Comparison of 4 Pediatric Intraosseous Access Devices A Randomized Simulation Study Lukasz Szarpak, PhD, DPH, EMT-P,* Jerzy R. Ladny, PhD, MD,† Marek Dabrowski, MSc, EMT-P,‡ Michael Ladny, MD,§ Jacek Smereka, PhD, MD,|| Sanchit Ahuja, MD,¶ and Kurt Ruetzler, PhD, MD¶# Background: Obtaining intravascular access can be challenging or even impossible in several clinical situations. As an alternative, medications and fluids can be administered via the intraosseous (IO) route, which is a well- tolerated and established alternative, especially in the emergency setting. Methods: Seventy-five novice physicians participated in this randomized simulation study. After a single educational session and 6 months without any clinical application, participants were asked to identify the correct puncture site and obtain IO access using 3 widely used mechanical de- vices (BIG Pediatric, Arrow EZ-IO, NIO Pediatric) and a manual device (Jamshidi needle) on a pediatric manikin and turkey bone, respectively. Results: Sixty-eight participants correctly identified the puncture site and performed IO cannulations. First placement attempt success rate was sim- ilar with mechanical devices (NIO Pediatric, 100%; Arrow EZ-IO, 97%; and BIG Pediatric, 90%), whereas was only 43% using the manual Jamshidi device. Also, procedure time was much faster using mechanical devices (ranging between 18 and 23 seconds) compared with the manual Jamshidi device (34 seconds). Conclusions: Although the efficacy of devices was demonstrated in sim- ulated environment in novice users, further studies are needed to assess the efficacy and safety of devices in clinical comparative settings. With more experienced users, the success rate may differ considerably as compared with naive users. Key Words: intraosseous vascular access, vascular access, simulation study (Pediatr Emer Care 2018;00: 00–00) E stablishment of early and effective vascular access for adminis- tration of pharmacological agents and fluid therapy is critically important in the emergency treatment of severely ill or injured patients. 1–3 Intraosseous (IO) route has already been introduced into clinical practice in the 1920s and has been widely used during the second world war, but its usage declined with the invention of intravenous catheters. 4,5 Intravenous catheters are reported to be easy to use, widely available, inexpensive, and devoid of any IO complications. In the 1980s, IO access was more commonly used again, as it was reported to be useful especially in several emer- gency scenarios. 6 Subsequently, IO administration of medications was incorporated as an alternative to intravascular administration by several international emergency guidelines. 7–11 The bone marrow typically of long bones has a rich network of noncollapsible vessels, which ultimately drain into central cir- culation. These intramedullary vessels can be accessed directly by insertion of specially designed device (known as IO devices) into the network of veins of bone marrow, which can maintain a descent amount of infusion rate for a considerable period of time. The total concentration of drug infused and time to peak via IO route yields comparable results with the intravenous route. 12,13 In principle, the IO technique can be used in all clinical situ- ations and patients, but because of the potential of complications, the IO route is mostly used in the emergency setting. Intraosseous route provides rapid, efficient, and timely access in clinical scenar- ios when intravascular route cannot be established or is difficult to obtain. 14 The preferred site of access in infants and children is the anteromedial surface of the tibia, approximately 1 to 2 cm below the tibia tuberosity. 15 Intraosseous access can be obtained with the help of 2 differ- ent techniques. The manual technique requires moderate to severe force applied by the provider, whereas the mechanical techniques depends on battery-powered or spring-loaded force. However, there are many different IO devices commercially available and the best device for pediatric IO device has not been established yet. Therefore, the aim of this study was to compare the success rate of 4 (mechanic: NIO Pediatric [NIO-P], BIG-P [BIG Pediatric], Arrow EZ-IO [EZ-IO], and the manual Jamshidi IO needle) widely used IO devices in a pediatric manikin study setting. Speed of inser- tion, ease of use, and complications served as secondary outcomes. METHODS Study Design and Participants This was a simulation study with a randomized design. After obtaining institutional review board approval from the Polish So- ciety of Disaster Medicine (approval number 25.12.2016.IRB), we recruited participants among novice physicians of the Polish Society of Disaster Medicine. The study was conducted between June 2016 and February 2017 at the Medical University of Warsaw, Poland, and all physicians participated voluntarily in this study. All participants were never trained on any IO access devices before the study. Devices Four IO access devices were investigated in this study (Fig. 1): 1. NIO-P (New Intraosseous PerSys Medical, Houston, Tex); 2. BIG-P (Bone Injection Gun PerSys Medical, Houston, Tex); 3. The intraosseous drill Arrow EZ-IO (Teleflex Medical Re- search Triangle Park, NC); and 4. Jamshidi IO needle 18G (Jamshidi, Baxter HealthCare Corpo- ration, Deerfield, Ill). From the *Lazarski University, Warsaw, Poland; †Department of Emergency Medicine and Disaster, Medical University Bialystok, Bialystok; ‡Department of Rescue and Disaster Medicine, Poznan University of Medical Sciences, Poznan; §Department of Traumatology and Orthopedics, Hospital SOLEC, Warszawa; ||Department of Emergency Medical Service, Wroclaw Medical University, Wroclaw, Poland; Departments of ¶Outcomes Research, and #General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH. Disclosure: The authors declare no conflict of interest. Funding: This study was funded by internal university funding only. Ethical approval: Approval was granted by the Institutional Review Board of the Polish Society of Disaster Medicine (approval number: 25.12.2016.IRB). Reprints: Kurt Ruetzler, PhD, MD, Department of Outcomes Research; Anesthesiology Institute, Cleveland Clinic, Cleveland, OH (e‐mail: kurt.ruetzler@reflex.at). Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0749-5161 ORIGINAL ARTICLE Pediatric Emergency Care • Volume 00, Number 00, Month 2018 www.pec-online.com 1 Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.