Intraosseous Vascular Access

Indications


Contraindications

  • Patient with Osteoporosis or Osteogenesis Imperfecta: these patients may have baseline increased risk for bone fractures
  • Placement in Extremity with a Fracture or Vascular Injury
  • Placement in an Area with Overlying Infection or Burn
  • Placement in an Area of Bone Where a Prior Intraosseous Needle Has Been in Place: in this case, fluids/medications may extravasate from the prior intraosseous site into the surrounding tissues
  • Right-to-Left Intracardiac Shunt (see Intracardiac and Extracardiac Shunt, [[Intracardiac and Extracardiac Shunt]]): due to concern related to potential for fat embolism

Physiology

  • Intraosseous Medication Delivery
    • Intraosseus Access Achieves Onset of Action and Drug Concentrations Similar to those Provided by Intravenous Administration: therefore, medication dose should be the same as for intravenous adminstration
  • Intraosseous Sample Tetsing
    • Blood Gas Analysis, Blood Group Typing, Electrolyte Levels, Drug Levels, and Hemoglobin Levels are Comparable to Those Obtained Intravenously: however, in patients who have undergone multiple fluid or drug administrations via the intraosseous needle, electrolyte and blood gas analysis values may subsequently be inaccurate
  • Infusion Rate Capability: an intraosseus needle can maintain an infusion rate comparable to a 21-gauge peripheral IV

Technique

Success Rate of Intraosseous Insertion

  • Success Rate: ranges from 75-100%
    • Unsuccessful Intraosseous Insertion May Be Related to Incorrect Landmarks, Pathologically Fragile Bone, Bent Intraosseous Needle, Clogged Intraosseous Needle (by Marrow, Bone Spicules, or Blood Clot), Intraosseous Needle Dislodgement, or Needle Penetration of the Posterior Cortex of the Bone
  • Time Required for Insertion: 3-120 sec (in most cases)

Common Commercially Available Intraosseus Access Systems

  • General Comments
    • Systematic Review of Intraosseous Devices (Resuscitation, 2012) [MEDLINE]
      • Only a Few Studies Have Compared Intraosseous Devices (Quality of Evidence is Low): studies suggest that the battery-powered intraosseous driver is superior to manual needles and other semi-automatic intraosseous infusion devices
  • Bone Injection Gun (BIG) (WaisMed Ltd; Houston, TX)
    • Approximate Cost: $39 per kit (total cost: $109)
  • EZ-IO (Vidacare Corp; San Antonio, TX)
    • Approximate Cost: $200 per kit (total cost: $580)
  • FAST1 Intraosseous Infusion System (Pyng Medical Corp; Vancouver, BC, Canada)
    • Approximate Cost: $195 per kit (total cost: $360)

EZ-IO

General Comments

  • FDA-Approved in 2004: in both adults and children

FDA-Approved Anatomic Insertion Sites

  • Humeral Head
  • Medial Tibia (Proximal or Distal): this site may be especially useful during a cardiac arrest, since it is far from the chest, where chest compressions may be ongoing

EZ-IO Insertion

Post-Insertion of EZ-IO Needle

  • Conscious Patient: slow injection of 2 ml of 2% lidocaine (equivalent to 40 mg) over 2 min -> this results in anesthesia of intraosseous space to prevent infusion pain
  • Unconscious Patient: flush with 10 ml NS -> resistance indicates that IO catheter is in the intraosseus space (lack of resistance indicates that the IO catheter is in the SQ tissue)

EZ-IO Removal

  • Remove Infusion Connector and EZ-Stabilizer Dressing from IO Needle
  • Turn IO Needle Clockwise with Pulling Motion: do not bend or rock to avoid separation of the needle from the hub

Adverse Effects of Intraosseous Vascular Access

General Comments

  • Overall Complication rate: 1%
  • Duration of Intraosseous Use: complication rates appear to increase with the duration of use
    • For This Reason, Intraosseous Needle Use Should Be Limited to Approximately 24 hrs

Dermatologic Adverse Effects

  • Cellulitis/Skin Abscess (see Cellulitis, [[Cellulitis]] and Skin Abscess, [[Skin Abscess]]))
    • Epidemiology: 0.7% of cases

Pulmonary Adverse Effects

  • Fat Embolism (see Fat Embolism, [[Fat Embolism]])
    • Epidemiology: microscopic pulmonary emboli are observed in 30% of cases in animal studies (Pediatr Crit Care Med, 2001) [MEDLINE]
      • Incidence in humans is unclear
    • Recommendation: since the clinical significance in humans is unclear, intraosseous access should probably be avoided in patients with know right-to-left intracardiac shunts

Rheumatologic/Orthopedic Adverse Effects

  • Extravasation of Fluids/Medications into the Surrounding Soft Tissue
  • Osteomyelitis (see Osteomyelitis, [[Osteomyelitis]])
    • Epidemiology: 0.6% of cases (most of these cases had prolonged infusions)

Other Adverse Effects

Adverse Effects Specifically Associated with Sternal Intraosseous Needle Insertion

  • Death
  • Injury to Great Vessels
  • Mediastinal Injury
  • Pneumothorax (see Pneumothorax, [[Pneumothorax]])

References

  • Intraosseous infusion and pulmonary fat embolism. Pediatr Crit Care Med 2001;2:133–8 [MEDLINE]
  • Intraosseous access. J Emerg Med. 2010;39:468–475 [MEDLINE]
  • Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 suppl 3):S729–S767 [MEDLINE]
  • Current advances in intraosseous infusion – a systematic review. Resuscitation. 2012 Jan;83(1):20-6. doi: 10.1016/j.resuscitation.2011.07.020. Epub 2011 Aug 24 [MEDLINE]
  • EZ-IO(®) intraosseous device implementation in a pre-hospital emergency service: A prospective study and review of the literature. Resuscitation. 2013 Apr;84(4):440-5. doi: 10.1016/j.resuscitation.2012.11.006. Epub 2012 Nov 14 [MEDLINE]