Intraosseous infusion (IO) is the process of injecting directly into the marrow of a bone to provide a non-collapsible entry point

into the systemic venous system.[1 !his techni"ue is used in emergency situations to provide fluids and medication when intravenous access is not available or not feasible. # comparison of intravenous (I$)% intramuscular (I&)% and intraosseous (IO) routes of administration concluded that the intraosseous route is demonstrably superior to intramuscular and comparable to intravenous administration (in delivering paediatric anaesthetic drugs).['

Procedure
!he needle is injected through the bone(s hard corte) and into the soft marrow interior which allows immediate access to the vascular system. #n IO infusion can be used on adult or pediatric patients when traditional methods of vascular access are difficult or impossible. Often the antero-medial aspect of the tibia is used as it lies just under the s*in and can easily be palpated and located. !he anterior aspect of the femur% the superior iliac crest and the head of the humerus are other sites that can be used. !his route of fluid and medication administration is an alternative one to the preferred intravascular route when the latter cannot be established in a timely manner. +hen intravascular access cannot be obtained intraosseous access is usually the ne)t approach. It can be maintained for ',-,. hours% after which another route of access should be obtained.[/ #lthough intravascular access is still the preferred method for medication delivery in the prehospital area% advances in IO access (such as the 0.#.1.!.1 and the 23-IO[, system) for adults has caused many systems to re-thin* their preferred secondary access route. In &assachusetts% for e)ample% IO is now a preferred administration over endotracheal (2!) drug administration. In fact% the #merican 4eart #ssociation no longer recommends using the endotracheal tube for resuscitation drugs since the efficacy is unclear. 5aramedics may perform intraosseous infusion in a cardiac arrest patient if no vein is clearly visible. !he IO is becoming more and more common in emergency medical services (2&1) systems around the world.[citation needed 0urthermore% any medication that can be introduced via I$ can be introduced via IO. 6ecause of this% adult IO systems (most of which use a mechanical or powered adjunct to place the catheter) have become more common across the 7nited 1tates in the prehospital setting. Intraosseous access has roughly the same absorption rate as I$ access% and (unli*e 2! administration) allows for fluid resuscitation as well as high-volume drugs such as sodium bicarbonate to be administered in the setting of a cardiac arrest when I$ access is unavailable. 2ndotracheal administration allows only specific drugs that have relatively low to)icity to lung tissue% and must be restricted to relatively low volumes to avoid drowning the patient. 8ue to the rapid advance and adoption of superior intraosseous access technology% IO access has now become the preferred method of establishing vascular access for patients in whom traditional access is difficult or impossible. !his includes patients e)periencing cardiac arrest% major trauma% airway compromise% severe dehydration% and9or hypoperfusion (shoc*). IO is also an alternative route for patients who typically have poor peripheral vasculature or challenging vascular access such as diabetics% renal patients% burn victims% I$ drug users% obese patients% dehydrated patients% the very young or elderly patients% and others. &any

2&1 services and hospitals are now using IO as their first line solution for vascular access in both adult and pediatric cardiac arrest victims% enabling administration of lifesaving drugs much earlier than previously possible with traditional peripheral I$ placement.

IO Devices

1everal IO devices !here are several 08# approved IO devices including $idacare(s battery-powered 23-IO and 5yng(s hand-powered 0#1!1 and (0#1!-:) 0#1!-;O&6#! and 0#1!-<215O=82<. Other devices include the spring-loaded +ais&ed(s 6I> (6one Injection >un)% the ;OO? IO needle% and the @amshidi 1A>. !here have been at least two studies comparing the 23-IO and the 6I>.[A [B #nother paper [C compared the 23-IO with the ;OO? IO needle. !hese three papers all found a minor preference for the 23-IO. #nother study [. compared the @amshidi 1A>% the 6I> 1A>% and the 0#1!1% finding median insertion times of /.% ,D and B' seconds respectively (p E F.FF,). !he 23-IO is used by DF percent of 71 advanced life support ambulances and over half of 71 2mergency 8epartments%[D [1F as well as the 71 &ilitary% [1F [11 [1' and is available in over AF countries worldwide.[1F [1/ !he 23-IO is 08#-cleared for use on adult and pediatric patients in medically necessary instances% including difficult vascular access situations% as well as resuscitation and shoc*. !he 23-IO can be inserted in the pro)imal tibia% pro)imal humerus and the distal tibia. 5yng(s 0#1!1 and 0#1!) (0#1!-;O&6#!% 0#1!-<215O=82<) is inserted into the manubrium (upper sternum)[1 . !his device completely removes any guesswor* during application. It is the only device that operates in this fashion% and is therefore deployable under limited visibility% in moving vehicles and under otherwise austere conditions. !his device cannot be Gover deployed%G to penetrate the target bone (manubrium) and enter the anterior mediastinumH other devices that are hand drilled% or mechanically drilled have been confirmed as having done this in several post-mortem radiologic e)aminations.

