Downloaded By: [University of Alberta] At: 18:04 21 June 2007 ABSTRACT Background. Intraosseous (IO) infusion provides an alterna- tive route for the administration of fluids and medications when difficulty with peripheral or central lines is encoun- tered during resuscitation of critically ill and injured patients. Objective. To report the first 50 uses of a new sys- tem for emergency IO infusion into the sternum in adults, the Pyng F.A.S.T.1 IO infusion system. Methods. Six emer- gency departments and five prehospital emergency medical services (EMS) sites in Canada and the United States pro- vided clinical and/or research data on their use of the IO system in a pilot study of success rates, insertion times, and complications. Indications for use included adult patient, urgent need for fluids or medications, and unacceptable delay or inability to achieve standard vascular access. A basic data set was standardized for all sites, and some sites collected additional data. Results. The overall success rate for achieving vascular access with the system was 84%. Success rates were 74% for first-time users, and 95% for experienced users. Failure to achieve vascular access occurred most frequently in patients (5 of 9) described sub- jectively by the user as “very obese,” in whom there was a thick layer of tissue overlying the sternum. Mean time to achieve vascular access was 77 seconds. Flow rates of up to 80 mL/min were reported for gravity drip, and more than 150 mL/min by syringe bolus. Pressure cuffs were also used successfully, although fluid rate was controlled by clamping the line. Further research on flow rates is needed. No com- plications or complaints were reported at two-month fol- low-up. Conclusion. These early data indicate that sternal IO infusion using the new F.A.S.T.1 IO system may provide rapid, safe vascular access and may be a useful technique for reducing unacceptable delays in the provision of emergency treatment. Key words: intraosseous infusion; sternum; adult; vascular access; intravenous; central line. PREHOSPITAL EMERGENCY CARE 2000;4:173–177 There is controversy in the literature concerning the use of intravenous (IV) infusions by paramedics, par- ticularly in trauma patients. 1,2 Resuscitation in the field is hampered by the time and difficulty associated with initiating IV therapy (reported to be as high as 12 minutes in one service), 3–5 the high access failure rate (10–40%), 6 and the small volumes of fluid that are typ- ically administered. 7 In the urban setting, the long delays caused by often unsuccessful attempts to initi- ate IV therapy and stabilize the patient (25 minutes or more) result in higher morbidity and mortality than the “scoop and run” approach. 5,8 However, other cen- ters have reported much shorter access times and higher success rates, and emphasize the need for physician supervision of paramedic care to ensure appropriate use of the technique. 1,6,9 In the 1980s, alternatives to IV cannulation were investigated for situations in which peripheral IV access was unsuccessful, particularly the prehospital environment, and the pediatric population. Over the past two decades, intraosseous infusion (IOI) into the tibia has become a widely accepted procedure for the resuscitation of critically ill and injured children. 10–14 Intraosseous infuson is now considered to be “an effective, reliable and relatively simple technique both for obtaining rapid vascular access and for the admin- istration of fluids and medications in the emergency setting,” but is almost exclusively limited to the pedi- atric population. 15 The only recent report of the use of IOI in the adult population 16 reported no difference between sternal IOI and peripheral vascular access in terms of blood pressure response, and no complications. According to a recent report by Halvorsen et al., 17 the best anatomic site for performing IOI has not yet been determined. There have been reports of the suc- cessful use of the adult tibia as a site for IOI, 18 but it is not considered to be an ideal site because of the phys- Received August 7, 1999, from the University of British Columbia (AM, JC, CR, MW), Vancouver, British Columbia, Canada; the Division of Critical Care, Children’s and Women’s Health Centre of British Columbia (AM), Vancouver, British Columbia, Canada; the Emergency Department, St. Paul’s Hospital (JC), Vancouver, British Columbia, Canada; Pyng Medical Corp. (JF, DJ), Vancouver, British Columbia, Canada; the Emergency Department, Maricopa Medical Center and Arizona Heart Hospital (BH, CP, BT), Phoenix, Arizona; Rural/Metro Ambulance (BH, BT), Phoenix, Arizona; EMS Med Flight One (LJ), Richmond, Virginia; Bates County Hospital (KP), Butler, Missouri; the Emergency Department, University of Maryland Medical Center, VA Hospital (DJR, TS), Baltimore, Maryland; the Emergency Department, Royal Columbian Hospital (CR), New Westminster, British Columbia, Canada; and Erways Ambulance Service (MW), Elmira, New York. Revision received December 8, 1999; accepted for publication December 8, 1999. Supported in part by the Science Council of British Columbia’s Technology BC Program. Equipment and training were provided by Pyng Medical Corp. Some authors (JF, DJ) are shareholders in Pyng Medical Corp., a publicly traded company. Address correspondence and reprint requests to: Andrew J. Macnab, MD, Room 2L5, ICU Physician’s Office, Children’s and Women’s Health Centre of British Columbia, 4480 Oak Street, Vancouver, British Columbia, V6H 3V4, Canada. e-mail: <amacnab @wpog.childhosp.bc.ca>. 173 A NEW SYSTEM FOR STERNAL INTRAOSSEOUS INFUSION IN ADULTS Andrew Macnab, MD, Jim Christenson, MD, Judy Findlay, PEng, MASc, Bruce Horwood, MD, David Johnson, PhD, Lanny Jones, Kelly Phillips, Charles Pollack, Jr., MD, David J. Robinson, MD, Chris Rumball, MD, Tom Stair, MD, Brian Tiffany, MD, PhD, Max Whelan, MD