized for several weeks and subsequently developed acute deterioration after the removal of previously placed percutaneous and central venous catheters. An 18-gauge butterfly needle was used to gain IO access via the infant's left tibia thereby allowing for the emergent infusion of fluids, antibiotics, sympathomimetic drugs, and analgesia.
As early as 1952, Tarrow et al.36 recognized that the IO route was plausible for the induction and maintenance of anesthesia noting that “the agents used in anesthesia may be given by way of the bone marrow with as rapid an effect as when given IV.” Additionally, reports from the veterinary literature demonstrate the efficacy of the IO route for the induction of anesthesia in various animal species.37,38 Valcerde et al.37 demonstrated the effective induction of anesthesia with either ketamine or thiopental in chickens and additionally demonstrated a lack of histopathologic changes in the bone marrow related to these medications. Kamiloglu et al.38 compared the effects of IM and IO ketamine in domestic pigeons. The onset of anesthetic effect was more rapid with IO as compared with IM administration (1.8 ± 0.4 min vs 7.5 ± 0.8 min).
There are a limited number of reports regarding the use of IO access in the operating room setting.39–41 In 3 of these cases, the IO route was used in a nonemergent situation when there were difficulties with obtaining vascular access. Stewart and Kain39 used the IO route in a 3-mo-old, low-birth-weight infant with polycythemia secondary to cyanotic congestion heart disease and a long history of difficult venous access when anesthetic care was required for revision of a ventriculoperitoneal shunt. Comorbid features included previous long-term use of percutaneous central venous access, prior venous cutdowns in all 4 extremities, and approximately 200 peripheral venipuncture attempts during a 12-wk stay in the pediatric ICU. After the inhaled induction of anesthesia, the decision to use the IO route was made after 20 min of unsuccessful attempts at peripheral IV placement. After successful establishment of IO access, pancuronium was administered. The IO access was discontinued after the scheduled surgery and no complications were noted.
Boucek and El Magd40 described their planned approach of combining IO, intrarterial, and surgically fashioned venous sites in a 52-yr-old woman scheduled for multivisceral transplantation. Because of an extended period of parenteral nutrition administration, venous access was eventually maintained via lumbar and transhepatic catheters that were placed using radiological guidance. Bilateral occlusion of the brachiocephalic, superior vena cava, and iliac veins was present on radiologic imaging studies. Attempts to recannulate these central veins were unsuccessful and during one attempt, the atrial appendage was avulsed from the superior vena cava. At the time of the planned transplantation surgery, the patient's only patent venous access was a small-bore transhepatic catheter. This catheter was used for the IV induction of anesthesia. IO access was planned preoperatively as part of their approach to this patient and access was obtained in the patient's right tibia using a 15.5-gauge IO infusion needle. However, flow was deemed inadequate for rapid transfusion and, although the needle was left in place to avoid periosteal bleeding, it was not used for intraoperative fluid administration. Intraoperatively under direct vision, acceptable venous access was obtained via the inferior mesenteric and ovarian veins.
Joshi and Tobias41 reported the successful use of IO access in an 8-mo-old, 5.4-kg infant with cyanotic congenital heart disease who was scheduled for direct laryngoscopy. During a prolonged illness in the pediatric ICU, which required chronic mechanical ventilation, the patient had several peripheral and central venous catheters placed. Because of the thrombotic disease of the superior and inferior vena caval systems, the patient's last central venous catheter, which had become nonfunctional 1 wk before the surgical procedure, was placed via a translumbar approach under radiologic guidance. When peripheral IV access could not be obtained, an 18-gauge IO needle was inserted into the right tibia. Ampicillin (50 mg/kg) was administered for subacute bacterial endocarditis prophylaxis. Atropine (5 μg/kg) was administered via the IO needle and the sevoflurane concentration was increased to 6% to allow for the performance of the direct laryngoscopy and bronchoscopy with assisted ventilation. Two IO doses of propofol (1 mg/kg) were administered during the direct laryngoscopy to achieve a deeper plane of anesthesia. After completion of the airway examination, which required 15 min, the infant was transported to the pediatric ICU with the IO needle in place. Once the infant had recovered from the general anesthetic, tube feedings were restarted. When the tube feedings were tolerated without incident for 3–4 h, the IO needle was removed. Before its removal, vancomycin (10 mg/kg) was administered. The remainder of the postoperative course was uneventful.
