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Diego Neuhaus - One of the best experts on this subject based on the ideXlab platform.

  • Intraosseous Infusion in elective and emergency pediatric anesthesia when should we use it
    Current Opinion in Anesthesiology, 2014
    Co-Authors: Diego Neuhaus
    Abstract:

    PURPOSE OF REVIEW Difficulties to establish a venous access may also occur in routine pediatric anesthesia and lead to hazardous situations. Intraosseous Infusion is a well tolerated and reliable but rarely used alternative technique in this setting. RECENT FINDINGS According to recent surveys, severe complications of Intraosseous Infusion stay a rare event. Minor complications and problems in getting an Intraosseous Infusion started on the other side seem to be more common than generally announced. The EZ-IO Intraosseous Infusion system has received expanded EU CE mark approval for an extended dwell time of up to 72 h and for insertion in pediatric patients in the distal femur. Key values of blood samples for laboratory analysis can be obtained with only 2 ml of blood/marrow waste and do also offer reliable values using an I-Stat point-of-care analyzer. SUMMARY Most problems in using an Intraosseous Infusion are provider-dependent. In pediatric anesthesia, the perioperative setting should further contribute to reduce these problems. Nevertheless, regular training, thorough anatomical knowledge and prompt availability especially in the pediatric age group are paramount to get a seldom used technique work properly under pressure. More longitudinal data on large cohorts were preferable to further support the safety of the Intraosseous Infusion technique in pediatric patients.

  • Intraosseous Infusion in elective and emergency pediatric anesthesia: when should we use it?
    Current opinion in anaesthesiology, 2014
    Co-Authors: Diego Neuhaus
    Abstract:

    PURPOSE OF REVIEW Difficulties to establish a venous access may also occur in routine pediatric anesthesia and lead to hazardous situations. Intraosseous Infusion is a well tolerated and reliable but rarely used alternative technique in this setting. RECENT FINDINGS According to recent surveys, severe complications of Intraosseous Infusion stay a rare event. Minor complications and problems in getting an Intraosseous Infusion started on the other side seem to be more common than generally announced. The EZ-IO Intraosseous Infusion system has received expanded EU CE mark approval for an extended dwell time of up to 72 h and for insertion in pediatric patients in the distal femur. Key values of blood samples for laboratory analysis can be obtained with only 2 ml of blood/marrow waste and do also offer reliable values using an I-Stat point-of-care analyzer. SUMMARY Most problems in using an Intraosseous Infusion are provider-dependent. In pediatric anesthesia, the perioperative setting should further contribute to reduce these problems. Nevertheless, regular training, thorough anatomical knowledge and prompt availability especially in the pediatric age group are paramount to get a seldom used technique work properly under pressure. More longitudinal data on large cohorts were preferable to further support the safety of the Intraosseous Infusion technique in pediatric patients.

  • Intraosseous Infusion in the pediatric emergency medical service analysis of emergency medical missions 1990 2009
    Anaesthesist, 2011
    Co-Authors: A. Sommer, Markus Weiss, Dubravka Deanovic, Mital H. Dave, Diego Neuhaus
    Abstract:

