Intraosseous infusions

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23.11 Intraosseous infusions

Lindsay Bridgford, Ronald A. Dieckmann

Background

Peripheral intravenous cannulation in a critically ill or injured child can be difficult, time consuming, and sometimes impossible. Small veins collapse or disappear during shock, and increased body fat may camouflage superficial skin veins. Central venous access and surgical cut-down are also technically difficult procedures that may be risky or impossible in critical situations. Although the endotracheal route is an alternative to vascular access in cardiopulmonary arrest, endotracheal intubation may be delayed, drug absorption may not be reliable, and large fluid administration is contraindicated by this route.

The intraosseous (IO) or intramedullary route for the delivery of resuscitation fluids and medications has been used for over 50 years in children and adults. Many studies have confirmed that the highly vascularised IO space is an excellent route for medications and fluids. The only technical problem is successfully piercing the bony cortex in older children. The bones of neonates and infants are usually soft and the IO space is relatively large, so needle insertion is easy in children of youngest age. Good equipment, preparation, and effective technique are especially important for success in IO needle insertion. While IO access is easy, quick, and safe, it is painful in a conscious child and therefore is only practical in a critically ill or injured child.

The IO space functions as a non-collapsible vein. There are several possible sites for insertion; but the easiest location in children is the proximal tibia. The emissary veins of the IO space absorb all parenteral medications, crystalloid fluids, or blood products – which move quickly into the central circulation. Complications are minor and infrequent. Out-of-hospital emergency-care professionals have also employed the IO technique with a high rate of success.

Indications

• Cardiopulmonary arrest.

• Any critical emergency when a peripheral cannulation site is unavailable and oral, transmucosal, intramuscular or inhalation routes are not adequate to meet the patient’s needs for fluids and/or medications.

Equipment

The EZ IO or intraosseous gun is an excellent alternative to the manual needle.

A variety of needles will work. Butterfly needles and spinal needles may be effective, especially in neonates and infants, but these needles bend too easily in the more calcified bones of children and adolescents.

Commercially available IO needles have more durable parts intended for penetration of bone. There are several styles (Fig. 23.11.1). A central stylet is universal. There are short, 2.5-cm, needles for neonates and infants and longer, 3.0 and 3.5-cm, needles for older children. Some needles have stylets with multifaceted cutting edges intended for a rotary insertion, others have bevels, and others can be screwed in place. The shaft may have side ports.

Stopcock (optional).

Fig. 23.11.1 IO needles.

Preparation

Identification of the entry site

The best site in children is the anteromedial aspect of the proximal tibia lateral to the tibial tuberosity. Alternative sites are the distal end of the femur 2–3 cm above the patella in the midline, and the medial malleolus at the ankle (Fig. 23.11.2). The sternum is not recommended in children. In adults, the medial malleolus may be the best site, although studies are lacking.

Fig. 23.11.2 IO needle entry sites.

Positioning the child

Place the child supine with the knee slightly flexed and a small towel roll or other bulky material under the popliteal fossa. Make sure the conscious child is well immobilised.

Selecting the correct side

A right-handed operator will more easily insert the needle in the child’s right leg, and vice-versa for the left-handed operator.

Procedure

Introduce the IO needle in the skin, directed slightly away from the growth plate. Grasping the limb with the non-dominant hand beside the insertion site (e.g. behind the knee for proximal tibia insertion) helps to steady the bone during placement.

Pierce the bony cortex with a firm, twisting motion from a position directly above the entry site. A ‘pop’ may be felt as the needle passes through the bony cortex and into the marrow cavity. Do not push too hard on the needle. Too much force may push the needle all the way through the bone and into the soft tissues.

Remove the stylet and aspirate marrow contents with a 10-mL syringe. Keep any bone marrow aspirate for glucose check or for other tests in the emergency department. Sometimes, marrow cannot be aspirated.

Confirm correct placement by infusing 10 mL of normal saline without resistance. Once the IO needle has been placed, attach a stopcock (if available) to the end of the needle before attaching the intravenous (IV) line.

Attach IV line to the hub and infuse fluids or drugs directly into IO space. Pushing the fluids too hard may force the fluids out of the IO space. The rate of fluid infusion may be limited by the small marrow space.

Secure the needle to the overlying skin with tape.

Monitor the calf to ensure that there is no swelling to indicate leakage of fluid.

Complications

• Compartment syndrome.

• Failed infusion.

• Growth-plate injury.

• Bone infection.

• Skin infection.

• Skin necrosis.

• Bony fracture.

Tips

• Be extremely careful using an EZ IO in a young infant, because it is quite easy to penetrate through the bone into the soft tissues and cause a compartment syndrome.

• If the child is conscious, provide generous local anaesthesia at the entry site.

• In addition to serving as a route for drug and fluid administration, blood samples drawn from the site can be used for culture, haematological, and biochemical analysis, but there are limitations. Emergency type and crossmatch is reliable with an adequate sample. A complete blood cell count may not be reliable, as it reflects the marrow cell count rather than the cell count in the peripheral circulation, and also because blood aspirated from the marrow usually clots rapidly, even if it is placed in a tube that contains heparin. Blood chemistry determinations are possible, but they may not correlate with blood samples taken from central veins.

• All commonly used intravenous fluids and drugs can be administered via the IO route.

• The rate of infection from IO needle placement is low and comparable to IV cannulation.

• A slow infusion rate does not mean the IO needle is misplaced, and pressure infusion may be necessary to maintain flow.

The EZ-IO

Mechanical devices such as the EZ-IO have simplified the insertion of an IO needle as they are not dependent on the manual process. The EZ-IO (Vidacare, San Antonio, TX, USA) is a reusable battery-powered device that operates like a small drill. The driver itself is a sealed unit that is good for about 700 insertions. The EZ-IO uses a bevelled drill tip that rotates into the IO space at a preset depth (Fig. 23.11.3).

Fig. 23.11.3 EZ-IO.

The procedures for insertion of the EZ-IO needle are similar to those described above for the manual device. The difference is in the preparation of the EZ-IO driver and paediatric needle set, with a 15-gauge, 15-mm long needle generally used for children weighing between 3 kg and 39 kg, a 15-gauge, 25-mm long needle for children weighing greater than 40 kg and a new 45-mm length needle is available for larger children with significant tissue or oedema overlying bone.

Further reading

Brunette D.D., Fischer R. Intravascular access in paediatric cardiac arrest. Ann Emerg Med. 1988;6:577.

Fiser D.H. Intraosseous infusion. N Engl J Med. 1990;322:1579.

Johnson L., Kissoon N., Fiallos M., et al. Use of intraosseous blood to assess blood chemistries and haemoglobin during cardiopulmonary resuscitation with drug infusions. Crit Care Med. 1999;27:1147-1152.

Phillips B., Zideman D., Garcia-Castrillo L., et al. European Resuscitation Council guidelines 2000 for advanced paediatric life support. Resuscitation. 2001;48:231-324.

Vidal R., Kissoon N., Gaylor M. Compartment syndrome following intraosseous infusion. Paediatrics. 1993;91:1201-1202.

Wenzel V., Lindner K.H., Augenstein S., et al. Intraosseous vasopressin improves coronary perfusion pressure rapidly during cardiopulmonary resuscitation in pigs. Crit Care Med. 1999;27:1565-1569.

Tobias J.D., Ross A.K. Intraosseous infusions: a review for the anesthesiologist with a focus on pediatric use. Anesth Analg. 2010;110(2):391-401.

Textbook of Paediatric Emergency Medicine