Pediatric Intraosseous Vascular Access Clinical Review

A German study of 27 children receiving IO access in the prehospital setting reported successful first attempt IO insertions in 96% of the cases. All insertions were completed within 60 seconds. The researchers concluded that IO infusion was simple, fast and safe for emergency access in children aged six years or less.1

A recent company sponsored retrospective clinical study demonstrated the safety and effectiveness of intraosseous access device (EZ-IO, Vidacare) in pediatric patients with.2 Successful insertion and infusion was achieved in 94% of the patients with insertion times of 10 seconds or less in 77% of the oneattempt successful cases reporting time to insertion. There were 4 minor complications (4%), but none significant. These included.

The risks associated with significant delay in achieving vascular access in unstable pediatric patients for the delivery of emergency fluids and drugs are well known. The most recent American Heart Association (AHA) guidelines for pediatric advanced life support (PALS), recommend that caregivers limit the time attempting venous access if it cannot be achieved quickly; and to instead establish IO access. In cardiac arrest, the guidelines recommend immediate IO access in the absence of immediate IV access.3

Many are concerned about the potential of damage to the epiphyseal growth plates when IO is used in the pediatric patient. There is little in the recent medical literature on this topic, though earlier studies suggest this is not a problem. A preclinical study of IO infusion in 20 young piglets found no growth disturbances or growth plate abnormalities after two months and six months.4 Another preclinical study in rabbits found no damage to bone growth plates following IO infusion of saline and bicarbonate infusions did no damage to growth plates. Loss of bone trabeculae that support the growth plate was observed, but the loss was rapidly repaired.5 IA 1942 clinical study examined long-term bone abnormalities during radiographic follow-up in 36 pediatric patients. No patient exhibited any bone abnormality and bone growth was normal for all patients. In an early (1942) study of 495 pediatric patients undergoing IO procedures, 36 were randomly selected for long-term radiographic follow-up for bone abnormalities. None of the 36 patients showed abnormality and in every instance the growth of the bone had proceeded normally on both sides.1 Investigators found no bone defects or distortions at six and 12 weeks post insertions in 1986 study of IO use in 10 pediatric patients.2

A 1990 review article published in the New England Journal of Medicine stressed the relative safety of IO and reported earlier findings of no lasting negative effects of IO infusion on thebone, growth plates and marrow elements.3

In conclusion, evidence from the peer-reviewed literature validates that IO insertion is a safe and effective way to expedite vascular access in the pediatric patient population. This reinforces the AHA’s recommendation that little time should be spent before attempting IO vascular access in pediatric patients in emergency situations.

References

  1. Helm M, Hauke J, Bippus N, Lampi L. Intraosseous puncture in preclinical emergency medicine: Ten years experience in air rescue service. Anaesthesist 2007;56(1):18-24.
  2. Horton MA, Beamer C. Powered intraosseous insertion provides safe and effective vascular access for pediatric emergency patients. Pediatric Emergency Care 2008;24(6):347-50.
  3. American Heart Association. Part 12: pediatric advanced life support. Circulation 2005;112:167-87.
  4. Brickman KR, Rega P, Koltz M, Guinness M. Analysis of growth plate abnormalities following intraosseous infusion through the proximal tibia epiphysis in pigs. Annals of Emergency Medicine 1988;17(2):121-3.
  5. Dedrick DK, Mase C, Ranger W, Burney RE, The effects of intraosseous infusion on the growth plate in a nestling rabbit model. Annals of Emergency Medicine 1992;21(5):494-7.
  6. Heinild S, Sondergaard T, Tuvad F. Bone marrow infusion in childhood. Journal of Pediatrics 1947;30:400-12.
  7. Iserson KV, Criss E. Intraosseous infusions: a usable technique. American Journal of Emergency Medicine 1986;4(6):540-2.
  8. Fiser DH. Intraosseous infusion. New England Journal of Medicine 1990;322(22):1579-81.