Intraosseous Infusion

intro

placing an IV catheter in an acutely ill child can be one

of the most challenging and frustrating procedures :

small peripheral vessels that collapse during shock

higher proportion of body fat makes visualization and

palpation of peripheral vessels difficult

Peripheral IV access can also be difficult in adults,

including those who are obese, have burn injuries, are

volumedepleted, or are in shock

IO access can provide rapid, lifesaving intravascular

access in challenging environments(prehospital or

military setting) and in both pediatric and adult patients

intro

IO access is often faster than IV access, and the success

rate after failed IV attempts is high

Anatomy & Physiology Long bones are richly vascular structures with a

dynamic circulation.

They are capable of accepting large volumes of fluid and rapidly transporting fluid or drugs to the central circulation.

The bone, like most organs, is supplied by a major artery (nutrient artery). The artery pierces the cortex and divides into ascending and descending branches, which further subdivide into arterioles that pierce the endosteal surface of the stratum compactum to become capillaries. The capillaries drain into medullary venous sinusoids throughout the medullary , which in turn drain into a central venous channel

Anatomy & Physiology

The medullary sinusoids accept fluid and drugs during

IO infusion and serve as a route for transport to the

central venous channel, which exits the bone as nutrient

and emissary veins

Anatomy & Physiology

Crystalloid infusion studies in animals have

demonstrated that infusion rates of 10 to 17 mL/min

may be achieved with gravity infusion and rates as high

as 42 mL/min with pressure infusion

Comparisons of IO and IV infusion of drugs have

demonstrated that the drugs reach the central

circulation by both routes in similar concentrations and

at the same time

sodium bicarbonate has been shown to provide greater

buffering capacity when administered by the IO route

than by the peripheral IV route

INDICATIONS When children or adults need immediate resuscitation and

IV access cannot be achieved quickly or reliably, the IO route provides a rapid and effective means of administering drugs, fluid, and blood

IO access is not commonly used in infants, but it is recommended as an alternative for medication and crystalloid administration when venous access is not readily obtained

Multiple sites, including the iliac crest, femur, proximal and distal ends of the tibia, radius, clavicle, and calcaneus may be used.

Of these, the tibia may be less desirable because red marrow is replaced by less vascular yellow marrow or fat by the fifth year of life

INDICATIONS In contrast, the sternum has been advocated as the best site to

establish IO access in adults because it is large and flat and can readily be located, it’s cortical bone is thin (1 to 2 mm) and the marrow space relatively uniform (6 to 11 mm).

A recent randomized controlled trial (RCT) of the BIG device versus the EZ-IO showed no significant differences in success rates or overall ease of use. Of 40 adults in the prehospital setting, vascular access was successfully achieved on the first attempt in 80% to 90% of patients within 2 minutes.58 Another recent RCT showed that a Jamshidi 15-gauge needle could be placed significantly faster than the FAST-1 device but had similar success and complication rates, as well as perceived ease of use

INDICATIONS In addition to serving as a route for fluid administration, the IO

needle may be used to obtain blood for typing, crossmatching, and determining blood chemistry in the marrow cavity. Serum electrolyte, blood urea nitrogen, creatinine, glucose, and calcium levels are very similar to those in samples obtained from an IO aspirate.60,61 Blood gas values obtained from the IO site were similar to those obtained from central venous sites during steady and low-flow states in one animal model.62 Brickman and colleagues63 demonstrated that bone marrow aspirates obtained from an IO needle in the iliac crest could be used reliably to type and screen blood for transfusion. A complete blood cell count may not be reliable because it reflects the marrow cell count rather than the cell count in the peripheral circulation. Furthermore, the aspirated blood usually clots within seconds, even if placed in a tube that contains heparin.

CONTRAINDICATIONS Osteoporosis and osteogenesis imperfecta are associated with a high potential

for fracture; therefore, unless absolutely necessary, the procedure should be avoided when these diagnoses are known

A fractured bone should be avoided because as fluid is infused, it increases intramedullary pressure and forces fluid to extravasateat the fracture site. This may slow the healing process, cause nonunion of the bone, or lead to a compartment syndrome.

