Effectiveness of intraosseous access during resuscitation. A retrospective cohort study.

Effectiveness of intraosseous access during resuscitation. 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A retrospective cohort study. Tim W.H. Rijnhout, Marin Kieft, Willemijn M. Klijn, Edward C.T.H. Tan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4344697/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 15 Oct, 2024 Read the published version in BMC Emergency Medicine → Version 1 posted 9 You are reading this latest preprint version Abstract Purpose During resuscitation in emergency situations, establishing intravascular access is crucial for promptly initiating delivery of fluids, blood, blood products, and medications. In cases of emergency, when intravenous (IV) access proves unsuccessful, intraosseous (IO) access serves as a viable alternative. However, there is a notable lack of information concerning the frequency and efficacy of IO access in acute care settings. This study aims to assess the efficacy of intraosseous (IO) access in acute care settings, especially focusing on children in a level 1 trauma center. Methods This retrospective study included patients with IO access in a level 1 trauma center emergency department (ED) between January 2015 and April 2020. Data regarding medication and fluid infusion was documented, and the clinical success rate was calculated. Results Of the 109,548 patients that were admitted to the ED, 25,686 IV lines were inserted. Documentation of 188 patients of which 73 (38.8%) children was complete and used for analysis. In these 188 patients, a total of 232 needles were placed. Overall, 182 patients had a functional needle (204 needles) (88%). In children (age < 18 years) success rate was lower as compared to adults, 71–84% as compared to 94%. However, a multivariate regression showed no correlation between the percentage of functional needles and gender, age, weight, BMI, health care location (prehospital and in hospital), anatomical position (tibia as compared to humerus) or type of injury. Conclusion Intraosseous access demonstrates a high success rate for infusion, independent of gender, age, body size, anatomical positioning, or healthcare setting, with minimal complication rates. Caution is especially warranted for children under the age of six months, since success rate was lower. Intraosseous infusion Trauma Resuscitation Emergency Department Figures Figure 1 Introduction During resuscitation in emergency situations, establishing intravascular access is crucial for promptly initiating delivery of fluids, blood, blood products, and medications. [ 1 ] When intravenous (IV) access fails or is insufficient, intraosseous (IO) access provide a rapid, stable, safe, and effective alternative [ 2 ] [ 3 ]. IO needles were first introduced in the 1940’s but disappeared due to introduction of plastic peripheral venous needles. In the 1980’s IO needles were re-introduced as a rapid alternative after failure of peripheral venous access. Nowadays, the European Resuscitation Council Guidelines for Resuscitation recommend an IO access when the first attempts at establishing IV access is unsuccessful or challenging. The challenges encountered may be influenced by patient-specific factors, such as age and weight, the expertise of healthcare practitioners, the type of cannula employed, and the anatomical location on the body. [ 4 ] In pediatric resuscitation, the use of IO needles is recommended when it is likely to be difficult to obtain IV access [ 5 ]. While the utilization of intraosseous (IO) needles has been deemed suitable in resuscitation, there remains ongoing debate, with some expressing reservations regarding flow rates and the potential hemolysis of blood products [ 6 ] [ 7 ]. Notably, even in austere environments, the efficacy of IO needle use has been demonstrated, albeit with a recognized risk of hemolysis. [ 8 ]. The success rate for placement varies from 53–97% in both adult and pediatric cases [ 9 ] [ 10 ]. However, detailed information regarding use and effectiveness of IO needles in emergency situations is scarce. Therefore, the aim of this study is to investigate the incidence and success rate of IO access in children and adults and healthcare provider categories in acute care settings. We hypothesize that intraosseous access is a safe and effective alternative for peripheral venous access in this level 1 trauma center. Materials and Methods Study design and setting This is a single center retrospective cohort study of IO needle use in the ED from 01-2015 to 04-2020. The study was performed in a level 1 trauma center (Radboud University Medical Center Nijmegen, the Netherlands) and was approved by the local medical ethical committee Arnhem / Nijmegen and acknowledges the standards and assessment framework of further use of patient data for research purposes (file number: 2020–6267). Obtaining informed consent was waived by the committee follow Dutch guidelines for retrospective investigation. Participants All patients who presented the ED from 01-2015 to 04-2020 who had a documented IO needle use, were included. We also included patients with an IO needle placed prehospital. Variables The primary outcome measure was the incidence of IO needle use. Secondary outcome was documented clinical success rate. Patient demographics age, weight, height, body mass index circulatory parameters, health care location, anatomical location of the IO needle insertion (tibia, humerus), documented success, and complications of the IO needle were collected. Body mass index was calculated and categorized as normal, underweight, overweight, or obese according to age [ 11 ]. Data sources / measurements Patient data was collected from the medical records in the Electronic Patient File (EPF) EPIC® (Epic Systems Corporation, 1979, Milky Way Verona). All files were screened for ED visits and the registration of an IO needle using the term “IO needle” as well as synonyms such as “bone needle” and “intraosseous access.” The IO needle used in the study hospital’s helicopter emergency medical services (HEMS)/ emergency medical services (EMS) area and ED is the EZ-IO System (Vidacare Corporation, San Antonio, TX, USA). The clinical position of IO needle placement was considered successful if there was documentation of aspiration and smooth infusion through the IO needle, or if it was documented that the IO needle was in a clinically sufficient position. The authors confirm that the data supporting the findings of this study are available within the article and its supplementary materials. Statistical methods The data was analyzed with SPSS (IBM SPSS statistics for Windows version 25.0, Armonk, NY, USA). Clinical success rate was calculated by dividing the cases with successful IO needle use by all IO needle use cases. The basic characteristics of the population (means, medians, and proportions, where appropriate) were determined and stratified by the functional placement of a needle. We studied the correlations between body mass index, age, and placement