In a final intraoperative report, Waisman et al.42 described the use of IO access to provide IO regional anesthesia as an alternative to IV regional anesthesia (Bier block). Preliminary work was performed in 5 dogs and in a cadaver model to demonstrate the feasibility of the technique and determine the best site for access. The most effective sites for access of the upper extremity were the distal radial metaphysis or epiphysis and the distal ulna epiphysis for the upper extremity. For the lower extremity, the best sites were found to be the proximal tibial epiphysis or metaphysis, the medial malleolus, and the distal epiphysis of the first metatarsus. They then demonstrated the efficacy of the technique for providing intraoperative anesthesia in 106 of 109 patients. Lidocaine levels were acceptable after tourniquet release.
Clearly, the use of IO access is not considered first line for intraoperative management in elective procedures. Particularly when a child will require IV access postoperatively for any extended period, the benefits for intravascular lines will outweigh those of IO access. However, it should be part of an algorithm that includes numbers of attempts at peripheral access, time taken at attempts at peripheral access, feasibility of central access, and other factors including the need for continued postoperative access to guide the decision. There is no such algorithm for elective procedures because the mindset remains that the IO route is for emergency situations.
COMPLICATIONS OF AND CONTRAINDICATIONS TO IO ACCESS
As with any invasive procedure, complications may occur with the use of IO access. A 1990 review of the literature reports that IO catheters cannot be placed 20% of the time because of operator failure to use appropriate landmarks, bending of the needle, dense marrow within a small cavity, or replacement of marrow by fat or fibrous tissue.43 Administration of hypertonic or strongly alkaline agents has been associated with an increased incidence of local infection, transient medullary histologic changes, and myonecrosis in animal models.43,44 Heinild et al.8 concluded that, among pediatric patients, hypertonic solutions were associated with an increased incidence of osteomyelitis when compared with patients receiving blood transfusions or isotonic fluid infusions. These issues have led to the suggestion that hypertonic solutions should be diluted before IO administration. Technical complications of the IO route include the possibility of needle dislodgement resulting in extravasation of fluid and medications resulting in tissue damage or even compartment syndrome.45
Other potential complications include iatrogenic fracture, infectious complications, growth or epiphyseal plate injury with subsequent leg length discrepancy, and fat embolism. Using an animal model (piglets with an average weight of 30.9 kg), Hasan et al.46 evaluated the impact of the amount of fluid administered, the pressure used to deliver the fluid, and the rate of administration on fat embolization. A bolus of 20 mL/kg fluid was administered under 300 mm Hg pressure in Group 1 (n = 6), 20 mL/kg fluid was administered under gravity flow in Group 2 (n = 6), 100 mL of fluid was administered over 20 min in Group 3 (n = 8), and 100 mL of fluid was administered over 7 min in Group 4 (n = 8). Lung specimens from both upper and lower lobes were subsequently examined. Fat emboli (1–3 per high-power field) were found in approximately 30% of the lung samples with no statistically significant difference among the 4 groups. Orlowski et al.47 also demonstrated as many as 4.48 fat emboli per square millimeter of lung tissue after IO infusions in a canine model. However, when evaluating changes in arterial blood gases to assess ventilation-perfusion relationships, there was no clinical effect noted related to the fat emboli. Despite these animal studies, there have been no documented cases of either fat or cortical bone emboli after IO infusions in infants and children. However, the literature continues to suggest that this may be a real complication of IO infusion in adults because of the differences in composition of the marrow cavity when comparing children with adults.48 Before 5 yr of age, the intramedullary space of the bone is predominantly composed of red marrow. After 5 yr of age, a significant portion of the red marrow has been converted to the less vascular, yellow marrow, which has a much higher fat component. These changes result in more difficult access, decreased infusion rates, and a potentially increased risk for fat emboli. However, in a prospective nonrandomized trial that included 50 adults, fat embolism was not among the complications noted.48
Rosetti et al.13 reviewed 30 clinical studies involving 4359 attempted IO infusions in pediatric and adult patients. Osteomyelitis occurred in 27 patients or an incidence of 0.6%. A single infusion lasting <1 h resulted in a similar risk of osteomyelitis when compared with a longer, continuous infusion. The authors recommended that hypertonic and alkaline fluids or medications be avoided or diluted. They also stressed the importance of maintaining appropriate sterile technique to limit the incidence of osteomyelitis. Antibiotic coverage for staphylococcal infection may be used if compromise of sterile technique is suspected.
