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Three Part Question

In [adults in cardiac arrest with no possible IV access], is [intraosseous access] compared to [peripheral/central venous access] a [faster and more reliable option for parenteral drug delivery]?

Clinical Scenario

A 55-year-old female patient is brought into the Emergency Department in cardiac arrest. She is intubated but you cannot get peripheral or central venous access. You wonder if intraosseous access is worth a try to deliver drugs and if this will improve outcome.

Search Strategy

Medline via Ovid interface (1950 to week 4 2010)

{[(exp infusions, intraosseous) OR (intraoss$.mp)] OR [(IO$.mp)]} AND {[(exp heart arrest) OR (cardiopulmonary arrest$.mp) OR (cardio-pulmonary arrest$.mp) OR (cardiac arrest.mp)] OR [(exp resuscitation) OR (resuscitation.mp) OR (exp cardiopulmonary resuscitation) OR (cardio-pulmonary resuscitation.mp) OR CPR.mp]} limit search to English language, humans and all adults (19 plus years).

Search Outcome

518 papers were found. The majority of them were case reports. Only two trials seemed to address our specific question, one was identified through a bibliographical search of a review on the subject.
Embase
[(exp intraosseous drug administration)] AND [(exp heart arrest) OR (exp resuscitation) OR (exp fluid resuscitation)]. Limit search to human and English language. 77 papers were found but none were relevant to our question.
Cochrane database
No yield

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Paxton et al. 2009 USA	Treatment group: 29 patients requiring urgent access received a proximal humerus intraosseous access (PHIO). Control group: 62 patients; 57 received peripheral vascular access (PIV) and 5 a central line (CVC).	Prospective cohort study	Time to catheter insertion with good flow.	Mean time to flow 1.5 minutes in the PIHO group vs. 3.6 minutes in the PIV/CVC group (p<0.001 for PIV and p<0.0056 for CVC). First attempt success rate was 73.7% for PIV, 20% for CVC and 80.6% for PHIO.	Insufficient power to assess for safety of procedure. No follow-up of patients after discharge for potential complications.
			Pain (for patients with a Glasgow Coma scale 15).	Mean pain score: 0.9 and 4.5 for insertion, 0 and 3.8 for infusion for PIV and PHIO respectively.
			Complication rate before leaving the Emergency Department.	Minor complications for PIHO: placement failure (6.7%), inability to flush (10%), poor flow (3.3%), catheter dislodgement(36.7%).
Waisman et al. 1997 Israel	50 patients: Group I: 31 patients for elective limb surgery requiring anaesthesia, Group II: 12 poly trauma and 7 medical emergencies requiring urgent vascular access.	Prospective non-randomised trial.	Success rates.	100% success rate.	Small numbers. Multiple sites used for insertion (tibial tuberosity, malleoli, radius). No follow-up after 24 hours for group 2.
			Time to insertion.	Insertion established within 1-2 minutes .
MacNab et al. 2000 USA/Canada	50 patients who needed urgent vascular access either in hospital or in a pre-hospital setting.	Cohort study.	Success rates.	Success rate 84%.	Small numbers. Low level of evidence.
			Insertion time.	Mean time to insertion 77 seconds.
			Complications.	No complications in the 11 survivors at two months follow-up.

Comment(s)

Intraosseous (IO) cannulation for the infusion of fluids and medications was described by Drinker et al, in 1922. Its first clinical use may have been by Josefson, who treated patients with pernicious anaemia by intraosseous injection of liver extract. The use of intraosseous access and drug administration in the paediatric population has previously been validated and is now widely accepted worldwide. Adult IO administration has been lagging behind for various reasons but the ILCOR guidelines now recognise IO as an alternative when a peripheral or central venous access cannot be obtained. There seem to be a large number of case reports published in the medical literature about the successful insertion and use of IO devices in both pre-hospital and hospital settings (Cooper et al). These describe it as a fast and reliable method to deliver drugs and fluids during cardiopulmonary resuscitation allowing achievement of adequate drug concentrations and desired pharmacological responses. A large comparative study is probably still needed to address its precise role, place and efficacy in cardiopulmonary resuscitation.

Clinical Bottom Line

It appears that IO access is an effective and safe way of obtaining vascular access when other methods have failed.

References

1. Paxton JH, Knuth TE, Klausner HA. Proximal humerous intraosseous infusion: a preferred emergency venous access. Journal of Trauma-Injury Infection & Critical Care 2009; 67 :606-611.
2. Waisman M, Waisman D. Bone marrow infusion in adults. Journal of Trauma-Injury Infection & Critical Care. 1997; 42: 288-293.
3. Macnab A, Christenson J, Findlay J, et al. A new system for sternal intraosseous infusion in adults. Prehospital Emergency Care 2000; 4: 173–177.
4. Drinker C., Drinker K, Lund C. The circulation in the mammalian bone marrow. Am J Physiol. 1922;62:1-92.
5. International Liaison Committee on Resuscitation. 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendation. Part 4 : Advanced life support. Resuscitation 2005 67 ;213-247.
6. Cooper BR, Mahoney PF, Hodgetts TJ, Mellro A. Intra-osseous access (EZ-IO) for resuscitation: UK military combat experience. JR Army Med Corps 153(4): 314-316.
7. Josefson, A New Method of Treatment - Intraossal Injections. Acta med. Scandinav. 1934; 81: 550