Intraosseous Vascular Access: a Review

TRAUMA Review Article Trauma 14(3) 195–232 ! The Author(s) 2012 Intraosseous vascular access: Reprints and permissions: sagepub.co.uk/journalsPermissions.nav A review DOI: 10.1177/1460408611430175 tra.sagepub.com James H Paxton Abstract Intraosseous cannulation is an increasingly common means of achieving vascular access for the administration of fluids and medications during the emergent resuscitation of both paediatric and adult patients. Improved tools and techniques for intraosseous vascular access have recently been developed, enabling the healthcare provider to choose from a wide range of devices and insertion sites. Despite its increasing popularity within the adult population, and decades of use in the paediatric population, questions remain regarding the safety and efficacy of intraosseous infusion. Although various potential complications of intraosseous cannulation have been theorized, few serious complications have been reported. This article aims to provide a review of the current literature on intraosseous vascular access, including discussion on the various intraosseous devices currently available in the market, the advantages and disadvantages of intraosseous access compared to conventional vascular access methods, complications of intraosseous cannulation and current recommendations on the use of this approach. Keywords Review, intraosseous, vascular access, resuscitation, infusion Introduction Quicker alternatives to PIV access for the administration of medications and fluids include Vascular access can be difficult to obtain in both the endotracheal (ET), oral, subcutaneous (SC) children and adults, especially during emergent and intramuscular (IM) routes. But many med- resuscitations. Even under the best of circum- ications cannot be administered via one or more stances, first-attempt success rates for peripheral of these routes, and none of these routes allow intravenous (PIV) catheter placement range for blood collection for laboratory analysis. from 34% to 75%, and 1 in 10 patients will Central venous catheter (CVC) placement is still be without vascular access after two PIV attempts (Kanter et al., 1986; Frey, 1998; Lininger, 2003; Black et al., 2005; Yen et al., Department of Emergency Medicine, Detroit Medical 2008; Paxton et al., 2009). Moreover, studies Center, Detroit, MI, USA have shown that the longer healthcare pro- Corresponding author: James H Paxton, Department of Emergency Medicine, viders take in attempting PIV placement, the Detroit Medical Center, 4201 Saint Antoine Street, less likely they are to ultimately succeed Suite 3R, Detroit, MI 48201, USA. (Jacobson and Winslow, 2005). Email: [email protected] 196 Trauma 14(3) commonly used in emergency situations in (Langer, 1870; Siraud, 1895; Drinker and which PIV access is either impossible or inade- Drinker, 1916; Drinker et al., 1922). Whether quate. Yet, even in the most capable hands, or not Drinker invented the concept of ‘marrow CVC placement can take up to four times infusions’, he was among the first to go beyond longer than PIV placement, and is associated descriptive anatomic studies to show the thera- with a higher incidence of life-threatening com- peutic utility of this technique. plications (Scott, 1988; Taylor and Palagiri, In 1916, Drinker and colleagues published 2007; Zingg et al., 2008; Askegard-Giesmann their initial report of an experiment in which a et al., 2009; Leidel et al., 2009; Paxton et al., cannula was inserted through the popliteal 2009). artery of an anaesthetized dog into the mouth Problems with these conventional routes for of the tibial nutrient artery (Drinker and medication and fluid administration have led Drinker, 1916). After injecting various sub- healthcare providers to explore the utility of vas- stances into the nutrient artery (including India cular access via intraosseous (IO) infusion. ink, hirudinized blood, physiological salts and Multiple studies have shown IO access to be typhoid vaccine), Drinker studied the way in faster and easier than traditional methods of which these substances were removed by the vascular access, including umbilical vein cathe- venous drainage system. He found that sub- terization (Abe et al., 2000), peripheral IV access stances injected in this manner were more or (Banerjee et al., 1994; Paxton et al., 2009) and less evenly distributed throughout the bone, central venous (CV) access (Leidel et al., 2009; and that increased infusion pressure enabled Paxton et al., 2009). These devices are also higher rates of blood flow through the venous versatile, appropriate for a wide variety of ana- plexus. Infusing a hirudinized physiological salt tomic sites, and have been used in patients of solution at pressures up to 240 mmHg, he was every shape and size, from the super-obese to