Intraosseous infusion
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Transcript of Intraosseous infusion
Intraosseous Infusion
intro
placing an IV catheter in an acutely ill child can be one
of the most challenging and frustrating procedures :
small peripheral vessels that collapse during shock
higher proportion of body fat makes visualization and
palpation of peripheral vessels difficult
Peripheral IV access can also be difficult in adults,
including those who are obese, have burn injuries, are
volumedepleted, or are in shock
IO access can provide rapid, lifesaving intravascular
access in challenging environments(prehospital or
military setting) and in both pediatric and adult patients
intro
IO access is often faster than IV access, and the success
rate after failed IV attempts is high
Anatomy & Physiology Long bones are richly vascular structures with a
dynamic circulation.
They are capable of accepting large volumes of fluid and rapidly transporting fluid or drugs to the central circulation.
The bone, like most organs, is supplied by a major artery (nutrient artery). The artery pierces the cortex and divides into ascending and descending branches, which further subdivide into arterioles that pierce the endosteal surface of the stratum compactum to become capillaries. The capillaries drain into medullary venous sinusoids throughout the medullary , which in turn drain into a central venous channel
Anatomy & Physiology
The medullary sinusoids accept fluid and drugs during
IO infusion and serve as a route for transport to the
central venous channel, which exits the bone as nutrient
and emissary veins
Anatomy & Physiology
Crystalloid infusion studies in animals have
demonstrated that infusion rates of 10 to 17 mL/min
may be achieved with gravity infusion and rates as high
as 42 mL/min with pressure infusion
Comparisons of IO and IV infusion of drugs have
demonstrated that the drugs reach the central
circulation by both routes in similar concentrations and
at the same time
sodium bicarbonate has been shown to provide greater
buffering capacity when administered by the IO route
than by the peripheral IV route
INDICATIONS When children or adults need immediate resuscitation and
IV access cannot be achieved quickly or reliably, the IO route provides a rapid and effective means of administering drugs, fluid, and blood
IO access is not commonly used in infants, but it is recommended as an alternative for medication and crystalloid administration when venous access is not readily obtained
Multiple sites, including the iliac crest, femur, proximal and distal ends of the tibia, radius, clavicle, and calcaneus may be used.
Of these, the tibia may be less desirable because red marrow is replaced by less vascular yellow marrow or fat by the fifth year of life
INDICATIONS In contrast, the sternum has been advocated as the best site to
establish IO access in adults because it is large and flat and can readily be located, it’s cortical bone is thin (1 to 2 mm) and the marrow space relatively uniform (6 to 11 mm).
A recent randomized controlled trial (RCT) of the BIG device versus the EZ-IO showed no significant differences in success rates or overall ease of use. Of 40 adults in the prehospital setting, vascular access was successfully achieved on the first attempt in 80% to 90% of patients within 2 minutes.58 Another recent RCT showed that a Jamshidi 15-gauge needle could be placed significantly faster than the FAST-1 device but had similar success and complication rates, as well as perceived ease of use
INDICATIONS In addition to serving as a route for fluid administration, the IO
needle may be used to obtain blood for typing, crossmatching, and determining blood chemistry in the marrow cavity. Serum electrolyte, blood urea nitrogen, creatinine, glucose, and calcium levels are very similar to those in samples obtained from an IO aspirate.60,61 Blood gas values obtained from the IO site were similar to those obtained from central venous sites during steady and low-flow states in one animal model.62 Brickman and colleagues63 demonstrated that bone marrow aspirates obtained from an IO needle in the iliac crest could be used reliably to type and screen blood for transfusion. A complete blood cell count may not be reliable because it reflects the marrow cell count rather than the cell count in the peripheral circulation. Furthermore, the aspirated blood usually clots within seconds, even if placed in a tube that contains heparin.
CONTRAINDICATIONS Osteoporosis and osteogenesis imperfecta are associated with a high potential
for fracture; therefore, unless absolutely necessary, the procedure should be avoided when these diagnoses are known
A fractured bone should be avoided because as fluid is infused, it increases intramedullary pressure and forces fluid to extravasateat the fracture site. This may slow the healing process, cause nonunion of the bone, or lead to a compartment syndrome.
