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Three Part Question

In [adult patients requiring volume replacement] does the [humeral or tibial site for intraosseous access] provide [higher fluid flow rates]?

Clinical Scenario

You are at the scene of a car crash with a medical team. The driver is showing signs of hypovolaemic shock, and the limited access and poor light make vascular access difficult. You elect to insert an intraosseous needle, but while preparing the proximal tibial site a paramedic suggests that using the humerus will allow for faster fluid infusion. You wonder if there is any evidence for this?

Search Strategy

[exp INFUSIONS, INTRAOSSEOUS/ OR intraosseous.ti,ab OR IO.ti,ab] AND [exp HUMERUS/ OR humer*.ti,ab] AND [exp TIBIA/ OR tibi*.ti,ab]
Limit to: English Language
Medline 1950 - Week 12 2013 via NHS Evidence
EMBASE 1980 – Week 12 2013 via NHS Evidence

Search Outcome

29 papers were identified by the stated search in Medline and 38 in EMBASE. One relevant paper was identified from Medline. The Embase search produced one further relevant result which was a non-systematic review; one relevant reference from this was used in this BET. In total two papers were found which provided the best evidence to answer this question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Ong ME 2009 Singapore	24 patients requiring intrasosseous access in opinion of treating doctor. All had tibial access; second line in humerus also inserted if clinically indicated; this occurred in 11 patients.	Prospective observational study	Flow rate with no pressure bag	Tibia: 73ml/min; Humerus 84.4ml/min	Observational study, not blinded or randomised. Humeral IO only inserted if tibial access inadequate; may be selection bias for those with low flow via tibial route. Small numbers.
			Flow rate with pressure bag	Tibia: 165.3ml/min; Humerus: 153.2ml/min
			Difference in flow rate with pressure bag (matched pairs only)	0.4ml/min (95% CI -35.2 - 36.1); Favours tibia
Miller L 2010 USA	Ten volunteers underwent IO insertion in each tibia. A further ten underwent IO insertion in the right humerus. Flow rates at increasing infusion pressures recorded.	Volunteer trial	Mean flow rate with 300mmHg pressure	Left tibia 828 ml/hr; Right tibia 1048ml/hr; Right humerus 5093ml/hr	Sponsored by manufacturer. Conference abstract only. Wide range of flow rates between individuals (828-9000ml/hr at humeral site). Small numbers.

Comment(s)

The use of the intraosseous route to gain vascular access in an emergency when peripheral intravenous access is difficult is well established. Some animal models have found that the humeral route permits more rapid infusions than the tibial [3,4]. Miller also found a significantly higher flow rate via the humeral route when using healthy volunteers [2]; this was not replicated by Ong et al. when studied in actual patients [1]. The studies are all small and suffer methodological flaws. The need for rapid fluid infusion via the intraosseous route is fortunately rare, making large-scale human studies difficult to perform.

Editor Comment

BF

Clinical Bottom Line

There is no overwhelming evidence base to suggest one route supports more rapid fluid infusion than another. Clinicians should use the route with which they are most familiar and comfortable.

References

1. Ong ME, Chan YH, Oh JJ, Ngo AS An observational, prospective study comparing tibial and humeral intraosseous access using the EZ-IO American Journal of Emergency Medicine 2009; 27(1):8-15
2. Miller L, Philbeck T, Montez D and Puga T A two-phase study of fluid administration measurement during intraosseous infusion Annals of Emergency Medicine 2010; 56(3):S151
3. Warren DW, Kissoon N, Sommerauer JF, Rieder MJ Comparison of fluid infusion rates among peripheral intravenous and humerus, femur, malleolus, and tibial intraosseous sites in normovolemic and hypovolemic piglets Annals of Emergency Medicine 1993; 22(2):183-186
4. Lairet JR, Bebarta V, Mathis D, Warren W, Lawler C, Lairet K, Muncy T, Boudreau S, Pitotti R, Brock J, King J Comparison of Intraosseous Infusion Rates of Blood Under High Pressure in an Adult Hypovolemic Swine Model in Three Different Limb Sites Annals of Emergency Medicine 2012; 60(4):S75