• Sign Up

Intraosseous Vascular Access


Intraosseous Vascular Access

Article Author:
Peter Dornhofer
Article Editor:
Jesse Kellar
Updated:
6/22/2020 5:39:44 PM
For CME on this topic:
Intraosseous Vascular Access CME
PubMed Link:
Intraosseous Vascular Access

Introduction

Intraosseous (IO) vascular access refers to the placement of a specialized hollow bore needle through the cortex of a bone, into the medullary space for infusion of medical therapy and laboratory tests.[1][2] The IO route is an option when standard venous access would delay therapy or is not easily obtained, in the hospital or pre-hospital setting [3]

IO success rates are twice as high as intravenous line placement in critical trauma patients without a blood pressure and should have priority over IV placement.[4] IO needle insertion has been shown by multiple studies to have high success rates by physicians, nurses, and paramedics in adults, pediatrics patients, animals, as well as sim model studies.[5][6]

Although IO access is superior in many clinical situations, it is highly underutilized.[7] Studies show that IO access can be acquired within 20 seconds, allowing rapid access in emergent patients who would otherwise be challenging to access intravenously.[8] Despite the proven value of IO access in the critical patient, barriers exist to its use. These barriers include a lack of confidence in the indications for using IO access by physicians and the belief that nursing staff is not familiar with IO access.[9] 

IO can be used to administer any substance that is infusible intravenously, but IO use should not be for longer than 24 hours due to an increased risk of complications.

Multiple IO devices are available from manufacturers, and availability varies institutionally. IO is easier than standard venous access and central lines in many situations and acceptable for all age groups, including preterm neonates.[10][8][11]

Anatomy and Physiology

Sternum, clavicle, humeral head, iliac crest, distal femur, proximal tibia, distal tibia, and calcaneus are all potential sites for intraosseous access. The proximal tibia, humeral head, and sternum are the preferred sites in adults. The distal femur, proximal tibia, and distal tibia are preferred sites for infants and neonates. Always palpate both margins of the boney site to ensure penetration of the bone centrally. Note that each site is always one to two fingerbreadths in measurement to locate the correct location.

  • Sternum: 1 cm below the sternal notch.
  • Humerus: The humerus should be internally rotated, and the hand placed on the abdomen with the elbow flexed to 90 degrees, ensuring that the bicep tendon is medially located and not penetrated. The surgical neck is palpated, and the needle is placed 2 cm above the surgical neck into the greater tubercle at about 45 degrees to the anterior plane. A longer IO needle is necessary, such as the 45 mm needle, to access the intramedullary space.
  • Distal femur: With the leg straightened and centered in the anterior plane, 1 cm proximal to the patella and 1 to 2 cm medially.
  • Proximal tibia: 1 cm to 2 cm inferior and medial to the tibial tuberosity in the flat portion of the tibia
  • Distal tibia: 2 cm proximal to the medial malleolus in the flat portion of the tibia.

Indications

  • Unable to obtain venous access or delayed venous access
  • Immediate vascular access is required
  • Blood for laboratory analysis or point of care testing
  • Access needed for contrast injection for radiologic evaluation.[12]

Contraindications

  • Adequate venous access
  • Fracture of the boney site
  • Burn site
  • Cellulitis or infection at the site
  • Osteogenesis imperfect
  • Osteoporosis (relative)
  • Previous IO attempted site
  • Previous IO site less than 48 hours
  • Recent orthopedic surgery[13]

Equipment

Several devices exist for IO insertion, including First Access for Shock and Trauma (FAST1), the EZ-IO, and the Bone Injection Gun (BIG). Manuel devices include the Jamshidi needle and the Diekman modified needle. Refer to the instruction manual that comes from the manufacturer with the device for specific details on proper use. All have similar applications and techniques, except the sternal site, which requires the purchase of the FAST1 product to avoid penetration of the posterior cortex into the thoracic aorta.[13]

Preparation

A standard sterile technique should be employed. The appropriate site is located, and if the patient is awake, although not mandatory, a local anesthetic can be injected into the site. The procedure is usually well-tolerated in the awake patient.[13]

Technique

The needle is placed perpendicular to the bone with special attention in the pediatric population, to avoid the epiphyseal plate. In pediatric placement, placement should be in the medial proximal tibia similar to the adult, but 1 cm distal to the tibial tuberosity.[10] Once the needle contracts the bone with the needle, a hard stop is felt, at least 5 mm of the needle should be visible above the skin to allow for penetration of the medullary space, if not, then choose a longer needle or a site with less soft tissue covering the bone. This scenario may occur with the obese patient, where the proximal tibial site is likely to be shallower.

Confirm placement of the IO needle by checking for the stability of needle in bone, aspiration of marrow, ability to flush with saline, and good IV flow rates. The inability to aspirate does not always indicate poor placement. If this occurs, continue with a saline flush and attempt aspiration again.

After needle insertion, flush with 5 to 10 cc normal saline for adults, and 2 to 5 ml for infants and children. Patients may have severe pain when flushing with saline. The Injection of 2% intravenous lidocaine 20 to 40 mg or 0.5 mg/kg pediatric dose into the IO needle for relief of injection pain has been advocated, but with mixed results on pain resolution.[14][15] Allow the Lidocaine 2 minutes to take effect before flushing.

