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Pediatric Intraosseous Access

  • Author: Pegeen Eslami, MD; Chief Editor: Marleta Reynolds, MD  more...
 
Updated: Feb 13, 2014
 

Overview

Background

In an acute resuscitation situation, after the airway is secured and adequate breathing and gas exchange are established, the next priority is to obtain vascular access. This is often difficult in infants and children. The physiologic processes of shock and hypothermia with resulting vascular constriction, which are often present in a resuscitative situation, may further complicate the problem; furthermore, the skill and experience levels of providers in caring for small children widely vary.

Intraosseous (IO) access has been used therapeutically since 1934 and has been proved to be a safe, reliable, and rapid means of introducing crystalloids, colloids, medications, and blood products into the systemic circulation.[1, 2, 3, 4, 5, 6, 7, 8, 9] The marrow cavity provides access to a noncollapsible venous plexus as blood flows from the medullary venous sinusoids into the central venous sinus and is then drained into the central venous circulation via nutrient and emissary veins.

With the development of the intravenous (IV) catheter, the IO needle fell into disuse. In the 1980s, however, IO access was rediscovered in the 1980s as an immediately available tool in resuscitation situations, when time is of the essence and conditions may be adverse.[10, 11] Since then, IO access has become widely accepted in pediatric settings, especially because these patients often provide a particular challenge to obtaining rapid intravascular access.

Indications

Initiation of IO access is indicated in adults, children, infants, or newborns in any clinical situation where vascular access is emergently needed but not immediately available via a peripheral vein. IO access provides a means of administering medications, glucose, and fluids, as well as (potentially) a means of obtaining blood samples. Such a situation would include any resuscitation; cardiopulmonary arrest; shock, regardless of etiology; life-threatening status epilepticus; or lack of venous access resulting from burns, edema, or obesity.

In comparison with child and infant peripheral IV access, central lines, or umbilical lines, IO access is safer, is associated with fewer complications, can be implemented with less delay, and requires less skill and practice on the part of practitioners who may use the techniques only rarely.[12]

IO needle placement does not constitute definitive therapy; rather, it allows the administration of life-saving medications and fluids in a context where intravascular access is vital. Often, definitive IV access is easier to obtain once a bolus of fluids and medications has been administered via the IO needle.

IO needles may be left in place in the marrow for up to 72-96 hours; presumably, the longer the needle remains in place, the greater the risk of infection and dislodgment. In practice, the needle is usually removed as soon as another means of vascular access (either peripheral or central) is available, ideally within 6-12 hours.

Contraindications

Contraindications to IO access include the following:

  • Ipsilateral fracture of the extremity, because of resulting extravasation and risk of compartment syndrome
  • Previous placement or attempted placement in the same leg or site (eg, sternum), because of consequent extravasation into soft tissue compartments through the previous puncture site
  • Osteogenesis imperfecta, because of the likelihood that puncture of the bone may cause a fracture
  • Osteopetrosis, because of the risk of fracture
  • Obvious overlying infection at the proposed puncture site, because of the risk of seeding infection (a relative contraindication)
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Periprocedural Care

Preprocedural Planning

Intraosseous (IO) access was initially thought to be less applicable in patients older than 6 years. However, historical and current data (eg, in military populations[13] ), as well as guidelines from the American Heart Association[14] and the American College of Critical Care Medicine,[15, 16] support the consideration of IO techniques in patients of any age as rapid and equally effective alternatives to intravenous (IV) peripheral lines.

Moreover, IO access is considered more appropriate than attempted placement of central lines in situations when immediate resuscitation is essential.[17, 18] In addition, IO needles provide rapid access to the central circulation, with good bioequivalence to IV infusion.[19, 20]

The particular site used (see Technique) varies as appropriate for the age of the patient, the anatomic landmarks present, and the bone density. It should be noted that the blood chemistry, drug levels, hemoglobin concentrations, blood typing, and acid-base status[21] of the blood in the marrow aspirates obtained from the IO needle have been found to be reliable predictors of the corresponding serum values (although this may not be true of blood chemistry and acid-base status in the setting of prolonged resuscitation).

Over the past decade, attitudes regarding the different settings in which IO access might be considered have changed and broadened. IO access is now part of the recommendations for emergent intravascular access in patients of all ages, not just in pediatric and neonatal patients. In addition, the literature includes reports regarding IO access use for local anesthesia and other nonemergent applications in adults, as well as case reports of nonemergent use in specific pediatric situations.[22]

Clearly, the use of IO access in a battlefield setting remains applicable; this venous route continues to be accessible even in the most hypovolemic patient, and military and trauma literature attest to its usefulness in that setting.