of the IO needle by a healthcare professional via the chi-squared test for categorical variables and via the Mann–Whitney U test for continuous variables. For categorical variables, the Wald test was used. Additionally, univariable logistic regression was used to determine which factors influenced incorrect placement of the needle. Subsequently, factors that were statistically significant were used in a multivariable logistic regression analysis. P-value descriptive data was calculated for all variables using a logistic regression analysis. P-value < .05 was considered to indicate statistical significance Results From 2015 to 2019, 109,548 patients were admitted to the ED of this level 1 trauma center. In this period, a total of 25,686 IV lines were inserted. Filtering the electronic patient file for the terms lines, drains, airways resulted in 290 patients with documentation of IO access. Proper documentation regarding functionality was available for 188 patients of which 73 (38.8%) were children. In total, 232 needles were placed of which 204 were defined functional (overall success rate of 88%). Overall, 182 patients had a functional needle (97%). For 28 needles infusions was not possible due to failure (presumable because of incorrect position). Thirty-five patients (19%) received two needles, three cases received three needles and in one case four IO needles were placed. In this child cardiopulmonary resuscitation case, four attempts were made in both tibia and femur (study flowchart in Fig. 1). Correlations Table 1 summarizes the clinical success rate for gender, age, weight, BMI, (anatomical) location of placement, setting (trauma / non-trauma) and percentage of functional needles. In children (aged < 18 years) success rate was lower as compared to adults (71–84% as compared to 94%). Also, in non-trauma settings and in lower BMI percentage success rate was lower. Univariate logistic regression analysis demonstrated a significant correlation between age, weight and setting (p < .05). A multivariate regression showed no correlation between the percentage of functional needles and gender, age, weight, BMI, health care location (prehospital and in hospital), anatomical position or traumatic injury (Table 2 ). Table 1 Clinical success rate for different body types and location of placement Functioning needle Nonfunctioning needle Total Success rate IO needle Age (n = 232) 18 year 130 8 138 94% Situation (n = 232) Trauma 165 17 182 91% Non-trauma 39 11 50 78% BMI (n = 116) 30 18 1 19 95% Location (n = 232) In hospital 32 5 37 86% Prehospital 135 17 152 89% Both 17 3 20 85% Unknown 20 3 23 87% Anatomical location (n = 232) Tibia 122 20 142 86% Humerus 13 0 13 100% Both 8 5 13 62% Unknown 61 3 64 95% Infusion (n = 222) Fluid 182 19 201 91% Blood 13 0 13 100% Combination 8 0 8 100% Table 2 Univariate and multivariate logistic regression analysis for functional needles Univariate Multivariate β p N β p Gender – Male .082 .264 188 Age .180 .014 188 .179 .230 Weight .211 .016 131 .014 .924 BMI .045 .592 99 Health care location (prehospital) .034 .667 188 Anatomic position – tibia .120 .180 188 Trauma − .176 .016 188 − .126 .179 Adverse events In 18 of 232 (7.7%) needles, a complication was reported. Extravasation occurred in three cases (3/232, 1.3%). In four cases, the IO catheter was removed due to pain after placement. In two patients, compartment syndrome was diagnosed after needle insertion, but was not directly correlated to the needle insertion. One of these two patients developed striker position foot after an IO needle placement in their leg; this was most likely caused by a hematoma in the peroneus loge that then triggered compartment syndrome. Both cases were treated with a fasciotomy. In one patient the needle was placed intra-articular and penetrating the growth plate according to an x-ray; the needle was then removed. In eight needles, wound leakage and hematoma were described, with no further long-term consequences. Discussion The objective of this study was to examine the incidence and success rate of intraosseous (IO) needle utilization in emergency situations within both pediatric and adult populations. The implementation of IO access was carried out in 0.27% of patients admitted to this level 1 trauma center, demonstrating an high overall clinical success rate of 97%. The incidence of IO needle placement in this cohort (2.7 per 1000 ED visits for adults and 0.87 per 1000 ED visits for pediatrics) was higher as compared to other countries United States (0.05 per 1000) and Japan (0.34 per 1000) [ 12 ] [ 13 ]. However, in contrast to these studies, our study only contains patients admitted to a level 1 trauma center which makes it more likely that this cohort contains more severely injured or ill patients. For these severely injured patients, rapid and early vascular access is important and should be performed in a prehospital setting. No discernible disparity is observed between prehospital and in-hospital intraosseous (IO) needle placement, as noted by Wampler et al., who reported a first attempt success rate of 91%, increasing to 94% after a second attempt [ 14 ]. Our findings corroborate that the environment does not present an obstacle to IO placement. Consequently, IO access should be conducted in all environments, including prehospital settings. The overall success rate of 97% in this study is comparable to other scientific reports. The randomized controlled trial conducted by Reades et al. reported a success rate of 91% for IO needle placement [ 15 ]. However, the clinical success rate drops in pediatric patients. We demonstrated that children aged 6 months or lower had lower success rates (71%) as compared to the overall success rate. There are several explanations for these results, that are in line with the study performed by Myers et al . [ 16 ] First, the target area of the pediatric tibial bone is small, with smaller bone shafts and largely cartilaginous epiphyses. Additionally, adults have the advantage of having a flat cortical surface along the medial aspect of the tibia, with only a thin cover of soft tissue. In an infant’s tibia, the tibial target area has a more rounded contour [ 17 ]. Besides the greater target area and larger bone size in adults, there is also a thicker cortex in the bone marrow. Because of the thinner cortex in infants, any slight movement of the IO needle after entering the bone marrow would likely result in greater chance of dislocating and failing [ 9 ]. Second, there may also be an association between needle length and failure [ 9 ]. Harcke et al. revealed that a 25-mm needle was not successful in six out of seven placements in infants of 2 years of age or younger. Among patients that had a 15-mm needle, 18 of 29 needles were within the medullary cavity of the bone marrow Harcke et al. report that the 15-mm needle length has a poor success rate in small infants and advice caution in using this IO needle for young infants [ 17 ]. The advised length for pediatric patients from 3–39 kg weight is 15mm, 25 mm for adult