Stabilization of the needle differs with each device used but is mandatory to avoid inadvertently dislodging or bending the IO needle.

Document date and time of placement of the IO to ensure it will be in use less than 24 hours. Following the obtaining of adequate IV access, the IO device should be removed and bandaged.

Complications

The inability to inject at the site indicates incomplete penetration of the needle through the cortex into the medullary space. This situation will be apparent due to the inability to flush with saline. Drilling deeper will resolve this problem.

Extravasation of fluid occurs secondary to drilling through the posterior cortex, placing an IO in a fracture site or in the bone that was previously accessed or at a recent orthopedic surgical site; this can cause compartment syndrome as well as the usual soft tissue complications similar to venous infiltration, depending on the product infused.

In the pediatric population, epiphyseal plate necrosis is avoidable by ensuring an IO insertion site is away from the epiphyseal plate.

Other complications include fracture, cellulitis, osteomyelitis, fat embolism, and inability to remove a bent IO needle. A bent needle may require surgical removal.[16][17]

Clinical Significance

IO access is fast and reliable with few complications and can be accomplished rather easily in the pre-hospital setting, with bedside training and by nursing staff and physicians.[18] IV access is the preferred route, but nurses and physicians should not delay IO access in emergent situations if IV access is limited or will delay care.

Intraosseous aspiration of blood is usable for laboratory tests. The first aspirate does not need to be discarded.[19] Studies vary on the accuracy of these results on hemodynamically stable and unstable animal sources. More comprehensive and standardized human studies in hemodynamically stable and unstable patients are needed to prove correlations with standard venous sampling - this is also true regarding the need to validate the values in point of care rapid testing. Following the obtaining of IV access, laboratory data should be repeated, ensuring accurate results.[2]

Animal studies have shown expected values for blood gases, hematocrit, creatinine, sodium, and creatinine kinase in stable and hemorrhagic swine, but lactate and glucose values vary.[1] Potassium values seem to be generally higher in IO samples compared with arterial and venous values in several studies.[20] Blood typing is accurate even after blood transfusion through an IO device in a patient in shock, allowing type and crossing to be performed even after emergent transfusion.[21]

Enhancing Healthcare Team Outcomes

Intraosseous access has been available to the medical community since 1922 and has had limited use since the advent of intravenous catheters.[13] However, when there is difficulty establishing IV access, members of the interprofessional healthcare team must be familiar and facile with establishing and utilizing IO access to deliver life-saving interventions. Rapid access to deliver life-saving medications is vital to improve morbidity and mortality. Comfort levels in its use in the prehospital and hospital environments have been low despite its proven effectiveness and superiority to the intravenous route in many clinical settings. IO access can be accomplished by training pre-hospital personnel, as well as all hospital physicians and nursing staff. For IO to serve as a useful life-saving tool to its full extent, the entire health care team, including the operating room and inpatient staff, needs to be educated. Unfortunately, to this date, only small case series [Level 5] have been conducted to try and increase training and comfort level in establishing IO access.[22] Other studies have been attempting to draw stress correlations between the individual and team performances. They have shown those who are more confident and less stressed perform better in establishing IO access.[23] [Level 5] Prehospital personnel, all hospital physicians, nursing staff, and pharmacists must be aware of the speed, ease of access, and ability to infuse any mediation or fluids through an IO needle. Much work needs to be done with IO access within the medical community to educate and elevate the comfort level of the entire health care team to that of a standard of an intravenous device. When all members of the interprofessional team are operating from the same playbook, better outcomes will result when IO access is necessary. [Level 5]


