INTRAOSSEOUS INFUSION
EMERGENCY VASCULAR ACCESS IN CHILDREN
INTRODUCTION
INTRODUCTION
Long bones in infants are filled with marrow which contains vascularized sinusoids. These sinusoids eventually drain into the systemic venous circulation. The marrow cavity acts as a rigid vein, and so will not collapse, even in the face of severe volume loss. No matter how dehydrated or volume depleted the child is, there is always a rigid tube which can be punctured to replace the required fluids.
This marrow is very vascular in infants. At about age 5 years, this marrow is replaced by less vascular marrow, and, although the intraosseous route is still available in older children and adults, it is a more difficult route for rapid volume replacement as compared to venous access. It is, however, still a good route for giving medications if peripheral access is not possible, and ACLS protocols now prefer intraosseous (IO) access over the endotracheal route for drug administration. [1,2]
Although bolus medications are rapidly effective, it is necessary to do a saline flush after each drug, and to administer volume under pressure using syringe and stopcock, infusion pump or pressure bag. Maximum rate of administration is equivalent to a #21 peripheral cannula. [3]
INDICATIONS
1. Vascular access is difficult or unsuccessful. Peripheral vein access tends to be difficult in small children, where this procedure is used most. Older children and adults have denser bony cortex, making IO procedures more difficult, while peripheral venous access is simpler.
2. Suggested as first attempt at vascular access in children in full cardiac arrest or severe shock, recognizing that establishment of airway and ventilation are a priority in these patients. [2]
3. Some sources suggest that failure to establish IV access in 90 seconds or 3 attempts mandates switch to IO access. [2]
Back to Top
CONTRAINDICATIONS
1. Compromise of the insertion site by trauma, burn or infection.
2. Ipsilateral laceration or fracture which would divert the volume being given.
3. Pelvic fracture
4. Abnormality of bone such as osteogenesis imperfecta or severe osteoporosis.
5. Previous failure to establish IO cannulation in the same extremity, increasing risk of compartment syndrome.
COMPLICATIONS
1. Local cellulitis or subcutaneous abscess (1%).
2. Hypertonic or irritating solutions can cause muscle necrosis if leakage occurs.
3. Hematoma
4. Osteomyelitis is rare.
5. Growth plate or joint injury if site of penetration is badly chosen. Risk is minimized by directing the needle away from the growth plate (Fig.1).
6. Compartment syndrome is reported. Risk rises with length of time the infusion is employed
7. Sepsis reported rarely.
8. Fat embolism reported rarely.
9. All complications increase with time and are minimized by removal within 3-4 hours. The site may be used for 72-96 hours if there is no alternative. [4]
Back to Top
EQUIPMENT
1. Sterile bone marrow SurFast (Cook) or Jamshidi (Baxter) needle 15-18 gauge, 2.5-5.0 cm length.
2. Povidone iodine and alcohol prep solutions.
3. 2% preservative-free xylocaine.
4. 1x5 ml. syringe containing saline, 1 empty 5 ml. syringe
5. 1x60 ml. syringe.
6. IV fluid bag and primed administration set ready for immediate use.
7. Appropriate needles for local anesthetic administration and drawing up bolus fluids.
8. 3-way stopcock
9. Saline solution for flushing lines.
10. Tape and 4X4 gauze to secure IO needle.
Back to Top
METHOD
1. Identify the insertion site:
· in children on the proximal tibia anteromedial flat surface 1-3 cm. (width of 1-2 fingers) below and medial to the tibial tuberosity. Can be directed caudad 10-15 degrees to avoid the growth plate (Fig.1).
· alternate site in children distal femur 2-3 cm. above the epicondyles in the midline directed cephalad at an angle of 10-15 degrees from the vertical.
· in adults an additional site is the distal tibia 1 cm. above the superior margin of the medial malleolus.
2. Position the patient and immobilize the limb. It may be helpful to place a small rolled-up towel under the knee.
3. Prep using sterile technique with povidone-iodine, waiting 2 minutes, and removing with alcohol.
4. Infiltrate locally with xylocaine 2% to periosteum.
5. Recheck landmarks.
6. Hold the limb firmly at the level of the knee. Do not put your hand behind the knee in the path of the needle at any time.
7. With the obturator in the bone marrow needle, puncture skin at the chosen site. Once the periosteum has been reached, direct the needle at a 10-15 degree angle away from the adjacent joint (Fig.1). Advance the needle by gently rotating it as you push it ahead. When the needle pops into the marrow space, a lack of resistance is detected.
