Full Details for Intraosseous Infusion

PRE-PROCEDURE

INTRODUCTION
Establishing vascular access in a critically ill or injured patient can be life saving (see Figure 1). The rapid
delivery of fluid, blood, and medication is often the difference between a successful and unsuccessful
resuscitation. Although this is true in both children and adults, placing an intravenous (IV) catheter in an ill
or injured child can be one of the most challenging and frustrating procedures a clinician can be called upon
to perform. Children have small peripheral vessels that collapse during shock, and their increased body fat
makes visualization and palpation of peripheral vessels difficult. These factors often result in prolonged
attempts and high failure rates.
Peripheral intravenous access can also be difficult in certain adults, including those who are obese, burned,
volume depleted, or in shock from any cause.1Intraosseous (IO) access can provide rapid, lifesaving
intravascular access in challenging environments and in difficult pediatric and adult patients. The American
Heart Association, the American Academy of Pediatrics, and the American College of Surgeons recommend
IO access in emergency situations in children when venous access is not immediately possible. 2The latest
edition of the Advanced Trauma Life Support Manual also notes that IO access using specially designed
equipment is also possible in adult trauma patients.3 IO access is as fast as IV access, and the success rate
after failed IV attempts is high.
Clinical Pearls: Almost every drug and fluid commonly used in resuscitation has been reported in clinical
and preclinical IO studies. Crystalloid infusion studies in animals have demonstrated that infusion rates of 10
to 17 mL/min may be achieved with gravity infusion and rates as high as 42 mL/min with pressure
infusions.4-6

Clinical Pearls: Comparisons of IO and IV infusion of drugs have demonstrated that the
drugs reach the central circulation by both routes in similar concentrations and at the same
time.7,8
INDICATIONS
Clinical Pearls: When children or adults need immediate resuscitation and intravascular access cannot be
rapidly or reliably achieved, the IO route provides a rapid and effective means of administering drugs, fluids,
and blood. Once the patient has been stabilized, percutaneous peripheral or central intravascular access may
be achieved.

The primary indication for IO access is cardiac arrest in infants and young children.

Clinical Pearls: IO access is not commonly used for premature or term infants but is recommended as an
alternative for medication and crystalloid administration when venous access is not readily obtained. 9

IO infusion is also indicated in adult patients in whom attempts at peripheral and venous access
have been unsuccessful. This may include adult patients with burns, trauma, shock, dehydration, or
status epilepticus.10,11

IO access serves as a route for fluid administration and can be used to obtain blood specimens for
obtaining blood type, crossmatch12and blood chemistry. Electrolyte, blood urea nitrogen (BUN),
creatinine, glucose, and calcium levels are very similar to those obtained from serum. 13,14 Blood gas

values may be an acceptable alternative to judging central acid-base status during CPR. 15

A complete blood cell count from a bone marrow aspirate may not be reliable because it reflects the
marrow cell count rather than the cell count in the peripheral circulation. Furthermore, the aspirated
blood usually clots within seconds, even if it is placed in a tube that contains heparin.

CONTRAINDICATIONS

Relatively few contraindications to IO infusion exist.

Osteoporosis and osteogenesis imperfecta are associated with a high fracture potential; therefore,
the procedure should be avoided when these diagnoses are known unless absolutely necessary.

A fractured bone must be avoided because as fluid is infused, it increases the intramedullary
pressure and forces fluid to extravasate at the fracture site (see Figure 2). This may slow the
healing process, cause a nonunion of the bone, or lead to a compartment syndrome.

Recent prior use of the same bone for IO infusion represents a relative contraindication to IO line
placement because extravasation of fluid can occur through recent IO puncture sites placed in the
same bone (with the same consequences as fracture).

Needle insertion through areas of cellulitis, infection, or burns should be avoided.

EQUIPMENT
Clinical Pearls: The following is a review of products currently available for intraosseous infusion. There
is limited information regarding the use of these products, and there have been few prospective studies
comparing IO needles or devices in clinical practice. Until more information becomes available, practitioners
are encouraged to review available products and choose those that best meet their needs.
Clinical Pearls: Needles used for IO access range in size from 13- to 20-gauge and must be sturdy enough
to penetrate bone without bending or breaking and long enough to reach the marrow cavity. Standard
needles for drawing blood or administering medications are not adequate for IO infusions; generally, they
are not sturdy enough to penetrate bone and do not have a stylet to prevent bone from plugging the lumen.