Effectiveness
!his #merican 4eart #ssociation guideline cited two randomiIed controlled trials% one of BF children[1, and one of electively cannulated hematology9oncology patients.[1A In addition% uncontrolled studies have been performed%[1B [1C one of which reported C'J to .CJ rates of successful insertion.[1B

INTRAOSSEUS ACCESS
;KI=I;#K 5<#;!I;2 >7I8KI=21

Notes
Intraosseous (IO) access is an effective route for fluid resuscitation% drug delivery and laboratory evaluation that may be attained in all age groups and has an acceptable safety profile.

Indications:

IO access is the recommended techni"ue for circulatory access in cardiac arrest. In decompensated shoc* IO access should be established if vascular access is not rapidly achieved (if other attempts at venous access fail% or if they will ta*e longer than ninety seconds to carry out.) !he e)ception is the newborn% where umbilical vein access continues to be the preferred route.

Contraindications:

5ro)imal ipsilateral fracture Ipsilateral vascular injury Osteogenesis imperfecta

Complications:

0ailure to enter the bone marrow% with e)travasation or subperiosteal infusion !hrough and through penetration of the bone Osteomyelitis (rare in short term use) 5hyseal plate injury Kocal infection% s*in necrosis% pain% compartment syndrome% fat and bone microemboli have all been reported but are rare

Equipment

#lcohol swabs 1.> needle with trochar (at least 1.A cm in length) A ml syringe 'F ml syringe

Infusion fluid

Analgesia, Anaesthesia, Sedation

Kocal anaesthesia may be re"uired if the patient is conscious.

Procedure

Identify the appropriate site o 5ro)imal tibiaL #nteromedial surface% '-/ cm below the tibial tuberosity
o o

8istal tibiaL 5ro)imal to the medial malleolus 8istal femurL &idline% '-/ cm above the e)ternal condyle

5repare the s*in Insert the needle through the s*in% and then with a screwing motion perpendicularly 9 slightly away from the physeal plate into the bone. !here is a give as the marrow cavity is entered <emove the trocar and confirm position by aspirating bone marrow through a A ml syringe. 1end marrow blood for laboratory sampling (suitable for most standard laboratory values% p4% p;O'% 4;O/-% and #6O and <h typing.)

&arrow cannot always be aspirated but it should flush easily. 1ecure the needle and start the infusion (this needs to be manually administered as boluses with the 'F ml syringe.)

Post Procedure Care

Intraosseous infusion should be limited to emergency resuscitation of the child and discontinued as other venous access has been obtained.