    BACKGROUND Timely establishment of venous access in infants and toddlers during emergency medical care can be a particularly challenging task. Alternative routes for drug and fluid administration, such as endobronchial, intramuscular, central venous or venous cut-down do not offer reliable solutions. Intraosseous Infusion (IOI) has become established as an effective alternative intravascular access for rapid and efficient drug delivery. IOI was introduced in our local emergency medical service (EMS) in 1993 and was assigned a high priority in international guidelines for pediatric emergency medical care in 2000 and 2005. The aim of this study was to review the impact of the introduction of IOI on drug administration routes during prehospital emergency treatment of critically ill or severely injured pediatric patients (NACA index V-VII) in our tertiary medical care centre over a period of 20 years. METHODS Pediatric prehospital emergency medical protocols from 1990 to 2009 were analyzed with respect to the administration routes for fluids and medications in severely injured or critically ill children with NACA severity scores V-VII. The frequency and mode of vascular access during prehospital treatment including IOI, endobronchial administration, central venous catheterization (CVC) and intramuscular administration as well as prehospital treatment and transportation without vascular access were analyzed. Two groups were compared: the introduction phase of IOI between 1990 and 1999 and the phase of growing IOI routine after introducing guidelines and regular staff IOI technique training between 2000 and 2009. Demographic data and drug administration routes in the two different time periods were analyzed using the Mann-Whitney-u test and t-test or χ(2)-test, respectively. A p-value <0.05 was regarded as significant. RESULTS A total of 5,279 pediatric prehospital emergency charts were analyzed and 401 patients (7.6%) were scored as NACA V-VII. At the emergency scene 299 patients (75%) received a peripheral intravenous access, 3 (0.7%) a central venous line access, 77 (19%) an Intraosseous needle and in 22 (5.4%) no vascular or Intraosseous access was used during the course of prehospital treatment (NACA VII - 13 patients, NACA VI - 2 patients, NACA V - 7 patients). Of the NACA VII patients 3 were transported under continuous cardiopulmonary resuscitation without vascular access. After 2002 all patients with NACA index VII were treated with vascular or Intraosseous access. In 48 patients (12%) at least initial medication was given by the endobronchial or alternative route but within the last 3 years endobronchial drug administration was no longer reported. Thus, in 124 critically ill patients (31%) routine peripheral venous access could not be established initially or until the end of treatment (77 times IOI, 22 times no access over the course of treatment, 3 times CVC and 22 times initial endobronchial followed by peripheral venous access). Over the reviewed period the use of IOI increased significantly (p<0.001), while the incidence of lacking vascular access (p<0.05) and alternative drug administration routes (p<0.001) continuously decreased. CONCLUSION The IOI technique has not only been assigned a high priority in the guidelines for pediatric emergency care of critically ill children with difficult or failed venous access but has also significantly influenced current prehospital care. The introduction of the IOI technique in our prehospital pediatric emergency system has markedly reduced the number of critically ill or severely injured pediatric patients without vascular access or with less reliable alternative administration routes in the last 20 years.

  • Intraosseous Infusion in the pediatric emergency medical service. Analysis of emergency medical missions 1990-2009
    Der Anaesthesist, 2010
    Co-Authors: A. Sommer, Markus Weiss, Dubravka Deanovic, Mital H. Dave, Diego Neuhaus
    Abstract:

    BACKGROUND Timely establishment of venous access in infants and toddlers during emergency medical care can be a particularly challenging task. Alternative routes for drug and fluid administration, such as endobronchial, intramuscular, central venous or venous cut-down do not offer reliable solutions. Intraosseous Infusion (IOI) has become established as an effective alternative intravascular access for rapid and efficient drug delivery. IOI was introduced in our local emergency medical service (EMS) in 1993 and was assigned a high priority in international guidelines for pediatric emergency medical care in 2000 and 2005. The aim of this study was to review the impact of the introduction of IOI on drug administration routes during prehospital emergency treatment of critically ill or severely injured pediatric patients (NACA index V-VII) in our tertiary medical care centre over a period of 20 years. METHODS Pediatric prehospital emergency medical protocols from 1990 to 2009 were analyzed with respect to the administration routes for fluids and medications in severely injured or critically ill children with NACA severity scores V-VII. The frequency and mode of vascular access during prehospital treatment including IOI, endobronchial administration, central venous catheterization (CVC) and intramuscular administration as well as prehospital treatment and transportation without vascular access were analyzed. Two groups were compared: the introduction phase of IOI between 1990 and 1999 and the phase of growing IOI routine after introducing guidelines and regular staff IOI technique training between 2000 and 2009. Demographic data and drug administration routes in the two different time periods were analyzed using the Mann-Whitney-u test and t-test or χ(2)-test, respectively. A p-value

  • Intraosseous Infusion. An important technique also for paediatric anaesthesia
    Der Anaesthesist, 2009
    Co-Authors: Markus Weiss, G Henze, Christoph Eich, Diego Neuhaus
    Abstract:

