eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Critical Care
Intraosseous Cannulation
Updated: Dec 9, 2008
Background
For patients in extremis from respiratory failure or shock, securing vascular access is crucial, along with establishing an airway and ensuring adequacy of breathing and ventilation. Peripheral intravenous catheter insertion is often difficult, if not impossible, in infants and young children with circulatory collapse. Intraosseous (IO) needle placement provides a route for administering fluid, blood, and medication. An IO line is as efficient as an intravenous route and can be inserted quickly, even in the most poorly perfused patients.
The use of IO access has gained acceptance over the past 15 years, but the technique has been used since the 1930s. It lost its popularity to the plastic intravenous catheters but saw a revival in the 1980s because numerous studies demonstrated the efficacy of IO administration of emergency medications in patients needing resuscitation in whom establishing intravenous (IV) access is difficult. Historically, IO use was recommended only in children younger than 6 years. However, current guidelines for cardiopulmonary resuscitation support the use of IO techniques in patients of all ages. Successful use in adults has been reported. IO access requires less skill and practice than central line and umbilical line placement. IO techniques have fewer serious complications and can be performed much faster.
Pathophysiology
The marrow of long bones has a rich network of vessels that drain into a central venous canal, emissary veins, and, ultimately, the central circulation. Therefore, the bone marrow functions as a noncollapsible venous access route when peripheral veins may have collapsed because of vasoconstriction. This approach is particularly important in patients in shock or cardiac arrest, when blood is shunted to the core due to compensatory peripheral vasoconstriction. The intraosseous (IO) route allows medications and fluids to enter the central circulation within seconds.
The levels of drugs, chemistries, and hemoglobin, as well as acid-base status, obtained from bone marrow are reliable predictors of serum levels.
Risks and Complications
The risks and complications of intraosseous (IO) insertion are few, and the benefits far outweigh the risks in a child without intravenous (IV) access who needs rapid administration of medication or fluid.
Extravasation of fluid is the most common complication. It typically occurs when a needle is misplaced. Rarely, extravasation occurs with a properly placed needle and is associated with excessive movement during or after insertion, which may lead to enlargement of the entry site in the bone relative to the diameter of the needle.
Compartment syndrome is a risk with IO insertion. The needle must enter through the cortex and into the marrow cavity without passing through the cortex on the other side. If the needle is passed through the opposite cortex, infused fluid enters the calf rather than the venous system. If left undetected, fluid accumulation may lead to a compartment syndrome, with potential loss of the limb. Frequent checks are therefore essential. This complication can also be limited by making only one attempt per tibia. Repeated attempts in the same bone allow fluid to flow through the previous holes produced in the bone.
Extravasation of hypertonic or caustic medications, such as sodium bicarbonate, dopamine, or calcium chloride, can result in necrosis of the muscle.
Infection and osteomyelitis are relatively rare complications and occur most commonly if aseptic technique is not followed during insertion. Children with bacteremia can develop this complication, as well. Cellulitis at the insertion site has also been reported.
Other possible complications include local hematoma, pain, growth plate injuries (with incorrect placement), and fat microemboli (not clinically significant).
Obtaining alternative IV access soon after the emergency and subsequent removal of the IO needle decreases the likelihood of these complications. In most instances, the goal is to remove the IO needle within 3-4 hours. IO needles may be left in place for 72-96 hours, but the risk of infection and dislodgment increase; in practice, the IO needle is removed once alternative vascular access is obtained.
Age
Intraosseous (IO) insertion was typically recommended for use in children younger than 6 years; however, it is now recognized to be both safe and effective in older children and adults.
The problems with IO use in older patients arise from the increased difficulty of insertion through thicker cortex of the bone and the smaller marrow cavity. Inability to enter the marrow may increase the likelihood of fracturing the bone.
Procedure
The most common site recommended for intraosseous (IO) insertion is the proximal tibia because it provides a flat surface with a thin layer of overlying tissue and ease of identifying landmarks. Also, it is distant from the airway and chest, where resuscitation attempts are in progress.The procedure for IO insertion in the proximal tibia is as follows:
- Identify the tibial tuberosity, just below the knee, by palpation.
