You are in: eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Critical Care Intraosseous CannulationArticle Last Updated: Aug 17, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: William Gluckman, DO, MBA, Assistant Professor, Department of Surgery, Section of Emergency Medicine, University of Medicine and Dentistry of New Jersey, University Hospital William Gluckman is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine 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; Sangeeta Lamba, MD, Assistant Professor of Surgery/Medicine, Section of Emergency Medicine, University of Medicine and Dentistry New Jersey University Hospital Editors: 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; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; 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; Mary E Cataletto, MD, Associate Director, Division of Pediatric Pulmonology, Winthrop University Hospital; Associate Professor, Department of Clinical Pediatrics, State University of New York at Stony Brook; Maureen Strafford, MD, Arnold P Gold Foundation Associate Professor, Departments of Anesthesiology and Pediatrics, Tufts University and Tufts-New England Medical Center Author and Editor Disclosure Synonyms and related keywords: intraosseous cannulation, cannulization, IO cannulation, IO, intraosseal, intraosteal, interosseous, interosseal, bone, intrabone, bone cannulation BACKGROUNDSection 2 of 11
  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 a number of studies demonstrated the efficacy of IO administration of emergency medications in patients needing resuscitation. Historically, IO use was recommended only in children younger than 6 years. Current guidelines for cardiopulmonary resuscitation, however, 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. PATHOPHYSIOLOGYSection 3 of 11
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. The bone marrow therefore 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 with peripheral vasoconstriction. The 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 COMPLICATIONSSection 4 of 11
The risks and complications of IO insertion are few, and the benefits far outweigh the risks in a child without intravenous 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 it 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 intravenous 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. AGESection 5 of 11
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. PROCEDURESection 6 of 11
The most common site recommended for 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:
Although fluid may run from the intravenous line by gravity, the rate is too slow for resuscitation. Faster rates of infusion occur by drawing up 30- 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 SITESSection 7 of 11
Alternative sites for 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:
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:
CONTRAINDICATIONSSection 8 of 11
The only absolute contraindication is fracture of the tibia or long bones, which are potential sites for IO insertion. Relative contraindications to IO insertion include the following:
WHAT'S NEW?Section 9 of 11
IO access is now considered as one of the recommendations for emergent vascular access in both children and adults. IO devices are being used for individuals in nontraditional settings such as patients with burns, trauma patients, 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. Devices that "drill" the IO needle into the bone, such as the EZ-IO (Vidacare, San Antonio, Tex), are also available and may decrease insertion time and misplacement rates. MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
Intraosseous Cannulation excerpt Article Last Updated: Aug 17, 2006 | |||||||||||||||||||||||||||||||||