    Timely establishment of venous access in infants and toddlers can prove a particularly challenging task. Since the 1940s the technique of Intraosseous Infusion has established itself as a valuable alternative means for rapid, efficient and safe delivery of drugs and fluids to critically ill children. Whereas international guidelines for paediatric emergency medical care have assigned Intraosseous Infusion a high priority, most anaesthetists utilize this well-proven technique with great reluctance. This article describes the technique of Intraosseous Infusion, introduces two different cannulation systems, and discusses its potential indications in paediatric anaesthesia, based on current emergency medical care guidelines as well as some of our own case studies. In particular, children with acutely life-threatening conditions, such as circulatory arrest, laryngospasm, acute airway haemorrhage, hypovolaemic shock or hypothermia secondary to extensive burns, should receive an Intraosseous cannula if intravenous access cannot be rapidly established. Future discussion may reveal whether a transiently inserted Intraosseous Infusion would also be indicated if the child with difficult or impossible venous access presents without acute life-threatening conditions for anaesthesia. Successful application of the Intraosseous Infusion technique requires immediate access to the necessary equipment, intensive education, continuous training and clear guidelines for its application in an anaesthesia department.

Niranjan Kissoon - One of the best experts on this subject based on the ideXlab platform.

  • Intraosseous Infusion and pulmonary fat embolism
    Pediatric Critical Care Medicine, 2001
    Co-Authors: Yousuf M Hasan, Niranjan Kissoon, Taj M Khan, Virgilio Saldajeno, Jeffrey Goldstein, Suzanne P Murphy
    Abstract:

    OBJECTIVES: To determine the incidence of pulmonary fat embolism after the Intraosseous (IO) Infusion of normal saline and drugs and to determine whether pulmonary capillary blood is a predictor of lung fat embolism. DESIGN: A randomized, prospective, animal study. SETTING: Animal research laboratory of a university hospital. SUBJECTS: Twenty-eight mixed breed piglets (average weight 30.9 kg). Interventions and Methods: Animals were anesthetized, intubated, mechanically ventilated, and instrumented. IO needles were placed in the tibial bone. Animals were assigned to one of four groups: Group 1 received fluid (20 mL/kg) under 300 mm Hg pressure (n = 6); group 2 received fluid (20 mL/kg) at free flow under gravity (n = 6); group 3 received 100 mL of fluid over 20 mins (n = 8); and group 4 received 100 mL of fluid over 7 mins (n = 8). MEASUREMENTS AND MAIN RESULTS: Buffy coat samples were obtained from pulmonary arterial catheter in the occluded position at baseline, after IO needle placement, and at the end of Infusion. Lung specimens (both upper and lower lobes) were obtained at the end of the Infusion. Specimens were stained with oil red O and graded for fat emboli by a pathologist blinded to experimental conditions. Fat emboli (one to three emboli per high power field) were found in about 30% of the lung specimens. The difference in number of fat emboli between groups was not statistically significant. Buffy coat stains yielded fat emboli, which were distributed sporadically in all groups. CONCLUSION: Fat embolism is common; however, the method of IO fluid administration does not influence the number of emboli. Our study therefore implies that the risk of fat embolization is of concern, but its clinical relevance is unclear. Until the clinical significance of pulmonary fat emboli and the prevalence of fat emboli syndrome are delineated more precisely, the IO route is an effective but not necessarily safe route for delivery of fluids and drugs.

