Intraosseous vascular access is the use of intraosseous needle placement to access the venous circulation via venous sinusoids in the bone.
Intraosseous access was first introduced by Drinker in 1922. After IV catheters were discovered, this method was abandoned until the 1980s, when it was reintroduced as a method of fast resuscitation.
Earlier, the intraosseous access was suggested for children aged 6 years or younger but studies have shown that it is safe for older children and adults as well.
Intraosseous vascular access in newborns has been shown to be faster than access via umbilical veins.
Intraosseous access can be used to obtain blood for investigations in the emergency, including pH level, carbon dioxide tension (PCO2), and ABO and Rh typing. The values may differ slightly from values obtained with venous blood samples because of low flow and stasis in the bone marrow.
Intraosseous access can also be used for administering blood products and medications too.
Even contrast for CT has been given by this route.
Intraosseous access is for short term only and should be removed as soon as permanent venous access is established [though convention, it does not have much data for support and longer stay of the needle has been recommended by some authors as well.
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. Thus, the bone marrow functions as a noncollapsible venous access route when peripheral veins may have collapsed.
This approach is particularly important in patients in shock or cardiac arrest when blood is shunted to the core due to compensatory peripheral vasoconstriction.
Therefore, intraosseous access may be more appropriate than attempted placement of central lines in situations when immediate resuscitation is essential. This route continues to be accessible even in the most hypovolemic patient.
Intraosseous Needle Insertion Sites
The insertion site of choice in children and infants is the proximal tibia as it provides a flat wide surface and is covered by a thin layer of overlying tissue, which allows easy identification of landmarks.
Distal tibia or the proximal humerus may be advantageous in adults because these provide reliable and evident landmarks and has a relatively thin cortex.
The distal femur may also be used, but it generally has much denser covering layers of fat, muscle, and soft tissue and landmark identification is generally difficult.
In adults, other insertion sites are ilium, the sternum, the distal radius or ulna.
Indications for Intraosseous Access
Intraosseous 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. For example cardiopulmonary arrest, shock, life-threatening status epilepticus; or lack of venous access resulting from burns, edema, or obesity.
The only absolute contraindication is fracture of the targeted bone. All the following are relative contraindications –
- Cellulitis overlying the insertion site
- Inferior vena caval injury
- Central venous access superior to the injury is preferred
- A previous attempt on the same leg bone
- Oteogenesis imperfecta
- Higher likelihood of fractures occurring
- Previous sternotomy or vascular injury near the sternum (sternum insertion)
Different Types of intraosseous Access Needles
Except in neonatal settings where spinal needles are occasionally used, the intraosseous (IO) needle should have a needle stylet to reduce risk of clogging while insertion.
Intraosseous needles should be marked to gauge the distance to which the needle has penetrated. Some needles have covering flange that prevents insertion deeper than a predetermined distance.
Various Types of needles for intraosseous vascular access are
- Spinal needles for neonates
- Hypodermic needle, 16-18 gauge
- Jamshidi needle
- Sur-Fast intraosseous needle
- Jamshidi disposable Illinois sternal/iliac needle
- Sussmane-Raszynski needle
- Arrow EZ-IO
- FAST1 Intraosseous Infusion System
- NIO [New Intraosseous Device]
- BIG [Bone Injection Gun]
The traditional needles (Cook, Jamshidi) are placed manually.
In the supine position, the knee of the patient is flexed. The site of insertion is two fingerbreadths distal to the tuberosity, between the anterior and posterior borders of the tibia [one fingerbreadth in infants].
Prepare the site with povidone-iodine and anesthetize the puncture site with 1-2 mL of lidocaine 1%.
Support the tibia by one hand [hold from dorsal side and not popliteal to avoid possible lacerations and through-and-through penetration].
Position the needle in other hand, direct a little to caudally to avoid puncturing the epiphysis.
Rotate the needle in a screwlike motion through the skin.[A small incision made with a scalpel will ease the passage through the skin.
Advance the needle until a sudden loss of resistance is felt. 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.
Make the device flush with skin by adjusting a screw-adjustable stabilizer of the device.
If the needle that stands freely and upright without support, it indicates correct placement.
Remove the trocar, and attach the syringe for marrow aspiration. Commonly, marrow is not aspirated upon insertion. [Inability to aspirate blood does not indicate improper placement]
Attach intravenous tubing to the hub, and infuse fluid. Observe the surrounding tissue for possible extravasation.
