Finding alternative sites for intraosseous infusions in newborns

Abstract

Aim: Intraosseous (IO)-access plays an alternative route during resuscitation. Our study in preterm and term stillborns was performed to find alternative IO puncture sites beside the recommended proximal tibia. Methods:The cadavers used were legal donations. 20 stillborns (mean: 29.2weeks, IQR 27.1À39.6) were investigated. Spectral-CT were analysed to calculate the diameter and circumferences of: i) proximal humerus ii) distal femur iii) proximal tibia iv) diaphyseal tibial. Contrast medium was applied under video documentation to investigate the drainage into the vascular system.Results: In term newborns, diameter of the cortex of the proximal humeral head is 12.1 AE 1.8 mm, distal end of the femur 11.9 AE 3.4 mm and the proximal tibial bone 12.0 AE 2.4 mm with cross-sectional diameter of 113.5 AE 19.7 mm 2 , 120.6 AE 28.2 mm 2 and 111.6 AE 29.5 mm 2 , respectively. Regarding the preterm groups, there is a strong age-related growth in diameter and cross -sectional size. The diaphyseal area is the smallest in all measured bones with an age-dependent increase and is about half of that of metaphyseal diameters (proximal and distal) and about one third of that of metaphyseal cross sectional areas. The proximal femoral head region has the largest diameter of all measured bones with an egg-shaped formation with an extensive joint capsula. All investigated metaphyseal areas lack a clearly enclosed bone marrow cavity. Infusion of contrast medium into the distal femoral end and the proximal humerus head demonstrate the drainage of contrast medium into the central venous system within seconds. Conclusion:Proximal humeral head and distal femoral end might be alternative IO areas which may lead to further IO puncture sites in neonates.

Finding the most suitable puncture site for intraosseous access in term and preterm neonates: an ultrasound-based anatomical pilot study

“…The mean (median) diameter of the proximal tibia at the most suitable puncture site was 8.4 mm (8.3) (transverse) and 9.2 mm (9.2) (anterior-posterior) in the 3000-4000 g weight group. These diameters are slightly larger than those reported by Suominen et al (7.4 mm transverse and 7.7 mm anterior-posterior diameter, assessed by X-ray) [5] and Tonder et al (7.1 mm transverse and 7.7 mm anterior-posterior) [3], and smaller than those reported by Eifinger et al, who found an average diameter of 12.0 mm at the proximal tibia [7]. These differences may be a result of the selected measurement technique (i.e., X-ray or computer tomography vs. ultrasound) but also, compared to Eifinger et al, the site of measurement differed.…”

“…Finally, it must be emphasized that this study only investigated the tibia as an option for IO access, which seems to be the most commonly selected site for IO access in neonatal and pediatric resuscitation [4,11], to date. Nonetheless, alternative puncture sites, such as the proximal humerus or distal femur, have been discussed [7] and should be further investigated.…”

“…This relatively broad recommendation was suggested to be adjusted to 10-mm distance at the proximal tibia for the age group of newborns [2][3][4]. However, the optimal puncture site in newborns has been rarely studied [3,[5][6][7].…”

Intraosseous access in neonates is feasible and safe – An analysis of a prospective nationwide surveillance study in Germany

“…An indentation the predominant puncture site used in this analysis was the proximal tibia (96%), but other sites (distal tibia, distal femur, and proximal humerus) were also chosen. Eifinger et al recently analyzed alternative sites for IO access in stillborn neonates and suggested the proximal humeral head as well as the distal femoral end as possible further puncture sites in neonates ( 18 ). Clearly, future studies are required to compare different puncture sites and success rates in the neonatal population.…”

Intraosseous infusion of acyclovir in a neonate

“…However, in infants, the distal tibia may be also selected. More recently, the superolateral aspect of the humerus and distal femoral end have been considered as an alternative IO site in newborns [ 7 ]. In inserting the IO needle, care must be taken in infants and young children to avoid the epiphyseal plates.…”