In the last decades, a traditional technique of intraosseous (IO) infusion for pediatric and adult individuals has regained interest and attention when it became difficult or impossible to use traditional intravenous infusion methods for some patients with severe injuries or critical conditions. This method is safe, simple, rapid and effective, and it can relieve almost every patient in emergency shock through rapid and reliable circulation reconstruction. In this paper, we intend to give a review of the history and current status of IO infusion technology, and provide an outlook on its development.
(I) Background of the era of IO infusion technology development
Although drug administration or rehydration via the IO route in adult emergency individuals is still a new technology in modern emergency medical equipment systems, IO infusion has had a long and rich history. It is unproven that IO technology first originated in the late nineteenth century, but the first scientific study and documentation of IO technology occurred in 1922 when Dr. Drinker of Harvard University, studying the sternal plate circulation, discovered and suggested that the intraosseous cavity was filled with a non-atrophic vein, and he further demonstrated experimentally that substances infused into the bone marrow cavity were quickly absorbed into the central circulatory system . Over the next two decades, research on IO technology developed dramatically.
In 1940, Dr. Tocantins and his colleague O’Neill of Philadelphia demonstrated together in clinical experiments that the marrow cavities of the long bones and sternum could also be used as access points for vascular infusion, and they also demonstrated that red dye injected into the tibial cavity of rabbits appeared in the heart 10 seconds after injection. In addition, the Tocantins published a number of case reports studying IO infusion, developed practical techniques for clinical IO infusion and designed special needles for IO infusion. 1942 Dr. Papper demonstrated that infusions given by IO or intravenous access had essentially identical circulation times, and in 1944 the British internist Hamilton Commenting on the use of IO infusions in wartime London, Dr. Bailey mentioned the potential risk of accidental puncture of the sternum and consequent damage to the heart with the IO needle, and in response Bailey designed a special IO cannula needle to protect the heart.
In the 1940s and 1950s, IO infusion techniques became popular for the administration of medications or blood transfusions to adults or children, and as a result, the technique appeared frequently in medical journals, primarily using manual puncture needles for IO infusions. During World War II, IO infusion was used extensively by field medical treatment facilities and saved the lives of more than 4,000 severely wounded soldiers. Before the use of IO infusion, many soldiers in hemorrhagic shock died because they were unable to establish intravenous fluid circulation, so the U.S. military considered IO infusion to be a standard measure for treating severely wounded soldiers. Unfortunately, the success of IO infusion techniques did not transfer from the military to the local level after World War II until 1968, when the first EMS facility was founded in Chicago by Dr. David Boyd and others. This was largely due to the rapid development and availability of plastic catheters for intravenous infusion and the fact that EMS was developed by local trauma centers rather than being born in the military. As a result, many trauma surgeons were not aware of IO technology and were content as long as those medics could perform IV infusions. It was not until 1984 that Dr. James Orlowski, while visiting cholera-endemic India, discovered that IO infusion techniques were being used to infuse and administer medications and save the lives of many patients who might have died from cholera, and upon his return he published an editorial entitled “My Kingdom of the IV Route” in which he advocated the use of IO techniques in pediatrics. He advocated the use of IO technology in pediatrics. This editorial revived interest in IO infusion techniques and was quickly adopted by pediatric treatment facilities and included in the PALS (Pediatric Advanced Life Support) guidelines, and in 1986, the American Heart Association (AHA) officially approved the inclusion of IO infusion techniques in pediatric emergency resuscitation procedures.
Over the past three decades, many studies have been conducted on the administration and pharmacokinetics of drugs by IO infusion in different animal models. Among them, a review of the literature on IO infusion published in the New England Journal of Medicine in 1990 indicated that any procedure that can be administered intravenously can also be administered by the IO route and can be rapidly absorbed and utilized by the central circulatory system. With the revival and popularity of IO technology, it is reasonable to take a closer look at the use of IO technology in adult individual infusion and how it is changing the way healthcare professionals, nurses, and physicians deliver IV infusions. nurses and physicians in problem solving solutions in difficult intravenous infusion situations.
(II) Current development and principles of IO infusion technology
1. How IO infusion works
There are many non-atrophic venous networks in the bone marrow cavity. In patients in shock or with massive blood loss due to trauma, the peripheral venous network often collapses or closes, while in such cases, the venous network in the bone marrow cavity, which is protected by the bone, is still able to maintain a direct and complete connection with the body circulation due to its special bone structure. It should also be noted that the blood flow through the bone marrow cavity is relatively constant, even in many patients in shock. The pressure of the vessels in the bone marrow cavity is approximately 35/25 mmHg, which is one third of the average arterial pressure of the body. The dense network of tiny, non-atrophic veins in the bone marrow cavity acts like a sponge to rapidly absorb the fluid that is perfused around it and to rapidly transfer it to the body’s circulation. This special anatomy of the veins in the bone marrow cavity is the fundamental reason why IO infusions of fluids or drugs can be rapidly transferred to the circulation and absorbed.