Similar extravasation of fluid can occur through recent IO puncture sites placed in the same bone. Hence, recent previous use of the same bone for IO infusion represents a relative contraindication to IO line placement

Needle insertion through areas of cellulitis, infection, or burns should also be avoided. Patients with right-to-left intracardiacshunts (e.g., tetralogy of Fallot, pulmonary atresia) may be at higher risk for fat or bone marrow embolization

IO Needles Needles used for IO access range in size from 13 to 20

gauge and must be sturdy enough to penetrate bone without bending or breaking.

They must also be long enough to reach the marrow cavity. Standard needles for drawing blood or administering medications are not adequate for IO infusions; they are not sturdy enough to penetrate bone and do not have a stylet to prevent bone from plugging the lumen

In the past, an 18-gauge spinal needle was commonly used in children younger than 12 to 18 months. This needle, though readily available in most EDs, often bends, is too long for rapid infusion of fluid, and has a greater risk for occlusion from clotted blood.67 Very small “butterfly” needles have been used with success in preterm infants

Bone Marrow Aspiration Needle Bone marrow aspiration needles can be used if needles

specifically designed for IO access are not available. These

needles are large enough (16 gauge) to be used in older children

and adults and are suitable for rapid administration of fluid

Illinois Sternal/Iliac Aspiration Needle The Illinois Sternal/Iliac Aspiration Needle was designed for

bone marrow aspiration but can be used for IO infusion

The needle is available in both 16 and 18 gauge.

It has an adjustable plastic sleeve to prevent the needle

from penetrating through the opposite bony cortex

Jamshidi Disposable Sternal/Iliac Aspiration Needle

Like the Illinois Sternal/Iliac Aspiration Needle, the Jamshidi

Disposable Sternal/Iliac Aspiration Needle was designed for

bone marrow aspiration, but it has a shorter shaft and smaller

handle, which makes it easier to use. It comes in either 15 or 18

gauge and also features an adjustable plastic sleeve to prevent

overpenetration

Cook IO Needle

is specifically designed for IO insertion and infusion. It comes in

a variety of sizes from 18 to 14 gauge and can be inserted to a

depth of 3 to 4 cm. It has a detachable handle, which reduces the

risk of it being dislodged, and a depth marker to help ensure

proper placement.

Sur-Fast Needle

is also specifically designed for IO insertion and infusion. It has

a threaded shaft that helps secure the needle in the bone and a

detachable handle that may be reused with multiple needles.

IO Devices

FAST-1 Intraosseous Infusion System

uses an impact-driven device designed for sternal

placement only

has a series of stabilizing probes that help maintain good

contact with the sternum and serve as the depth control

mechanism for insertion of the needle

Once the device is positioned against the sternum,

additional pressure triggers the release of a hollow needle

into the medullary space

The handle is automatically released from the stylet and

infusion tubing once the needle has met its preset depth

The FAST-1 is larger and heavier than other IO devices and,

once triggered, cannot be reused

FAST-1 Intraosseous Infusion System

Bone Injection Gun

is another springloaded,impact-driven device that

comes in both pediatric and adult sizes

is designed for single use only

An advantage of the BIG is the ability to adjust the

depth of insertion, which allows it to be used at

different sites (e.g., tibia, humerus).

there is the potential for operator and patient injury

if the device is accidentally triggered or mistargeted

Bone Injection Gun

EZ-IO Device

handheld, battery-powered device that drills an IO

needle to the appropriate depth in the IO space.

The EZ-IO device allows the operator to control the

pressure or force used during insertion.