Bone Marrow Aspiration Needle

Bone marrow aspiration needles can be used if needles specifically designed for IO
access are not available. These needles are large enough (16-gauge) to be used in older
children and adults and are suitable for rapid fluid administration.

Illinois Sternal/Iliac Aspiration Needle (Monojet, Division of Sherwood Medical, St. Louis, Mo.)
This needle was designed for bone marrow aspiration but can be used for IO infusion. The
needle is available in both 16- and 18-gauge sizes. It has an adjustable plastic sleeve to
prevent the needle from penetrating through the opposite bony cortex. However, its long
shaft and poorly designed handle make it prone to dislodgement during transport and other
procedures.

Jamshidi Disposable Sternal/Iliac Aspiration Needle (Cardinal Health, Dublin, Ohio) (see Figure 3).
Like the Illinois sternal/iliac aspiration needle, the Jamshidi Disposable Sternal/Iliac
aspiration needle was designed for bone marrow aspiration, but it has a shorter shaft and

smaller handle, making it easier to use. It comes in either 15- or 18-gauge sizes and also
features an adjustable plastic sleeve to prevent overpenetration. Once inserted, the needle
protrudes approximately 2 inches from the skin, increasing the risk for accidental
dislodgment. In a study using a turkey-bone model, participants rated the Jamshidi needle
easier to use than the Cook IO needle.16

Cook IO Needle (Cook Critical Care, Bloomington, Ind.) (see Figure 4).
The Cook IO is specifically designed for IO insertion and infusion. It comes in a variety of
sizes from 14- to 18-gauge and can be inserted to a depth of 3 to 4 cm. It has a detachable
handle that reduces the risk of it being dislodged and a depth marker to help assure proper
placement.

Sur-Fast Needle (Cook Critical Care, Inc, Bloomington, Ind.)

The Sur-Fast needle is also specifically designed for IO insertion and infusion. It has a
threaded shaft that helps secure the needle in the bone and a detachable handle that may
be reused with multiple needles. In a study by Jun and colleagues, the Sur-Fast IO needle
had a similar success rate to a standard bone marrow aspiration needle. 17

Intraosseous Devices

FAST-1 Intraosseous Infusion System (PYNG Medical Corporation, Richmond, B.C., Canada)
The FAST-1 Intraosseous Infusion System employs an impact-driven device designed
for sternal placement only. The FAST-1 has not been evaluated in the emergency
department setting but has been successfully used by both military and pre-hospital care
providers.18,19 In one prehospital care study, flow rates of 80 mL/min and 150 mL/min were
obtained using gravity and a pressure bag, respectively.20
The device has a series of stabilizing probes that help maintain good contact with the
sternum and serve as the depth control mechanism for needle insertion. These probes use
the surface of the manubrium rather than the patients skin to ensure the proper depth of
insertion. Once the device is positioned against the sternum, additional pressure triggers
the release of a hollow needle into the medullary space. The needle comes preconnected to
intravenous tubing. The handle is automatically released from the stylet and infusion tubing
once the needle has met its pre-set depth. Removal of the needle requires a threaded tool
provided with the device. The FAST-1 is larger and heavier than other IO devices and, once
triggered, it cannot be reused.

Bone Injection Gun (BIG; Waismed; Yokenam, Israel)

The Bone Injection Gun is another spring-loaded, impact-driven device that comes in
both pediatric and adult sizes. Like the FAST-1 system, this device is designed for single use
only. An advantage of the Bone Injection Gun is the ability to adjust the depth of insertion,
allowing use in different sites (e.g., tibia, humerus). However, if the device is not carefully
stabilized before and during insertion, incorrect placement can easily occur. In addition,
there is the potential for operator and patient injury if the device is accidentally triggered or
mistargeted.19

EZ-IO Device (Vida-Care, San Antonio, Texas) (see Figure 5).