patients > 39 kg weight and 45 mm in length for obese patients [ 18 ]. In contrast to other studies, body mass index was not correlated to success rate. For example, Pifko et al. described a success rate of 97% in patients > 8 kg and 47% for patients < 8 kg. They equated 8 kg to an average age of 6 months; although this study grouped patients by age, comparison between the studies is nonetheless valid [ 9 ]. For neonatal patients IO access seems even more challenging [ 19 ]. To improve the success rate of IO needle use in children under the age of 6 months and patients with lower body weight, more routine IO simulation training may be beneficial [ 9 ]. This study found a 7.7% complication risk for IO needle use, a lower percentage as compared to IV access (23–44%) [ 20 ] [ 21 ]. However, adverse events after IO access are often severe such as extravasation, compartment syndrome, pain, osteomyelitis, growth plate injuries and fracture. Beyond a few case studies, no numbers are known for the incidence of compartment syndrome after using an IO needle. A meta-analysis review of 4.270 cases of IO needles found 27 (0.63%) cases of osteomyelitis [ 22 ]. In the present study, there was one case in which the needle may have penetrated the growth plate. It has been shown that penetration of the growth plate does not result infusion in a subsequent leg length discrepancy [ 23 ]. Although the frequency of adverse events is low, misplacement can lead to serious complications. To investigate influencing factors on the success rate especially in infants aged < 6 months, further research should be conducted in a prospective setting. Despite IO needles are a safe and effective tool for rapid access, intravenous access remains and will be the golden standard for most cases. Understandable, since it is less invasive and burdensome for the patient. However, a randomized controlled trial (RCT) comparing IO and IV access during cardiac arrest, revealed a 48% difference in first attempt success rate in favor of IO access [ 15 ]. Also during trauma resuscitation, first attempt IO needle placement were higher as compared to first attempt intravenous access [ 3 ]. In this study, no separate analysis was performed for these patient groups. Limitations This is a retrospective database study based on documented IO needle use. The study design may have led to underestimation of the incidence and success rate of IO needle in the ED due to the insufficient data reportion. Several devices exist for IO insertion, including First Access for Shock and Trauma (FAST1), the EZ-IO, and the Bone Injection Gun (BIG). In addition, the definition of success was based on retrospective interpretation of file notes. In patients with no other infusion system mentioned beyond the IO needle, the documentation of successful injection of drugs is interpreted as a clinically successful IO needle use. The retrospective design of this study has limitations. It was not possible to extract variables such as needle length, the experience of an individual health care professional, or the time needed to insert the needle from the files, but these variables may have affected patients’ outcomes. Additionally, other variables were not always documented, such as weight, blood pressure, and heart rate. It is imaginable that due to this low reportion rate, the multivariate analysis was not significant. The limited documentation could be explained by the emergent setting given that there is little time and a hectic atmosphere in the ED. Conclusions Intraosseous access demonstrates a high success rate for infusion, independent of gender, age, body size, anatomical positioning, or healthcare setting, with minimal complication rates. Consequently, it represents a viable substitute for peripheral venous access during emergency resuscitation. Caution is especially warranted for children under the age of six months, as the percentage of functional needles was lower in this group. Abbreviations BMI, body mass index ED, emergency department EPF, electronic patient file HEMS, helicopter emergency medical services IV, intravenous IO, intraosseous Declarations Ethics approval and consent to participate This study was approved by the local medical ethical committee Arnhem/Nijmegen (file number: 2020-6267). Obtaining informed consent was waived by the committee follow Dutch guidelines for retrospective investigation since persons were not subjected to actions or rules of conduct are imposed on them. In retrospective anonymous research, informed consent is not mandatory, as the data can never be traced back to the test subjects. https://www.radboudumc.nl/over-het-radboudumc/kwaliteit-veiligheid/toetsen-van-medisch-wetenschappelijk-onderzoek/bij-welke-commissies-kunt-u-terecht/cmo-radboudumc. Consent for publication Not applicable. Availability of data and materials The authors confirm that the data supporting the findings of this study are available within the article and its supplementary materials. Competing interest The opinions or assertions contained herein are the private views of the authors. Funding None. Authors’ contributions M.K, W.K and E.T compiled the study protocol and design. T.R. and M.K performed the literature search and conducted data and performed analysis. M.K, T.R.,W.K and E.T all contributed to data interpretation, writing of the manuscript, critical appraisal and all agreed to the final version of the manuscript. Acknowledgements Not applicable. References Andersen, L.W., et al., Time to Epinephrine and Survival After Pediatric In-Hospital Cardiac Arrest. Jama, 2015. 314 (8): p. 802-10. Biarent, D., et al., European Resuscitation Council Guidelines for Resuscitation 2010 Section 6. Paediatric life support. Resuscitation, 2010. 81 (10): p. 1364-88. Wang, D., et al., Efficacy of intraosseous access for trauma resuscitation: a systematic review and meta-analysis. World J Emerg Surg, 2023. 18 (1): p. 17. Soar, J., et al., European Resuscitation Council Guidelines 2021: Adult advanced life support. Resuscitation, 2021. 161 : p. 115-151. Van de Voorde, P., et al., European Resuscitation Council Guidelines 2021: Paediatric Life Support. Resuscitation, 2021. 161 : p. 327-387. Bjerkvig, C.K., et al., Emergency sternal intraosseous access for warm fresh whole blood transfusion in damage control resuscitation. J Trauma Acute Care Surg, 2018. 84 (6S Suppl 1): p. S120-s124. Burgert, J.M., et al., Effects of intraosseous transfusion of whole blood on hemolysis and transfusion time in a swine model of hemorrhagic shock: a pilot study. Aana j, 2014. 82 (3): p. 198-202. Lewis, P. and C. Wright, Saving the critically injured trauma patient: a retrospective analysis of 1000 uses of intraosseous access. Emerg Med J, 2015. 32 (6): p. 463-7. Pifko, E.L., et al., Observational review of paediatric intraosseous needle placement in the paediatric emergency department. J Paediatr Child Health, 2018. 54 (5): p. 546-550. Maxien, D., et al., Intraosseous needles in pediatric cadavers: Rate of malposition. Resuscitation, 2019. 