Placement can be achieved in less than 10 seconds

in the vast majority of patients, with first-time

successful insertion rates ranging from 77% to 97%

EZ-IO Device

TIAX Reusable IO Infusion Device

a compact, portable, and reusable IO infusion

device for quick vascular access through the

sternum of soldiers wounded in combat

Lightweight (217 g), can be operated with one

hand, and has a reusable driver/depth control

system to insert single-use IO needles

is currently in phase II trials

TIAX Reusable IO Infusion Device

PROCEDURE

Sites for IO Needle Placement

age and size are the two most important factors when

choosing the best site for needle penetration

In infants and children younger than 6 years, the proximal end

of the tibia is the preferred site, followed by the distal ends of

the tibia and femur

Other sites such as the clavicle and humerus have been used,

but neither has gained popularity

In adults, the distal part of the tibia has been the most

common site for IO access.

with the introduction of spring-loaded and drill devices, IO

locations once reserved only for children are now potential

sites in adults as well.

the FAST-1 System makes the sternum a simple and effective

location for IO access in adults.

Sites for IO Needle Placement

Proximal Tibia The tibia is a large bone with a thin layer of overlying subcutaneous tissue

that allows landmarks to readily be palpated

Insertion here does not interfere with airway management or CPR

On the proximal end of the tibia, the broad, flat, anteromedial surface is used

and the tibial tuberosity serves as a landmark

The site of IO cannulation is approximately 1 to 3 cm (2 finger widths) below

the tuberosity

This location is far enough away from the growth plate to prevent damage

In adults, penetrating the thick bone in the proximal end of the tibia is much

more difficult and requires a 13- to 16-gauge needle

A spring-loaded device such as the BIG or a battery-powered drill such as the

EZ-IO can make penetration much easier and allows the use of smaller-gauge

needles

tibial placement was significantly more successful (90%) than humeral

placement (60%) with a lower rate of needle dislodgement

Distal Tibia a preferred site in adults, may be used in children as well

The cortex of the bone and the overlying tissue are both thin.

The site of needle insertion is the medial surface at the junction

of the medial

malleolus and the shaft of the tibia, posterior to the greater

saphenous vein

The needle is inserted perpendicular to the long axis of the bone

or 10 to 15 degrees cephalad to avoid the growth plate

Sternum

has several advantages over peripheral bones but is

rarely used in the ED

Its advantages include a large, relatively flat body

that can be readily located; retention of a high

proportion of red marrow, which allows rapid

transfer of infused fluids and drugs to the central

circulation; and thinner, more uniform cortical bone

overlying a relatively uniform marrow space

In addition, the sternum is less likely to be

fractured in major trauma

Humerus

The proximal end of the humerus is a relatively

new option for IO access, but it is well tolerated

and easily accessed

The close proximity of the greater tubercle of the

humerus to the heart provides rapid infusion of

medication and fluid into the general circulation

Other Sites

The distal portion of the femur is occasionally used

as an alternative site in children, but because of

thick overlying muscle and soft tissue, it is more

difficult to palpate bony landmarks

the needle should be inserted 2 to 3 cm above the

femoral condyles in the midline and directed

cephalad at an angle of 10 to 15 degrees from the

vertical

Other sites, including the clavicle and calcaneus,

can be used as alternatives, but these sites are les

popular

Site Preparation

To prepare the proximal end of the tibia or distal

end of the femur for IO insertion, a small support

such as a towel roll should be placed behind the

knee

All insertion sites should be cleansed with

chlorhexidine, povidone-iodine, or an alcohol-

based antibacterial solution.

If the patient is conscious,the skin and periosteum

should be anesthetized

Manual Needle Insertion Before insertion, stabilize the site with the free hand and use it to

identify the landmarks.

Direct the IO needle perpendicular (90 degrees) to the bone’s long axis

and slightly caudad (60 to 75 degrees to helps avoid penetration of the

growth plate)

Advance the needle with a twisting or rotating motion (but not a

rocking motion) to drive it into the bone and to puncture the cortex

Once the cortex has been penetrated, there will be a sudden decrease

in bony resistance and a “crunchy” feeling as the needle enters the

marrow cavity

Aspirate for blood or marrow contents (or both) to confirm correct

placement

Other signs of correct placement include the needle’s ability to remain

upright without support and to have free-flowing fluid without signs

Manual Needle Insertion

Once proper placement is confirmed, secure the needle and

tubing with tape.

