Comparison Study of Intraosseous, Central Intravenous, Peripheral Intravenous Infusions of Emergency Drugs James P. Orlowski, MD; David T. Porembka, DO; Jean M. John D. Lockrem, MD; Frederick VanLente, PhD \s=b\ Intraosseous infusion of emergency
drugs is a lifesaving alternative to intravenous administration when intravenous access cannot be rapidly established. We
studied the comparative pharmacokinetics of the following six emergency drugs and solutions: epinephrine hydrochloride, 0.01 mg/kg; sodium bicarbonate, 1 mEq/kg; calcium chloride, 10 mg/kg; hydroxyethyl starch, 10 mL/kg; 50% dextrose in water, 250 mg/kg; and lidocaine hydrochloride, 1 mg/kg. Studies were conducted in normotensive, anesthetized dogs, with three animals studied with each of the drugs or solutions and each animal being treated with all three routes of administration (central intravenous, peripheral intravenous, and intraosseous) in randomized sequence. The effects of epinephrine were also assessed in a shock model. The intraosseous route of administration was comparable with the central and peripheral intravenous routes for all of the emergency drugs and solutions studied, with equivalent magnitudes of peak effect or drug level and equal or longer durations of action. Time to placement of the intraosseous needle varied from 15 seconds to 5 minutes, with a mean of 60 seconds. Time to placement of the needle varies with the skill and experience of the individual. With experience, all individuals could place the intraosseous needle in 60 seconds or less. The intraosseous route is comparable in effect to the central and peripheral intravenous routes of drug administration for epinephrine, sodium bicarbonate, hydroxyethyl starch, calcium chloride, 50% dextrose in water, and lidocaine and is a clinically feasible alternative when intravenous access will be critically delayed.
(AJDC. 1990;144:112-117)
'"The technique of intraosseous infusion is a lifesaving alternative when in¬ travenous access is impossible or will be Accepted for publication July 31,1989. From the Pediatric and Surgical Intensive Care Units, The Cleveland (Ohio) Clinic Foundation. Reprint requests to Pediatric Intensive Care, The Cleveland Clinic Foundation, One Clinic Center, 9500 Euclid Ave, Cleveland, OH 44195-5086 (Dr Orlowski).
Gallagher, RN, CCRN;
critically delayed. Despite the skill of many physicians, it is occasionally diffi¬
cult to establish intravenous access, es¬ pecially in children. This problem is compounded in the infant or child in a state of shock or cardiac arrest. In these situations, volume resuscitation is frequently needed and requires direct access to the circulatory system. If pe¬ ripheral venopuncture cannot be accom¬ plished, central venous catheterization or venous cutdown are options, but both require experience, take time, and are fraught with potential complications. A study from a pédiatrie emergency de¬ partment revealed that in 24% (16/66) of cardiac arrest situations, venous access required more than 10 minutes, and in 6% of the cardie arrests, intravenous ' access was never obtained. Intraosseous infusion is a technique for access to the circulation. It is actual¬ ly an intravenous infusion through intramedullary blood vessels within the bone marrow that are held open by a rigid, noncollapsible bony wall. Unlike peripheral veins, the intramedullary blood vessels do not collapse in shock.2 To be of the greatest use as an emer¬ gency alternative to intravenous ac¬ cess, intraosseous infusion of drugs and solutions should be comparable in effect to intravenous infusion. This study was undertaken to compare the pharmacokinetics of emergency drugs and solutions administered by the intraosseous, cen¬ tral intravenous, and peripheral intra¬ venous
and
routes.
MATERIALS AND METHODS This study was approved by the Animal Care and Research Projects Committee of the Cleveland (Ohio) Clinic Foundation. Twenty-one dogs, weighing 18.4 to 26.8 kg, were studied with a 14-gauge bone marrow needle in the distal femur; a 16-gauge, 2-in intravenous catheter in the femoral vein; and a 16-gauge, 2-in intrave¬ nous catheter in a peripheral forepaw vein. Distance of each catheter from the right atri-
estimated by surface measurements in centimeters. The animals were maintained in an anesthetized state with pentobarbital sodium. The drugs and solutions adminis¬ tered by the intraosseous, central intrave¬ nous (femoral vein), and peripheral intrave¬ nous routes were as follows: epinephrine hydrochloride, 0.01 mg/kg; sodium bicarbon¬ ate, 1 mEq/kg; calcium chloride, 10 mg/kg; lidocaine hydrochloride, 1 mg/kg; 6% hydroxyethyl starch in normal saline, 10 mL/kg; and 50% dextrose in water, 0.25 g/kg. Three dogs were studied with each drug or solution administered by each of the three routes in a randomized sequence. The drug effect or level was allowed to return to base¬ line for at least 30 minutes before the drug was administered by an alternate route. Epi¬ nephrine effect was assessed by change in blood pressure, sodium bicarbonate by a change in pH, and end-tidal carbon dioxide
um was
concentration, calcium chloride, by ionized calcium concentrations, lidocaine by plasma lidocaine concentrations, hydroxyethyl starch by colloid osmotic pressure, and 50% dextrose in water by blood glucose concen¬ trations. Drugs were injected as a bolus fol¬ lowed by 5 mL of normal saline to clear the
catheter. Studies of the effect of epinephrine in a shock model were also performed, in which the animal was acutely bled to 50% of its total blood volume (assuming a blood vol¬ ume of 80 mL/kg), and the effects of epineph¬ rine on blood pressure when administered by all three routes were compared. Statistical analysis was by paired t test, analysis of variance, and Duncan's Multiple Range Test. Significance was determined by aP
drugs is a lifesaving alternative to intravenous administration when intravenous access cannot be rapidly established. We
studied the comparative pharmacokinetics of the following six emergency drugs and solutions: epinephrine hydrochloride, 0.01 mg/kg; sodium bicarbonate, 1 mEq/kg; calcium chloride, 10 mg/kg; hydroxyethyl starch, 10 mL/kg; 50% dextrose in water, 250 mg/kg; and lidocaine hydrochloride, 1 mg/kg. Studies were conducted in normotensive, anesthetized dogs, with three animals studied with each of the drugs or solutions and each animal being treated with all three routes of administration (central intravenous, peripheral intravenous, and intraosseous) in randomized sequence. The effects of epinephrine were also assessed in a shock model. The intraosseous route of administration was comparable with the central and peripheral intravenous routes for all of the emergency drugs and solutions studied, with equivalent magnitudes of peak effect or drug level and equal or longer durations of action. Time to placement of the intraosseous needle varied from 15 seconds to 5 minutes, with a mean of 60 seconds. Time to placement of the needle varies with the skill and experience of the individual. With experience, all individuals could place the intraosseous needle in 60 seconds or less. The intraosseous route is comparable in effect to the central and peripheral intravenous routes of drug administration for epinephrine, sodium bicarbonate, hydroxyethyl starch, calcium chloride, 50% dextrose in water, and lidocaine and is a clinically feasible alternative when intravenous access will be critically delayed.
