eMedicine Specialties > Pediatrics: Surgery > General Surgery

Intraosseous Access

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

Updated: Jan 27, 2010

Introduction

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 techniques have been used for decades and have been proven to be safe, reliable, and rapid means of providing crystalloids, colloids, medications, and blood products into the systemic circulation.^{[1 ]}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.

History of the Procedure

The first therapeutic use of IO access was reported in 1934.^{[2 ]}Subsequently, in the 1940s, a series of reports confirmed the widespread applicability of the technique for the delivery of various agents (eg, medications, fluids, blood products) to both adult and pediatric patients in a wide variety of settings.^{[3,4,5,6,7,8,9 ]}With the development of the intravenous catheter, the IO needle fell into disuse. The needle 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 the 1980s, IO access has become widely accepted in pediatric settings, especially because these patients often provide a particular challenge to obtaining rapid intravascular access.

IO access was initially thought to be less applicable in patients older than 6 years. However, historical and current data (eg, in military populations^{[12 ]}), as well as both the 2000 Emergency Cardiac Care guidelines^{[13 ]}and the 2007 Critical Care guidelines^{[14 ]}for the management of neonates and pediatric patients with septic shock, support the consideration of IO techniques in patients of any age as rapid and equally effective alternatives to intravenous peripheral lines. Moreover, IO access is considered more appropriate than attempted placement of central lines in situations when immediate resuscitation is essential.^{[15,16 ]}In addition, IO needles provide rapid access to the central circulation with good bioequivalence to intravenous infusion.^{[17,18 ]}

The particular site used may appropriately vary with the age of the patient and depending on landmarks and bone density. Of note, the levels of chemistries, drugs, and hemoglobin; the blood typing; and the acid-base status^{[19 ]}obtained from the blood in the marrow aspirates obtained from the IO needle have been found to be reliable predictors of serum levels, although this may not hold true in terms of chemistries and acid-base status in the setting of prolonged resuscitation.

Indications

Initiation of intraosseous (IO) access is indicated in adults, children, infants, or newborns in any clinical situation in which vascular access is emergently needed but not immediately available via peripheral vein. IO access provides a means of administering medications, glucose, and fluids and, potentially, provides 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 due to burns, edema, or obesity. IO access is safer, is associated with fewer complications and time delay, and requires less skill and practice for those who rarely use such techniques when compared with child and infant peripheral intravenous access, central lines, or umbilical lines.^{[20 ]}

IO needle placement is not definitive therapy; rather, it allows for the administration of life-saving medications and fluids in a context in which intravascular access is vital. Often, the definitive intravenous access is easier to obtain once a bolus of fluids and medications have been administered via the IO needle. IO needles may be left in place in the marrow up to 72-96 hours; presumably, the longer the needle remains in place the greater the risk of infection and dislodgement. In practice, the IO needle is usually removed as soon as another means of vascular access, whether peripheral or central, is available, ideally within 6-12 hours.

Relevant Anatomy

The sternum is the original site of access reported and is a useful site to consider in adult patients, as is the ilium. Studies suggests that intraosseous (IO) infusion may be effective even when the bones used do not contain a medullary cavity, such as the calcaneus and radial styloid.^{[21,22 ]}

The site of choice in children and infants is the proximal tibia; the distal tibia and proximal femur are alternatives (see Media file 1).

Intraosseous needle insertion sites in an infant or small child.

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. The anterolateral proximal humerus is another site that is often used in adults. As powered devices become more widely available and IO access is used increasingly in the prehospital setting and in adults, this site will become increasing 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 Media file 2).

Intraosseous needle insertion sites in an older child, adolescent, or adult.

The proximal femur may also be used but generally has much denser covering layers of fat, muscle, and soft tissue, which make identification of landmarks and bony penetration more difficult. In adults, other insertion sites have included several different iliac sites (see Media file 3), the sternum, the distal radius or ulna, and, as mentioned above, the humerus.

Alternative intraosseous needle insertion site. Iliac insertion site.

A recently marketed sternal IO system (F.A.S.T.1 system; Pyng Medical Corp) for use 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 (see Media file 4).

Sternal needle, F.A.S.T.1 system, Pyng Medical Corp.

Contraindications

Contraindications to intraosseous (IO) access include the following:

• Ipsilateral fracture of the extremity because of resulting extravasation and risk of compartment syndrome
• Previous attempt or 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 of causing a fracture when puncturing the bone
• Osteopetrosis because of fracture risk
• Obvious overlying infection at the proposed puncture site because of the risk of seeding infection (a relative contraindication)

Treatment

Medical Therapy

Several needle types are available (see Media files 4-11). 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 does not need to be advanced more than 1 cm to provide stability and access to the marrow cavity.

The technique described below is applicable to the types of IO needles that are available in pediatric emergency department and hospital settings.

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

  

  Cook-type intraosseous needle.

  
  
  

  

  Cook-type screw tip intraosseous needle (Sur-Fast needle).

  
  
  

  

  Jamshidi intraosseous needle.