Similar extravasation of fluid can occur through recent IO puncture sites placed in the same bone. Hence, recent previous use of the same bone for IO infusion represents a relative contraindication to IO line placement
Needle insertion through areas of cellulitis, infection, or burns should also be avoided. Patients with right-to-left intracardiacshunts (e.g., tetralogy of Fallot, pulmonary atresia) may be at higher risk for fat or bone marrow embolization
IO Needles Needles used for IO access range in size from 13 to 20
gauge and must be sturdy enough to penetrate bone without bending or breaking.
They must also be long enough to reach the marrow cavity. Standard needles for drawing blood or administering medications are not adequate for IO infusions; they are not sturdy enough to penetrate bone and do not have a stylet to prevent bone from plugging the lumen
In the past, an 18-gauge spinal needle was commonly used in children younger than 12 to 18 months. This needle, though readily available in most EDs, often bends, is too long for rapid infusion of fluid, and has a greater risk for occlusion from clotted blood.67 Very small “butterfly” needles have been used with success in preterm infants
Bone Marrow Aspiration Needle Bone marrow aspiration needles can be used if needles
specifically designed for IO access are not available. These
needles are large enough (16 gauge) to be used in older children
and adults and are suitable for rapid administration of fluid
Illinois Sternal/Iliac Aspiration Needle The Illinois Sternal/Iliac Aspiration Needle was designed for
bone marrow aspiration but can be used for IO infusion
The needle is available in both 16 and 18 gauge.
It has an adjustable plastic sleeve to prevent the needle
from penetrating through the opposite bony cortex
Jamshidi Disposable Sternal/Iliac Aspiration Needle
Like the Illinois Sternal/Iliac Aspiration Needle, the Jamshidi
Disposable Sternal/Iliac Aspiration Needle was designed for
bone marrow aspiration, but it has a shorter shaft and smaller
handle, which makes it easier to use. It comes in either 15 or 18
gauge and also features an adjustable plastic sleeve to prevent
overpenetration
Cook IO Needle
is specifically designed for IO insertion and infusion. It comes in
a variety of sizes from 18 to 14 gauge and can be inserted to a
depth of 3 to 4 cm. It has a detachable handle, which reduces the
risk of it being dislodged, and a depth marker to help ensure
proper placement.
Sur-Fast Needle
is also specifically designed for IO insertion and infusion. It has
a threaded shaft that helps secure the needle in the bone and a
detachable handle that may be reused with multiple needles.
IO Devices
FAST-1 Intraosseous Infusion System
uses an impact-driven device designed for sternal
placement only
has a series of stabilizing probes that help maintain good
contact with the sternum and serve as the depth control
mechanism for insertion of the needle
Once the device is positioned against the sternum,
additional pressure triggers the release of a hollow needle
into the medullary space
The handle is automatically released from the stylet and
infusion tubing once the needle has met its preset depth
The FAST-1 is larger and heavier than other IO devices and,
once triggered, cannot be reused
FAST-1 Intraosseous Infusion System
Bone Injection Gun
is another springloaded,impact-driven device that
comes in both pediatric and adult sizes
is designed for single use only
An advantage of the BIG is the ability to adjust the
depth of insertion, which allows it to be used at
different sites (e.g., tibia, humerus).
there is the potential for operator and patient injury
if the device is accidentally triggered or mistargeted
Bone Injection Gun
EZ-IO Device
handheld, battery-powered device that drills an IO
needle to the appropriate depth in the IO space.
The EZ-IO device allows the operator to control the
pressure or force used during insertion.
Placement can be achieved in less than 10 seconds
in the vast majority of patients, with first-time
successful insertion rates ranging from 77% to 97%
EZ-IO Device
TIAX Reusable IO Infusion Device
a compact, portable, and reusable IO infusion
device for quick vascular access through the
sternum of soldiers wounded in combat
Lightweight (217 g), can be operated with one
hand, and has a reusable driver/depth control
system to insert single-use IO needles
is currently in phase II trials
TIAX Reusable IO Infusion Device
PROCEDURE
Sites for IO Needle Placement
age and size are the two most important factors when
choosing the best site for needle penetration
In infants and children younger than 6 years, the proximal end
of the tibia is the preferred site, followed by the distal ends of
the tibia and femur
Other sites such as the clavicle and humerus have been used,
but neither has gained popularity
In adults, the distal part of the tibia has been the most
common site for IO access.
with the introduction of spring-loaded and drill devices, IO
locations once reserved only for children are now potential
sites in adults as well.
the FAST-1 System makes the sternum a simple and effective
location for IO access in adults.