The optimal duration of IO access is still the subject of controversy. On an intuitive basis, it would seem that long-term use of IO access should increase the risk of potential infection, but the infection and complication rates are actually very low, even in the most exigent circumstances. No data support the common informal recommendation that another access avenue must be obtained before transfer from the emergency department or that the IO needle should be removed as soon as possible.

Equipment

Several needle types are available (see the images below). The traditional needles are inserted manually, but powered needle insertion devices are becoming more popular.

Cook-type intraosseous needle. Cook-type intraosseous needle.
Cook-type screw-tip intraosseous needle (Sur-Fast Cook-type screw-tip intraosseous needle (Sur-Fast needle).
Jamshidi intraosseous needle. Jamshidi intraosseous needle.
Illinois sternal iliac intraosseous needle. Illinois sternal iliac intraosseous needle.
Shown are 3 different sizes of intraosseous needle Shown are 3 different sizes of intraosseous needles for use in EZ IO (Vidacare). Appropriate size is determined by patient weight and size.
Bone Injection Gun (BIG) spring-loaded intraosseou Bone Injection Gun (BIG) spring-loaded intraosseous insertion device (Waismed).
Sternal needle: F.A.S.T.1 system (Pyng Medical Cor Sternal needle: F.A.S.T.1 system (Pyng Medical Corporation).
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Technique

Intraosseous Needle Insertion Methods

With the exception of neonatal settings or neonatal intensive care unit (NICU) settings, in which spinal needles are occasionally used, the intraosseous (IO) needle should have a needle stylet to reduce the likelihood of bony spicules or a clot clogging the needle. In addition, the IO needle should have some means for the operator to gauge the distance to which the needle has penetrated, either with markings on the shaft or a covering flange that prevents insertion deeper than a predetermined distance.

Once the bony cortex has been penetrated, the needle usually need not be advanced more than 1 cm to provide stability and access to the marrow cavity.

The various types of IO needles currently available in pediatric emergency department (ED) and hospital settings are placed by means of different insertion methods.

The traditional needles (Cook, Jamshidi) are placed manually; the site, force required, and depth of insertion are determined by the operator.

However, powered insertion devices are used with increasing frequency in pediatric patients in US hospitals—in emergency departments (EDs), critical care units (CCUs), and even operating rooms (ORs).[22] Since 2006, 2 devices have been approved by the US Food and Drug Administration (FDA) for use in adult and pediatric patients: the Bone Injection Gun (BIG) device (Waismed) and the EZ IO (Vidacare).

The BIG device, which is more widely used outside of the United States, has a spring-loaded handle that injects the IO needle to a preset depth, determined by the patient's age. In the United States, the EZ IO is now widely used in field and transport settings (eg, emergency medical service situations). It has a battery-powered drill handle that powers the needle insertion; the length of the needle is determined by the patient's weight in kilograms, and the depth of insertion is determined by the operator (as with the manual devices).

Both the BIG device and the EZ IO are approved for use at the following sites:

  • Proximal and distal tibia (in both pediatric and adult populations)
  • Humeral head (in adult populations)

Neither device requires special removal equipment. Training videos are available on the respective Web sites (Vidacare and Waismed).

A retrospective review from Minnesota that compared the use of a manual IO access device with the use of the EZ IO in an emergency medical services (EMS) setting found that substituting an EZ IO for a manual device did not improve the first-attempt success rate or the success-per-attempt rate, but it more than tripled the rate at which IO access was used by EMS providers.[23]

The F.A.S.T.1 system (Pyng Medical Corporation) for sternal IO needle placement in adults includes both a marker patch and a special introducer device to simplify needle placement and the depth of needle insertion. In addition, this system uses a flexible infusion tube rather than a rigid stylet after needle removal to minimize displacement. It requires the use of a removal device, which is included with the kit.

Intraosseous Needle Insertion Sites

The sternum is the original site of IO access (see the image below) and is a useful site to consider in adult patients, as is the ilium. Studies suggest that IO infusion may be effective even in bones that do not contain a medullary cavity, such as the calcaneus and the radial styloid.[24, 25]

Sternal intraosseous needle insertion. Sternal intraosseous needle insertion.

The insertion site of choice in children and infants is the proximal tibia; the distal tibia and distal femur are alternatives (see the images below). The proximal tibia provides a flat wide surface and has only a thin layer of overlying tissue, which allows easy identification of landmarks. Additionally, the proximal tibia is distant from the airway and chest, where cardiopulmonary resuscitation (CPR) is often in progress.

Intraosseous needle insertion sites in infant or s Intraosseous needle insertion sites in infant or small child.
Proximal tibia intraosseous needle insertion site. Proximal tibia intraosseous needle insertion site.

The anterolateral proximal humerus is another site that is often used in adults. As powered devices become more widely available and IO access becomes more commonly used in the prehospital setting and in adults, this site will become increasingly relevant.