  
  
• Since 2006, two additional devices have been approved for use in adult and pediatric patients: the Bone Injection Gun (BIG) device (WaisMed) and the EZ IO (Vidacare).
  • In the United States, the EZ IO is now widely used in field and transport settings (eg, emergency medical service situations). The EZ IO 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).
    
    

    

    Three different sizes of intraosseous needles for use in the EZ IO. Appropriate size is determined by patient weight and size.

    
    
  • Powered insertion devices are used with increasing frequency in pediatric patients in US hospitals—in emergency departments, critical care units, and even operating rooms.^{[23 ]}
  • 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, which is determined by the patient's age.
    
    

    

    Bone Injection Gun (BIG) spring-loaded intraosseous (IO) insertion device.

    
    
  • Both the BIG device and the EZ IO are approved for use in the proximal and distal tibia in both the pediatric population and in adults and in the humeral head in adults.
  • Neither device requires special removal equipment.
  • Training videos are available on the respective Web sites (Vidacare and Waismed).
• The F.A.S.T.1 system for sternal IO needle placement in adults incorporates an insertion device to localize and place the needle at a predetermined depth, specialized connector tubing, and a cover for added stability. It requires the use of a removal device, which is included with the kit.
  
  

  

  Sternal needle, F.A.S.T.1 system, Pyng Medical Corp.

  
  

Complications

Complications of intraosseous (IO) needle placement are rare, especially if the correct techniques are followed and frequent subsequent evaluations of position within the bone are performed.^{[24 ]}

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

• Incorrect identification of landmarks
• A bent needle, which is more common with longer needles or a spinal needle
• 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 potentially 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, osteogenesis imperfecta), which allows leakage, extravasation, and potential compartment syndrome to occur
• Penetration of the mediastinal structures or space with 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), with an incidence of less than 0.6% in a literature review of 4000 cases over 35 years (although 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, although not reported in animals or humans^{[25 ]}
• Fat embolus, with rare reports in adult patients and not reported when an IO needle is placed in the tibia (rather than other sites such as the ilium or sternum)
• Bone embolus, although not reported in humans
• Mediastinitis after sternal IO puncture

Future and Controversies

During the last 5-10 years, attitudes have changed and broadened as to the different settings in which intraosseous (IO) access might be considered. IO access is now part of the recommendations for emergent intravascular access in any age group, not just for 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.^{[23 ]}Clearly, the use of IO access in a battlefield setting remains applicable because this venous route remains accessible even in the most hypovolemic patient, and military and trauma literature attest to its usefulness in that setting.

Controversy remains as to the optimal duration of use of IO access. Although, intuitively, long-term uses of IO access should increase the risk of potential infection, the infection and complication rate is actually very low, even in the most exigent circumstances. No data support the common colloquial recommendation that another access avenue must be obtained prior to transfer from the emergency department or that the IO access should be removed as soon as possible.

Multimedia

Media file 1: Intraosseous needle insertion sites in an infant or small child.

Media file 2: Intraosseous needle insertion sites in an older child, adolescent, or adult.

Media file 3: Alternative intraosseous needle insertion site. Iliac insertion site.

Media file 4: Sternal needle, F.A.S.T.1 system, Pyng Medical Corp.

Media file 5: Cook-type intraosseous needle.

Media file 6: Cook-type screw tip intraosseous needle (Sur-Fast needle).

Media file 7: Jamshidi intraosseous needle.

Media file 8: Illinois sternal iliac intraosseous needle.

Media file 9: Three different sizes of intraosseous needles for use in the EZ IO. Appropriate size is determined by patient weight and size.

Media file 10: Bone Injection Gun (BIG) spring-loaded intraosseous (IO) insertion device.

Media file 11: Proximal tibia intraosseous needle insertion site.

Media file 12: Distal tibia intraosseous needle insertion site.

Media file 13: Distal femur intraosseous needle insertion site.

Media file 14: Sternal insertion

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Keywords

intraosseous access, IO access, IO, intraosteal, within bone, intraosseous needle, IO needle, intraosseous infusion, IO infusion, IO cannulation, IO placement, vascular access, intravenous access, peripheral intravenous access, shock, hypothermia, vascular constriction, cardiopulmonary arrest, status epilepticus, obesity, burns, edema, ipsilateral fracture, osteopenia, osteopetrosis, osteogenesis imperfecta

Contributor Information and Disclosures

Author

Pegeen Eslami, MD, Assistant Professor of Pediatrics, Division of Pediatric Emergency Medicine, UMass Memorial Medical Center
Pegeen Eslami, MD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, American College of Emergency Physicians, and Massachusetts Medical Society
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: Nothing to disclose.

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

Marleta Reynolds, MD, Professor of Surgery, Feinberg School of Medicine, Northwestern University; Interim Head, Department of Surgery and Surgeon in Chief, Head, Division of Pediatric Surgery, Children's Memorial Hospital of Chicago
Marleta Reynolds, MD is a member of the following medical societies: American Pediatric Surgical Association
Disclosure: Nothing to disclose.

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