145 : p. 1-7. Cole, T.J., et al., Establishing a standard definition for child overweight and obesity worldwide: international survey. Bmj, 2000. 320 (7244): p. 1240-3. Hansen, M., et al., Intraosseous line use, complications, and outcomes among a population-based cohort of children presenting to California hospitals. Pediatr Emerg Care, 2011. 27 (10): p. 928-32. Mori, T., et al., Semi-automatic intraosseous device (EZ-IO) in a paediatric emergency department. J Paediatr Child Health, 2020. 56 (9): p. 1376-1381. Wampler, D., et al., Paramedics successfully perform humeral EZ-IO intraosseous access in adult out-of-hospital cardiac arrest patients. Am J Emerg Med, 2012. 30 (7): p. 1095-9. Reades, R., et al., Intraosseous versus intravenous vascular access during out-of-hospital cardiac arrest: a randomized controlled trial. Ann Emerg Med, 2011. 58 (6): p. 509-16. Myers, L.A., C.S. Russi, and G.M. Arteaga, Semiautomatic intraosseous devices in pediatric prehospital care. Prehosp Emerg Care, 2011. 15 (4): p. 473-6. Harcke, H.T., et al., Tibial Intraosseous Insertion in Pediatric Emergency Care: A Review Based upon Postmortem Computed Tomography. Prehosp Emerg Care, 2020. 24 (5): p. 665-671. Leidel, B.A., et al., Is the intraosseous access route fast and efficacious compared to conventional central venous catheterization in adult patients under resuscitation in the emergency department? A prospective observational pilot study. Patient Saf Surg, 2009. 3 (1): p. 24. Mileder, L.P., B. Urlesberger, and B. Schwaberger, Use of Intraosseous Vascular Access During Neonatal Resuscitation at a Tertiary Center. Front Pediatr, 2020. 8 : p. 571285. Helm, R.E., et al., Accepted but unacceptable: peripheral IV catheter failure. J Infus Nurs, 2015. 38 (3): p. 189-203. Simin, D., et al., Incidence, severity and risk factors of peripheral intravenous cannula-induced complications: An observational prospective study. J Clin Nurs, 2019. 28 (9-10): p. 1585-1599. Rosetti, V.A., et al., Intraosseous infusion: an alternative route of pediatric intravascular access. Ann Emerg Med, 1985. 14 (9): p. 885-8. Fiser, R.T., et al., Tibial length following intraosseous infusion: a prospective, radiographic analysis. Pediatr Emerg Care, 1997. 13 (3): p. 186-8. Additional Declarations No competing interests reported. Supplementary Files STROBEchecklistcohort.docx Cite Share Download PDF Status: Published Journal Publication published 15 Oct, 2024 Read the published version in BMC Emergency Medicine → Version 1 posted Editorial decision: Revision requested 15 Jul, 2024 Reviews received at journal 11 Jul, 2024 Reviewers agreed at journal 02 Jul, 2024 Reviews received at journal 22 Jun, 2024 Reviewers agreed at journal 20 Jun, 2024 Reviewers invited by journal 19 Jun, 2024 Editor assigned by journal 14 May, 2024 Submission checks completed at journal 14 May, 2024 First submitted to journal 29 Apr, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4344697","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":305440520,"identity":"677cb7f1-93f0-4205-837e-eeba7b2c9f4d","order_by":0,"name":"Tim W.H. 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A retrospective cohort study.","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDuring resuscitation in emergency situations, establishing intravascular access is crucial for promptly initiating delivery of fluids, blood, blood products, and medications. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] When intravenous (IV) access fails or is insufficient, intraosseous (IO) access provide a rapid, stable, safe, and effective alternative [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. IO needles were first introduced in the 1940\u0026rsquo;s but disappeared due to introduction of plastic peripheral venous needles. In the 1980\u0026rsquo;s IO needles were re-introduced as a rapid alternative after failure of peripheral venous access. Nowadays, the European Resuscitation Council Guidelines for Resuscitation recommend an IO access when the first attempts at establishing IV access is unsuccessful or challenging. The challenges encountered may be influenced by patient-specific factors, such as age and weight, the expertise of healthcare practitioners, the type of cannula employed, and the anatomical location on the body. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] In pediatric resuscitation, the use of IO needles is recommended when it is likely to be difficult to obtain IV access [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. While the utilization of intraosseous (IO) needles has been deemed suitable in resuscitation, there remains ongoing debate, with some expressing reservations regarding flow rates and the potential hemolysis of blood products [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Notably, even in austere environments, the efficacy of IO needle use has been demonstrated, albeit with a recognized risk of hemolysis. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The success rate for placement varies from 53\u0026ndash;97% in both adult and pediatric cases [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, detailed information regarding use and effectiveness of IO needles in emergency situations is scarce. Therefore, the aim of this study is to investigate the incidence and success rate of IO access in children and adults and healthcare provider categories in acute care settings. We hypothesize that intraosseous access is a safe and effective alternative for peripheral venous access in this level 1 trauma center.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eThis is a single center retrospective cohort study of IO needle use in the ED from 01-2015 to 04-2020. The study was performed in a level 1 trauma center (Radboud University Medical Center Nijmegen, the Netherlands) and was approved by the local medical ethical committee Arnhem / Nijmegen and acknowledges the standards and assessment framework of further use of patient data for research purposes (file number: 2020\u0026ndash;6267). Obtaining informed consent was waived by the committee follow Dutch guidelines for retrospective investigation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eAll patients who presented the ED from 01-2015 to 04-2020 who had a documented IO needle use, were included. We also included patients with an IO needle placed prehospital.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eVariables\u003c/h2\u003e \u003cp\u003eThe primary outcome measure was the incidence of IO needle use. Secondary outcome was documented clinical success rate. Patient demographics age, weight, height, body mass index circulatory parameters, health care location, anatomical location of the IO needle insertion (tibia, humerus), documented success, and complications of the IO needle were collected. Body mass index was calculated and categorized as normal, underweight, overweight, or obese according to age [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData sources / measurements\u003c/h2\u003e \u003cp\u003ePatient data was collected from the medical records in the Electronic Patient File (EPF) EPIC\u0026reg; (Epic Systems Corporation, 1979, Milky Way Verona). All files were screened for ED visits and the registration of an IO needle using the term \u0026ldquo;IO needle\u0026rdquo; as well as synonyms such as \u0026ldquo;bone needle\u0026rdquo; and \u0026ldquo;intraosseous access.