Bowley et al.49 described an iatrogenic fracture associated with IO access in a 2-yr-old trauma patient after IO access placement was attempted unsuccessfully with an 18-gauge B.I.G. device at the left proximal tibia followed by 2 manual attempts with the same needle at the same site. The authors reported that “considerable force was required” by the 100-kg emergency room physician. Once the device was inserted, a 20 mL/kg bolus of crystalloid was started and completed without difficulty. A full skeletal survey later revealed a fracture of the proximal tibia, which was deemed to be iatrogenic, despite the multiple traumatic fractures found elsewhere. Given this albeit rare complication, it has been suggested that follow-up radiographs be obtained for all children in whom IO access has been attempted.49,50
Multiple attempts to gain access at the same site are discouraged because repeated long bone puncture attempts can result in extravasation of subsequently administered resuscitation drugs, leading to skin necrosis or compartment syndrome. Despite concerns expressed regarding damage to the growth plate, there are no reports of such injuries. In a prospective follow-up of tibial length after IO infusion in 10 pediatric patients, Fiser et al.51 found no identifiable growth disturbance at 1 yr. The greatest difference was 0.6 cm in 2 of the patients, 1 of whom had a longer tibia on the side of the infusion, whereas the other had a longer control tibia. Heinild et al.8 roentgenographically examined 72 of the 495 patients in their study over the course of 1–2 yr and concluded that IO blood transfusion at the tibial site may result in transient radiologic changes, but these changes are not permanent and did not appear to affect bone growth.
There are few absolute contraindications to IO placement. These include bone diseases, such as osteogenesis imperfecta, osteopetrosis, or other disorders with an increased incidence of fracture, infection or thermal injury to the overlying skin, or the presence of a fracture. Previously used sites for IO access should not be used for 1–2 days and repeated attempts at the same site are discouraged. An additional concern when IO access is used intraoperatively is that the IO site may be difficult to secure and maintain in place, especially in the operating room setting, thereby leading to potential malfunction at a critical time during anesthetic management. Manufacturers have responded to this concern by providing devices that include the equipment and instructions on how to secure the IO line once inserted.
Complications of the IO route are compared with other intravascular routes in Table 2. Although all routes include infection as a potential complication, the length of time that the access is kept in place is more predictive of infection rate than the actual route of access itself.
When vascular access cannot be obtained intraoperatively, there are various options including percutaneous placement of a central venous cannula, achieving peripheral venous or central venous access via a cutdown, use of the IM route, or placement of an IO needle. Because each of these techniques has its own advantages and disadvantages, the appropriate choice must be based on the risk/benefit ratio given the clinical scenario. Intravenous access remains the route of choice, but may in rare cases be unattainable, both at alternative peripheral sites (scalp, chest wall, and abdominal wall veins) and at central venous sites despite multiple attempts by experienced hands. Venous cutdown may not be practical in emergent situations because of inherent time constraints. Cutdown access is achieved at approximately 11 min for neonates, 8 min in patients 1 mo to 5 yr of age, and 6 min in patients older than 6 yr.52 Although certain drugs may be administered via the IM route, such as succinylcholine, rocuronium, and atropine, there may be variability in absorption depending on the site of injection and the hemodynamic status of the patient, thus resulting in an unpredictable or delayed onset time.53 The IM route is not feasible for many other medications and also cannot be used for fluid resuscitation. With respect to ET intubation using a deep plane of inhaled anesthesia, complications may be more likely when ET intubation in infants is performed without the use of neuromuscular blocking drugs.54 Except for very brief procedures, vascular access is still required as there are a limited number of medications that can be administered via the ET tube and these are used only during resuscitative efforts. Additionally, in infants with comorbid features such as congenital heart disease, establishment of vascular access before ET intubation is often preferred because a deep plane of inhaled anesthesia may result in hemodynamic instability.
The current applications of IO access primarily include the emergent resuscitation of infants and children when IV access cannot be obtained in emergent scenarios including cardiac arrest, traumatic and thermal injuries, shock, status epilepticus, and diabetic ketoacidosis. In these clinical scenarios, IO access has been used for the administration of fluids and vasoactive medications. In addition to isotonic crystalloid, the IO route has been used for the administration of various blood products (fresh frozen plasma, whole blood, and packed red blood cells). Medications administered have included epinephrine, dopamine, dobutamine, digitalis, diazoxide, calcium, diazepam, phenytoin, antibiotics, insulin, glucose, heparin, and neuromuscular blocking drugs including succinylcholine. Current resuscitation guidelines suggest that the IO route should not be used as a routine alternative to venous access but rather should be limited to situations in which peripheral and central vein cannulation cannot be rapidly obtained.55–57 Although rarely reported in the anesthesia literature, it seems that IO access is a technique that anyone involved in the provision of anesthesia care to children should consider when presented with the infant or child who has difficult IV access. In emergency situations, it can be used for the administration of lifesaving medications and may on occasion be used when other attempts at venous access fail. With appropriate technique and equipment, the literature reports an acceptably low complication rate. Given that IO access may be occasionally used in the perioperative setting in both emergent and nonemergent scenarios, it may be beneficial to have appropriate IO needles in the operating room.
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