Comparison of the Fluid Resuscitation Rate with and without External Pressure Using Two Intraosseous Infusion Systems for Adult Emergencies, the CITRIN (Comparison of InTRaosseous infusion systems in emergency medicINe)-Study

Hammer, Niels; Möbius, Robert; Gries, A.; Hoßfeld, Björn; Bechmann, Ingo; Bernhard, Michaël

doi:10.1371/journal.pone.0143726

Cited by 24 publications

(22 citation statements)

References 36 publications

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“…Despite the fact the cavity is empty after saline flush, bone spicules increase flow resistance between bone cavity and vascular system. Therefore, use of pressure bags is absolutely required to enhance flow rates [ 15 ] and enable medications to reach the vascular system. When this recommendation is implemented, the IO access allows rapid delivery of large amounts of fluids and medications in emergency situations.…”

Section: Results and Discussionmentioning

confidence: 99%

Use of intra-osseous access in adults: a systematic review

et al. 2016

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BackgroundIndications for intra-osseous (IO) infusion are increasing in adults requiring administration of fluids and medications during initial resuscitation. However, this route is rarely used nowadays due to a lack of knowlegde and training. We reviewed the current evidence for its use in adults requiring resuscitative procedures, the contraindications of the technique, and modalities for catheter implementation and skill acquisition.MethodsA PubMed search for all articles published up to December 2015 was performed by using the terms “Intra-osseous” AND “Adult”. Additional articles were included by using the “related citations” feature of PubMed or checking references of selected articles. Editorials, comments and case reports were excluded. Abstracts of all the articles that the search yielded were independently screened for eligibility by two authors and included in the analysis after mutual consensus. In total, 84 full-text articles were reviewed and 49 of these were useful for answering the following question “when, how, and for which population should an IO infusion be used in adults” were selected to prepare independent drafts. Once this step had been completed, all authors met, reviewed the drafts together, resolved disagreements by consensus with all the authors, and decided on the final version.ResultsIO infusion should be implemented in all critical situations when peripheral venous access is not easily obtainable. Contraindications are few and complications are uncommon, most of the time bound to prolonged use. The IO infusion allows for blood sampling and administration of virtually all types of fluids and medications including vasopressors, with a bioavailability close to the intravenous route. Unfortunately, IO infusion remains underused in adults even though learning the technique is rapid and easy.ConclusionsIndications for IO infusion use in adults requiring urgent parenteral access and having difficult intravenous access are increasing. Physicians working in emergency departments or intensive care units should learn the procedures for catheter insertion and maintenance, the contraindications of the technique, and the possibilities this access offers.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1277-6) contains supplementary material, which is available to authorized users.

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Section: Results and Discussionmentioning

confidence: 99%

Use of intra-osseous access in adults: a systematic review

et al. 2016

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“…This finding is not surprising as prior studies of blood, crystalloid, and hetastarch infusions noted higher flow rates with increasing infusion pressures. 23,34,35,[40][41][42] Previous research has also noted pressure bag flow rates to be superior to the rapid infuser. 23,43 The difference between PB and rapid infuser in both studies was related primarily to interruption in infusion from frequent overpressure alarms.…”

Section: Discussionmentioning

confidence: 99%

“…Human, cadaver, and animal research has consistently shown pressurized IO infusion rates are superior to gravity flow rates. 34,40,44 The gravity transfusion arm was removed from this present study after noting futile flow rates during the pilot phase. 23 On the surface, pilot data may appear to be in conflict with a recent research on IO blood transfusion via gravity, in which flow rates were reported at 50 mL/min in the human sternum.…”

Section: Discussionmentioning

confidence: 99%

Safety of Pressurized Intraosseous Blood Infusion Strategies in a Swine Model of Hemorrhagic Shock