\u0026rdquo; The IO needle used in the study hospital\u0026rsquo;s helicopter emergency medical services (HEMS)/ emergency medical services (EMS) area and ED is the EZ-IO System (Vidacare Corporation, San Antonio, TX, USA). The clinical position of IO needle placement was considered successful if there was documentation of aspiration and smooth infusion through the IO needle, or if it was documented that the IO needle was in a clinically sufficient position. The authors confirm that the data supporting the findings of this study are available within the article and its supplementary materials.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical methods\u003c/h2\u003e \u003cp\u003eThe data was analyzed with SPSS (IBM SPSS statistics for Windows version 25.0, Armonk, NY, USA). Clinical success rate was calculated by dividing the cases with successful IO needle use by all IO needle use cases. The basic characteristics of the population (means, medians, and proportions, where appropriate) were determined and stratified by the functional placement of a needle. We studied the correlations between body mass index, age, and placement of the IO needle by a healthcare professional via the chi-squared test for categorical variables and via the Mann\u0026ndash;Whitney U test for continuous variables. For categorical variables, the Wald test was used. Additionally, univariable logistic regression was used to determine which factors influenced incorrect placement of the needle. Subsequently, factors that were statistically significant were used in a multivariable logistic regression analysis. P-value descriptive data was calculated for all variables using a logistic regression analysis. P-value\u0026thinsp;\u0026lt;\u0026thinsp;.05 was considered to indicate statistical significance\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eFrom 2015 to 2019, 109,548 patients were admitted to the ED of this level 1 trauma center. In this period, a total of 25,686 IV lines were inserted. Filtering the electronic patient file for the terms lines, drains, airways resulted in 290 patients with documentation of IO access. Proper documentation regarding functionality was available for 188 patients of which 73 (38.8%) were children. In total, 232 needles were placed of which 204 were defined functional (overall success rate of 88%). Overall, 182 patients had a functional needle (97%). For 28 needles infusions was not possible due to failure (presumable because of incorrect position). Thirty-five patients (19%) received two needles, three cases received three needles and in one case four IO needles were placed. In this child cardiopulmonary resuscitation case, four attempts were made in both tibia and femur (study flowchart in Fig.\u0026nbsp;1).\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eCorrelations\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the clinical success rate for gender, age, weight, BMI, (anatomical) location of placement, setting (trauma / non-trauma) and percentage of functional needles. In children (aged\u0026thinsp;\u0026lt;\u0026thinsp;18 years) success rate was lower as compared to adults (71\u0026ndash;84% as compared to 94%). Also, in non-trauma settings and in lower BMI percentage success rate was lower. Univariate logistic regression analysis demonstrated a significant correlation between age, weight and setting (p\u0026thinsp;\u0026lt;\u0026thinsp;.05). A multivariate regression showed no correlation between the percentage of functional needles and gender, age, weight, BMI, health care location (prehospital and in hospital), anatomical position or traumatic injury (Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical success rate for different body types and location of placement\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFunctioning needle\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNonfunctioning needle\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSuccess rate IO needle\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge (n\u0026thinsp;=\u0026thinsp;232)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u0026lt; 0.5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e71%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e0.5\u0026ndash;2 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e77%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e2\u0026ndash;18 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e84%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;18 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e94%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSituation (n\u0026thinsp;=\u0026thinsp;232)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eTrauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e165\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e182\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e91%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNon-trauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e78%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eBMI (n\u0026thinsp;=\u0026thinsp;116)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u0026lt; 18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e79%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e18\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e70%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e21\u0026ndash;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e26\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u0026gt; 30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eLocation (n = 232)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eIn hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e86%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePrehospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e135\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e152\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e89%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e85%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e87%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eAnatomical location (n\u0026thinsp;=\u0026thinsp;232)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eTibia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e142\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e86%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eHumerus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e62%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eInfusion (n\u0026thinsp;=\u0026thinsp;222)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFluid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e182\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e201\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e91%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCombination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariate