Intraosseous Access 

Intraosseous vascular access was first introduced by Drinker in 1922 as a method for accessing noncollapsible venous plexuses through the bone marrow cavity to systemic circulation. The method was abandoned with the development of intravenous catheters until the 1980s, when intraosseous access was reintroduced, particularly for rapid fluid infusion during resuscitation.^[1]

Based on previous guidelines, intraosseous access was suggested for children aged 6 years or younger,^[2] although recent studies have shown that it is safe in older children and adults.^{[3, 4, 5, 6]} Successful infusions in newborns have further suggested that access via the intraosseous route is faster than access via umbilical veins.^{[7, 8]}

According to the Emergency Cardiovascular Care Guidelines in 2000, intraosseous access is recommended in all children after 2 failed attempts of intravenous access or during circulatory collapse. In 2005, the American Heart Association recommended intraosseous access if venous access cannot be quickly and reliably established.^[9]

Intraosseous access may be easily established by users with little training and is more rapidly achieved than intravenous access.^[10] Manual insertion with force had previously been the primary method for intraosseous insertion, but automated intraosseous insertion devices such as the EZ-IO (Vidacare Corp, San Antonio, Tex)^[11] , have recently gained popularity.^[12] Studies have suggested these automated devices are safe and highly successful on first attempts in both children and adults.^{[13, 14, 15, 16]}

Blood obtained through intraosseous access may be used to obtain most laboratory values, including pH level, PCO₂ level, and ABO and Rh typing.^[17] The 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. All medications and blood products can be safely administered through the intraosseous line, and the onset of action and peak drug levels are comparable to those of intravenous administration. Intraosseous needles left in the marrow for longer than 72 hours are at a higher risk of local infection; thus, needles should be removed as soon as permanent venous access is established.

Difficulty in establishing venous access

• Burns
• Obesity
• Edema
• Seizures

Necessity for rapid high-volume fluid infusion

• Hypovolemic shock
• Burns

Access to systemic venous circulation

• Cardiopulmonary arrest
• Burns
• Blood draws
• Local anesthesia
• Medication infusion

• Infection at entry site
• Burn at entry site
• Ipsilateral fracture of the extremity
• Osteogenesis imperfecta
• Osteopenia
• Osteopetrosis
• Previous attempt at the same site
• Previous attempt in different location on same bone
• Previous sternotomy (sternum insertion)
• Sternum fracture or vascular injury near sternum (sternum insertion)
• Unable to locate landmarks

• For conscious patients, local anesthesia with 1-2 mL of lidocaine 1% can be administered at the puncture site after antiseptic preparation. For more information, see Local Anesthetic Agents, Infiltrative Administration.
• Adult studies have used 5 mL of lidocaine 1% infusion after access has been established to decrease pain and discomfort associated with the force of high-volume infusion.

• Gloves
• Antiseptic solution
• Lidocaine 1%
• Syringe, 5-10 mL, for blood draws or solution infusion
• Intraosseous needle and trocar options (depending on insertion site and patient age) (See the image below.)Intraosseous needle and trocar.
• Spinal needles for neonates
• Hypodermic needle, 16-18 gauge (ga)
• Jamshidi needle (Baxter Healthcare Corp, McGaw Park, Ill) (See the image below.)Jamshidi intraosseous needle.
• Sur-Fast intraosseous needle (Cook Inc, Bloomington, Ind)
• Jamshidi disposable Illinois sternal/iliac needle (Baxter Healthcare Corp, McGaw Park, Ill) (See the image below.)Illinois intraosseous needle.
• Sussmane-Raszynski needle (Cook Inc, Bloomington, Ind)
• EZ-IO (Vidacare Corp, San Antonio, Tex)^[18] (See the image below.) EZ-IO with needle.
• FAST1 Intraosseous Infusion System (Pyng Medical Corp, Richmond BC, Canada)^[19] (See the image below.) FAST1 intraosseous infusion system.

• Multiple sites are available for intraosseous access entry.

  • Proximal tibia, distal to the tibial tuberosity
  • Distal end of the radial bone in the upper limb
  • Proximal metaphysis of the humerus
  • Distal tibia, proximal to the medial malleolus
  • Distal femur, above the femur plateau
  • Sternum
  • Calcaneus
• This article describes proximal tibia insertion. See the video below.

  Location of proximal tibial tuberosity for intraosseous insertion.

  • For intraosseous insertion at the proximal tibia, position the patient supine with the knee flexed.
  • Stabilize the lower leg by placing one hand firmly distal to the knee for support.