Auten

McEvoy

Roszko

et al. 2020

Journal of Surgical Research

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Background: Current guidelines support intraosseous access for trauma resuscitation when intravenous access is not readily available. However, safety of intraosseous blood transfusions with varying degrees of infusion pressure has not been previously characterized. Materials and methods: Adult female Yorkshire swine (Sus scrofa; n ¼ 36; mean (M): 80 kg, 95% CI: 78-82 kg) were cannulated and then bled approximately 30% total blood volume. Swine were randomly assigned to proximal humerus intraosseous blood infusion with either Rapid Infuser, or Pressure Bag, or Push-Pull methods (n ¼ 12 each). Flow rates, infusion pressures, vitals, biochemical variables, and pulmonary and renal tissue pathology were contrasted between groups. Results: Flow rates were greater for the Push-Pull strategy than Pressure Bag (96.5 mL/min versus 72.6 mL/min, P ¼ 0.02) or Rapid Infuser (96.5 mL/min versus 60 mL/min, P ¼ 0.002) strategies. The pressures generated during the Push-Pull transfusion (3058 mmHg) were greater than the other strategies (360 mmHg). After the observation period, plasma-free hemoglobin levels were higher in the Push-Pull strategy than in the Rapid Infuser (40 mg/dL versus 12 mg/dL, P ¼ 0.02) or Pressure Bag (40 mg/dL versus 12 mg/dL, P ¼ 0.01). Groups did not significantly differ in vitals, biochemical variables, or tissue pathology. Conclusions: Push-Pull conferred the highest flow rates, but with higher infusion pressures and evidence of intravascular hemolysis. Rapid Infuser and Pressure Bag infusions had no increase from baseline in plasma-free hemoglobin. Pressure Bag infusion was noted to confer an advantage in flow rates over Rapid Infuser. Intraosseous blood transfusion with pressure bags can safely bridge toward central access in the early phases of trauma resuscitation.

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“…Intraosseous injection provides entry for resuscitation drugs and fluid resuscitation [12][13][14]. However, flow through the IO catheter must be initiated by an initial flush of at least 10 mL of saline and maintained with the use of a pressure infusion bag inflated at 300 mmHg in accordance with the instructions of use [15].…”

Section: Discussionmentioning

confidence: 99%

Comparison of Two Intraosseous Access Devices Employed During Simulated Cardiopulmonary Resuscitation. A Prospective, Randomized, Crossover, Manikin Study

Ramirez¹,

Truszewski²,

Drozd³

2016

Disaster Emerg Med J

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BACKGROUND: Intraosseous injection is an alternative method used regarding unsuccessful intravenous access during many emergency situations. The aim of the present study was to compare injections made by the Bone Injection Gun (BIG) with NIO Adult intraosseous access devices during simulated CPR performed by paramedics. METHODS: 40 paramedics took part in this prospective, randomized, crossover, manikin study. The participants were chosen at random, while each paramedic performed an intraosseous injection with the Bone Injection Gun (BIG) or with the NIO Adult Intraosseous access device. The effectiveness of the intraosseous injection was analyzed as times T1, T2, and T3. Time T1 is defined as the time-lapse from placing the intraosseous device into one's hand to performing the intraosseous injection; Time T2 is the time-lapse from placing the intraosseous device into one's hand to the moment of stabilizing it at the injection site; while Time T3 is defined as the time-lapse from putting the intraosseous device into one's hand, attaching the syringe with a test aspiration, to connecting the infusion line. Attitudes toward the use of intraosseous access during resuscitation were also analyzed in the present study. RESULTS: The efficacy of intraosseous access obtained with the use of NIO was at 100% where the efficacy of the use of BIG was at 95%. The average time of T1 was similar in the groups randomized to use BIG and NIO, represented as 5.4 ± 3.5 vs. 3.5 ± 2.5 s, respectively (p = 0.014); the average time of T2 was 17.5 ± 4.5 vs. 3.5 ± 2.5 s, respectively (p < 0.001); while the average time of T3 was 25 ± 5.5 vs. 11.5 ± 2.5 s, respectively (p < 0.001). Notably, 90% of the study's participating paramedics preferred to use the NIO during cardiopulmonary resuscitation (p < 0.001). CONCLUSIONS: The present study shows that after a short period of training paramedics can perform an intraosseous injection with a high degree of efficiency. Thus, the authors stress the need for training medical personnel to have the skill to perform intraosseous injections along with knowledge and understanding of the indications and contraindication for IO access.

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Comparison of the Fluid Resuscitation Rate with and without External Pressure Using Two Intraosseous Infusion Systems for Adult Emergencies, the CITRIN (Comparison of InTRaosseous infusion systems in emergency medicINe)-Study

Cited by 24 publications

References 36 publications

Use of intra-osseous access in adults: a systematic review

Use of intra-osseous access in adults: a systematic review

Safety of Pressurized Intraosseous Blood Infusion Strategies in a Swine Model of Hemorrhagic Shock

Comparison of Two Intraosseous Access Devices Employed During Simulated Cardiopulmonary Resuscitation. A Prospective, Randomized, Crossover, Manikin Study

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