Fastening the leg to an appropriately sized leg board helps

further stabilize a lower extremity insertion site in infants

and small children.

Protect the needle from accidental dislodgment by cutting

the bottom out of a plastic cup and taping and bandaging

the cup in place over the device.

Remove the IO needle as soon as IV access has been

secured, and apply a sterile dressing over the site.

Control excessive bleeding by applying direct pressure over

the site for 5 minutes

FAST-1 was designed specifically to penetrate the sternum

prepackaged with alcohol and iodine and comes with a protective

dressing to hold the device in place

After disinfecting the skin site over the sternum, place the target patch

over the midline of the manubrium with the hole in the middle of the

target approximately 1.5 cm below the sternal notch

place the FAST-1 introducer in the center of the target zone. The

introducer has a “bone cluster” of needles that form a circle. These

needles “sense” the cortex of the sternum and help ensure proper

needle depth

apply pressure to the handle to release an inner needle located in the

center of the bone cluster

This needle has a small metal tip that is preconnected to plastic

infusion tubing

FAST-1 After release,the central IO needle advances 5 mm beyond the circular

cluster of needles, stops at the bony cortex, and positions the metal tip

at the cortex-medullary junction.

At this point, withdraw the handle so that only the plastic infusion tube

is left protruding from the insertion site.

Marrow aspiration and rapid flow of fluid help verify the appropriate

position.

Attach the plastic dome to the target patch via Velcro fasteners and

secure the tubing in place.

Removal of the infusion tube requires the use of a threaded-tip

remover, which is included

BIG incorporates a loaded spring to facilitate penetration of the bone.

To adjust the depth of insertion, remove the safety pin from one end

and turn the other end clockwise or counterclockwise to reduce or

increase needle depth, respectively

Place the BIG firmly against the skin perpendicular or slightly caudad

to the long axis of the bone

Fire the gun by applying palmar force on the back of the unit and

pulling on the flanges with the middle and ring fingers

Confirm placement by aspirating marrow, flushing with the same

syringe, and observing flow through the IV tubing. Slide the slotted

safety pin into the needle to maintain stability.

To remove the needle, rotate it back and forth with the small clamps

provided with the unit.

EZ-IO Needle This battery-operated “drill” can drive the IO needle through thick bone with

relative ease

The EZ-IO kit comes with a battery-operated drill and an IO needle with a

stylet; the EZ-IO AD comes with a 15-gauge, 25-mm IO needle for use in

patients heavier than 40 kg; and the EZ-IO PD comes with a 15-gauge, 15-

mm needle for use in patients lighter than 39 kg.

To operate the drill, insert the needle into the driver tip and make sure that it

is securely seated onto the drill

Remove the safety cap from the needle and position the drill perpendicular

(or slightly caudad) to the insertion site

Squeeze the trigger while applying gentle pressure to penetrate the skin.

When the tip of the needle comes in contact with the bone, at least 5 mm of

the IO catheter should be visible.

To penetrate the bone, continue to squeeze the trigger while applying steady

downward pressure until a sudden “give” or “pop” occurs, which signals

entry into the medullary space.

EZ-IO Needle After entry into the marrow cavity, attach the EZ-Connect extension set

provided with the EZ-IO kit and aspirate blood and bone marrow contents to

confirm correct placement. Once catheter placement has been checked, fluids

or medications can be infused.

Avoid attaching syringes and IV tubing directly to the IO needle because this

can enlarge the hole in the cortex and result in extravasation of fluid. Secure

the tubing with tape and cover the area with appropriate dressing

COMPLICATIONS

Technical Difficulties are the most common complications, but they decrease as familiarity with the

technique increases

The most common mistake is to place excessive pressure on the needle during

insertion and force it entirely through the bone and out the other side

Minimize this risk by using:

appropriate landmarks

keeping the needle perpendicular to the long axis of the bone

hold the needle with the index finger approximately 1 cm from the bevel

When this finger touches the skin, the needle should be in the marrow cavity

and no further pressure needs to be applied

Some IO needles have a mark 1 cm from the bevel (e.g., Cook IO Needle),

whereas others have a special guide or mechanism to ensure proper insertion

and depth of penetration (e.g., Illinois Sternal/Iliac Aspiration Needle)