and multivariate logistic regression analysis for functional needles\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eUnivariate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eMultivariate\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eβ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eβ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e \u0026ndash; Male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.082\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.264\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e188\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e188\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.179\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.230\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWeight\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.211\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.924\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.045\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.592\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHealth care location\u003c/b\u003e (prehospital)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.034\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.667\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e188\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAnatomic position\u003c/b\u003e \u0026ndash; tibia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e188\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTrauma\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.176\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e188\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.179\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eAdverse events\u003c/h2\u003e \u003cp\u003eIn 18 of 232 (7.7%) needles, a complication was reported. Extravasation occurred in three cases (3/232, 1.3%). In four cases, the IO catheter was removed due to pain after placement. In two patients, compartment syndrome was diagnosed after needle insertion, but was not directly correlated to the needle insertion. One of these two patients developed striker position foot after an IO needle placement in their leg; this was most likely caused by a hematoma in the peroneus loge that then triggered compartment syndrome. Both cases were treated with a fasciotomy. In one patient the needle was placed intra-articular and penetrating the growth plate according to an x-ray; the needle was then removed. In eight needles, wound leakage and hematoma were described, with no further long-term consequences.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe objective of this study was to examine the incidence and success rate of intraosseous (IO) needle utilization in emergency situations within both pediatric and adult populations. The implementation of IO access was carried out in 0.27% of patients admitted to this level 1 trauma center, demonstrating an high overall clinical success rate of 97%.\u003c/p\u003e \u003cp\u003eThe incidence of IO needle placement in this cohort (2.7 per 1000 ED visits for adults and 0.87 per 1000 ED visits for pediatrics) was higher as compared to other countries United States (0.05 per 1000) and Japan (0.34 per 1000) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, in contrast to these studies, our study only contains patients admitted to a level 1 trauma center which makes it more likely that this cohort contains more severely injured or ill patients. For these severely injured patients, rapid and early vascular access is important and should be performed in a prehospital setting. No discernible disparity is observed between prehospital and in-hospital intraosseous (IO) needle placement, as noted by Wampler et al., who reported a first attempt success rate of 91%, increasing to 94% after a second attempt [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Our findings corroborate that the environment does not present an obstacle to IO placement. Consequently, IO access should be conducted in all environments, including prehospital settings.\u003c/p\u003e \u003cp\u003eThe overall success rate of 97% in this study is comparable to other scientific reports. The randomized controlled trial conducted by Reades \u003cem\u003eet al.\u003c/em\u003e reported a success rate of 91% for IO needle placement [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, the clinical success rate drops in pediatric patients. We demonstrated that children aged 6 months or lower had lower success rates (71%) as compared to the overall success rate. There are several explanations for these results, that are in line with the study performed by Myers \u003cem\u003eet al\u003c/em\u003e. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] First, the target area of the pediatric tibial bone is small, with smaller bone shafts and largely cartilaginous epiphyses. Additionally, adults have the advantage of having a flat cortical surface along the medial aspect of the tibia, with only a thin cover of soft tissue. In an infant\u0026rsquo;s tibia, the tibial target area has a more rounded contour [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Besides the greater target area and larger bone size in adults, there is also a thicker cortex in the bone marrow. Because of the thinner cortex in infants, any slight movement of the IO needle after entering the bone marrow would likely result in greater chance of dislocating and failing [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Second, there may also be an association between needle length and failure [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Harcke \u003cem\u003eet al.\u003c/em\u003e revealed that a 25-mm needle was not successful in six out of seven placements in infants of 2 years of age or younger. Among patients that had a 15-mm needle, 18 of 29 needles were within the medullary cavity of the bone marrow Harcke \u003cem\u003eet al.\u003c/em\u003e report that the 15-mm needle length has a poor success rate in small infants and advice caution in using this IO needle for young infants [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The advised length for pediatric patients from 3\u0026ndash;39 kg weight is 15mm, 25 mm for adult patients\u0026thinsp;\u0026gt;\u0026thinsp;39 kg weight and 45 mm in length for obese patients [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In contrast to other studies, body mass index was not correlated to success rate. For example, Pifko \u003cem\u003eet al.