This new handheld, battery-powered device drills an IO needle to the appropriate depth in
the intraosseous space. The EZ-IO device allows the operator to control the pressure or
force used during insertion.21In one study of 250 prehospital uses, successful placement
was achieved in 97% of patients.22The authors of this study strongly recommend flushing

the needle to ensure optimal flow. In another study of the EZ-IO device, placement was
successful in 118 out of 125 attempts, with an average insertion time of 4.5 seconds. 23

TIAX Reusable IO Infusion Device (TIAX LLC, Cambridge, Mass.)

TIAX has developed a compact, portable, and reusable IO infusion device for quick vascular
access through the sternum of soldiers wounded in battle situations. The device is
lightweight (217 g), can be operated with one hand, and uses a driver/depth control system
that can be used repeatedly to insert single use IO needles. The device is currently in phase
II trials.

ANATOMY

Bone anatomy
Long bones are richly vascular structures with a dynamic circulation. They are capable of
accepting large volumes of fluid and rapidly transporting fluids or drugs to the central
circulation. The bone, like most organs, is supplied by a major artery (nutrient artery). The
artery pierces the cortex and divides into ascending and descending branches, which
further subdivide into arterioles that pierce the endosteal surface of the stratum compactum
to become capillaries.
The capillaries drain into medullary venous sinusoids throughout the medullary space,
which in turn drain into a central venous channel. The medullary sinusoids accept fluid and
drugs during IO infusion and serve as a route for transport to the central venous channel,
which exits the bone as nutrient and emissary veins. 24 The medullary cavity functions as a
rigid, noncollapsible vein, even in the presence of profound shock or cardiopulmonary
arrest.25Radiographic studies have demonstrated that radiopaque dye spreads only a few
centimeters in the medullary space before being transported to the venous system. 26
The richly vascular red marrow cavity of the long bones is gradually replaced by less
vascular yellow marrow after age 5.27

Sites for IO Needle Placement

The patients age and size are the two most important factors when choosing the best site
for needle penetration.
In infants and children younger than 6 years of age, the proximal tibia is the preferred
site, followed by the distal tibia and distal femur. Other sites, such as the clavicle and
humerus, have been used, but neither has gained popularity.
In adults, the distal tibia has been the most common site for IO access. However, with the
introduction of spring-loaded and drill devices, IO locations once reserved only for children
are now potential sites in adults as well. In addition, the FAST-1 system makes the
sternum a simple and effective location for IO access in adults.

Locations for IO access18,28,30

Iliac crest
Femur (see Figure 6)

The distal portion of the femur is occasionally used as an alternate site in children,

but because of thick overlying muscle and soft tissue, it is more difficult to palpate
bony landmarks. If chosen, the needle should be inserted 2 to 3 cm above the
femoral condyles in the mid-line and directed cephalad at an angle of 10 degrees to
15 degrees from the vertical.
Proximal tibia (see Figure 7)

The tibia is a less desirable location in adults because red marrow is replaced by
less vascular yellow marrow or fat by the fifth year of life. 31,32

The tibia is a large bone with a thin layer of overlying subcutaneous tissue that
allows landmarks to be readily palpated, and insertion here does not interfere with
airway management and cardiopulmonary resuscitation.

On the proximal tibia, the broad, flat, anteromedial surface is used, with the tibial
tuberosity serving as a landmark. The site of IO cannulation is approximately 1 to 3
cm (2 finger widths) below the tuberosity. This location is far enough from the
growth plate to prevent damage but is in an area in which the bone is still soft
enough to allow easy penetration of a needle.

In adults, penetrating the thick bone in the proximal tibia is much more difficult
and requires a 13- to 16-gauge needle. A spring-loaded device such as the BIG or
a battery-powered drill such as the EZ-IO can make penetration much easier and
allows the use of smaller gauge needles.

Distal tibia (see Figure 8)

The distal tibia, although a preferred site in adults, may be used as a site in
children as well. The cortex of the bone and the overlying tissue are both thin.

The site of needle insertion is the medial surface at the junction of the medial
malleolus and the shaft of the tibia, posterior to the greater saphenous vein. The
needle is inserted perpendicular to the long axis of the bone or 10 degrees to 15
degrees cephalad to avoid the growth plate.

