Coimbatore Call Girls in Coimbatore 7427069034 genuine Escort Service Girl 10...
17.15 17.30 john rogers - publiceren
1. Safety
of
Intraosseous
Vascular
Access
in
the
21st
Century
John
J.
Rogers,
MD,
FACS,FACEP
ED
Medical
Director
Coliseum
Health
System,
Macon,
Georgia,
USA
Board
of
Directors
American
College
of
Emergency
Physicians
6. The
Problem
IV
Cannot
Be
Started
in
over
5
Million
IV
Extremely
Difficult
in
over
7
Million
Anxiety
and
Panic
Thousands
Die
Every
Year
7. Current
SoluTons
to
IV
Failure
EMS
ET,
SQ,
IM,
Rectal,
Oral,
Nasal,
InhalaTon,
Sublingual,
Transdermal
Drive
FASTER
8. Current
SoluTons
to
IV
Failure
Emergency Department
Central Venous Lines
Time to Insert
Resources – Staff and Equipment (US)
Training
400,000 complications/year (FDA)
$2,300 or more per complication (CDC)
More than 10 % mortality
9. Central Venous Line Challenges
– 5 million central lines placed annually
– 500,000 strictly for rapid vascular access
– Complications in up to 26%
– Infections cost $50,000+ per episode
– Safe placement up to 20 minutes
Initiatives to decrease complications
– Medicare will not pay for complications
– Aim for Zero Campaign
– National Patient Safety Goals
10. NPSG
07.04.01
Implement
evidence
based
precauTons
to
prevent
central
line
associate
bloodstream
infecTons.
Avoid
Central
Lines
12. Current
SoluTons
to
IV
Failure
Alternative – Intraosseous Access (IO)
Standard of care in pediatrics and adults
Recommended if no IV can be established rapidly
Safety and efficacy proven in thousands of cases
Has Saved Hundreds of Lives
13.
14. Thousands of small veins lead from the medullary space to the central circulation
18. Intraosseous
(IO)
Vascular
Access
• Inside the bone is a huge non-collapsible vein
• All drugs reach the circulation the same as IV
• Volume of up to 9 Liters per hour (EZ-IO)
• Pain of insertion equivalent to peripheral (EZ-IO)
• Lab studies, Blood Type
• Lytic therapy, SVT with Adenosine, RSI
• Can be learned easily (EZ-IO)
• Can be inserted quickly (EZ-IO)
• Technology was possible in kids because their bones are soft
19. ComplicaTons
–
Commonly
Reported
Central
Venous
Catheters
Severity
Frequent
Occasional
Rare
Serious
DVT(30%*)
InfecTon
(5-‐9%)
Death
InfecTon
(1%)
DVT
(8
–
26%)
Air
Embolism
(0.5%)
PE
(15
%*)
Bleed/Pneumo
(1-‐3%)
Arterial
puncture
(3.5%)
Less
Serious
Hematoma
(4.5%)
Minor
MalposiTon
(9%)
Intraosseous
Access
Catheters
Severity
Frequent
Occasional
Rare
Serious
OsteomyeliTs
(0.6%)
Less
Serious
ExtravasaTon
(0.8%)
SQ
abscess
(0.1%)
Minor
Leakage
(0.4%)
Removal
problems
(0.2%)
20. Landmark
Study
Rosef
et
al
1985
Meta-‐analysis
of
30
studies
involving
4,270
paTents
Only
37
complicaTons
reported
OsteomyeliTs
most
prevalent
(n=27)
at
0.6%
Device
leh
in
place
many
days
–
weeks
21. Needed:
Update
of
Rosef’s
Numbers
27
years
later,
Rosef’s
0.6%
sTll
quoted
But…IO
has
drasTcally
changed
since
1985
BeKer
devices
Greater
uTlity
BeKer
Guidelines
for
use
dwell-‐Tme
≤
24
hours
(USA)
up
to
72
hours
in
Europe
frequent
site
checks
contraindicaTons
22. Methods
Literature
search
– Pub
Med
– Google
– Vidacare’s
IO
access
bibliography
• Available
at
vidacare.com
Checked
FDA’s
Manufacturer
and
User
Facility
Device
Experience
(MAUDE)
database
for
Medical