Technical Difficulties the needle appears to be in the marrow cavity,but blood or bone

marrow cannot be aspirated and fluids do not flow freely. This may

follow incomplete penetration of the bone or overpenetration into the

opposite cortex

Incomplete penetration usually results in extravasation of fluids and

can be corrected by replacing the stylet and slowly advancing the

needle until successful aspiration of marrow contents and free flow of

fluids occur

If overpenetration is suspected, pull the needle back 1 to 2 mm and

check for free flow of fluids

To ensure flow, rapidly inject 10 mL of saline into the marrow. This is

a painful procedure in awake patients, but failure to initially flush the

compartment is a common reason for inadequate flow

A pressurized bag system is suggested if large volumes of fluid are

administered. Flush each dose of medication with 3 to 5 mL of saline

Technical Difficulties Extravasation may be caused by fluids being infused under excessive

pressure and with prolonged use of an IO site

extravasation may also result from incomplete needle penetration or

penetration through the opposite cortex. Even when an IO needle has

been positioned properly, fluid can leak out through holes made by

previous IO attempts or through an insertion site made too large from

“rocking” during insertion or from an improperly secured needle that

becomes loose with movement

the type of needle used does not appear to influence extravasation

rates

Regardless of the cause, if extravasation occurs, remove the needle

quickly and apply pressure to the site

Soft Tissue and Bony

Complications

Infection Although the potential for infection is real, its actual incidence is low

The most common infection is cellulitis at the puncture site, which

usually responds well to antibiotics.

Osteomyelitis is less common but also usually responds well to

antibiotics.

incidence of infection for IO needles placed in emergency conditions

was less than 3%.

In addition to infection, inflammatory reactions of the bone may be

seen. Such reactions are most common when hypertonic or sclerosing

agents are used and may produce an elevation of the periosteum on

plain radiographs or a positive bone scan

One hypertonic sclerosing drug that may be used during cardiac arrest

is sodium bicarbonate

Skin Sloughing Skin sloughing and myonecrosis have been reported secondary to

extravasation of infused fluids and medications

When drugs such as calcium chloride, epinephrine, and sodium

bicarbonate are infused, care should be taken to prevent dislodgment

of the needle and extravasation into tissue

In addition, it is best to infuse such drugs only by gravity because

infusion under pressure increases the risk for extravasation.

Compartment Syndrome may occur when fluids leak out of the bone into a closed compartment

such as the anterior or deep posterior compartment of the lower leg.

The risk for compartment syndrome can be reduced by carefully

placing and securing the IO needle, limiting the number of attempts in

the same bone, and removing the needle once IV access has been

obtained.

it is prudent to check the insertion site frequently, especially when

fluids are being infused under pressure.

Epiphyseal Injuries Injury to the growth plate and subsequent developmental

abnormalities of the bone are ongoing concerns with the IO route.

Regardless, these fears are largely unsupported in the available

literature

there have been no reports of growth plate damage or permanent

abnormalities of the bone

By pointing the needle away from the joint space and using the

previously mentioned landmarks for insertion, the risk for epiphyseal

injury is remote.

Whereas growth plate abnormalities appear to be very rare, tibial

fractures have been reported after IO placement. Hence, it is

appropriate to take follow-up radiographs of patients who have

undergone IO needle attempts or placement

Fat Embolism This condition is rare, however, and has been reported only in adult

patients

Because the marrow in infants and children is primarily

hematopoietic, this potential complication is unlikely to occur in this

population.

Pain with Infusion Most patients undergoing IO infusion will not be in a condition to

sense pain, but infusion into bone marrow can be quite painful.

Infusing 2 to 5 mL of 2% lidocaine before infusion has been suggested

to relieve pain in awake patients

Medications intended to remain in the medullary space, such as local

anesthetics, must be injected very slowly until the desired anesthetic

effect if achieved