Sternum (see Figure 9)

The sternum has been advocated as the best site to establish IO access in adults
because it is large, flat, and can be readily located.33 The sternums cortical bone is
thin (1-2 mm) and the marrow space relatively uniform (6-11 mm). 32 In addition, it
is less likely to be fractured in major trauma than the long bones.

The high proportion of red marrow allows rapid transfer of infused fluids and drugs
to the central circulation.

The introduction of the FAST-1 system, which allows safe and effective penetration
of the sternum, has led to increased utilization and popularity of sternal IO
insertion in adults.

Other potential sites for IO insertion

Radius

Clavicle

Humerus

Calcaneus

PROCEDURE

Positioning
Place the patient supine with the insertion site accessible.
To prepare the proximal tibia or distal femur for IO insertion, a small support such as a
towel roll should be placed behind the knee.

Choose an appropriate site for IO needle insertion.

Observe universal precautions. **UNIVERSAL PRECAUTIONS**

Site Preparation
Cleanse the insertion site with chlorhexidine or povidone-iodine (see Figure 10). **STERILE
TECHNIQUE**
For patients with severe shock, dehydration, or cardiopulmonary arrest, local anesthesia
may be considered, but is not necessary. If the patient is conscious, anesthetize the skin
and periosteum. See Local Anesthesia for further details.

Manual Needle Insertion

Prior to insertion, use your free hand (i.e., the hand not holding the IO needle) to stabilize
the site and act as a guide for identification of landmarks (see Figure 11).

For example, during proximal tibial insertion, use the thumb and index finger of the
free hand to stabilize the proximal tibia and identify (palpate) the tibial tuberosity
(the main bony landmark for proximal tibial insertion).

During insertion, avoid puncturing your free hand by keeping it out of the plane of insertion
and clear of the puncture site.
Direct the IO needle perpendicular (90 degrees) to the bones long axis or slightly caudad
(60-75 degrees). Directing the needle slightly caudad will help avoid penetration of the
growth plate (see Figure 12).
Advance the needle using a twisting or rotating motion, driving it into the bone and
puncturing the cortex.
Once the cortex is penetrated, there will be a sudden decrease in bony resistance and a
crunchy feeling as the needle enters the marrow cavity. Penetration of the inner cortex
usually occurs at approximately 1 cm.
Aspirate blood and/or marrow contents to confirm correct placement (see Figure 13). Other

signs of correct placement include the needles ability to remain upright without support
and free-flowing fluid without signs of extravasation into surrounding tissue.
Clinical Pearls: If available, ultrasound imaging or a miniature C-arm device has also been shown to
reliably confirm IO placement.34-37

FAST-1 device
This device was designed specifically to penetrate the sternum and has been gaining
popularity for both pre-hospital and military applications where rapid, simple, and reliable
intraosseous access is required.18,38
The FAST-1 device is prepackaged with alcohol and iodine and comes with a protective
dressing that holds the device in place and a threaded tip remover for easy removal of the
metal tip and infusion tubing.
Disinfect the skin site on the sternum, then place the target patch over the midline of the
manubrium with the hole in the middle of the target approximately 1.5 cm below the
sternal notch.
Next, place the FAST-1 introducer in the center of the target zone. The introducer has a
bone cluster of needles that form a circle. These needles sense the cortex of the
sternum and help ensure the proper needle depth.
Once in position over the target zone, apply pressure to the handle to release an inner
needle located in the center of the bone cluster. This needle has a small metal tip that is
pre-connected to plastic infusion tubing.
After release, the central IO needle advances 5 mm beyond the circular cluster of needles
stopping at the bony cortex and positioning the metal tip at the cortex-medullary junction.
At this point, withdraw the handle, leaving only the plastic infusion tube protruding from the
insertion site.
Aspirate marrow and note rapid flow of fluid to verify position.
Attach the plastic dome to the target patch via Velcro fasteners to secure the tubing in
place.
To remove the infusion tube, use the included threaded-tip remover. The tube can also be
removed by direct pulling; however, the metal tip is sometimes left behind and must be
extracted through a small incision.18

Bone Injection Gun (BIG)

The BIG incorporates a loaded spring to facilitate penetration of the bone.
To adjust the depth of insertion, remove the safety pin from one end and turn the other end
clockwise or counter-clockwise to reduce or increase needle depth, respectively.
Place the BIG firmly against the skin perpendicular to the long axis of the bone (or slightly
caudad) and fire the gun by applying palmar force on the back of the unit while pulling on
the flanges with the middle and ring fingers.