Device
Reports
(MDRs)
from
manufacturers
– Available
at
accessdata.fda.gov
23. Intraosseous
Vascular
Access
Serious
ComplicaTons
Found
in
the
Literature:
Osteomyeli*s
Since
Rosef
(1985),
only
single
cases
cited
in
literature
• PlaK
et
al
(1993):
2-‐1/2
month
old
with
IO
needle
leh
in
place
3
days,
resulted
in
fungal
osteomyeliTs;
treated/recovered
• Rosovsky
et
al
(1994):
14
month
old
with
bilateral
femoral
osteomyeliTs
• Barron
(1994):
20
month
old
with
Tbial
osteomyeliTs;
treated/recovered
• Stoll
et
al
(2001):
3
month
old
with
Tbial
osteomyeleTs
aher
adrenalin
infusion;
required
orthopedic
stabilizaTon
surgery
for
recovery
• Dogan
et
al
(2004):
5
month
old
with
Tbial
osteomyeliTs;
treated/
recovered
• Henson
(2010):
62
year
old
with
co-‐morbidiTes
including
diabetes,
MRSA
colonizaTon;
had
Tbial
IO;
presented
6
months
later
with
osteomyeliTs
24. Intraosseous
Vascular
Access
Serious
ComplicaTons
Found
in
the
Literature:
Other
Cases
since
Rosef
(1985)
Compartment
syndrome:
18
Fracture:
3
Skin
necrosis:
2
Suspected
air
embolism:
2
25. Compartment
Syndrome
Atanda
2008,
Am
J
Ortho:
“With
proper
aKenTon
to
detail
and
serial
monitoring
of
the
involved
limb,
compartment
syndrome
and
other
potenTal
complicaTons
of
IO
line
placement
can
be
avoided.”
26. Compartment
Syndrome
Taylor
and
Clark,
2011
BMJ
Compartment
syndrome
leading
to
amputaTon
“by
day
7
the
right
limb
was
perfused
but
the
leh
had
become
demarcated
to
the
mid
calf
level.”
27. Compartment
Syndrome
Waltzman,
Harvard
Medical
School:
“To
aKribute
the
rare
complicaTon
of
compartment
syndrome
to
these
devices
and
not
to
either
the
technique
of
inserTon
or
lack
of
careful
monitoring
is
unfortunate.
These
devices
have
been
shown
to
decrease
the
Tme
needed
to
obtain
vascular
access
and
speed
the
delivery
of
fluids
and
medicaTons,
thereby
saving
the
lives
of
many
children.”
28. Compartment
Syndrome
Waltzman,
Harvard
Medical
School:
Hand
driven
placement
of
IO
needles
are
also
misplaced
either
due
to
incomplete
placement
in
the
marrow
space
or
penetraTon
through
the
posterior
cortex….it
is
not
the
needle
type
that
results
in
extravasaTon,
but
the
difficulty
with
inserTon
and
penetraTon
of
both
corTces
during
stressful
emergency
situa*ons.”
29. Compartment
Syndrome
Moen
and
Sarwark
2008,
Orthopedics
1
case
following
difficult
resuscitaTon
recognized
immediately
Lesson
Use
correct
needle
size,
don’t
force
the
drill,
watch
for
extravasaTon
early
especially
when
giving
large
fluid
volumes,
parTcularly
in
children.
30. EZ-‐IO
Intraosseous
Vascular
Access
Serious
ComplicaTons
Found
on
the
FDA
Website*
Compartment
Syndrome:
4
OsteomyeliTs:
1
In
over
1
million
inserTons
*Source:
www.accessdata.fda.gov/scripts/cdrh/cfdocs/dfMAUDE/search.cfm
32. Summary
• Simple
extravasaTon
most
prevalent
complicaTon:
<5%
of
IO
placements
• OsteomyeliTs
not
a
great
concern
– 6
cases
reported
in
literature
– 1
case
reported
to
FDA
by
MDR
(EZ-‐IO)
• 1
case
out
of
>1
million
placements
=
<0.0001%
• Compartment
syndrome
is
greater
concern
– 18
cases
reported
in
literature
since
1985
– Most
cases
secondary
to
undetected
extravasaTon
– Indicates
need
for
closer
monitoring
of
IO
site
• Other
serious
complicaTons
(e.g.
air
embolism,
fracture)
excep*onally
rare
