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EMERGENCY MEDICINE

Intraosseous Drug Administration in Children and Adults During Cardiopulmonary Resuscitation

Clinical Pharmacy Specialist, Pediatrics, Department of Pharmacy Services; Clinical Associate Professor, Department of Pediatrics, University of Virginia Health System, Charlottesville, VA

Barbara S Wiggins, PharmD BCPS (AQ Cardiology CLS)

Clinical Pharmacy Specialist, Cardiology, Department of Pharmacy Services; Clinical Assistant Professor, Department of Internal Medicine, Division of Cardiology, University of Virginia Health System

Jefferson M Sesler, PharmD BCPS

Clinical Pharmacy Specialist, Cardiology, Department of Pharmacy Services, University of Virginia Health System

Reprints: Dr. Buck, Department of Pharmacy Services, Box 800674, University of Virginia Health System, Charlottesville, VA 22908, fax 434/982-1682, mlb3u{at}virginia.edu

OBJECTIVE: To review and assess the available literature on the use of intraosseous (IO) drug administration during cardiopulmonary resuscitation, addressing the benefits and risks of using this method of drug delivery in children and adults.

DATA SOURCES: The MEDLINE (1950-July 2007) database was searched for pertinent abstracts, using the key term intraosseous infusions. Additional references were obtained from the bibliographies of the articles reviewed. Manufacturer Web sites were used to obtain information about IO insertion devices.

STUDY SELECTION AND DATA EXTRACTION: All available English-language clinical trials, retrospective studies, and review articles describing IO drug administration were reviewed. Studies conducted in animal models to evaluate the effectiveness and safety of IO drug administration were also included.

DATA SYNTHESIS: IO access uses the highly vascularized bone marrow to deliver fluids and medications during cardiopulmonary resuscitation. This route, developed in the 1940s, has been revived in the past decade as a means of achieving rapid vascular access when intravenous access cannot be obtained. The primary advantage of IO access is the high success rate (approximately 80%). Most trained providers can place an IO line within 1-2 minutes. A number of small-scale studies and retrospective reviews have established the usefulness of this route for the delivery of many commonly used resuscitation drugs. In addition, animal models have demonstrated rapid drug delivery to the systemic circulation. While all resuscitation drugs can be given by the IO route, administration of ceftriaxone, chloramphenicol, phenytoin, tobramycin, and vancomycin may result in lower peak serum concentrations. The most common adverse effect seen with IO use, extravasation, has been reported in 12% of patients. Compartment syndrome, osteomyelitis, and tibial fracture are rare, but have also been reported.

CONCLUSIONS: IO administration is a safe and effective method for delivering drugs during cardiopulmonary resuscitation. It should be considered whenever intravenous access cannot be rapidly obtained.

Key Words: cardiopulmonary resuscitation, intraosseous infusions

Published Online, August 14, 2007. www.theannals.com, DOI 10.1345/aph.1K168

THIS ARTICLE IS APPROVED FOR CONTINUING EDUCATION CREDIT
ACPE UNIVERSAL PROGRAM NUMBER: 407-000-07-024-H01