To the Editor:—

In their editorial “No substitute for the Intravenous Route,” Donati and Guay 1come to the conclusion that, apart from succinylcholine, the intramuscular route is a poor alternative for administration of neuromuscular blocking agents in life-threatening situations in pediatric anesthesia. We fully agree with this conclusion and with the statement that all possible strategies to relieve laryngospasm should be considered. It is unfortunately true that there are still situations in which intravenous access cannot be obtained quickly. Indeed, the fact that all new neuromuscular blocking drugs have been investigated for rapidity of action after intramuscular administration indicates the continuing interest in finding ways of reliable and rapid neuromuscular blockade in the absence of venous access. Rather than continue to search for a neuromuscular blocker with rapid onset of action after intramuscular administration, we believe that the intraosseous route already offers an efficient alternative by which good intubating conditions can be rapidly obtained using currently available neuromuscular blocking drugs. Therefore, we disagree with the authors’ final statement that all efforts should be focused on a search for intravenous access and no site, including the femoral route, should be rejected to relieve laryngospasm. 1We are convinced that in the dreaded “cannot insert the intravenous catheter, cannot ventilate” scenario, the intraosseous route offers an excellent substitute. Ample scientific evidence proves that this route is easy, fast, and devoid of serious complications. 2Instead of losing time with repeated futile attempts at venous cannulation in emergency situations, intraosseous access should be established right away. The intraosseous infusion technique is proven, quick, and efficient in the emergency care of both children and adults. 2It is simple and has been used successfully by paramedical personnel. Parenteral access is obtained within 30–60 s, and there are few complications. Essentially, all fluids and drugs can be administered by the intraosseous route with faster central circulation times and better pharmacokinetics compared with peripheral intravenous injection. In prehospital emergency medicine, emergency departments, and pediatric intensive care units, its use is recommended in critically ill pediatric patients when intravenous access cannot be established within 90–120 s. The newly published Pediatric Advanced Life Support guidelines suggest it be the route of first choice in cardiocirculatory arrest. 3Nonetheless, intraosseous infusion remains a technique rarely used in operating rooms. Although elective use of intraosseous infusion in children with difficult vascular access during anesthesia remains debatable, there is no question that it provides simple, safe, and highly successful parenteral access in all emergency situations. 4,5Pediatric anesthesiologists take pride in their ability to establish intravenous access in difficult circumstances; however, we should not let this pride stand in the way of more rapid access by use of the intraosseous needle. This technique should be part of basic anesthesia training to ensure better management of pediatric emergencies when intravenous access is not available. Every anesthesiologist should become proficient in intraosseous technique and should not hesitate to use it in an emergency. Sets with all equipment required should be readily available in all locations where children are anesthetized.

Donati F, Guay J: No substitute for the intravenous route. A nesthesiology 2001; 94: 1–2
Kruse JA, Vyskocil JJ, Haupt MT: Intraosseous infusions: A flexible option for the adult or child with delayed, difficult or impossible conventional vascular access. Crit Care Med 1994; 22: 728–9
American Heart Association: Pediatric advanced life support. Circulation 2000; 102: 305–6
American Heart Association:
Stewart FC, Kain ZN: Intraosseous infusion: Elective use in pediatric anesthesia. Anesth Analg 1992; 75: 626–9
Schwartz RE, Pasquariello CA, Stayer SA: Elective use in pediatric anesthesia of intraosseous infusion: Proceed only with extreme caution. Anesth Analg 1993; 76: 918–9