1. Intraosseous Insertion Gwen Hollaar University of Calgary

2. Outline How does it work Indications and Contraindications Technique Complications Review

3. How Does It Work Bone has two components –Bone cortex –Bone marrow Bone marrow contains –Developing blood cells –Framework for vascular complex of the medulla Provides blood supply for bone

4. How Does It Work Path of fluids into body blood vessels Fluid enters venous sinusoids in medullary cavity Fluid drains into central venous channel Fluid exits bone cortex through nutrient veins

5. How Does It Work Intraosseous (IO) infusion –Can deliver fluids as quickly as IV method –Can administer drugs and blood through IO infusion Onset and peak drug levels are similar to IV administration

6. Indications and Contraindications Indications –EMERGENCY VASCULAR ACCESS when usual methods have failed –Initially recommended in children < 6 years –Now also recognized as useful resuscitation technique for adults

7. Indications and Contraindications Absolute Contraindication –Fracture near access site Relative Contraindications –Cellulitis over insertion site –Bacteremia –Osteoporosis

8. Technique Sterile Procedure Equipment –Sterile gloves –Drape –Alcohol or cleaning solution –IO needle holder –12 to 20 gauge needle –Gauze –Tubing –10 or 20 cc syringe or IV bag

9. Technique: Intraosseous Needle Holder Designed and made by Richard Near rbn@nearmfg.com

10. Technique Choice of needle: –Children < 18 months –16, 18, or 20 gauge needle 18 months to 6 years –12, 14, 16 gauge needle –Older children and adults 12 or 14 gauge needle

11. Technique Usually use proximal tibia because easy to landmark Need to be distal to growth plate in children Landmark –Palpate tibial tuberosity –Move distal 2 cm and slightly medial –Relatively flat area

12. Technique Place small towel behind knee Restrain leg Use local anesthetic in subcutaneous tissue and periosteum if patient conscious as the procedure is painful Put on gloves / Drape area / Sterile technique Load needle onto IO needle holder

13. Technique Landmark and insert needle angled to 10-15º caudally -- to avoid injury to growth plate Insert through skin until you feel bone Begin to twist and push - Keep index finger down on IO holder to prevent plunging in You will feel a ‘pop’ when you reach marrow Immediately flush small amount of sterile fluid through needle to dislodge ‘bone plug’ knee foot

14. Technique Confirm proper location of needle before starting infusion –Needle should stand on its own without support if it is through bone cortex –Aspirate blood or marrow –5-10 ml bolus should enter with little resistance and with no extravasation If you make a hole in the cortex, do not put another hole in the cortex of the same bone as this will result in possible fluid extravasation into the soft tissue

15. Technique Attach stopcock or syringe or IV tubing Tape gauze pads around needle to stabilize it Should use IO access for resuscitation and replace with conventional IV line when resuscitation is completed –IO lines should not be used for a prolonged period of time to minimize risk of osteomyelitis

16. Technique Use syringe to give fluid bolus –If needle is attached to IV tubing, you need pressure bag or pump to infuse at a rapid rate Use isotonic solution (normal saline) For resuscitation in children: 20 ml / kg

17. Possible Complication Extravasation of fluid into subcutaneous tissue –Most common complication –Caused by: Misplaced needle Multiple attempts (put other holes in bone) Enlargement of IO hole from needle movement –May result in: Subcutaneous tissue or muscle necrosis Compartment syndrome

18. Possible Complications Osteomyelitis –Incidence in children is 0.6% –Risk increased if: Prolonged use of IO needle Pre-existing bacteremia Use of hypertonic saline Other rare complications –Fracture at IO site –Compartment syndrome –Cellulitis or local abscess

19. Preparation of IO Holder Needs to be cleaned and sterilized after each use Can be used and cleaned like all other surgical instruments because it is stainless steel Method –Cleaning –Sterilization

20. Preparation of IO Holder Cleaning –Use scrub brush –Decreases possible pieces of blood and tissue that prevents heat or chemical sterilization

21. Preparation of IO Holder Chemical Sterilization –Undiluted bleach or 1:1 bleach dilution Kills bacteria, virus, fungus, TB (not bacterial spores) Needs 1 hour contact, then rinse with sterile water –2% glutaraldehyde Needs 6-10 hour contact, then rinse with sterile water Heat Sterilization –Autoclave Unwrapped at 124ºC for 15 minutes Kills bacteria, virus, fungus, TB, and bacterial spores –Steam Sterilization Wrapped at 121ºC for 30 minutes

22. Review Important way to gain emergency IV access for resuscitation when other methods have failed Placement of needle is in flat area medial and distal to tibial tuberosity Confirm position and stabilize needle Bolus 20 ml / kg in children Replace with conventional IV line when resuscitation completed

23. References Intraosseous Infusion –Brian LaRocco, Henry Wang –Prehospital Emergency Care 2003;7:280-285 Clinical Review: Vascular Access for fluid infusion in children –Nikolaus Haas –Critical Care 2004;8(6):478-484