Intraosseous Infusion

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  • The primary indication for IO access is cardiac arrest in infants and young children.
  • IO infusion is indicated in adults in whom attempts at peripheral and venous access have failed.
  • Relatively few contraindications to IO infusion exist.
  • Relative contraindications include osteoporosis, osteogenesis imperfecta, fractured bone, recent prior use of the same bone for IO infusion, or insertion through areas of cellulitis, infection, or burns.
  • Bone Marrow Aspiration Needle
  • Illinois Sternal/Iliac Aspiration Needle (Monojet, Division of Sherwood Medical, St. Louis, Mo.)
  • Jamshidi Disposable Sternal/Iliac Aspiration Needle (Cardinal Health, Dublin, Ohio)
  • Cook IO Needle (Cook Critical Care, Bloomington, Ind.)
  • Sur-Fast Needle (Cook Critical Care, Inc, Bloomington, Ind.)

Intraosseous Devices

  • FAST-1 Intraosseous Infusion System (PYNG Medical Corporation, Richmond, B.C., Canada)
  • Bone Injection Gun (BIG; Waismed; Yokenam, Israel)
  • EZ-IO Device (Vida-Care, San Antonio, Texas)
  • TIAX Reusable IO Infusion Device (TIAX LLC, Cambridge, Mass.)
  • Sites for IO Needle Placement.
    • In infants and children less than 6 years of age, the proximal tibia is the preferred site, followed by the distal tibia and distal femur.
  • Locations for IO access
    • Iliac crest
    • Femur
      • The needle should be inserted 2 to 3 cm above the femoral condyles in the midline and directed cephalad at an angle of 10 degrees to 15 degrees from the vertical.
    • Proximal tibia
      • The tibia is a less desirable location in adults.
      • On the proximal tibia, the broad, flat, anteromedial surface is used. The site of IO cannulation is approximately 1 to 3 cm (2 finger widths) below the tuberosity. This site requires a 13- to 16-gauge needle.
    • Distal tibia
      • The site of needle insertion is the medial surface at the junction of the medial malleolus and the shaft of the tibia, posterior to the greater saphenous vein. The needle is inserted perpendicular to the long axis of the bone or 10 degrees to 15 degrees cephalad to avoid the growth plate.
    • Sternum
      • The sternum has been advocated as the best site to establish IO access in adults.
    • Other potential sites for IO insertion
      • Radius
      • Clavicle
      • Humerus
      • Calcaneus

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The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

  • After confirming proper placement, secure the needle and the tubing with tape.
  • For infants and small children, fasten the leg to an appropriate-sized leg board to further stabilize a lower extremity insertion site.
  • Protect the IO needle from accidental dislodgement by a shield or plastic cup.
  • Remove the IO needle as soon as intravenous access has been secured and apply a sterile dressing over the site.
  • Control excessive bleeding by applying direct pressure held over the site for 5 minutes.
  • Technical difficulties
    • Forcing the IO entirely through the bone
    • No blood return or flow of fluids
    • Extravasation of fluid
  • Infection
  • Inflammatory reactions
  • Skin sloughing
  • Compartment syndrome
  • Epiphyseal injuries
  • Fat embolism
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