References

[1] Strandberg G,Larsson A,Lipcsey M,Eriksson M, Comparison of Intraosseous, Arterial, and Venous Blood Sampling for Laboratory Analysis in Hemorrhagic Shock. Clinical laboratory. 2019 Jul 1;     [PubMed PMID: 31307157]
[2] Jousi M,Björkman J,Nurmi J, Point-of-care analyses of blood samples from intraosseous access in pre-hospital critical care. Acta anaesthesiologica Scandinavica. 2019 Jul 10;     [PubMed PMID: 31290560]
[3] Lewis P,Wright C, Saving the critically injured trauma patient: a retrospective analysis of 1000 uses of intraosseous access. Emergency medicine journal : EMJ. 2015 Jun;     [PubMed PMID: 24981009]
[4] Chreiman KM,Dumas RP,Seamon MJ,Kim PK,Reilly PM,Kaplan LJ,Christie JD,Holena DN, The intraosseous have it: A prospective observational study of vascular access success rates in patients in extremis using video review. The journal of trauma and acute care surgery. 2018 Apr     [PubMed PMID: 29300281]
[5] Feldman O,Nasrallah N,Bitterman Y,Shavit R,Marom D,Rapaport Z,Kabesa S,Benacon M,Shavit I, Pediatric Intraosseous Access Performed by Emergency Department Nurses Using Semiautomatic Devices: A Randomized Crossover Simulation Study. Pediatric emergency care. 2018 Sep 25     [PubMed PMID: 30256319]
[6] Isayama K,Nakatani T,Tsuda M,Hirakawa A, Current status of establishing a venous line in CPA patients by Emergency Life-Saving Technicians in the prehospital setting in Japan and a proposal for intraosseous infusion. International journal of emergency medicine. 2012 Jan 9     [PubMed PMID: 22230330]
[7] Bloch SA,Bloch AJ,Silva P, Adult intraosseous use in academic EDs and simulated comparison of emergent vascular access techniques. The American journal of emergency medicine. 2013 Mar;     [PubMed PMID: 23380121]
[8] Ngo AS,Oh JJ,Chen Y,Yong D,Ong ME, Intraosseous vascular access in adults using the EZ-IO in an emergency department. International journal of emergency medicine. 2009 Aug 11;     [PubMed PMID: 20157465]
[9] James Cheung W,Rosenberg H,Vaillancourt C, Barriers and facilitators to intraosseous access in adult resuscitations when peripheral intravenous access is not achievable. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2014 Mar     [PubMed PMID: 24628749]
[10] Ellemunter H,Simma B,Trawöger R,Maurer H, Intraosseous lines in preterm and full term neonates. Archives of disease in childhood. Fetal and neonatal edition. 1999 Jan;     [PubMed PMID: 10325819]
[11] Leidel BA,Kirchhoff C,Bogner V,Braunstein V,Biberthaler P,Kanz KG, Comparison of intraosseous versus central venous vascular access in adults under resuscitation in the emergency department with inaccessible peripheral veins. Resuscitation. 2012 Jan     [PubMed PMID: 21893125]
[12] Schindler P,Helfen A,Wildgruber M,Heindel W,Schülke C,Masthoff M, Intraosseous contrast administration for emergency computed tomography: A case-control study. PloS one. 2019;     [PubMed PMID: 31150466]
[13] Petitpas F,Guenezan J,Vendeuvre T,Scepi M,Oriot D,Mimoz O, Use of intra-osseous access in adults: a systematic review. Critical care (London, England). 2016 Apr 14;     [PubMed PMID: 27075364]
[14] Ilicki J,Scholander J, Lidocaine can reduce the pain of intra-osseous fluid infusion. Critical care (London, England). 2016 Jun 20;     [PubMed PMID: 27320792]
[15] Schalk R,Schweigkofler U,Lotz G,Zacharowski K,Latasch L,Byhahn C, Efficacy of the EZ-IO needle driver for out-of-hospital intraosseous access--a preliminary, observational, multicenter study. Scandinavian journal of trauma, resuscitation and emergency medicine. 2011 Oct 26;     [PubMed PMID: 22029625]
[16] Chalopin T,Lemaignen A,Guillon A,Geffray A,Derot G,Bahuaud O,Agout C,Rosset P,Castellier C,De Pinieux G,Valentin AS,Bernard L,Bastides F, Acute Tibial osteomyelitis caused by intraosseous access during initial resuscitation: a case report and literature review. BMC infectious diseases. 2018 Dec 17;     [PubMed PMID: 30558553]
[17] Krishnan M,Lester K,Johnson A,Bardeloza K,Edemekong P,Berim I, Bent Metal in a Bone: A Rare Complication of an Emergent Procedure or a Deficiency in Skill Set? Case reports in critical care. 2016;     [PubMed PMID: 28018682]
[18] Hafner JW,Bryant A,Huang F,Swisher K, Effectiveness of a Drill-assisted Intraosseous Catheter versus Manual Intraosseous Catheter by Resident Physicians in a Swine Model. The western journal of emergency medicine. 2013 Nov;     [PubMed PMID: 24381684]
[19] Wakabayashi T,Ozawa S,Arai J,Takai M,Koshihara Y,Murota S, Antiallergic action of TMK-777, a leukotriene biosynthesis inhibitor. Advances in prostaglandin, thromboxane, and leukotriene research. 1987;     [PubMed PMID: 2889331]
[20] Jousi M,Laukkanen-Nevala P,Nurmi J, Analysing blood from intraosseous access: a systematic review. European journal of emergency medicine : official journal of the European Society for Emergency Medicine. 2019 Apr;     [PubMed PMID: 30124518]
[21] Pac LJ,Rossi HA,Theyagarajan KV,Monoski TJ,Louzon MJ,Riveira MC,Hess JR, Blood sample from an intraosseous device. Transfusion. 2018 Nov;     [PubMed PMID: 30284285]
[22] Itoh T,Lee-Jayaram J,Fang R,Hong T,Berg B, Just-in-Time Training for Intraosseous Needle Placement and Defibrillator Use in a Pediatric Emergency Department. Pediatric emergency care. 2018 Jun 14;     [PubMed PMID: 29912085]
[23] Ghazali DA,Darmian-Rafei I,Ragot S,Oriot D, Performance Under Stress Conditions During Multidisciplinary Team Immersive Pediatric Simulations. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. 2018 Jun;     [PubMed PMID: 29432402]