Clinical paperEZ-IO® intraosseous device implementation in a pre-hospital emergency service: A prospective study and review of the literature?
Introduction
Rapid intravascular access is frequently required in order to administer emergency drugs or fluids in critical patients. Peripheral venous cannulation remains the standard of care, but may be altogether difficult to achieve and time-consuming in life-threatening situations. Intraosseous (IO) access is increasingly recognised as an effective alternative to peripheral venous cannulation. The IO access is characterised by a rapid learning curve and an effectiveness equivalent to peripheral venous cannulation in terms of pharmacokinetic and clinical efficacy.1, 2 Initially used in children, IO access has been implemented progressively with good results in the adult population, particularly since the development of the semi-automatic insertion devices in the late 90s, which may be more effective than manual IO techniques.3 Since 2010, IO access became a standard of care in adult advanced life support and the first recommended alternative to peripheral venous cannulation in cardiac arrest patients.4 Contraindications include orthopaedic hardware, infection at the site of insertion, traumatic extensive limb injuries, amputation of a limb and osseous pathologies such as osteogenesis imperfecta.5
The EZ-IO®, a new power drill semi-automatic device, has been introduced over the last ten years. To date, several articles about the EZ-IO device use have been published. They are mainly focused on the success rate and rapidity of insertion, but there is limited information about the complications and outcomes of patients in whom an intraosseous access has been attempted.
We prospectively studied the indications, localisations, medications administered and success rate of achieving intraosseous access with the EZ-IO in a physician-based pre-hospital setting. The complications and mortality rate of patients were also recorded. At the same time, all the published studies involving the EZ-IO device in the emergency setting were systematically reviewed in order to compare the results of our study, and to inventory all drugs and fluids administered by this route.
Section snippets
Study design and setting
This prospective study was conducted from January 1st, 2009 to December 31st, 2011, in the pre-hospital emergency medical service (EMS) of the Centre Hospitalier Universitaire Vaudois (CHUV). The CHUV is a 1000-bed university hospital located in Lausanne, Switzerland, and is the level 1 Trauma Centre and Burn Centre for a population of over one million people in the western part of the country. It is also the primary hospital for an immediate catchment area comprising about 300 000 persons. Road
Results
Among the 8378 patients who required an emergency physician intervention during the study period, 58 patients (0.7%) met the inclusion criteria, representing 60 EZ-IO insertion attempts (two patients each underwent two intraosseous insertion attempts).
Discussion
The predominance of males among our study subjects is consistent with the findings of other studies, and is most likely explained by the large proportion of cardio-respiratory arrests and major trauma situations. The 90% success rate of EZ-IO insertion in our study is similar to the pooled data of the available studies (Table 2).6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 The failure to achieve IO access in our study was
Conclusion
The EZ-IO device was shown to be effective in achieving vascular access in the pre-hospital setting. The 90% success rate, the localisation of insertion and the reasons for inserting an intraosseous device were similar to what is described in the literature. The intraosseous route can be used to administer a wide range of drugs and fluids.
Further studies are needed to evaluate the impact of the intraosseous route, particularly on the patient's survival, and on the occurrence of delayed
Conflict of interest statement
None to declare. The EZ-IO devices were the property of the Emergency Service and the study was conducted independently of the manufacturer.
Source of funding
Funding was provided exclusively by the Emergency Service, Lausanne University Hospital, Lausanne, Switzerland.
Acknowledgement
We would like to thank Danielle Wyss for proofreading and final translation.
References (42)
- et al.
Use of a battery-operated needle driver for intraosseous access by novice users: skill acquisition with cadavers
Ann Emerg Med
(2009) - et al.
Does intraosseous equal intravenous? A pharmacokinetic study
Am J Emerg Med
(2008) - et al.
Intraosseous access in osteogenesis imperfecta (IO in OI)
Resuscitation
(2009) - et al.
Complication of intraosseous administration of systemic fibrinolysis for a massive pulmonary embolism with cardiac arrest
Resuscitation
(2012) - et al.
A compartment syndrome secondary to intraosseous infusion
Ann Fr Anesth Reanim
(2011) - et al.
Intraosseous injection of iodinated computed tomography contrast agent in an adult blunt trauma patient
Ann Emerg Med
(2011) - et al.
Systemic fibrinolysis through intraosseous vascular access in ST-segment elevation myocardial infarction
Ann Emerg Med
(2011) - et al.
Efficient prehospital induction of therapeutic hypothermia via intraosseous infusion
Resuscitation
(2010) - et al.
Feasibility of point-of-care colour Doppler ultrasound confirmation of intraosseous needle placement during resuscitation
Resuscitation
(2009) - et al.
Intraosseous needles: they’re not just for kids anymore
J Emerg Nurs
(2008)
EZ-IO in the ED: an observational, prospective study comparing flow rates with proximal and distal tibia intraosseous access in adults
Am J Emerg Med
Efficacy and safety of the EZ-IO intraosseous device: out-of-hospital implementation of a management algorithm for difficult vascular access
Resuscitation
An observational, prospective study comparing tibial and humeral intraosseous access using the EZ-IO
Am J Emerg Med
Paramedics successfully perform humeral EZ-IO intraosseous access in adult out-of-hospital cardiac arrest patients
Am J Emerg Med
Comparison of intraosseous versus central venous vascular access in adults under resuscitation in the emergency department with inaccessible peripheral veins
Resuscitation
Intraosseous versus intravenous vascular access during out-of-hospital cardiac arrest: a randomized controlled trial
Ann Emerg Med
Comparison of two intraosseous access devices in adult patients under resuscitation in the emergency department: a prospective, randomized study
Resuscitation
Intraosseous extravasation complication reports
Ann Emerg Med
Intraosseous infusion: an alternative route of pediatric intravascular access
Ann Emerg Med
Osteomyelitis at the injection site of adrenalin through an intraosseous needle in a 3-month-old infant
Resuscitation
Gas embolism following intraosseous medication application proven by post-mortem multislice computed tomography and autopsy
Resuscitation
Cited by (94)
Clinical evaluation of intravenous alone versus intravenous or intraosseous access for treatment of out-of-hospital cardiac arrest
2021, ResuscitationCitation Excerpt :In prehospital OHCA, EZ-IO has been used as second line therapy when IV failed, although these studies had small sample sizes. Between 58–95 patients received tibial IO for each study with success rates between 89.7% to 97%.3,6–8 Studies on automated devices have found a higher success rate for EZ-IO compared to BIG9 or FAST1.10
Intraosseous needles in pediatric cadavers: Rate of malposition
2019, ResuscitationInsights From a Tertiary Care Intraosseous Insertion Practice Improvement Registry: A 2-Year Descriptive Analysis
2019, Journal of Emergency NursingTrauma
2019, A Practice of Anesthesia for Infants and ChildrenSex differences in appropriate insertion depth for intraosseous access in adults: An exploratory radiologic single-center study
2024, Journal of Vascular Access
- ?
A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2012.11.006.