Intraosseous fluid: Which route is most rapid?
Date First Published:
March 24, 2013
Last Updated:
April 25, 2013
Report by:
Michael Stewart, ST5 Emergency Medicine (Blackpool Victoria Hospital)
Search checked by:
Shelley Regan, Blackpool Victoria Hospital
Three-Part Question:
In [adult patients requiring volume replacement] does the [humeral or tibial site for intraosseous access] provide [higher fluid flow rates]?
Clinical Scenario:
You are at the scene of a car crash with a medical team. The driver is showing signs of hypovolaemic shock, and the limited access and poor light make vascular access difficult. You elect to insert an intraosseous needle, but while preparing the proximal tibial site a paramedic suggests that using the humerus will allow for faster fluid infusion. You wonder if there is any evidence for this?
Search Strategy:
[exp INFUSIONS, INTRAOSSEOUS/ OR intraosseous.ti,ab OR IO.ti,ab] AND [exp HUMERUS/ OR humer*.ti,ab] AND [exp TIBIA/ OR tibi*.ti,ab]
Limit to: English Language
Limit to: English Language
Search Details:
Medline 1950 - Week 12 2013 via NHS Evidence
EMBASE 1980 – Week 12 2013 via NHS Evidence
EMBASE 1980 – Week 12 2013 via NHS Evidence
Outcome:
29 papers were identified by the stated search in Medline and 38 in EMBASE. One relevant paper was identified from Medline. The Embase search produced one further relevant result which was a non-systematic review; one relevant reference from this was used in this BET. In total two papers were found which provided the best evidence to answer this question.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| An observational, prospective study comparing tibial and humeral intraosseous access using the EZ-IO Ong ME, Chan YH, Oh JJ, Ngo AS 2009 Singapore | 24 patients requiring intrasosseous access in opinion of treating doctor. All had tibial access; second line in humerus also inserted if clinically indicated; this occurred in 11 patients. | Prospective observational study | Flow rate with no pressure bag | Tibia: 73ml/min; Humerus 84.4ml/min | Observational study, not blinded or randomised. Humeral IO only inserted if tibial access inadequate; may be selection bias for those with low flow via tibial route. Small numbers. |
| Flow rate with pressure bag | Tibia: 165.3ml/min; Humerus: 153.2ml/min | ||||
| Difference in flow rate with pressure bag (matched pairs only) | 0.4ml/min (95% CI -35.2 - 36.1); Favours tibia | ||||
| A two-phase study of fluid administration measurement during intraosseous infusion Miller L, Philbeck T, Montez D and Puga T 2010 USA | Ten volunteers underwent IO insertion in each tibia. A further ten underwent IO insertion in the right humerus. Flow rates at increasing infusion pressures recorded. | Volunteer trial | Mean flow rate with 300mmHg pressure | Left tibia 828 ml/hr; Right tibia 1048ml/hr; Right humerus 5093ml/hr | Sponsored by manufacturer. Conference abstract only. Wide range of flow rates between individuals (828-9000ml/hr at humeral site). Small numbers. |
Author Commentary:
The use of the intraosseous route to gain vascular access in an emergency when peripheral intravenous access is difficult is well established. Some animal models have found that the humeral route permits more rapid infusions than the tibial [3,4].
Miller also found a significantly higher flow rate via the humeral route when using healthy volunteers [2]; this was not replicated by Ong et al. when studied in actual patients [1].
The studies are all small and suffer methodological flaws. The need for rapid fluid infusion via the intraosseous route is fortunately rare, making large-scale human studies difficult to perform.
Miller also found a significantly higher flow rate via the humeral route when using healthy volunteers [2]; this was not replicated by Ong et al. when studied in actual patients [1].
The studies are all small and suffer methodological flaws. The need for rapid fluid infusion via the intraosseous route is fortunately rare, making large-scale human studies difficult to perform.
Bottom Line:
There is no overwhelming evidence base to suggest one route supports more rapid fluid infusion than another. Clinicians should use the route with which they are most familiar and comfortable.
References:
- Ong ME, Chan YH, Oh JJ, Ngo AS. An observational, prospective study comparing tibial and humeral intraosseous access using the EZ-IO
- Miller L, Philbeck T, Montez D and Puga T. A two-phase study of fluid administration measurement during intraosseous infusion
- Warren DW, Kissoon N, Sommerauer JF, Rieder MJ. Comparison of fluid infusion rates among peripheral intravenous and humerus, femur, malleolus, and tibial intraosseous sites in normovolemic and hypovolemic piglets
- Lairet JR, Bebarta V, Mathis D, Warren W, Lawler C, Lairet K, Muncy T, Boudreau S, Pitotti R, Brock J, King J. Comparison of Intraosseous Infusion Rates of Blood Under High Pressure in an Adult Hypovolemic Swine Model in Three Different Limb Sites