In addition, there is no doubt that the bone marrow cavity is also filled with bone marrow consisting of blood, a network of hematopoietic cells and connective tissue, including mainly red and yellow marrow. The red marrow is mainly located in the reticular cancellous mass at the ends of the long bones and contains a high concentration of blood cells, while the yellow marrow is mainly located in the central cavity of adult long bones. In newborns and children, only red marrow is present, and as they age, some of the red marrow is replaced by fatty tissue and gradually becomes yellow marrow. The fluid or drug infused into the bone marrow cavity, whether through the red or yellow marrow, can quickly reach the body circulation.
2.Current common IO infusion devices
EZ-IO: In 2004, the FDA approved the first battery-powered IO infusion device, EZ-IO, which is unique compared to previous IO infusion devices in that it uses a specially designed drill needle to enter the bone marrow cavity. Compared with other spring-powered IO infusion devices, the battery-powered driver EZ-IO is able to drill the drill needle steadily into the bone marrow cavity. The advantage of this approach is that it is easy and fast for the operator to use and enables more accurate positioning and tighter connection between the puncture needle and the puncture bone site, thus avoiding the possibility of extravasation of infusion fluid to the greatest extent possible.
3.The necessity of promoting IO infusion technology
The rapid development and popularization of intravenous catheter provides an important early treatment measure for emergency medicine, and intravenous infusion can provide a “lifeline” for critically ill patients. is the most critical issue. Typically, it takes about 10-12 minutes to successfully place an intravenous catheter in an adult emergency patient in a moving ambulance, and there is a 10-40% failure rate. Studies have shown that emergency medical system staff perform pediatric indwelling venous catheters in over 5 minutes in one-third of cases and in over 10 minutes in another quarter of cases, and that approximately 6% of cases fail completely and fail to re-establish circulation. Since time is an important factor in emergency care, IO infusion techniques with 70-100% success rate and less than 1 minute for pediatric and adult patients are highly advantageous compared to conventional indwelling catheters. Given the difficulty of inserting the jugular and subclavian veins during CPR, the risk of femoral veins is very high, with an 8.34% chance of thrombosis. Therefore, the recommended approach is to do IO first and then make subclavian vein indwelling after stabilization, which reduces the possibility of complications.
Guidelines from the American Heart Association (AHA), the European Resuscitation Council (ERC), the International Liaison Committee on Resuscitation (ILCOR), and the American Board of Emergency Physicians (NAEMSP).
IO infusion should be considered as early as possible in the establishment of vascular access in the course of an emergency: IO access should be established immediately after 2 unsuccessful peripheral venipunctures in adults, and IO access is preferred in pediatric patients;
Tracheal intubation is no longer recommended;
Central venous administration is also not recommended.
4.Location of IO infusion puncture
Usually, for pediatric patients, the site of choice for IO infusion is mainly at the proximal or distal tibia and the distal femur. In adult individuals, the IO infusion site is mostly chosen at the sternal stalk or tibia. Of course, there are other alternative sites of input, including the radius, ulna, pelvis, clavicle, and heel bone. The choice of the puncture site should take full account of the patient’s age, the prevailing conditions, the puncture device and the experience and level of the operator. Of course, no matter which location is chosen, it should be based on the principle that it is simple and feasible and does not affect resuscitation measures such as cardiopulmonary resuscitation.
5. Indications for carrying out IO infusion techniques
(1) When pediatric emergency patients have an urgent need to establish blood input access, but the intravenous indwelling catheter is very difficult or fails, and delayed treatment may put the patient at risk.
(2) Pediatric resuscitation guidelines usually refer to the “90 seconds; three attempts; either one first” principle of emergency care. That is, for a child in cardiac arrest, attempts should be made to rapidly establish fluid access through IO infusion, peripheral or central intravenous input within 90 seconds, and in practice, these methods can be performed simultaneously.
(3) For a period of time, IO infusion techniques were limited to pediatric patients, but recently the development of IO infusion devices has led to their rapid development as a reliable alternative to traditional IV catheters for adult emergency patients.
(4) Adult patients in shock or heart failure who require intravenous access, but encounter the conditions mentioned in (1), should also be selected for IO infusion measures.
(5) Studies have shown that IO infusion is an alternative and effective measure for infants in infectious shock, dehydrated children, patients in cardiac arrest, burns, epilepsy, or contusions.