(AJDC. 1990;144:112-117)
'"The technique of intraosseous infusion is a lifesaving alternative when in¬ travenous access is impossible or will be Accepted for publication July 31,1989. From the Pediatric and Surgical Intensive Care Units, The Cleveland (Ohio) Clinic Foundation. Reprint requests to Pediatric Intensive Care, The Cleveland Clinic Foundation, One Clinic Center, 9500 Euclid Ave, Cleveland, OH 44195-5086 (Dr Orlowski).
Gallagher, RN, CCRN;
critically delayed. Despite the skill of many physicians, it is occasionally diffi¬
cult to establish intravenous access, es¬ pecially in children. This problem is compounded in the infant or child in a state of shock or cardiac arrest. In these situations, volume resuscitation is frequently needed and requires direct access to the circulatory system. If pe¬ ripheral venopuncture cannot be accom¬ plished, central venous catheterization or venous cutdown are options, but both require experience, take time, and are fraught with potential complications. A study from a pédiatrie emergency de¬ partment revealed that in 24% (16/66) of cardiac arrest situations, venous access required more than 10 minutes, and in 6% of the cardie arrests, intravenous ' access was never obtained. Intraosseous infusion is a technique for access to the circulation. It is actual¬ ly an intravenous infusion through intramedullary blood vessels within the bone marrow that are held open by a rigid, noncollapsible bony wall. Unlike peripheral veins, the intramedullary blood vessels do not collapse in shock.2 To be of the greatest use as an emer¬ gency alternative to intravenous ac¬ cess, intraosseous infusion of drugs and solutions should be comparable in effect to intravenous infusion. This study was undertaken to compare the pharmacokinetics of emergency drugs and solutions administered by the intraosseous, cen¬ tral intravenous, and peripheral intra¬ venous
and
routes.
MATERIALS AND METHODS This study was approved by the Animal Care and Research Projects Committee of the Cleveland (Ohio) Clinic Foundation. Twenty-one dogs, weighing 18.4 to 26.8 kg, were studied with a 14-gauge bone marrow needle in the distal femur; a 16-gauge, 2-in intravenous catheter in the femoral vein; and a 16-gauge, 2-in intrave¬ nous catheter in a peripheral forepaw vein. Distance of each catheter from the right atri-
estimated by surface measurements in centimeters. The animals were maintained in an anesthetized state with pentobarbital sodium. The drugs and solutions adminis¬ tered by the intraosseous, central intrave¬ nous (femoral vein), and peripheral intrave¬ nous routes were as follows: epinephrine hydrochloride, 0.01 mg/kg; sodium bicarbon¬ ate, 1 mEq/kg; calcium chloride, 10 mg/kg; lidocaine hydrochloride, 1 mg/kg; 6% hydroxyethyl starch in normal saline, 10 mL/kg; and 50% dextrose in water, 0.25 g/kg. Three dogs were studied with each drug or solution administered by each of the three routes in a randomized sequence. The drug effect or level was allowed to return to base¬ line for at least 30 minutes before the drug was administered by an alternate route. Epi¬ nephrine effect was assessed by change in blood pressure, sodium bicarbonate by a change in pH, and end-tidal carbon dioxide
um was
concentration, calcium chloride, by ionized calcium concentrations, lidocaine by plasma lidocaine concentrations, hydroxyethyl starch by colloid osmotic pressure, and 50% dextrose in water by blood glucose concen¬ trations. Drugs were injected as a bolus fol¬ lowed by 5 mL of normal saline to clear the
catheter. Studies of the effect of epinephrine in a shock model were also performed, in which the animal was acutely bled to 50% of its total blood volume (assuming a blood vol¬ ume of 80 mL/kg), and the effects of epineph¬ rine on blood pressure when administered by all three routes were compared. Statistical analysis was by paired t test, analysis of variance, and Duncan's Multiple Range Test. Significance was determined by aP
