423 - Can Point-of-Care Ultrasound be Used to Identify Through-And-Through Intraosseous Access Misplacement in Infant-Sized Bone Models?

Publication Number: 423.4432

Barbara Ximenes Braz, Nicklaus Children’s Hospital, Miami, FL, United States; Natalie M. Fernandez, Nicklaus Children’s Hospital, Miami, FL, United States; Olivia Pena, Duke University, Miami, FL, United States; Juan M. Lozano, Florida International University, Miami, FL, United States; Jose Vargas-Loayza, Nicklaus Children’s Hospital, Miami, FL, United States; Cloty Toro, Nicklaus Children’s Hospital, Coral Gables, FL, United States; Paul Khalil, Nicklaus Children’s Hospital, Miami, FL, United States

Background: Intraosseous access (IO) placement is an essential skill during resuscitation. Misplacement may delay the delivery of essential medications and fluids, and predispose to complications such as tissue necrosis or compartment syndrome. Studies found that 23.3- 34.8% of pediatric IOs were incorrectly placed on post-mortem skeletal surveys and CTs, respectively. Point-of-care Ultrasound (POCUS) has been recently proposed as a method to confirm correct IO placement, with 100% accuracy on a small sample of adult human cadavers.

Objective: The aim of the study was to determine if POCUS videos can be reliably and accurately interpreted by healthcare providers to determine IO position in animal models.

Design/Methods: We created POCUS video clips of IOs in 12 animal models. The models were built using intact chicken bones and designed to be comparable in size to the infant lower extremity. Six models had correctly placed IOs, while six had through-and-through misplaced IOs, with the tip of the needle posterior to the bone. The video clips were obtained with a handheld ultrasound device in linear probe MSK settings, using color doppler mode while flushing the IOs.
The study was conducted on healthcare providers with multiple levels of training, from POCUS-fellowship trained attendings to medical students. Participants underwent a standardized 10-minute teaching session. They then observed the 12 videos in randomized sequences for up to 20 seconds per clip and recorded their assessments on an answer sheet.

Results: Participants detected IO position on POCUS with a sensitivity of 98.8% (95% CI 97.4 -99.5), specificity of 94.6% (95% CI 92.3-96.3), Positive Predictive Value of 94.9% (95% CI 92.6-96.4), and Negative Predictive Value of 98.8% (95% CI 97.3-99.4). Diagnostic accuracy was 96.7% (95% CI 95.4-97.7).

Conclusion(s): Conventional methods to verify IO placement are observational and may be unreliable. The anterior misplacement is easily identifiable on visual inspection. The through-and-through misplacement, however, may be challenging to detect given that visual cues might be delayed. In those cases, we found very high diagnostic accuracy of medical providers’ POCUS interpretation in IO models resembling the infant population, which is at high risk for misplacement.
In our study, POCUS was found to be an invaluable tool to quickly and accurately identify IO misplacement throughout multiple levels of training. This study suggests that assessing IOs with POCUS can potentially improve early detection of a common and impactful complication in pediatric resuscitation: the through-and-through misplacement of IOs.

Correctly placed IO on POCUS Color Doppler
Bone marrow seen in transectional or short-axis view as the circular area immediately posterior to the hyperechoic bone cortex. Note the positive color doppler within the bone marrow while the needle is being flushed.

Through-and-Through misplaced IO on POCUS Color Doppler
Bone marrow seen in transectional or short-axis view as the circular area immediately posterior to the hyperechoic bone cortex. Note the positive color doppler posterior to the bone marrow while the needle is being flushed, indicating through-and-through or posterior misplacement of the IO needle.

Table 1 - Characteristics of the 84 participants of this study