Aspirate marrow, then flush with the same syringe, and note flow through the IV tubing to
confirm placement.
Slide the slotted safety pin into the needle to maintain stability.
To remove the needle, rotate it back and forth using the small clamps provided with the
unit.
Dress the site as deemed appropriate.

EZ-IO Needle
This battery-operated drill can drive the IO needle through even thick bone with relative
ease. The EZ-IO kit comes with the battery-operated drill and an IO needle with a stylet;
the EZ-IO AD comes with a 15-gauge, 25-km IO needle for use in patients >40 kg while the
EZ-IO PD comes with a 15-gauge, 15-mm needle for use in patients <39 kg (see Figure
14).
To operate the drill, insert the needle into the driver tip and make sure it is securely seated
on to drill.
Remove the safety cap from the needle and position the drill perpendicular (or slightly
caudad) to the insertion site.
Squeeze the trigger while applying gentle pressure to penetrate the skin.
When the tip of the needle comes in contact with the bone, at least 5 mm of the IO
catheter should be visible. If not, the overlying soft tissue may be too deep for the needle
to enter the marrow cavity.
To penetrate the bone, continue to squeeze the trigger while applying steady downward
pressure until a sudden give or pop occurs, signaling entry into the medullary space
(see Figure 15). Too much pressure on the device can cause the drill to stall, preventing the
needle from penetrating the cortex.
After entry into the marrow cavity, attach the EZ-connect extension set provided with EZ-IO
kit and aspirate blood and bone marrow contents to confirm correct placement (see Figure
16).
After checking catheter placement, proceed with infusion of fluids and or medications.
Avoid attaching syringes and IV tubing directly to the IO needle, as this can enlarge the
hole in the cortex resulting in extravasation of fluid.
Secure the tubing with tape and cover the area with an appropriate dressing.

POST-PROCEDURE

POST-PROCEDURE CARE

After confirming proper placement, secure the needle and the tubing with tape.

For infants and small children, fasten the leg to an appropriate-sized leg board to further stabilize a
lower extremity insertion site.

Protect the IO needle from accidental dislodgement by using a plastic cup with the bottom cut out,
taped, and bandaged into place over the device. Commercially made shields are also available for
this purpose.

Remove the IO needle as soon as intravenous access has been secured, and apply a sterile dressing
over the site.

Control excessive bleeding by applying direct pressure held over the site for 5 minutes. 39

COMPLICATIONS

Technical difficulties
Technical difficulties are the most common complications, but these decrease as familiarity
with the technique increases.
Forcing the IO entirely through the bone

The most common mistake is to place excessive pressure on the needle during
insertion and force it entirely through the bone.

Avoid this by using appropriate landmarks and keeping the needle perpendicular
(or slightly caudad) to the long axis of the bone. In addition, hold the needle with
the index finger approximately 1cm from the bevel. When this finger touches the
skin, the needle should be in the marrow cavity and no further pressure should be
applied.

Some IO needles have a mark 1 cm from the bevel (e.g., Cook IO Needle), while
others have a special guide or mechanism to ensure proper insertion depth of
penetration (e.g., Illinois Sternal/Iliac Aspiration Needle). If available, use of these
adjuncts will also help prevent overpenetration.

No blood return or flow of fluids

There will be times when the needle appears to be in the marrow cavity but blood
or bone marrow cannot be aspirated and fluids do not flow freely. This may occur
due to incomplete penetration of the bone or overpenetration into the opposite
cortex.

Incomplete penetration usually results in extravasation of fluids and can be

corrected by replacing the stylet and slowly advancing the needle until successful
aspiration of marrow contents and free flow of fluid occurs. Penetration into the
opposite cortex generally results in little or no flow. If overpenetration is suspected,
pull the needle back 1 to 2 mm and check for free flow of fluids.

