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+ years).

Search outcome

Five hundred and eighteen papers were found. The majority of them were case reports. Only two trials and one cohort study seemed to address our specific question, one of which was identified through a bibliographical search of a review on the subject table 2.

Embase [(exp intraosseous drug administration)] AND [(exp heart arrest) OR (exp resuscitation) OR (exp fluid resuscitation)]. Limit search to human and English language. Seventy-seven papers were found but none were relevant to our question.

Cochrane database No yield.

Abbreviations

CVC central venous catheter, PHIO proximal humerus intraosseous, PVC peripheral venous catheter.

Comments

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 (International Liaison Committee on Resuscitation) 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 prehospital and hospital settings (by 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.

▶ Paxton JH, Knuth TE, Klausner HA. Proximal humerus intraosseous infusion: a preferred emergency venous access. J Trauma 2009;67:606–11.

▶ Waisman M, Waisman D. Bone marrow infusion in adults. J Trauma 1997;42:288–93.

▶ Macnab A, Christenson J, Findlay J, et al. A new system for sternal intraosseous infusion in adults. Prehosp Emerg Care 2000;4:173–7.

▶ Drinker C, Drinker K, Lund C. The circulation in the mammalian bone marrow. Am J Physiol 1922;62:1–92.

▶ 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;67:213–47.

▶ Cooper BR, Mahoney PF, Hodgetts TJ, et.al. Intra-osseous access (EZ-IO) for resuscitation: UK military combat experience. JR Army Med Corps 153:314–16.

▶ Josefson A. A new method of treatment—intraossal injections. Acta med Scandinav 1934;81:550.