Time delay and risk of toxicity of intraosseous anaesthesia use for awake intraosseous access in children.

Introduction: Intraosseous access (IO) is a crucial, life-saving alternative vascular access in paediatric emergency medicine. In awake paediatric patients, the pain of drilling and flushing the marrow cavity are barriers to the use of the IO method or prompt the use of an intraosseous anaesthetic agent, which introduces the risk of dosing errors and drug toxicity. This study aims to identify the frequency of use of anaesthetic agents and analyse the time delay caused by their use.

Methods: Prospective surveillance study analysing all patients, aged > 28 days to 18 years, who received one or more IO attempt(s) in and out of the hospital setting in Germany from 1 July 2017 to 30 June 2019 via the reporting mechanism of the German Paediatric Surveillance Unit (GPSU).

Results: Our analysis identified 74 patients who received an IO attempt while awake. All patients were younger than 6 years old. Almost every third child (31.6%) was awake during IO use. In 18.9% of all awake patients, an intraosseous anaesthetic was used before the IO was drilled or the marrow cavity was flushed, introducing a significant time delay of approximately 3 min (p = 0.001) compared to IO attempts without intraosseous anaesthesia.

Conclusions: Intraosseous anaesthesia prolongs the establishment of working vascular access in an emergency and introduces the risk of drug toxicity. To prevent adverse events, particular emphasis must be placed on placement without intraosseous anaesthesia, and alternative pain management (intranasal) must be considered if necessary. Training courses and guidelines should reflect the advised current practice.