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 with hospital policy regarding informing the patient or guardian in an emergency, as this policy varies among institutions.
• Take universal precautions at all times by wearing gloves and disposing of sharps in designated locations.
• Position the patient supine with the knee flexed.
• Locate the tibial tuberosity and palpate approximately 2 fingerbreadths distal to the tuberosity, between the anterior and posterior borders of the tibia. In infants, measure one fingerbreadth below the tibial tuberosity. This is the site of insertion. See the video below.

  Location of proximal tibial tuberosity for intraosseous insertion.
• Prepare the puncture site with a topical antiseptic (eg, povidone iodine [Betadine]). See the video below.

  Topical antiseptic preparation with povidone iodine (Betadine).
• In conscious patients, anesthetize the puncture site with 1-2 mL of lidocaine 1%. See the video below.

  Lidocaine injection to insertion site.
• Place one hand over the dorsal proximal tibia and below the knee for firm support.
• Hold the needle in the palm of the other hand and relocate the insertion site.
• Tilt the needle caudally to avoid puncturing the epiphysis and rotate the needle in a screwlike motion through the skin. See the video below.

  Intraosseous insertion.
• Advance until the needle gives a sudden loss of resistance. If a screw-adjustable stabilizer is present on the device, use it to make the device flush with the skin once the needle is in the correct position. A needle that stands freely and upright without support indicates correct placement.
• Remove the trocar and attach the syringe for marrow aspiration. Commonly, marrow is not aspirated upon insertion.
• Attach intravenous tubing to the hub and infuse fluid. Observe the surrounding tissue for possible extravasation. See the video below.

  Blood draw and fluid infusion.
• Secure the line firmly after insertion. An acceptable technique is to apply tape to either side of the plastic skirt. Additional stability may be achieved by padding the plastic extension between the skirt and the hub with gauze prior to taping or by placing a small cup with a hole for the intravenous tubing over the device as an additional layer of protection. See the video below.

  Line security with taping.
• Remove the intraosseous line as soon as an intravenous or central line is established.

Automated intraosseous insertion with EZ-IO

• Select needle size based on patient weight (See the image below.)EZ-IO needles.

  • 25 mm, 15 gauge for patients 40 kg and greater
  • 15 mm, 15 gauge for patients 3 to 39 kg
• Locate landmark for proximal tibia tuberosity for insertion as previously described. Ensure line is properly secured prior to blood draws and fluid infusions. See the video below.

  EZ-IO insertion.

Sternum insertion with FAST1 intraosseous infusion system

• Clean the exposed sternum.
• Use the index finger to locate the sternal notch and align notch with the provided patch. See the image below.Locate sternum notch and apply patch.
• Place bone probe in the "target zone" on the patch. Ensure that the introducer is angled at 90 º to the skin. See the image below.Sternum intraosseous alignment.
• Press straight and firmly in the target zone until a sudden loss of resistance is felt. See the video below.

  Sternum intraosseous insertion.
• Pull back on the introducer to expose the infusion tube for blood draws and infusion. See the video below.

  Sternum intraosseous infusion.
• Secure the intraosseous line with the provided protector dome. See the image below.Protector dome.

• The clinician should not place his or her hand underneath the knee (popliteal fossa area) during the proximal tibia needle insertion. This is a safety precaution to prevent possible lacerations and through-and-through penetration during insertion.
• Point the needle distally to avoid epiphysis during insertion.
• If initial skin 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.

Demonstrated complications

• Infections such as cellulitis and osteomyelitis from poor antiseptic technique or prolonged (>72 h) needle placement (For information on wound care, see Medscape's Wound Management Resource Center.)
• Extravasation of blood or infusion into surrounding soft tissue from poor technique or prolonged infusion
• Compartment syndrome from extravasation
• Bent needle from poor technique or missed landmarkBent intraosseous needle.
• Bone fracture or through-and-through penetration from excessive force
• Pneumothorax, mediastinitis, or surrounding organ and tissue injury from sternal puncture
• Clogged needle

Rare complications

• The risk of a pulmonary fat embolus is present in adults, although studies in piglets with intraosseous access during cardiopulmonary resuscitation (CPR) showed no increased risk over CPR alone.^[20]
• Concerns of fluid type have been reported, although studies have shown no increase in risk of injury to surrounding tissues when using isotonic solutions versus hypertonic solutions.
• Concerns of bone growth from insertion exist, although no cellular or marrow changes have been demonstrated in animal studies.^[21]