- If marrow is not aspirated, push a 5-mL to 10-mL bolus of isotonic sodium chloride solution. Extravasation should not be there
- If flow is good and extravasation is not evident, connect the intravenous (IV) line with a 3-way stopcock a
Faster rates can be achieved by administering manual fluid boluses via the stopcock.
Secure the line firmly after insertion.
Secure by taping. Gap between the skirt and the hub should be padded.
A small cup with a hole for the IV tubing over the device provides an additional layer of protection.
The limb is immobilized for extra stability.
Increasingly case powered insertion devices are used [Bone Injection Gun (BIG) device and the EZ IO]
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)
The BIG device, which has a spring-loaded handle that injects the IO needle to a preset depth, determined by the patient’s age.
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.
Needle selection (based on the weight of patient)
- Pink 15mm (3-39kg)
- Blue 25mm (40kg and above)
- Yellow 45mm (excessive tissue)
When needle tip contacts bone there should be 5mm of catheter visible outside of skin (if not then a longer needle is needed may need a longer needle)
The F.A.S.T.1 system
This is sternal IO needle placement system in adults that includes both a marker patch and a special introducer device to simplify needle placement and the depth of needle insertion. It requires the use of a removal device, which is included with the kit.
Other Insertion Sites
- Palpate the flat portion of distal tibia, just proximal to the medial malleolus.
- Angle the needle 10-15° cephalad to minimize the risk of growth plate injury.
Not preferred due to difficult to locate landmarks and thick overlying tissues.
- 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.
- Abduct the shoulder is adducted and make the greater tuberosity prominent by
- Identify the greater tuberosity.
- Insert the needle at a 90-degree angle directly into the greater tuberosity.
Demonstrated complications of intraosseous access include the following –
- Infections such
- Cellulitis and osteomyelitis
- Often from poor antiseptic technique
- Extravasation of blood or infusion
- Poor technique or prolonged infusion
- Compartment syndrome from extravasation
- Bent needle
- Poor technique
- Missed landmark
- Bone fracture
- Through-and-through penetration from excessive force
- Pneumothorax, mediastinitis, or surrounding organ and tissue injury from sternal puncture
- Clogged needle
- Pulmonary fat embolism [rare]
- Local hematoma
- Growth plate injuries (with incorrect placement),
Intraosseous needle is removed once alternative vascular access is obtained.
Failure of Procedure
One or more of the following may be responsible for the failure of the procedure
- Incorrect identification of landmarks
- A bent needle
- More common with longer needles or spinal needles
- Clogging of the needle with marrow, clot, or bone spicules
- Use frequent flushing of the needle or continuous infusion
- Through-and-through penetration of both anterior and posterior cortices
- Excessive force
- Weak bone
- Subcutaneous or subperiosteal infiltration
- Incomplete penetration of the placement of the needle
- Dislodged needle
- Fractures during the procedure
- Excess force
- Fragile bones
- Penetration of the mediastinal space
Few Things Worth Remembering
- Blood drawn from an IO can be used for type and cross, chemistry, blood gas.
- Lab values
- No correlation with Sodium, Potassium, CO2, and calcium levels
- Elevated potassium [hemolysis]
- Cannot use intraosseous blood for CBC
- Higher and platelet counts are lower
- Epinephrine infused via the intraosseous humeral site has the identical peak serum concentration as if it were instilled via a subclavian central line
- Drips or IV fluids should be given with pressure bag or infusion pump
- Neuhaus D, Weiss M, Engelhardt T, Henze G, Giest J, Strauss J, et al. Semi-elective intraosseous infusion after failed intravenous access in pediatric anesthesia. Paediatr Anaesth. 2010 Feb. 20(2):168-71.
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- Hansen M, Meckler G, Spiro D, Newgard C. Intraosseous line use, complications, and outcomes among a population-based cohort of children presenting to California hospitals. Pediatr Emerg Care. 2011 Oct. 27(10):928-32.
- Burke T, Kehl DK. Intraosseous infusion in infants. Case report of a complication. J Bone Joint Surg Am. 1993 Mar. 75(3):428-9.
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- Guy J, Haley K, Zuspan SJ. Use of intraosseous infusion in the pediatric trauma patient. J Pediatr Surg. 1993 Feb. 28(2):158-61.
- Rosetti VA, Thompson BM, Miller J. Intraosseous infusion: an alternative route of pediatric intravascular access. Ann Emerg Med. 1985 Sep. 14(9):885-8.