  • INCIDENCE OF FAT AND BONE MARROW EMBOLISM WITH THE USE OF Intraosseous Infusion DURING CARDIO-PULMONARY RESUSCITATION. † 264
    Pediatric Research, 1996
    Co-Authors: Mariano Fiallos, Talaat Abdelmoneim, Niranjan Kissoon, Lindsev Johnson, Suzanne Murphy, Shala Masood, Ahamed H. Idris
    Abstract:

    INCIDENCE OF FAT AND BONE MARROW EMBOLISM WITH THE USE OF Intraosseous Infusion DURING CARDIO-PULMONARY RESUSCITATION. † 264

  • compartment syndrome following Intraosseous Infusion
    Pediatrics, 1993
    Co-Authors: R Vidal, Niranjan Kissoon, Michael O Gayle
    Abstract:

    Cannulation of an Intraosseous (IO) site allows rapid access to the vascular space under emergency conditions. With increasing acceptance of this technique, some of its complications are now being fully appreciated. We present a case of a child who developed compartment syndrome and had a lower extremity amputation after Infusion of fluids through an IO needle inserted in the proximal tibia. This case is presented to highlight the precautions that may prevent compartment syndrome. Additional emphasis is placed on early recognition and aggressive treatment of compartment syndrome to preserve function in the affected limb. CASE REPORT A 1-month-old infant with fever and irritability was treated at a community hospital.

Michael Bernhard - One of the best experts on this subject based on the ideXlab platform.

  • RESEARCH ARTICLE Comparison of the Fluid Resuscitation Rate with and without External Pressure Using Two Intraosseous Infusion Systems for Adult
    2016
    Co-Authors: Niels Hammer, Robert Mobius, A Gries, B Hossfeld, Ingo Bechmann, Michael Bernhard
    Abstract:

    Intraosseous Infusion systems in emergenc

  • 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
    PLOS ONE, 2015
    Co-Authors: Niels Hammer, Robert Mobius, A Gries, B Hossfeld, Ingo Bechmann, Michael Bernhard
    Abstract:

    Introduction Intraosseous Infusion is recommended if peripheral venous access fails for cardiopulmonary resuscitation or other medical emergencies. The aim of this study, using body donors, was to compare a semi-automatic (EZ-IO®) device at two insertion sites and a sternal Intraosseous Infusion device (FASTR™).

  • 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
    2015
    Co-Authors: Niels Hammer, Robert Mobius, A Gries, B Hossfeld, Ingo Bechmann, Michael Bernhard
    Abstract:

    IntroductionIntraosseous Infusion is recommended if peripheral venous access fails for cardiopulmonary resuscitation or other medical emergencies. The aim of this study, using body donors, was to compare a semi-automatic (EZ-IO®) device at two insertion sites and a sternal Intraosseous Infusion device (FASTR™).MethodsTwenty-seven medical students being inexperienced first-time users were randomized into three groups using EZ-IO and FASTR. The following data were evaluated: attempts required for successful placement, insertion time and flow rates with and without external pressure to the Infusion.ResultsThe first-pass insertion success of the EZ-IO tibia, EZ-IO humerus and FASTR was 91%, 77%, and 95%, respectively. Insertion times (MW±SD) did not show significant differences with 17±7 (EZ-IO tibia) vs. 29±42 (EZ-IO humerus) vs. 33±21 (FASTR), respectively. One-minute flow rates using external pressures between 0 mmHg and 300 mmHg ranged between 27±5 to 69±54 ml/min (EZ-IO tibia), 16±3 to 60±44 ml/min (EZ-IO humerus) and 53±2 to 112±47 ml/min (FASTR), respectively. Concerning pressure-related increases in flow rates, negligible correlations were found for the EZ-IO tibia in all time frames (c = 0.107–0.366; p≤0.013), moderate positive correlations were found for the EZ-IO humerus after 5 minutes (c = 0.489; p = 0.021) and strong positive correlations were found for the FASTR in all time frames (c = 0.63–0.80; p≤0.007). Post-hoc statistical power was 0.62 with the given sample size.ConclusionsThe experiments with first-time users applying EZ-IO and FASTR in body donors indicate that both devices may be effective Intraosseous Infusion devices, likely suitable for fluid resuscitation using a pressure bag. Variations in flow rate may limit their reliability. Larger sample sizes will prospectively be required to substantiate our findings.