- Locate a consistent flat area of bone 2 cm distal and slightly medial to the tibial tuberosity. (Identifying these landmarks helps avoid hitting the growth plate.)
- Support the flexed knee by placing a towel under the calf.
- If time permits, cleanse the area with an iodine solution and drape it. Perform insertion using sterile gloves and technique.
- Inject local anesthetic (1% lidocaine) into the skin, into the subcutaneous tissue, and over the periosteum, especially if the patient is awake.
- Insert the IO needle through the skin and subcutaneous tissue; this should occur easily. Upon reaching the bone, hold the needle with the index finger and thumb as close to the entry point as possible and, with constant pressure on the needle with the palm of the same hand, use a twisting motion to advance the needle through the cortex until reaching the marrow. A 10-15° caudal angulation may be used to further decrease the risk of hitting the growth plate, but direct entry parallel to the bone is acceptable.
- Advance the needle from the cortex into the marrow space, at which point a popping sensation or lack of resistance is felt. Do not advance the needle any farther.
- The first indication of proper placement occurs when the needle stands up on its own. At this point, remove the inner trocar, attach a syringe to the needle, and aspirate bone marrow. Obtaining marrow confirms placement.
- If marrow is not aspirated, push a 5-mL to 10-mL bolus of isotonic sodium chloride solution through the syringe. Resistance to flow should be minimal, and extravasation should not be evident. Observing the calf area is important.
- If flow is good and extravasation is not evident, connect the intravenous (IV) line with a 3-way stopcock at the needle, and secure the needle with gauze pads and tape.
Although fluid may run from the IV line by gravity, the rate is too slow for resuscitation. Faster rates of infusion occur by drawing up 30-mL to 60-mL aliquots from the intravenous bag and administering manual fluid boluses via the stopcock. Administering medications this way is much easier, as well, and it provides more accurate administration of fluid to small infants. As an alternative for larger boluses, an intravenous pump or pressure bag can be used to increase flow.
Alternative Insertion Sites
Alternative sites for intraosseous (IO) insertion include the distal tibia and femur. Alternative sites are used in special situations, such as fractures of the tibia.
The procedure for IO insertion in the distal tibia is as follows:
- Palpate the flat portion of distal tibia, just proximal to the medial malleolus. Slightly abduct and externally rotate the hip to expose the site.
- Angle the needle 10-15° cephalad to minimize the risk of growth plate injury.
- Follow technique as detailed above.
Use of the distal femur for IO insertion is the last resort after failed tibial attempts because landmarks in the distal femur are harder to locate and because overlying tissues are thicker.
The procedure for IO insertion in the distal femur is as follows:
- Slightly flex and externally rotate the hip, and flex the knee so that the quadriceps are relaxed.
- Insert the needle in the anterior midline, above the external epicondyles, 1-3 cm above the femoral plateau.
- Follow technique as detailed above.
Contraindications
The only absolute contraindication is fracture of the tibia or long bones, which are potential sites for intraosseous (IO) insertion.
Relative contraindications to IO insertion include the following:
- Cellulitis overlying the insertion site (Despite the risk of introducing bacteria into the bone or bloodstream, in the absence of other alternatives, cellulitis overlying the selected site does not preclude IO needle placement.)
- Inferior vena caval injury (The fluid infused must be able to drain into the central circulation. If this injury is suspected, central venous access superior to the injury is preferred.)
- Previous attempt on the same leg bone
- Osteogenesis imperfecta because of a higher likelihood of fractures occurring
- Osteopetrosis
What's New?
Intraosseous (IO) access is now considered as one of the recommendations for emergent vascular access in both children and adults. IO devices are currently used for individuals in nontraditional settings, such as patients with burns, patients who experienced trauma, military personnel, and those undergoing simulated chemical and biological disaster training. The spring-loaded, impact-driven devices, which inject needles to a preset depth, have great potential value in mass casualties.1 Devices that "drill" the IO needle into the bone, such as the EZ-IO (Vidacare, San Antonio, Texas), are also available and demonstrate high success rates and low complication rates.2,3
Multimedia
Media file 1: Bilateral misplaced intraosseous needles.