Fluids that initially flowed freely may stop flowing if the needle becomes clogged by
clot or bone spicules. Frequently flushing the needle with 3 to 5 mL of saline will
help avoid this problem. If none of these maneuvers results in free flow of fluid, the
needle should be removed and reinserted in the opposite extremity (or another

site) to avoid fluid extravasation through the hole left after needle removal.
Extravasation of fluid

Extravasation of fluid is a less common technical difficulty, but one that may be
associated with a number of adverse events.40-44

Extravasation may be caused by fluids being infused under excessive pressure and
prolonged use of an IO site.45

Extravasation may result from incomplete needle penetration or penetration

through the opposite cortex. Even when an IO needle has been properly positioned,
fluid can leak out through holes made from previous IO attempts, through an
insertion site made too large from excessive rocking during insertion, or from an
improperly secured needle that becomes loose with movement. 44,46Interestingly, the
type of needle used does not appear to influence extravasation rates. 47

Regardless of the cause, if extravasation occurs, the needle should be quickly

removed and pressure applied to the site. Left unchecked, extravasation can lead
to a number of adverse events. In addition, while not directly harmful,
extravasation of fluid through multiple cortical defects from previous IO attempts
has been associated with lower serum levels of infused drugs. 48

Infection

A major concern for any person receiving IO infusion is infection. In the past, this
concern has lead clinicians to shy away from using the bone and to continue
searching for other methods of vascular access. Although the potential for infection
is real, its actual incidence is low. A literature review of more than 4000 cases from
1942 to 1977 found a 0.6% incidence of infection. 49Although most of the affected
access sites were not placed under emergency conditions, the needles were often
left in 1 to 2 days, thus increasing the likelihood of infection. A survey of more than
1000 U.S. and foreign medical schools found that the incidence of infection for IO
needles placed in emergency conditions was less than 3%.50

The most common infection is cellulitis at the puncture site, which usually responds
well to antibiotics. Osteomyelitis is less common, but it also usually responds to
antibiotics.

Inflammatory reactions

Inflammatory reactions of the bone may be seen. These are most common when
hypertonic or sclerosing agents are used and may produce an elevation of the
periosteum with a positive bone scan. Unlike the clinical appearance of a patient
with osteomyelitis due to bacteria, a child with a sterile inflammatory reaction does
not look toxic.

Skin sloughing

Skin sloughing and myonecrosis have been reported secondary to extravasation of

infused fluids and medications.41,51This occurs if fluid or drugs extravasate from the
puncture site into the surrounding tissues. Care should be taken when infusing
drugs such as calcium chloride, epinephrine, and sodium bicarbonate to prevent
dislodgement of the needle and extravasation into the tissue. In addition, it is best
to infuse such drugs only by gravity, because infusion under pressure increases the

chances of extravasation.
Compartment syndrome. See Compartment Syndrome Evaluation for further details.

Compartment syndrome may occur when fluids leak out of the bone into a closed
compartment, such as the posterior compartment of the leg. 42,52,55Reduce the
chances of extravasation by carefully placing and securing the IO needle, limiting
the number of attempts in the same bone and removing the needle once
intravenous access has been obtained. In addition, check the insertion site
frequently, especially when fluids are being infused under pressure.

Epiphyseal injuries

Injury of the growth plate and developmental abnormalities of the bone are
ongoing concerns. These fears have not been supported in the literature, however.
There have been no reports of growth plate damage or permanent abnormalities of
the bone. While growth plate abnormalities seem to be very rare, tibial fractures
have been reported after IO placement.56-58 Hence, follow-up radiographs of
patients who have undergone IO needle placement or attempts at such placement
are indicated. Cortical defects may be seen on radiographs for up to 40 days after
injection.59

Fat embolism

Fat embolism has been reported as a potential complication of IO insertion. 11,49

However, this condition is rare and has been reported only in adult
patients.60Because the marrow in infants and children is primarily hematopoietic,
this potential complication is unlikely to occur.

REFERENCES
Copyright 2010 Elsevier Inc. All rights reserved.