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Three Part Question

In [ED pediatric patients] do [powered intraosseous (IO) insertion devices] compared to [intravenous access] provide [safe and effective vascular access]?

Clinical Scenario

An 8-year-old female is hit by a car while riding her bike. Upon arrival to the emergency department she is hypotensive and tachycardic. Multiple intravenous attempts were made en route to the hospital but have been unsuccessful. You question if a powered intraosseous insertion device would provide access as safe and effective as intravenous access?

Search Strategy

Medline 1950-08/11 using OVID interface, Cochrane Library (2011), PubMed clinical queries.
[(exp infusions, intraosseous) AND (powered.mp)]. Limit to English language and human.

Search Outcome

Ten papers were identified; three were relevant to the clinical question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Lamhaut L, et al. 2010 France	Nine nurses and 16 physicians randomly performed 4 procedures on a training manikin. The 4 procedures were (1) IV insertion while wearing standard pre-hospital equipment (IV No-CBRN), (2) IV insertion while wearing CBRN equipment including a filtration respirator and butyl gloves (IV CBRN), (3) IO insertion while wearing standard pre-hospital equipment (IO No-CBRN) and (4) IO insertion while wearing CBRN equipment (IO CBRN). All IO insertions were performed using a battery-powered IO infusion gun (EZ-IO).	Prospective cohort study	Compare the overall time to establish IO infusion with the EZ-IO® device and the equivalent time for peripheral IV infusion	The mean time saved by IO infusion over IV infusion was respectively 20±24 s (P < 0.001) and 39±20 s (P < 0.001) under No-CBRN and CBRN conditions.	Procedures were performed on a manikin. Extremely small sample size of physicians and nurses.
			Emergency personnel in standard (No-CBRN) protective equipment	The time to establish IO infusion was shorter than the equivalent IV time (50±9 vs. 70±30 s).
			Emergency personnel in (CBRN) protective equipment	The time for IO infusion was shorter than for IV infusion (65±17 vs. 104±30 s).
Shavit I, et. al. 2009 Israel and Canada	29 paramedic students watched videos describing the use of two mechanical IO devices, the spring-loaded Bone Injection Gun (BIG), and the EZ-IO. This was followed by a demonstration on how to use each device on a turkey bone model. Subjects were then divided into two study groups: BIG-first or EZ-IO-first. Each participant performed one insertion attempt with each device independently.	Randomized crossover study	Success rate of insertion on first attempt and the preferred device (EZ-IO or BIG)	Participants had a significantly higher one-attempt success rate with the EZ-IO than with the BIG (28/29 vs 19/29, p = 0.016), and selected the EZ-IO as their first choice (20/29)	Powered IO insertion was not compared to manual IO needles. Small sample size. Non-human bone model was used. Bones were stripped of all soft tissue, which may not accurately simulate a human leg. Success rates were recorded after only one attempt.
Horton MA 2008 United States	95 medical and trauma pediatric patients requiring vascular access at a single children’s hospital in Texas. All patients had access attempted using the EZ-IO.	Prospective observational study	Insertion success rate	94% of patients	Lack of definition of time to insertion. Too few patients (N=9) with a GCS score high enough to adequately assess pain levels.
			Patient pain level during insertion and infusion using a modified visual analog scale (1-10)	Mean insertion pain score was 2.3. Mean infusion pain score was 3.2.
			Insertion time (estimated by the operator)	≤10 seconds in 80% of patients
			Types of drugs that could be administered	Fluids, cardiac medications, paralytics, sedatives and glucose
			Device ease of use on a scale of 1-5	Easy to use 71% of the time
			Complications	4% (all classified as minor)

Comment(s)

Vascular access in a pediatric emergency is of extreme importance for the infusion of both fluids and medications. Intraosseous access has been used for over eighty years, but concerns regarding safety and effectiveness have hindered its use. Data with powered devices listed above do not support the previous fear of significant complications, including osteomyelitis. Data from the above mentioned studies also show that IO access is relatively quick and successfully placed, however, these were in non-human models. Further studies in human models are needed.

Clinical Bottom Line

IO insertion and infusion appears to be safe in emergency department pediatric patients and carries a low complication rate. IO insertion using the EZ-IO battery-powered device appears to be effective with fast insertion times on first attempt in non-human models, but further studies are needed to prove effectiveness in humans.

References

1. Lamhaut L. Dagron C. Apriotesei R. Gouvernaire J. Elie C. Marx JS. Telion C. Vivien B. Carli P Comparison of intravenous and intraosseous access by pre-hospital medical emergency personnel with and without CBRN protective equipment Resuscitation January 2010; 81(1):65-8
2. Shavit I. Hoffmann Y. Galbraith R. Waisman Y Comparison of two mechanical intraosseous infusion devices: a pilot, randomized crossover trial Resuscitation 2009 September; 80(9):1029-33
3. Horton MA. Beamer C Powered intraosseous insertion provides safe and effective vascular access for pediatric emergency patients Pediatric Emergency Care 2008 June; 24(6):347-50