title: Double-barrelled resuscitation: A feasibility and simulation study of dual-intraosseous needles into a single humerus.
abstract: BACKGROUND
  Resuscitation can be delayed, or impaired, by insufficient vascular access. This study examines whether dual-intraosseous needles, inserted into a single porcine humerus, can facilitate rapid and concomitant fluid and medication delivery.
  
  
  METHODS
  After inserting one- and then two-intraosseous needles into the same porcine humerus, we determined the rate of fluid administration using (i) an infusion pump set to 999mL/h, and (ii) a standard pressure-bag set to 300mmHg. Next, we concomitantly infused blood, crystalloid and medications into the same medullary canal, using the two-needle set-up. Humeri were inspected for fluid-leakage, needle-displacement, and bone damage.
  
  
  RESULTS
  Using an infusion pump, the mean normal-saline infusion-rate was significantly higher with dual-intraosseous needles compared to a single-intraosseous needle: the infusion-rate was 16mL/min using dual-needles versus 8mL/min for a single needle set-up (p<0.001). In contrast, using the pneumatic pressure-bag, the infusion rate was not statistically different when comparing dual-intraosseous needles versus single-intraosseous: the infusion-rate was 22mL/min versus 21ml/min (p=0.4) for 500mL, and 22ml/min versus 21ml/min (p=0.64) for one-litre, respectively. Blood product could be infused at a mean rate of 20mL/min through one needle while tranexamic acid was simultaneously infused through a second. There were no complications with a dual-intraosseous set-up (no fluid leakage; no needle-displacement; no high-pressure alarms, and no external bone-fractures or internal macrohistological damage) during any of our simulated resuscitation scenarios.
  
  
  CONCLUSIONS
  This is the first published study evaluating dual-intraosseous needles in a single bone. Despite limitations, this preliminary study (using a porcine humerus) suggests that dual-intraosseous needles are feasible. For critically-ill patients with limited insertion sites, dual-intraosseous (a.k.a. 'double-barrelled resuscitation') may facilitate rapid and concurrent resuscitation.
authors.affiliation: Trauma and Emergency Services, Royal Alexandra Hospital, 10240 Kingsway Avenue NW, Edmonton, AB, Canada T5H3V9. Electronic address: matthew.douma@albertahealthservices.ca.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Douma
authors.affiliation: Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada. Electronic address: gbara@ualberta.ca.
authors.forename: Gurpaul S
authors.initials: GS
authors.lastname: Bara
authors.affiliation: Shock Trauma Air Rescue Society, Edmonton, Canada. Electronic address: dodochartaigh@stars.ca.
authors.forename: Domhnall
authors.initials: D
authors.lastname: O'Dochartaigh
authors.affiliation: Neurosciences Intensive Care, Alberta, Canada. Electronic address: Peter.Brindley@albertahealthservices.ca.
authors.forename: Peter G
authors.initials: PG
authors.lastname: Brindley
mesh_terms: D000818:Animals; D000077324:Crystalloid Solutions; D005240:Feasibility Studies; D005440:Fluid Therapy / Q000295:instrumentation / Q000379:methods*; D006811:Humerus / Q000473:pathology*; D017148:Infusions, Intraosseous / Q000379:methods*; D007552:Isotonic Solutions / Q000008:administration & dosage*; D008297:Male; D012151:Resuscitation / Q000295:instrumentation / Q000379:methods*; D013552:Swine
chemical_list: D000077324:Crystalloid Solutions; D007552:Isotonic Solutions
keywords: Fluid administration; Intraosseous; Polytrauma; Resuscitation; Vascular access