8. Remove the cap and obturator and see if marrow appears. If not, attach an empty syringe, and try to aspirate back marrow or blood (most people now omit this step because it may draw the bone plug back into the syringe). [5] This action can cause some visceral pain. Lack of marrow on aspiration does not necessarily mean poor placement. If you are in the right place, the needle should stand securely on its own. Any aspirated blood can be sent for chemistry or culture, type and screen, drug levels and hematology. [5]
9. Because marrow clots very quickly, immediately take a second syringe filled with 5-10 cc. of sterile saline and flush the needle while checking the back of the limb for swelling indicating leakage into soft tissue or under periosteum. There should be no resistance with proper placement. If fluid does not flow easily, try advancing the needle further.
· If these measures fail or if swelling becomes apparent, try re-insertion in the other limb with less angulation.
· If re-insertion is done in the same limb because of suspected blockage, it must be at the same site, as the original site can leak and cause compartment syndrome.
10. If good flow is confirmed, attach a 3-way stopcock and the IV tubing. For conscious patients, 2 cc. 2% lidocaine (preservative-free) will eliminate visceral pain during volume infusion.
· For volume resuscitation, 30 to 60 ml. aliquots of fluid can be administered rapidly by syringe. Alternatively, use a pressure bag or IV infusion pump.
· After any drug administration, always do a 2-10 ml saline flush to avoid a depot effect.
11. The inserted needle will protrude at the penetration site. Secure it with sterile gauze and strapping. Do not tape circumferentially or obscure the site with dressings. Continue to check for extravasation or calf swelling.
12. As soon as volume replacement improves perfusion, obtain 1 or 2 reliable peripheral sites and consider removal of the IO access site.
Back to Top
ADULT IO ACCESS
Because the success rate is high with occasional use, and the IO route is always available in circulatory collapse, this technique is being used more frequently in adults, particularly in pre-hospital, trauma or military settings. Higher bone density makes for more difficult access, therefore alternative techniques for bone penetration have been devised.
1. Standard IO needle use has had a 50% success rate by paramedics in the field with patients over age 10. [6]
2. The F.A.S.T.1 device provides fast and accurate sternal placement. Emergency department trials have shown success rates of 74% for first time users and 95% for experienced users. This may be particularly useful for patients with lower extremity or pelvic trauma. [7]
3. The Bone Injection Gun (B.I.G.) is a compact spring loaded device which places a pencil point needle at preset depth into bone. It has been extensively used by the Israeli military. [8,3]
4. The EZ-IO device uses a battery powered drill to place the IO needle at a specific depth. Pre-hospital trials show an 87% success rate. The F.A.S.T.1 device used in the same trial showed 72% success. [9]
Back to Top
IMPORTANT POINTS TO REMEMBER
1. This is the most rapid method of intravascular access in young children.
2. A vast variety of fluids can be administered by this route.
3. The technique can probably be done proficiently despite infrequent use. [10]
4. This is a temporary measure for fluid replacement until vascular access is possible by another route. Alternate access should be planned after a few hours.
5. Calf circumference should be followed carefully to detect fluid entering soft tissue compartments.
REFERENCES
1. Field JM, editor. Advanced Cardiovascular Life support provider manual. Dallas: American Heart Association 2006; IV: 48
2. American Heart Association. 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and neonatal patients: pediatric advanced life support. Circulation 2005;112:IV-167-IV-187.
3. Adult IO arrives: The solution to difficult vascular access. JEMS 2005; 30(10) Suppl: S1-34.
4. Gluckman W, Forti RJ. Intraosseous cannulation. eMedicine 2006. [updated 2006 Aug. 17; cited 2007 Oct. 25]. Available from: http://www.emedicine.com/ped/topic2557.htm
5. Bailey, P. Intraosseous cannulation. In: UpToDate, Rose, BD (Ed)., UpToDate ver.15.2, Waltham, MA, 2007.
6. Glaeser PW, Helmich TR, Szewczuga, Losec JD, Smith DS. Five-year experience in pre-hospital intraosseous infusions in children and adults. Annals of Emergency Medicine 1993; 22: 1119-1124.
7. Macnab A, Christenson J, Findlay J, Horwood B, Johnson D, Jones L, et al. A new system for sternal intraosseous infusion in adults. Prehosp Emerg Care 2000; 4(2): 173-177.
8. Curran A, Sen A. Bone injection gun placement of intraosseous needles. Emergency Medicine Journal 2005; 22(5): 366
9. Franscone RJ, Jensen JP, Kaye K, Salzman JG. Consecutive field trials using two different intraosseous devices. Prehosp Emerg Care 2007; 11(2): 164-171.
10. Nijssen-Jordan C. Emergency department utilization and success rates for intraosseous infusion in pediatric resuscitations. CJEM 2000; 2(1): 10-14.