You are in: eMedicine Specialties > Pediatrics: Surgery > General Surgery Intraosseous AccessArticle Last Updated: Mar 7, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Pegeen Eslami, MD, Assistant Professor of Pediatrics, Division of Pediatric Emergency Medicine, UMass Memorial Medical Center Pegeen Eslami is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, American College of Emergency Physicians, and Massachusetts Medical Society 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 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 INTRODUCTIONSection 2 of 10
  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 ProcedureThe 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 populations older than 6 years; however, historical and current data, as well as the 2000 Emergency Cardiac Care guidelines, support the consideration of IO techniques in patients of any age as rapid and equally effective alternatives to intravenous peripheral lines.12 The particular site used may appropriately vary with the age of the patient and depending landmarks and bone density. Of note, the levels of chemistries, drugs, and hemoglobin; the blood typing; and the acid-base status13 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 situations of prolonged resuscitation. INDICATIONSSection 3 of 10
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.14 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 ANATOMYSection 4 of 10
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.15, 16 The site of choice in children is the proximal tibia; the distal tibia and proximal femur are alternatives (see Media file 1). 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. With increasing age, the cortical thickness increases, which makes penetration more difficult and forceful; thus, in older children and adults, using the distal tibia 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). 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 the humerus. 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). CONTRAINDICATIONSSection 5 of 10
Contraindications to intraosseous (IO) access include the following:
TREATMENTSection 6 of 10
Medical therapySeveral needle types are available (see Media files 4-7). 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.
COMPLICATIONSSection 7 of 10
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.17 Failure to achieve effective IO placement may be the result of one or more of the following:
Complications even after effective placement and timely removal are rare but may include the following:
FUTURE AND CONTROVERSIESSection 8 of 10
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. 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. MULTIMEDIASection 9 of 10
REFERENCESSection 10 of 10
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