\u003c/em\u003e described a success rate of 97% in patients\u0026thinsp;\u0026gt;\u0026thinsp;8 kg and 47% for patients\u0026thinsp;\u0026lt;\u0026thinsp;8 kg. They equated 8 kg to an average age of 6 months; although this study grouped patients by age, comparison between the studies is nonetheless valid [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. For neonatal patients IO access seems even more challenging [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. To improve the success rate of IO needle use in children under the age of 6 months and patients with lower body weight, more routine IO simulation training may be beneficial [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study found a 7.7% complication risk for IO needle use, a lower percentage as compared to IV access (23\u0026ndash;44%) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, adverse events after IO access are often severe such as extravasation, compartment syndrome, pain, osteomyelitis, growth plate injuries and fracture. Beyond a few case studies, no numbers are known for the incidence of compartment syndrome after using an IO needle. A meta-analysis review of 4.270 cases of IO needles found 27 (0.63%) cases of osteomyelitis [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In the present study, there was one case in which the needle may have penetrated the growth plate. It has been shown that penetration of the growth plate does not result infusion in a subsequent leg length discrepancy [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Although the frequency of adverse events is low, misplacement can lead to serious complications. To investigate influencing factors on the success rate especially in infants aged\u0026thinsp;\u0026lt;\u0026thinsp;6 months, further research should be conducted in a prospective setting.\u003c/p\u003e \u003cp\u003eDespite IO needles are a safe and effective tool for rapid access, intravenous access remains and will be the golden standard for most cases. Understandable, since it is less invasive and burdensome for the patient. However, a randomized controlled trial (RCT) comparing IO and IV access during cardiac arrest, revealed a 48% difference in first attempt success rate in favor of IO access [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Also during trauma resuscitation, first attempt IO needle placement were higher as compared to first attempt intravenous access [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In this study, no separate analysis was performed for these patient groups.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis is a retrospective database study based on documented IO needle use. The study design may have led to underestimation of the incidence and success rate of IO needle in the ED due to the insufficient data reportion. Several devices exist for IO insertion, including First Access for Shock and Trauma (FAST1), the EZ-IO, and the Bone Injection Gun (BIG). In addition, the definition of success was based on retrospective interpretation of file notes. In patients with no other infusion system mentioned beyond the IO needle, the documentation of successful injection of drugs is interpreted as a clinically successful IO needle use. The retrospective design of this study has limitations. It was not possible to extract variables such as needle length, the experience of an individual health care professional, or the time needed to insert the needle from the files, but these variables may have affected patients\u0026rsquo; outcomes. Additionally, other variables were not always documented, such as weight, blood pressure, and heart rate. It is imaginable that due to this low reportion rate, the multivariate analysis was not significant. The limited documentation could be explained by the emergent setting given that there is little time and a hectic atmosphere in the ED.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIntraosseous access demonstrates a high success rate for infusion, independent of gender, age, body size, anatomical positioning, or healthcare setting, with minimal complication rates. Consequently, it represents a viable substitute for peripheral venous access during emergency resuscitation. Caution is especially warranted for children under the age of six months, as the percentage of functional needles was lower in this group.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBMI, body mass index\u003c/p\u003e\n\u003cp\u003eED, emergency department\u003c/p\u003e\n\u003cp\u003eEPF, electronic patient file\u003c/p\u003e\n\u003cp\u003eHEMS, helicopter emergency medical services\u003c/p\u003e\n\u003cp\u003eIV, intravenous\u003c/p\u003e\n\u003cp\u003eIO, intraosseous\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the local medical ethical committee Arnhem/Nijmegen (file number: 2020-6267). Obtaining informed consent was waived by the committee follow Dutch guidelines for retrospective investigation since persons were not subjected to actions or rules of conduct are imposed on them. In retrospective anonymous research, informed consent is not mandatory, as the data can never be traced back to the test subjects. https://www.radboudumc.nl/over-het-radboudumc/kwaliteit-veiligheid/toetsen-van-medisch-wetenschappelijk-onderzoek/bij-welke-commissies-kunt-u-terecht/cmo-radboudumc.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors confirm that the data supporting the findings of this study are available within the article and its supplementary materials.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe opinions or assertions contained herein are the private views of the authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eM.K, W.K and E.T compiled the study protocol and design. T.R. and M.K performed the literature search and conducted data and performed analysis. M.K, T.R.,W.K and E.T all contributed to data interpretation, writing of the manuscript, critical appraisal and all agreed to the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAndersen, L.W., et al., \u003cem\u003eTime to Epinephrine and Survival After Pediatric In-Hospital Cardiac Arrest.\u003c/em\u003e Jama, 2015. \u003cstrong\u003e314\u003c/strong\u003e(8): p. 802-10.\u003c/li\u003e\n\u003cli\u003eBiarent, D., et al., \u003cem\u003eEuropean Resuscitation Council Guidelines for Resuscitation 2010 Section 6. Paediatric life support.\u003c/em\u003e Resuscitation, 2010. \u003cstrong\u003e81\u003c/strong\u003e(10): p. 1364-88.\u003c/li\u003e\n\u003cli\u003eWang, D., et al., \u003cem\u003eEfficacy of intraosseous access for trauma resuscitation: a systematic review and meta-analysis.\u003c/em\u003e World J Emerg Surg, 2023. \u003cstrong\u003e18\u003c/strong\u003e(1): p. 17.\u003c/li\u003e\n\u003cli\u003eSoar, J., et al., \u003cem\u003eEuropean Resuscitation Council Guidelines 2021: Adult advanced life support.\u003c/em\u003e Resuscitation, 2021. \u003cstrong\u003e161\u003c/strong\u003e: p. 115-151.\u003c/li\u003e\n\u003cli\u003eVan de Voorde, P., et al., \u003cem\u003eEuropean Resuscitation Council Guidelines 2021: Paediatric Life Support.\u003c/em\u003e Resuscitation, 2021. \u003cstrong\u003e161\u003c/strong\u003e: p. 327-387.\u003c/li\u003e\n\u003cli\u003eBjerkvig, C.K., et al., \u003cem\u003eEmergency sternal intraosseous access for warm fresh whole blood transfusion in damage control resuscitation.\u003c/em\u003e J Trauma Acute Care Surg, 2018. \u003cstrong\u003e84\u003c/strong\u003e(6S Suppl 1): p. S120-s124.