With increasing age, the cortical thickness of long bones, particularly the tibia, increases, making penetration more difficult and forceful; thus, in older children and adults, using the distal tibia or the proximal humerus may be advantageous because it also provides reliable and evident landmarks, has a relatively thin cortex, and is distant from ongoing CPR (see the images below).

Intraosseous needle insertion sites in older child Intraosseous needle insertion sites in older child, adolescent, or adult.
Distal tibia intraosseous needle insertion site. Distal tibia intraosseous needle insertion site.

The distal femur (see the image below) may also be used for IO access, but it generally has much denser covering layers of fat, muscle, and soft tissue, which make identification of landmarks and bony penetration more difficult.

Distal femur intraosseous needle insertion site. Distal femur intraosseous needle insertion site.

In adults, other insertion sites have included several different iliac sites (see the image below), the sternum, the distal radius or ulna, and, as mentioned above, the humerus.

Alternative intraosseous needle insertion site: il Alternative intraosseous needle insertion site: ilium.

Complications of Intraosseous Needle Placement

Complications of intraosseous (IO) needle placement are rare, especially if the correct techniques are followed and frequent subsequent evaluations of the needle's position within the bone are carried out.[26]

Failure to achieve effective IO placement may be the result of 1 or more of the following:

  • Incorrect identification of landmarks
  • A bent needle, which is more common with longer needles or spinal needles
  • Clogging of the needle with marrow, clot, or bone spicules, which can be avoided by frequent flushing of the needle or by continuous infusion
  • Through-and-through penetration of both anterior and posterior cortices caused by excess force after the needle has penetrated the cortex, which renders the punctures useless because of fluid extravasation and which may cause a compartment syndrome
  • Subcutaneous or subperiosteal infiltration, caused by incomplete placement of needle or by a dislodged needle
  • Fractures caused by excess force or by fragile bones (eg, marked osteoporosis or osteopenia, osteopetrosis, or osteogenesis imperfecta), which allows leakage, extravasation, and potential compartment syndrome to occur
  • Penetration of the mediastinal structures or space with the potential for pneumothorax, vascular injury, lung injury, in the case of a sternal needle

Complications even after effective placement and timely removal are rare but may include the following:

  • Local infection (cellulitis and osteomyelitis are quite rare) - The incidence was less than 0.6% in a literature review of 4000 cases over 35 years (though it was found that the rate may increase with prolonged placement) and less than 3% in another large review
  • Compartment syndrome secondary to fluid extravasation
  • Local hematoma
  • Pain
  • Potential for growth plate injuries (though this has not been reported in animals or humans [27] )
  • Fat embolus - This is rarely reported in adult patients and has not been reported when an IO needle is placed in the tibia rather than in other sites, such as the ilium or sternum
  • Bone embolus (though this has not been reported in humans)
  • Mediastinitis after sternal IO puncture
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Contributor Information and Disclosures
Author

Pegeen Eslami, MD Associate Professor of Pediatrics, Division of Pediatric Emergency Medicine, UMass Memorial Medical Center

Pegeen Eslami, MD is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American College of Emergency Physicians, Massachusetts Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Marleta Reynolds, MD Professor of Surgery, Northwestern University, The Feinberg School of Medicine; Head, Department of Surgery and Surgeon in Chief, Head, Division of Pediatric Surgery, Ann and Robert H Lurie Children's Hospital of Chicago

Marleta Reynolds, MD is a member of the following medical societies: American Pediatric Surgical Association

Disclosure: Nothing to disclose.

Acknowledgements

G Patricia Cantwell, MD Clinical Professor, Department of Pediatrics, University of Miami, Leonard M Miller School of Medicine; Director of Pediatric Critical Care Medicine, Holtz Children's Hospital/Jackson Memorial Hospital

G Patricia Cantwell, MD is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

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.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

References
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  2. Josefson A. A new method of treatment--intraosseous injections. Acta Med Scand. 1934. 81:550.

  3. Arbeiter HI, Greengard J. Tibial bone marrow infusion in infants. J Pediatr. 1944. 25:1.

  4. Elston JT, Jayne RV, Kaump DH, et al. Intraosseous infusions in infants. Am J Clin Pathol. 1947. 17:143.

  5. Heinild S, Sondergaard T, Tudvad F. Bone marrow infusion in childhood: Experiences from a thousand infusions. J Pediatr. 1947. 30:400.

  6. Tocantins LM. Rapid absorption of substances injected into the bone marrow. Proc Soc Exp Biol Med. 1940. 45:292.

  7. Tocantins LM, O'Neil JF. Infusions of blood and other fluids into the general circulation via the bone marrow. Surg Gynecol Obstet. 1941. 73:281.