Sites for IO Needle Placement
Proximal Tibia The tibia is a large bone with a thin layer of overlying subcutaneous tissue
that allows landmarks to readily be palpated
Insertion here does not interfere with airway management or CPR
On the proximal end of the tibia, the broad, flat, anteromedial surface is used
and the tibial tuberosity serves as a landmark
The site of IO cannulation is approximately 1 to 3 cm (2 finger widths) below
the tuberosity
This location is far enough away from the growth plate to prevent damage
In adults, penetrating the thick bone in the proximal end of the tibia is much
more difficult and requires a 13- to 16-gauge needle
A spring-loaded device such as the BIG or a battery-powered drill such as the
EZ-IO can make penetration much easier and allows the use of smaller-gauge
needles
tibial placement was significantly more successful (90%) than humeral
placement (60%) with a lower rate of needle dislodgement
Distal Tibia a preferred site in adults, may be used in children as well
The cortex of the bone and the overlying tissue are both thin.
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 to 15 degrees cephalad to avoid the growth plate
Sternum
has several advantages over peripheral bones but is
rarely used in the ED
Its advantages include a large, relatively flat body
that can be readily located; retention of a high
proportion of red marrow, which allows rapid
transfer of infused fluids and drugs to the central
circulation; and thinner, more uniform cortical bone
overlying a relatively uniform marrow space
In addition, the sternum is less likely to be
fractured in major trauma
Humerus
The proximal end of the humerus is a relatively
new option for IO access, but it is well tolerated
and easily accessed
The close proximity of the greater tubercle of the
humerus to the heart provides rapid infusion of
medication and fluid into the general circulation
Other Sites
The distal portion of the femur is occasionally used
as an alternative site in children, but because of
thick overlying muscle and soft tissue, it is more
difficult to palpate bony landmarks
the needle should be inserted 2 to 3 cm above the
femoral condyles in the midline and directed
cephalad at an angle of 10 to 15 degrees from the
vertical
Other sites, including the clavicle and calcaneus,
can be used as alternatives, but these sites are les
popular
Site Preparation
To prepare the proximal end of the tibia or distal
end of the femur for IO insertion, a small support
such as a towel roll should be placed behind the
knee
All insertion sites should be cleansed with
chlorhexidine, povidone-iodine, or an alcohol-
based antibacterial solution.
If the patient is conscious,the skin and periosteum
should be anesthetized
Manual Needle Insertion Before insertion, stabilize the site with the free hand and use it to
identify the landmarks.
Direct the IO needle perpendicular (90 degrees) to the bone’s long axis
and slightly caudad (60 to 75 degrees to helps avoid penetration of the
growth plate)
Advance the needle with a twisting or rotating motion (but not a
rocking motion) to drive it into the bone and to puncture the cortex
Once the cortex has been penetrated, there will be a sudden decrease
in bony resistance and a “crunchy” feeling as the needle enters the
marrow cavity
Aspirate for blood or marrow contents (or both) to confirm correct
placement
Other signs of correct placement include the needle’s ability to remain
upright without support and to have free-flowing fluid without signs
Manual Needle Insertion
Once proper placement is confirmed, secure the needle and
tubing with tape.
Fastening the leg to an appropriately sized leg board helps
further stabilize a lower extremity insertion site in infants
and small children.
Protect the needle from accidental dislodgment by cutting
the bottom out of a plastic cup and taping and bandaging
the cup in place over the device.
Remove the IO needle as soon as IV access has been
secured, and apply a sterile dressing over the site.