\u003c/li\u003e\n\u003cli\u003eBurgert, J.M., et al., \u003cem\u003eEffects of intraosseous transfusion of whole blood on hemolysis and transfusion time in a swine model of hemorrhagic shock: a pilot study.\u003c/em\u003e Aana j, 2014. \u003cstrong\u003e82\u003c/strong\u003e(3): p. 198-202.\u003c/li\u003e\n\u003cli\u003eLewis, P. and C. Wright, \u003cem\u003eSaving the critically injured trauma patient: a retrospective analysis of 1000 uses of intraosseous access.\u003c/em\u003e Emerg Med J, 2015. \u003cstrong\u003e32\u003c/strong\u003e(6): p. 463-7.\u003c/li\u003e\n\u003cli\u003ePifko, E.L., et al., \u003cem\u003eObservational review of paediatric intraosseous needle placement in the paediatric emergency department.\u003c/em\u003e J Paediatr Child Health, 2018. \u003cstrong\u003e54\u003c/strong\u003e(5): p. 546-550.\u003c/li\u003e\n\u003cli\u003eMaxien, D., et al., \u003cem\u003eIntraosseous needles in pediatric cadavers: Rate of malposition.\u003c/em\u003e Resuscitation, 2019. \u003cstrong\u003e145\u003c/strong\u003e: p. 1-7.\u003c/li\u003e\n\u003cli\u003eCole, T.J., et al., \u003cem\u003eEstablishing a standard definition for child overweight and obesity worldwide: international survey.\u003c/em\u003e Bmj, 2000. \u003cstrong\u003e320\u003c/strong\u003e(7244): p. 1240-3.\u003c/li\u003e\n\u003cli\u003eHansen, M., et al., \u003cem\u003eIntraosseous line use, complications, and outcomes among a population-based cohort of children presenting to California hospitals.\u003c/em\u003e Pediatr Emerg Care, 2011. \u003cstrong\u003e27\u003c/strong\u003e(10): p. 928-32.\u003c/li\u003e\n\u003cli\u003eMori, T., et al., \u003cem\u003eSemi-automatic intraosseous device (EZ-IO) in a paediatric emergency department.\u003c/em\u003e J Paediatr Child Health, 2020. \u003cstrong\u003e56\u003c/strong\u003e(9): p. 1376-1381.\u003c/li\u003e\n\u003cli\u003eWampler, D., et al., \u003cem\u003eParamedics successfully perform humeral EZ-IO intraosseous access in adult out-of-hospital cardiac arrest patients.\u003c/em\u003e Am J Emerg Med, 2012. \u003cstrong\u003e30\u003c/strong\u003e(7): p. 1095-9.\u003c/li\u003e\n\u003cli\u003eReades, R., et al., \u003cem\u003eIntraosseous versus intravenous vascular access during out-of-hospital cardiac arrest: a randomized controlled trial.\u003c/em\u003e Ann Emerg Med, 2011. \u003cstrong\u003e58\u003c/strong\u003e(6): p. 509-16.\u003c/li\u003e\n\u003cli\u003eMyers, L.A., C.S. Russi, and G.M. Arteaga, \u003cem\u003eSemiautomatic intraosseous devices in pediatric prehospital care.\u003c/em\u003e Prehosp Emerg Care, 2011. \u003cstrong\u003e15\u003c/strong\u003e(4): p. 473-6.\u003c/li\u003e\n\u003cli\u003eHarcke, H.T., et al., \u003cem\u003eTibial Intraosseous Insertion in Pediatric Emergency Care: A Review Based upon Postmortem Computed Tomography.\u003c/em\u003e Prehosp Emerg Care, 2020. \u003cstrong\u003e24\u003c/strong\u003e(5): p. 665-671.\u003c/li\u003e\n\u003cli\u003eLeidel, B.A., et al., \u003cem\u003eIs the intraosseous access route fast and efficacious compared to conventional central venous catheterization in adult patients under resuscitation in the emergency department? A prospective observational pilot study.\u003c/em\u003e Patient Saf Surg, 2009. \u003cstrong\u003e3\u003c/strong\u003e(1): p. 24.\u003c/li\u003e\n\u003cli\u003eMileder, L.P., B. Urlesberger, and B. Schwaberger, \u003cem\u003eUse of Intraosseous Vascular Access During Neonatal Resuscitation at a Tertiary Center.\u003c/em\u003e Front Pediatr, 2020. \u003cstrong\u003e8\u003c/strong\u003e: p. 571285.\u003c/li\u003e\n\u003cli\u003eHelm, R.E., et al., \u003cem\u003eAccepted but unacceptable: peripheral IV catheter failure.\u003c/em\u003e J Infus Nurs, 2015. \u003cstrong\u003e38\u003c/strong\u003e(3): p. 189-203.\u003c/li\u003e\n\u003cli\u003eSimin, D., et al., \u003cem\u003eIncidence, severity and risk factors of peripheral intravenous cannula-induced complications: An observational prospective study.\u003c/em\u003e J Clin Nurs, 2019. \u003cstrong\u003e28\u003c/strong\u003e(9-10): p. 1585-1599.\u003c/li\u003e\n\u003cli\u003eRosetti, V.A., et al., \u003cem\u003eIntraosseous infusion: an alternative route of pediatric intravascular access.\u003c/em\u003e Ann Emerg Med, 1985. \u003cstrong\u003e14\u003c/strong\u003e(9): p. 885-8.\u003c/li\u003e\n\u003cli\u003eFiser, R.T., et al., \u003cem\u003eTibial length following intraosseous infusion: a prospective, radiographic analysis.\u003c/em\u003e Pediatr Emerg Care, 1997. \u003cstrong\u003e13\u003c/strong\u003e(3): p. 186-8.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"emmd","sideBox":"Learn more about [BMC Emergency Medicine](http://bmcemergmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/emmd","title":"BMC Emergency Medicine","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Intraosseous infusion, Trauma, Resuscitation, Emergency Department","lastPublishedDoi":"10.21203/rs.3.rs-4344697/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4344697/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eDuring resuscitation in emergency situations, establishing intravascular access is crucial for promptly initiating delivery of fluids, blood, blood products, and medications. In cases of emergency, when intravenous (IV) access proves unsuccessful, intraosseous (IO) access serves as a viable alternative. However, there is a notable lack of information concerning the frequency and efficacy of IO access in acute care settings. This study aims to assess the efficacy of intraosseous (IO) access in acute care settings, especially focusing on children in a level 1 trauma center.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective study included patients with IO access in a level 1 trauma center emergency department (ED) between January 2015 and April 2020. Data regarding medication and fluid infusion was documented, and the clinical success rate was calculated.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf the 109,548 patients that were admitted to the ED, 25,686 IV lines were inserted. Documentation of 188 patients of which 73 (38.8%) children was complete and used for analysis. In these 188 patients, a total of 232 needles were placed. Overall, 182 patients had a functional needle (204 needles) (88%). In children (age\u0026thinsp;\u0026lt;\u0026thinsp;18 years) success rate was lower as compared to adults, 71\u0026ndash;84% as compared to 94%. However, a multivariate regression showed no correlation between the percentage of functional needles and gender, age, weight, BMI, health care location (prehospital and in hospital), anatomical position (tibia as compared to humerus) or type of injury.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIntraosseous access demonstrates a high success rate for infusion, independent of gender, age, body size, anatomical positioning, or healthcare setting, with minimal complication rates. Caution is especially warranted for children under the age of six months, since success rate was lower.\u003c/p\u003e","manuscriptTitle":"Effectiveness of intraosseous access during resuscitation. 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