Intraosseous infusions

Published on 23/06/2015 by admin

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Last modified 23/06/2015

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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.

Contraindications

• Do not use an IO infusion if the child is stable.
• Do not place an IO needle below a fracture site. Use the other side.
• Avoid placement of an IO below any open injury on an extremity. Use the other side.

Relative contraindications

• Avoid IO needle insertion in children with osteoporosis and osteogenesis imperfecta, due to the high fracture potential.
• Recent prior use of the same bone for IO infusion, due to the potential for extravasation from previous IO sites.

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

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