  8. Tocantins LM, O'Neil JF, Jones HW. Infusions of blood and other fluids via the bone marrow. JAMA. 1941. 117:1229.

  9. Tocantins LM, O'Neil JF. Complications of intraosseous therapy. Ann Surg. 1945. 122:266.

  10. Berg RA. Emergency infusion of catecholamines into bone marrow. Am J Dis Child. 1984 Sep. 138(9):810-1. [Medline].

  11. Brunette DD, Fischer R. Intravascular access in pediatric cardiac arrest. Am J Emerg Med. 1988 Nov. 6(6):577-9. [Medline].

  12. Abe KK, Blum GT, Yamamoto LG. Intraosseous is faster and easier than umbilical venous catheterization in newborn emergency vascular access models. Am J Emerg Med. 2000 Mar. 18(2):126-9. [Medline].

  13. Beekley AC, Starnes BW, Sebesta JA. Lessons learned from modern military surgery. Surg Clin North Am. 2007 Feb. 87(1):157-84, vii. [Medline].

  14. de Caen AR, Reis A, Bhutta A. Vascular access and drug therapy in pediatric resuscitation. Pediatr Clin North Am. 2008 Aug. 55(4):909-27, x. [Medline].

  15. Brierley J, Carcillo JA, Choong K, Cornell T, Decaen A, Deymann A, et al. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med. 2009 Feb. 37(2):666-88. [Medline].

  16. Kissoon N, Orr RA, Carcillo JA. Updated American College of Critical Care Medicine--pediatric advanced life support guidelines for management of pediatric and neonatal septic shock: relevance to the emergency care clinician. Pediatr Emerg Care. 2010 Nov. 26(11):867-9. [Medline].

  17. Banerjee S, Singhi SC, Singh S, Singh M. The intraosseous route is a suitable alternative to intravenous route for fluid resuscitation in severely dehydrated children. Indian Pediatr. 1994 Dec. 31(12):1511-20. [Medline].

  18. Horton MA, Beamer C. Powered intraosseous insertion provides safe and effective vascular access for pediatric emergency patients. Pediatr Emerg Care. 2008 Jun. 24(6):347-50. [Medline].

  19. Von Hoff DD, Kuhn JG, Burris HA 3rd, Miller LJ. Does intraosseous equal intravenous? A pharmacokinetic study. Am J Emerg Med. 2008 Jan. 26(1):31-8. [Medline].

  20. Engle WA. Intraosseous access for administration of medications in neonates. Clin Perinatol. 2006 Mar. 33(1):161-8, ix. [Medline].

  21. Kissoon N, Rosenberg H, Gloor J, Vidal R. Comparison of the acid-base status of blood obtained from intraosseous and central venous sites during steady- and low-flow states. Crit Care Med. 1993 Nov. 21(11):1765-9. [Medline].

  22. Joseph G, Tobias JD. The use of intraosseous infusions in the operating room. J Clin Anesth. 2008 Sep. 20(6):469-73. [Medline].

  23. Myers LA, Russi CS, Arteaga GM. Semiautomatic intraosseous devices in pediatric prehospital care. Prehosp Emerg Care. 2011 Oct-Dec. 15(4):473-6. [Medline].

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  25. McCarthy G, O'Donnell C, O'Brien M. Successful intraosseous infusion in the critically ill patient does not require a medullary cavity. Resuscitation. 2003 Feb. 56(2):183-6. [Medline].

  26. Zabala Arguelles JI, Maranon Pardillo R, Gonzalez Serrano P, Serina Ramirez C. [Main vascular access in situations of extreme urgency: intra-osseous infusion]. An Esp Pediatr. 1992 Dec. 37(6):489-92. [Medline].

  27. Brickman KR, Rega P, Koltz M, Guinness M. Analysis of growth plate abnormalities following intraosseous infusion through the proximal tibial epiphysis in pigs. Ann Emerg Med. 1988 Feb. 17(2):121-3. [Medline].

 
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Intraosseous needle insertion sites in infant or small child.
Intraosseous needle insertion sites in older child, adolescent, or adult.
Alternative intraosseous needle insertion site: ilium.
Sternal needle: F.A.S.T.1 system (Pyng Medical Corporation).
Cook-type intraosseous needle.
Cook-type screw-tip intraosseous needle (Sur-Fast needle).
Jamshidi intraosseous needle.
Illinois sternal iliac intraosseous needle.
Shown are 3 different sizes of intraosseous needles for use in EZ IO (Vidacare). Appropriate size is determined by patient weight and size.
Bone Injection Gun (BIG) spring-loaded intraosseous insertion device (Waismed).
Proximal tibia intraosseous needle insertion site.
Distal tibia intraosseous needle insertion site.
Distal femur intraosseous needle insertion site.
Sternal intraosseous needle insertion.
 
 
 
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