able to increase the rate of blood flow through 800 -g premature babies (Ramet et al., 1998). the dog tibia from a physiological rate of 15 mL/ Although researchers have been studying the min to as high as 60 mL/min. He was also able intraosseous circulation for centuries, we have to induce vasoconstriction of the venous plexus yet to master this potentially life-saving tech- using direct nerve stimulation and intravenous nique. The present review will provide a histor- epinephrine infusion (Drinker et al., 1922). ical perspective on the development of Charles A. Doan, a medical student at Johns medullary infusion techniques and outline Hopkins University, was also studying the recent advances in our use and understanding of venous drainage of the long bones in 1922. IO vascular access. Along the way, we will Attempting to delineate the microscopic anat- explore some of the limitations and complica- omy of the radius and ulna in several animal tions associated with IO infusion and identify models, he injected saline and India ink into areas in which further study is needed. the IO space. Constricted by the ‘rigid bony con- fines’ of the cortex, Doan found that venous History of intraosseous access drainage from the IO space was relatively con- stant, regardless of the systemic blood pressure Cecil K. Drinker (1887–1956), a Harvard phys- or volume of fluid infused. Excessive infusion iologist, is frequently cited as the inventor of pressures caused capillary rupture and extrava- therapeutic intraosseous infusion. But Drinker sation in his model, rather than increased out- himself acknowledged previous bone marrow flow. However, his examination of hypoplastic infusion studies by French anatomists Marie (‘yellow’) marrow revealed a complex network François Xavier Bichat (1771–1802) and M. of ‘functionally dormant’ capillaries, which he Siraud, Austrian anatomist Karl Langer (1819– theorized might be recruited to enhance outflow 1887), and the German anatomist Franz Mu¨ller in times of ‘crisis’ (Doan, 1922). Drinker also Paxton 197 believed that ‘large capillaries are frequently dye injected into the tibia of a rabbit ‘took ten practically closed to the passage of blood’, but seconds or less’ to reach the animal’s heart he remained sceptical about the existence of (Tocantins, 1940; Tocantins and O’Neill, Doan’s ‘occult’ system of capillary drainage 1940). The popularity of these articles in the (Drinker et al., 1922). United States and Great Britain initiated an Unfortunately, the progress made towards explosion of interest in IO infusion at the ster- developing a usable clinical technique for IO num and proximal tibia, and led many to believe infusion was disrupted after 1922. Drinker that Tocantins himself had originated the tech- moved on to more detailed studies of the lym- nique (Goerig and Agarwal-Koslowski, 2002). phatic and pulmonary systems, and Doan would Sternal infusions became quite popular subsequently tackle a wide variety of other hae- during World War II, both in the United matological subjects. The technique of sternal States and in Europe. Several authors com- bone marrow biopsy for diagnostic purposes mented on the ease of insertion and the massive was first described by Arinkin (1929). But the volumes that could be infused by this route first reported use of therapeutic IO infusion in (Doud and Tysell, 1942). In 1942, Doud humans came in 1933, when A. Josefson reported a case in which a young soldier with reported 10 cases in which sternal IO injection massive gastrointestinal bleeding was given of Campolon (liver extract) was used to treat 9 L of whole blood and 14 L of fluid (0.85% pernicious anaemia (Josefson, 1934). Soon normal saline and 5% dextrose solutions) other clinical researchers were experimenting through a standard 15-gauge sternal IO with medullary infusion at the sternum, includ- needle over a period of 10 days. No discomfort ing injections of radiographic contrast, bacteria, was noted under gravity infusions, but a mercury and various other medications and ‘moderate, indefinite sense of pressure’ was fluids (Benda, 1937; Benda et al., 1940). described by the patient during pressurized syr- In May of 1940, Norbert Henning, a German inge infusions. Sternal X-rays taken 25 days haematologist, reported his own study of venous after catheter removal were normal, and no drainage from the sternum in an animal model other complications were identified (Doud following injections of whole blood, glucose and and Tysell, 1942). dye. He found that substances injected into the Although Tocantins and others recom- IO space were rapidly taken up by the systemic mended IO access only ‘when quick absorption circulation, and that the time to central circula- is desired and prevailing circumstances...make

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