Lee PMJ, Lee C, Rattner P, Wu X, Gershengorn H, Acquah S. Crit Care Med. 2015;43(6):1233-1238
Intraosseous Versus Central Venous Catheter Utilization and Performance During Inpatient Medical Emergencies
Single-center, prospective observational study
Objective
- To assess the performance and utilization of intraosseous access against landmark-guided central venous catheter placement during inpatient medical emergencies
In the event of a medical emergency, obtaining prompt vascular access in critical patients is an essential technical skill for medical emergency team (MET) members. Research has shown that IO devices outperform CVCs in terms of first-pass success rates, rapid placement, and complication rates following training sessions. The authors therefore hypothesized that IO use among house staff trainees on METs would be superior to landmark-guided CVC placement in regard to success rates and time to placement.
The authors enrolled adults experiencing inpatient emergencies such as shock, respiratory distress, and cardiac arrest who required central access placement, between February 2012 and July 2013 at an urban teaching hospital. The hospital METs included post-graduate year (PGY) 1, 2, and 3 internal medicine residents, nurses, a respiratory therapist, and a pulmonary/critical care fellow or attending physician. The team was provided with monthly simulation training on CVC insertion and also a 60-minute IO training and simulation program. The primary landmark for IO placement was the medial aspect of the proximal tibia and the secondary target was the proximal humeral head. The MET leaders recommended that IO access to be used in in-patient emergencies if a CVC could not be placed in two attempts or within 5 minutes, or as the primary access method in the instance of a cardiac arrest. Data collected included insertion times, number of attempts, anatomical location, number of kits used, patient BMI, operator training level, and complications. In addition, insertion sites were inspected 24 hours after initial placement. After 18 months, the MET members were surveyed to assess operator’s experience with IO and CVC training, satisfaction, ease of placement, and any barriers to use. The primary outcome was first-pass success rate of CVC and IO placement.
Secondary outcomes included time to successful placement, number of attempts, BMI, anatomical location, number of kits used, and complications.
Emergent central access placement was observed in 79 patients, with 169 CVC and 33 IO attempts. Femoral CVCs were attempted in 48 patients as the primary device and IO access was used in 31 patients. The proximal tibia was the most commonly attempted IO access site. There were no significant differences between patients who received CVC vs. IO placement.
First-pass success rates were significantly higher for IO attempts than for CVC (90.3 vs. 37.5%; P< 0.001). Overall success rates were also significantly higher during IO attempts than during CVC placement (96.8 vs. 81.3%; P=0.04). Attempts at CVC placement took significantly longer when compared with IO (10.7 vs. 1.2 min; P<0.001), with placement time measured from the opening of the kit to when marrow aspirates were confirmed from the attached tubing. Mean CVC attempts per patient were significantly higher (2.8 vs. 1.1; P<0.001) with more CVC kits used, on average, per patient than IO (1.3 vs. 1.1; P=0.03). Observed complications with CVC placement included arterial puncture, bladder puncture, and kinked guidewire. Observed complications related to IO placement included extravasation of vasopressors into the subdermal space, significant pain, and needle dislodgment. Survey results indicated that MET members had a rating of 4 out of 5 in their confidence with IO placement and recalled 81.3% successful first-pass IO attempts. For CVC placement, the median confidence score was 4.5 out of 5, however, close to 60% of respondents recalled multiple failed attempts. The most notable barriers to IO kit use were a delay in kit acquisition (28.1%), followed by poorly stocked kits (6.3%).
In conclusion, IO placement was a faster means to obtain central access and had higher first-pass success rates when compared to landmark-guided CVC placement.
Furthermore, the study demonstrated that it is feasible to incorporate this new technical skill into a MET training program. Complications from IO insertion were far fewer
when compared with CVC placement (three of 31 vs. 24 of
48 patients). The authors state that the use of intraosseous needles in hospitals should be “viewed as a ‘bridge’ to resuscitation with the goal of placing a sterile, ultrasound guided, CVC in an ICU.” The limitations of the study include the use
of a small convenience sample from a single institution and inconsistent data collection on weekends and nights.
Conclusions
The authors concluded that:
- Intraosseous access is feasible and should be considered during adult inpatient emergencies
- Intraosseous needles are a much faster means to obtain central access with higher first-attempt success rates when compared to CVCs, potentially leading to earlier administration of time-sensitive therapies
- Operators, including junior trainees, show both high satisfaction and confidence with use of intraosseous access
Tables recreated from original article
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