[Intraosseous infusion in the pediatric emergency medical service. Analysis of emergency medical missions 1990-2009].

BACKGROUND: Timely establishment of venous access in infants and toddlers during emergency medical care can be a particularly challenging task. Alternative routes for drug and fluid administration, such as endobronchial, intramuscular, central venous or venous cut-down do not offer reliable solutions. Intraosseous infusion (IOI) has become established as an effective alternative intravascular access for rapid and efficient drug delivery. IOI was introduced in our local emergency medical service (EMS) in 1993 and was assigned a high priority in international guidelines for pediatric emergency medical care in 2000 and 2005. The aim of this study was to review the impact of the introduction of IOI on drug administration routes during prehospital emergency treatment of critically ill or severely injured pediatric patients (NACA index V-VII) in our tertiary medical care centre over a period of 20 years.
METHODS: Pediatric prehospital emergency medical protocols from 1990 to 2009 were analyzed with respect to the administration routes for fluids and medications in severely injured or critically ill children with NACA severity scores V-VII. The frequency and mode of vascular access during prehospital treatment including IOI, endobronchial administration, central venous catheterization (CVC) and intramuscular administration as well as prehospital treatment and transportation without vascular access were analyzed. Two groups were compared: the introduction phase of IOI between 1990 and 1999 and the phase of growing IOI routine after introducing guidelines and regular staff IOI technique training between 2000 and 2009. Demographic data and drug administration routes in the two different time periods were analyzed using the Mann-Whitney-u test and t-test or χ(2)-test, respectively. A p-value <0.05 was regarded as significant.
RESULTS: A total of 5,279 pediatric prehospital emergency charts were analyzed and 401 patients (7.6%) were scored as NACA V-VII. At the emergency scene 299 patients (75%) received a peripheral intravenous access, 3 (0.7%) a central venous line access, 77 (19%) an intraosseous needle and in 22 (5.4%) no vascular or intraosseous access was used during the course of prehospital treatment (NACA VII - 13 patients, NACA VI - 2 patients, NACA V - 7 patients). Of the NACA VII patients 3 were transported under continuous cardiopulmonary resuscitation without vascular access. After 2002 all patients with NACA index VII were treated with vascular or intraosseous access. In 48 patients (12%) at least initial medication was given by the endobronchial or alternative route but within the last 3 years endobronchial drug administration was no longer reported. Thus, in 124 critically ill patients (31%) routine peripheral venous access could not be established initially or until the end of treatment (77 times IOI, 22 times no access over the course of treatment, 3 times CVC and 22 times initial endobronchial followed by peripheral venous access). Over the reviewed period the use of IOI increased significantly (p<0.001), while the incidence of lacking vascular access (p<0.05) and alternative drug administration routes (p<0.001) continuously decreased.
CONCLUSION: The IOI technique has not only been assigned a high priority in the guidelines for pediatric emergency care of critically ill children with difficult or failed venous access but has also significantly influenced current prehospital care. The introduction of the IOI technique in our prehospital pediatric emergency system has markedly reduced the number of critically ill or severely injured pediatric patients without vascular access or with less reliable alternative administration routes in the last 20 years.