  • Comparison of two Intraosseous Infusion systems for adult emergency medical use
    Resuscitation, 2008
    Co-Authors: Thorsten Brenner, Michael Bernhard, Matthias Helm, Sara Doll, Alfred Völkl, Nicole Ganion, Claudia Friedmann, M. Sikinger, Jürgen Knapp, Eike Martin
    Abstract:

    Summary Introduction The current guidelines of the European Resuscitation Council (ERC) stipulate that an Intraosseous access should be placed if establishing a peripheral venous access for cardiopulmonary resuscitation (CPR) would involve delays. The aim of this study was therefore to compare a manual Intraosseous Infusion technique (MAN-IO) and a semi-automatic Intraosseous Infusion system (EZ-IO) using adult human cadavers as a model. Materials and methods After receiving verbal instruction and giving their written informed consent, the participants of the study were randomized into two groups (group I: MAN-IO, and group II: EZ-IO). In addition to the demographic data, the following were evaluated: (1) Number of attempts required to successfully place the Infusion, (2) Insertion time, (3) Occurrence of technical complications and (4) User friendliness. Results Evaluation protocols from 84 study participants could be evaluated (MAN-IO: n =39 vs. EZ-IO: n =45). No significant differences were seen in the study participants' characteristics. Insertion times (MW±S.D.) of the respective successful attempts were comparable (MAN-IO: 33±28s vs. EZ-IO: 32±11s). When using the EZ-IO, the access was successfully established significantly more often on the first attempt (MAN-IO: 79.5% vs. EZ-IO: 97.8%; p p p Conclusions In an adult human cadaver model, the semi-automatic system was proven to be more effective. The EZ-IO gave more successful results, was associated with fewer technical complications, and is user friendlier.

Thomas Schmidt - One of the best experts on this subject based on the ideXlab platform.

  • Preferred anatomic site for Intraosseous Infusion in Danish emergency departments
    Scandinavian Journal of Trauma Resuscitation and Emergency Medicine, 2010
    Co-Authors: Rune Molin, Peter Hallas, Mikkel Brabrand, Thomas Schmidt
    Abstract:

    Background Intraosseous Infusion (IOI) is recommended when intravenous access cannot be readily established in resuscitation. There has been debate as to whether which anatomic site should be preferred for IOI. Although success and flow rates in e.g. proximal tibia compared with proximal humerus are not significant different some stress that the tibia should be first choice for IOI because of easily identifiable landmarks. We have as part of a project on IOI use in Danish emergency departments (EDs) assessed the preferred anatomic site for IOI. We hope to promote a debate concerning first choice insertion site for IOI.

  • Current use of Intraosseous Infusion in Danish emergency departments: a cross-sectional study
    Scandinavian journal of trauma resuscitation and emergency medicine, 2010
    Co-Authors: Rune Molin, Peter Hallas, Mikkel Brabrand, Thomas Schmidt
    Abstract:

    Intraosseous Infusion (IOI) is recommended when intravenous access cannot be readily established in both pediatric and adult resuscitation. We evaluated the current use of IOI in Danish emergency departments (EDs). An online questionnaire was e-mailed to the Heads of Department of the twenty EDs currently established in Denmark. The questionnaire focused on the use of IOI in the EDs and included questions on frequency of use, training, equipment and attitudes towards IOI. We received a total of 19 responses (response rate of 95%). Of the responding 19 Danish EDs 74% (n = 14) reported having Intraosseous devices available. The median number of IOI procedures performed in these departments over the preceding 12 months was 5.0 (range: 0-45). In 47% (n = 9) of the departments, prior training sessions in the use of Intraosseous devices had not been provided, and 42% (n = 8) did not have local guidelines on IOI. The indication for IOI use was often not clearly defined and only 11% (n = 2) consistently used IOI on relevant indication. This is surprising as 95% (n = 18) of responders were aware that IOI can be utilized in both pediatric and adult resuscitation. The study shows considerable variations in IOI usage in Danish EDs despite the fact that IOI devices were available in the majority of EDs. In addition, in many EDs there were no local guidelines on IOI and no training in the procedure. We recommend more extensive training of medical staff in IOI techniques in Danish EDs.

R Arguero - One of the best experts on this subject based on the ideXlab platform.