Pediatric Emergency Cases Managed with Intraosseous Access: Indications, Complication and Outcomes

Intraosseous (IO) access is an alternative way of administering fluid and drug and also taking biopsies needed for clinical and laboratory tests in cases when peripheral venous access couldn’t be established. The IO route was successfully secured in all cases with a significant shorter time of vascular access insertion, shorter length of stay and reduction in mortality in IO group vs. IV group.  IO access was first used in 1922. This technique was widely used during 1940’s when emergency medical care was routinely needed for seriously injured patients in World War II. Since 1950’s after the introduction of peripheral venous access technique IO access lost its actuality. In management of Pediatric emergencies intravascular (venous) access is prior but sometimes establishing peripheral venous access is impossible or it may take too much time because of anatomical or physiological characteristics, such as an excessive subcutaneous fatty tissue and veins with a small diameter. Vasoconstriction, reduction of circulating blood volume and peripheral venous collapse takes place during cardiopulmonary arrest, septic or hypovolemic shock and prolonged status epilepticus. This features alone or in combination can make venous catheterization impossible.For pediatric resuscitation, vascular access must be established quickly, often in difficult circumstances. Alternative methods of peripheral access, such as umbilical catheter, central venous lines, venous cut-down, and ultrasound guided access, may be poor options because of the patient’s age or condition, the urgency of resuscitation, and/or the skill of available clinicians. Anatomically, the described site is suggested to offer a safe alternative access point for emergency infusion in severely hypovolemic newborns and infants, without the risk of damage to any anatomical structures. IO access complications are infection - cellulites, abscess, osteomyelitis and fracture. The most widespread complication is extravasation, which, if left unidentified, can cause compartment syndrome. The EZ-IO® device is easy to use and requires minimal training. These studies suggest that the EZ-IO® is an easy to use, easy to learn tool that can be used successfully in resuscitation scenarios with minimal training.  It is evident that blood samples drawn immediately after intraosseous cannulation can provide accurate laboratory and blood bank data to aid in resuscitation. More recently, the pharmacokinetics of intraosseous drug delivery has been compared with central venous drug delivery

Rhinitis associated with asthma is distinct from rhinitis alone : The ARIA-MeDALL hypothesis

Asthma, rhinitis, and atopic dermatitis (AD) are interrelated clinical phenotypes that partly overlap in the human interactome. The concept of "one-airway-one-disease," coined over 20 years ago, is a simplistic approach of the links between upper- and lower-airway allergic diseases. With new data, it is time to reassess the concept. This article reviews (i) the clinical observations that led to Allergic Rhinitis and its Impact on Asthma (ARIA), (ii) new insights into polysensitization and multimorbidity, (iii) advances in mHealth for novel phenotype definitions, (iv) confirmation in canonical epidemiologic studies, (v) genomic findings, (vi) treatment approaches, and (vii) novel concepts on the onset of rhinitis and multimorbidity. One recent concept, bringing together upper- and lower-airway allergic diseases with skin, gut, and neuropsychiatric multimorbidities, is the "Epithelial Barrier Hypothesis." This review determined that the "one-airway-one-disease" concept does not always hold true and that several phenotypes of disease can be defined. These phenotypes include an extreme "allergic" (asthma) phenotype combining asthma, rhinitis, and conjunctivitis. Rhinitis alone and rhinitis and asthma multimorbidity represent two distinct diseases with the following differences: (i) genomic and transcriptomic background (Toll-Like Receptors and IL-17 for rhinitis alone as a local disease; IL-33 and IL-5 for allergic and non-allergic multimorbidity as a systemic disease), (ii) allergen sensitization patterns (mono- or pauci-sensitization versus polysensitization), (iii) severity of symptoms, and (iv) treatment response. In conclusion, rhinitis alone (local disease) and rhinitis with asthma multimorbidity (systemic disease) should be considered as two distinct diseases, possibly modulated by the microbiome, and may be a model for understanding the epidemics of chronic and autoimmune diseases.Peer reviewe