6. Contraindications to IO infusion techniques
The current consensus is that the bone where the fracture occurred should not be selected as the site for IO infusion. Patients with osteogenesis imperfecta, patients with severe osteoporosis, and patients with cellulitis at the puncture site are also relatively contraindicated for IO infusion. In addition, once an IO infusion has been attempted on bone, it should be avoided when attempting IO infusion on the same bone again to avoid the risk of potential leakage.
7. Potential complications of IO infusion technique
The most frequently mentioned potential complications of IO placement are necrosis of the muscle and subcutaneous tissue around the injection site due to fluid and drug extravasation, and even the risk of septal syndrome. Infection is also a complication of IO placement, and IO placement may lead to cellulitis and local abscess formation. The risk of osteomyelitis has been reported with IO placement, and studies have shown that the risk of this infection can be reduced to less than 0.6% by strict asepsis, and the rate of infection is lower if the IO puncture device is removed earlier. There is also a common concern about the potential risk of fracture at the puncture site and inhibition of bone growth, but to date there is no direct evidence that IO infusion affects bone growth.
8. A few frequently asked questions about IO infusion techniques
(1) Does it hurt when I do an intramedullary injection puncture? If we divide the pain into 10 levels, level 0 is no pain and level 10 is the most painful. The pain when performing a puncture is grade 2, and only the very thin periosteum is painful. The pain of infusion into the bone marrow is level 10, so the awake patient must be anesthetized with 1% lidocaine first, and the lidocaine needs to be pushed very slowly, and then pushed in quickly with 10 ml (5 ml for children) of saline under pressure after 1 minute. A syringe with a connected connector and saline is required before drilling.
(2) Is there any difference in the infusion rate and pharmacokinetics when different sites are selected for puncture for intramedullary injection? Studies have shown that when the sternum and tibia are selected as puncture sites, the flow rate of fluid can reach 4L/h and the humerus can reach 6L/h. If saline is not pressurized and advanced before the infusion, the infusion rate will be very slow. In terms of pharmacokinetics, the test was done on experimental animals in pigs for each channel. The pigs were made to stop the heart with potassium chloride, and cardiopulmonary resuscitation was performed after 8 minutes, and the cardiopulmonary resuscitation lasted for two minutes, after a total of 10 minutes, the emergency drug was used from each point, and the drug content in the blood was detected: the peak blood concentration in the median elbow vein and tibial IO was the same, and reached the peak in 90s; the peak blood concentration in the humeral and subclavian veins was the same, and The peak is reached in 30s. While the vein takes 5~7 minutes to complete, IO is much faster.
(3) Is there any difference between IO puncture dosing and conventional IV catheter dosing? Studies have shown that the dose of medication used is the same as that of IV, and IO can be used for all medications available for IV, including all blood products.
(iii) Outlook for IO infusion technology
IO infusion technology has been widely used in pediatric emergency medicine for the past 20 years. The IO infusion device development organizations in the United States are now working to standardize and upgrade IO infusion techniques so that they can be incorporated as soon as possible into standard measures applied to adult emergencies, which is especially important for critically ill emergency patients for whom indwelling intravenous catheters are very difficult or have failed. It is gratifying to note that newly developed IO infusion devices and a better understanding of the advantages of IO infusion techniques are further driving the process of expanding the use of this infusion modality. Despite the fact that rapid and effective intravenous input is the consensus of every first responder, 10-30% of critically ill patients transported to the ED are still not able to have an intravenous catheter infusion established quickly and effectively, and this has not changed in the last 25 years. With the gradual expansion and widespread use of the three FDA-approved IO infusion devices, it is optimistic that this situation is likely to change radically in the near future.
U.S. IO infusion technology professionals predict that the future development of cutting-edge, state-of-the-art devices for adult IO infusion will be based on the current need to better address the needs of patients who have difficulty with intravenous catheter infusion and to provide more robust technical expertise to acute care specialty facilities. For example.
(1) New guidelines may specify that each critically ill patient requiring infusion may choose to be infused or administered by intravenous catheter (IV) infusion or intraosseous (IO) infusion;
(2) All ALS drugs will be administered rapidly within 5 minutes;
(3) The study will also demonstrate that IO infusion techniques are not only rapid, but will also improve resuscitation outcomes.
(4) Several other anatomical sites for IO puncture will be identified and utilized. This may include the femur, clavicle, radius, heel, elbow eminence, etc. In fact, just as an IV needle can puncture any vein, so will a future IO puncture needle be able to puncture any bone for infusion.
(5) In the future, IO puncture infusion may replace the current deep venous puncture infusion technique used in the emergency department in adult emergency patients. This is because IO infusion techniques are faster, safer, and less costly.
(6) IO infusion techniques will become the preferred option for patients who have not been able to effectively establish venous catheterization to date.