IN!"AOSSE#S $edscape Overvie%

Intraosseous vascular access was first introduced by 8rin*er in 1D'' as a method for accessing noncollapsible venous ple)uses through the bone marrow cavity to systemic circulation. !he method was abandoned with the development of intravenous catheters until the 1D.Fs% when intraosseous access was reintroduced% particularly for rapid fluid infusion during resuscitation.[1 6ased on previous guidelines% intraosseous access was suggested for children aged B years or younger%[' although recent studies have shown that it is safe in older children and adults.[/% ,% A% B 1uccessful infusions in newborns have further suggested that access via the intraosseous route is faster than access via umbilical veins.[C% . #ccording to the 2mergency ;ardiovascular ;are >uidelines in 'FFF% intraosseous access is recommended in all children after ' failed attempts of intravenous access or during circulatory collapse. In 'FFA% the #merican 4eart #ssociation recommended intraosseous access if venous access cannot be "uic*ly and reliably established.[D Intraosseous access may be easily established by users with little training and is more rapidly achieved than intravenous access.[1F &anual insertion with force had previously been the primary method for intraosseous insertion% but automated intraosseous insertion devices such as the 23-IO ($idacare ;orp% 1an #ntonio% !e))[11 % have recently gained popularity.[1' 1tudies have suggested these automated devices are safe and highly successful on first attempts in both children and adults.[1/% 1,% 1A% 1B 6lood obtained through intraosseous access may be used to obtain most laboratory values% including p4 level% 5;O' level% and #6O and <h typing.[1C !he results of these standard laboratory tests may differ slightly from results obtained with venous blood samples because of low flow and stasis in the bone marrow. #ll medications and blood products can be safely administered through the intraosseous line% and the onset of action and pea* drug levels are comparable to those of intravenous administration. Intraosseous needles left in the marrow for longer than C' hours are at a higher ris* of local infectionH thus% needles should be removed as soon as permanent venous access is established.

Indications
8ifficulty in establishing venous access

6urns Obesity 2dema 1eiIures

=ecessity for rapid high-volume fluid infusion

4ypovolemic shoc* 6urns

#ccess to systemic venous circulation

;ardiopulmonary arrest 6urns 6lood draws Kocal anesthesia &edication infusion

Contraindications

Infection at entry site 6urn at entry site Ipsilateral fracture of the e)tremity Osteogenesis imperfecta Osteopenia Osteopetrosis 5revious attempt at the same site 5revious attempt in different location on same bone 5revious sternotomy (sternum insertion) 1ternum fracture or vascular injury near sternum (sternum insertion) 7nable to locate landmar*s

Anesthesia

0or conscious patients% local anesthesia with 1-' mK of lidocaine 1J can be administered at the puncture site after antiseptic preparation. 0or more information% see Kocal #nesthetic #gents% Infiltrative #dministration. #dult studies have used A mK of lidocaine 1J infusion after access has been established to decrease pain and discomfort associated with the force of high-volume infusion.

Equipment

>loves #ntiseptic solution Kidocaine 1J 1yringe% A-1F mK% for blood draws or solution infusion Intraosseous needle and trocar options (depending on insertion site and patient age)

(1ee the image below.)

Intraosseous needle and trocar.

1pinal needles for neonates 4ypodermic needle% 1B-1. gauge (ga) @amshidi needle (6a)ter 4ealthcare ;orp% &c>aw 5ar*% Ill) (1ee the image below.)

@amshidi intraosseous needle.

1ur-0ast intraosseous needle (;oo* Inc% 6loomington% Ind)

@amshidi disposable Illinois sternal9iliac needle (6a)ter 4ealthcare ;orp% &c>aw

5ar*% Ill) (1ee the image below.)

Illinois intraosseous needle.

1ussmane-<asIyns*i needle (;oo* Inc% 6loomington% Ind) 23-IO ($idacare ;orp% 1an #ntonio% !e))[1. (1ee the image below.)

23-IO with needle.

0#1!1 Intraosseous Infusion 1ystem (5yng &edical ;orp% <ichmond 6;% ;anada)[1D

(1ee the image below.)

0#1!1 intraosseous infusion system.

Positioning

&ultiple sites are available for intraosseous access entry. o 5ro)imal tibia% distal to the tibial tuberosity
o o o

8istal end of the radial bone in the upper limb 5ro)imal metaphysis of the humerus 8istal tibia% pro)imal to the medial malleolus

o o o

8istal femur% above the femur plateau 1ternum ;alcaneus

Kocation of pro)imal tibial tuberosity for intraosseous insertion. 0or intraosseous insertion at the pro)imal tibia% position the patient supine with the *nee fle)ed. 1tabiliIe the lower leg by placing one hand firmly distal to the *nee for support.

