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]
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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]
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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.
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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.
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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]
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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.
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,
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,
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.