Media file 2: Properly placed intraosseous needle.
Media file 3: Cook intraosseous needle.
Media file 4: EZ-IO drill with needle.
References
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Horton MA, Beamer C. Powered intraosseous insertion provides safe and effective vascular access for pediatric emergency patients. Pediatr Emerg Care. Jun 2008;24(6):347-50. [Medline].
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Dogan A, Irmak H, Harman M. Tibial osteomyelitis following intraosseous infusion: a case report. Acta Orthopedica et traumatologica turcica. 2004;38(5):357-360. [Medline].
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Hodge D 3rd. Intraosseous infusions: a review. Pediatr Emerg Care. Dec 1985;1(4):215-8. [Medline].
La Fleche FR, Slepin MJ, Vargas J. Iatrogenic bilateral tibial fractures after intraosseous infusion attempts in a 3-month-old infant. Ann Emerg Med. Oct 1989;18(10):1099-101. [Medline].
Rosetti VA, Thompson BM, Miller J. Intraosseous infusion: an alternative route of pediatric intravascular access. Ann Emerg Med. Sep 1985;14(9):885-8. [Medline].
Schwartz SB, Kleid DM. Fictitious fracture after infusion of intravenous contrast material via an intraosseous needle. Pediatric Emergency Care. 2004;20(12):829-831. [Medline].
Smith R, Davis N, Bouamra O, Lecky F. The utilisation of intraosseous infusion in the resuscitation of paediatric major trauma patients. Injury. Sep 2005;36(9):1034-8; discussion 1039. [Medline].
Spivey WH. Intraosseous infusions [published erratum appears in J Pediatr 1987 Dec;111 (6 Pt 1):941]. J Pediatr. Nov 1987;111(5):639-43. [Medline].
Vardi A, Berkenstadt H, Levin I. Intraosseous vascular access in the treatment of chemical warfare casualties assessed by advanced simulation: proposed alteration of treatment protocol. Anesthesia and Analgesia. June 2004;98(6):1753-1758. [Medline].
Keywords
intraosseous cannulation, cannulization, IO cannulation, IO, intraosseal, intraosteal, interosseous, interosseal, bone, intrabone, bone cannulation, respiratory failure, shock, compartment syndrome, osteomyelitis, bacteremia, cellulitis, resuscitation
Contributor Information and Disclosures
Author
William Gluckman, DO, MBA, FACEP, Assistant Professor, Department of Surgery, Section of Emergency Medicine, University of Medicine and Dentistry of New Jersey, University Hospital; Attending Emergency Physician, St Joseph's Regional Medical Center; President and CEO, FastER Urgent Care
William Gluckman, DO, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Coauthor(s)
Rene J Forti, MD, Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, Albert Einstein College of Medicine and Children's Hospital at Montefior
Rene J Forti, MD is a member of the following medical societies: Ambulatory Pediatric Association and American Academy of Pediatrics
Disclosure: Nothing to disclose.
Sangeeta Lamba, MD, Resident Physician, Section of Emergency Medicine, University Hospital, University of Medicine and Dentistry of New Jersey
Sangeeta Lamba, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Medical Editor
G Patricia Cantwell, MD, Associate Clinical Professor, Department of Pediatrics, University of Miami; Director of Pediatric Critical Care Medicine, Miller School of Medicine, Jackson Children's Hospital
G Patricia Cantwell, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.
Pharmacy Editor
Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation
Managing Editor
Barry J Evans, MD, Assistant Professor of Pediatrics, Temple University Medical School; Director of Pediatric Critical Care and Pulmonology, Associate Chair for Pediatric Education, Temple University Children's Medical Center
Barry J Evans, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.
CME Editor
Mary E Cataletto, MD, Associate Director, Division of Pediatric Pulmonology, Winthrop University Hospital; Professor of Clinical Pediatrics, State University of New York at Stony Brook; Director of Children's Sleep Services, Winthrop University Hospital
Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Chest Physicians
Disclosure: Shering Plough Pharmaceuticals Honoraria Consulting
Chief Editor
Timothy E Corden, MD, Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin
Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society
Disclosure: Nothing to disclose.
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