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

Abstract

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.

The Efficacy of Intraosseous Access for Initial Resuscitation in Patients with Severe Trauma: A Retrospective Multicenter Study in South Korea

“…Using a pressure bag significantly increased administration speed, which was not inferior to that of IV access. The infusion flow rates associated with pressure bag use in IO administration are known to range from 30 to 70 mL/min, and our study reflects these results [32][33][34]. Increasing the pressure during blood transfusion can increase the possibility of hemolysis, indicating a need for further research into the safety of blood administration [34][35][36][37].…”

Single Versus Double Anatomic Site Intraosseous Blood Transfusion in a Swine Model of Hemorrhagic Shock

“…22 , 25 One of these studies reported evidence of intravascular hemolysis secondary to pressurized IO infusions, but only when blood was transfused via a 10 mL syringe above at maximum infusion pressures greater than 4,000 mmHg. 22 The results of all of these studies suggest a potentially non-linear infusion pressure threshold that is consistent with Darcy's Law, which states that, as bone density increases, transfusion pressures must be increased proportionally to produce the same flow rates. IO pressure bag infu-sion flow rates are intermediate (30-70 mL/min) in nature and more rapid flow may be required in damage control resuscitation.…”

“…20 , 26 Improving the rate of blood transfusion would require increasing the driving pressure of a viscous solution, conceivably leading to increased clinical complications of intravascular hemolysis and fat embolism. 22 Prior research on flow and safety were performed on a juvenile swine model, and pressure driven complications may occur more frequently in the unevaluated skeletally mature subjects. 23 , 44-46 Utilization of multiple anatomic sites with pressure bag IO infusion has been suggested as a prehospital strategy to increase flow rates while minimizing excessive infusion pressures.…”

Sternal Intraosseous Devices: Review of the Literature

“… 26 Furthermore, because the sternum is a non weight-bearing bone, its density is predicted to be 25% less than the proximal humerus. 5 Therefore, lower infusion pressures are required and flow rates are higher with a sternal as compared to a humeral route. As an additional anatomic advantage, the sternum can be identified in every shape and size person, to include the morbidly obese.…”

“…3 Any fluids or medications that can be administered through an IV can also be given IO, including blood products and IV contrast agents. 2,[4][5][6] Intraosseous access is now supported for use in Pediatric Advanced Life Support, Advanced Cardiac Life Support, and Advanced Trauma Life Support. 1,4 As this access is vital in emergent cases, a review of the literature is warranted to keep apace of current trends and supports.Building on preliminary work by Drinker et al in 1916 and Arnold Josefson in 1934, the IO route for vascular access came to…”