!echnique
Proximal tibia insertion Explain the procedure and the risks and benefits of the procedure to the patient or guardian prior to access in nonemergent cases Consult !ith hospital polic" regarding informing the patient or guardian in an emergenc"# as this polic" $aries among institutions Take uni$ersal precautions at all times b" !earing glo$es and disposing of sharps in designated locations

%osition the patient supine !ith the knee flexed &ocate the tibial tuberosit" and palpate approximatel" ' fingerbreadths distal to the tuberosit"# bet!een the anterior and posterior borders of the tibia In infants# measure one fingerbreadth belo! the tibial tuberosit" This is the site of insertion

%repare the puncture site !ith a topical antiseptic (eg# po$idone iodine )*etadine+, In conscious patients# anestheti-e the puncture site !ith ./' m& of lidocaine .0

M 5lace one hand over the dorsal pro)imal tibia and below the *nee for firm support. M 4old the needle in the palm of the other hand and relocate the insertion site. M !ilt the needle caudally to avoid puncturing the epiphysis and rotate the needle in a screwli*e motion through the s*in. M #dvance until the needle gives a sudden loss of resistance. If a screw-adjustable stabiliIer is present on the device% use it to ma*e the device flush with the s*in once the needle is in the correct position. # needle that stands freely and upright without support indicates correct placement. M <emove the trocar and attach the syringe for marrow aspiration. ;ommonly% marrow is not aspirated upon insertion. M #ttach intravenous tubing to the hub and infuse fluid. Observe the surrounding tissue for possible e)travasation.
Secure the line firml" after insertion An acceptable techni1ue is to appl" tape to either side of the plastic skirt Additional stabilit" ma" be achie$ed b" padding the plastic extension bet!een the skirt and the hub !ith gau-e prior to taping or b" placing a small cup !ith a hole for the intra$enous tubing o$er the de$ice as an additional la"er of protection

Remo$e the intraosseous line as soon as an intra$enous or central line is established

Automated intraosseous insertion with EZ-IO Select needle si-e based on patient !eight (See the image belo! ,

o o

E2/IO needles '3 mm# .3 gauge for patients 45 kg and greater .3 mm# .3 gauge for patients 6 to 67 kg

&ocate landmark for proximal tibia tuberosit" for insertion as pre$iousl" described Ensure line is properl" secured prior to blood dra!s and fluid infusions

Sternum insertion with FAST1 intraosseous infusion system Clean the exposed sternum Use the index finger to locate the sternal notch and align notch !ith the pro$ided

patch See the image belo! and appl" patch

&ocate sternum notch

%lace bone probe in the 8target -one8 on the patch Ensure that the introducer is

angled at 75 9 to the skin See the image belo! Sternum intraosseous alignment

%ress straight and firml" in the target -one until a sudden loss of resistance is felt

%ull back on the introducer to expose the infusion tube for blood dra!s and infusion

Secure the intraosseous line !ith the pro$ided protector dome See the image belo!

%rotector dome

Pearls

!he clinician should not place his or her hand underneath the *nee (popliteal fossa area) during the pro)imal tibia needle insertion. !his is a safety precaution to prevent possible lacerations and through-and-through penetration during insertion. 5oint the needle distally to avoid epiphysis during insertion. If initial s*in penetration is difficult% a small incision made with a scalpel may be necessary prior to insertion. Inability to aspirate blood does not indicate improper placement.

Complications
Demonstrated om!li ations Infections such as cellulitis and osteom"elitis from poor antiseptic techni1ue or prolonged (:;' h, needle placement (<or information on !ound care# see =edscape>s ?ound =anagement Resource Center , Extra$asation of blood or infusion into surrounding soft tissue from poor techni1ue or prolonged infusion

Compartment s"ndrome from extra$asation

*ent needle from poor techni1ue or missed landmark intraosseous needle

*ent

*one fracture or through/and/through penetration from excessi$e force

%neumothorax# mediastinitis# or surrounding organ and tissue in@ur" from sternal puncture Clogged needle

"are om!li ations The risk of a pulmonar" fat embolus is present in adults# although studies in piglets !ith intraosseous access during cardiopulmonar" resuscitation (C%R, sho!ed no increased risk o$er C%R alone )'5+ Concerns of fluid t"pe ha$e been reported# although studies ha$e sho!n no increase in risk of in@ur" to surrounding tissues !hen using isotonic solutions $ersus h"pertonic solutions

Concerns of bone gro!th from insertion exist# although no cellular or marro! changes ha$e been demonstrated in animal studies )'.+