Control excessive bleeding by applying direct pressure over
the site for 5 minutes
FAST-1 was designed specifically to penetrate the sternum
prepackaged with alcohol and iodine and comes with a protective
dressing to hold the device in place
After disinfecting the skin site over the sternum, place the target patch
over the midline of the manubrium with the hole in the middle of the
target approximately 1.5 cm below the sternal notch
place the FAST-1 introducer in the center of the target zone. The
introducer has a “bone cluster” of needles that form a circle. These
needles “sense” the cortex of the sternum and help ensure proper
needle depth
apply pressure to the handle to release an inner needle located in the
center of the bone cluster
This needle has a small metal tip that is preconnected to plastic
infusion tubing
FAST-1 After release,the central IO needle advances 5 mm beyond the circular
cluster of needles, stops at the bony cortex, and positions the metal tip
at the cortex-medullary junction.
At this point, withdraw the handle so that only the plastic infusion tube
is left protruding from the insertion site.
Marrow aspiration and rapid flow of fluid help verify the appropriate
position.
Attach the plastic dome to the target patch via Velcro fasteners and
secure the tubing in place.
Removal of the infusion tube requires the use of a threaded-tip
remover, which is included
BIG incorporates a loaded spring to facilitate penetration of the bone.
To adjust the depth of insertion, remove the safety pin from one end
and turn the other end clockwise or counterclockwise to reduce or
increase needle depth, respectively
Place the BIG firmly against the skin perpendicular or slightly caudad
to the long axis of the bone
Fire the gun by applying palmar force on the back of the unit and
pulling on the flanges with the middle and ring fingers
Confirm placement by aspirating marrow, flushing with the same
syringe, and observing flow through the IV tubing. Slide the slotted
safety pin into the needle to maintain stability.
To remove the needle, rotate it back and forth with the small clamps
provided with the unit.
EZ-IO Needle This battery-operated “drill” can drive the IO needle through thick bone with
relative ease
The EZ-IO kit comes with a battery-operated drill and an IO needle with a
stylet; the EZ-IO AD comes with a 15-gauge, 25-mm IO needle for use in
patients heavier than 40 kg; and the EZ-IO PD comes with a 15-gauge, 15-
mm needle for use in patients lighter than 39 kg.
To operate the drill, insert the needle into the driver tip and make sure that it
is securely seated onto the drill
Remove the safety cap from the needle and position the drill perpendicular
(or slightly caudad) to the insertion site
Squeeze the trigger while applying gentle pressure to penetrate the skin.
When the tip of the needle comes in contact with the bone, at least 5 mm of
the IO catheter should be visible.
To penetrate the bone, continue to squeeze the trigger while applying steady
downward pressure until a sudden “give” or “pop” occurs, which signals
entry into the medullary space.
EZ-IO Needle After entry into the marrow cavity, attach the EZ-Connect extension set
provided with the EZ-IO kit and aspirate blood and bone marrow contents to
confirm correct placement. Once catheter placement has been checked, fluids
or medications can be infused.
Avoid attaching syringes and IV tubing directly to the IO needle because this
can enlarge the hole in the cortex and result in extravasation of fluid. Secure
the tubing with tape and cover the area with appropriate dressing
COMPLICATIONS
Technical Difficulties are the most common complications, but they decrease as familiarity with the
technique increases
The most common mistake is to place excessive pressure on the needle during
insertion and force it entirely through the bone and out the other side
Minimize this risk by using:
appropriate landmarks
keeping the needle perpendicular to the long axis of the bone
hold the needle with the index finger approximately 1 cm from the bevel
When this finger touches the skin, the needle should be in the marrow cavity
and no further pressure needs to be applied
Some IO needles have a mark 1 cm from the bevel (e.g., Cook IO Needle),
whereas others have a special guide or mechanism to ensure proper insertion
and depth of penetration (e.g., Illinois Sternal/Iliac Aspiration Needle)
Technical Difficulties the needle appears to be in the marrow cavity,but blood or bone
marrow cannot be aspirated and fluids do not flow freely. This may
follow incomplete penetration of the bone or overpenetration into the
opposite cortex
Incomplete penetration usually results in extravasation of fluids and
can be corrected by replacing the stylet and slowly advancing the
needle until successful aspiration of marrow contents and free flow of
fluids occur
If overpenetration is suspected, pull the needle back 1 to 2 mm and
check for free flow of fluids
To ensure flow, rapidly inject 10 mL of saline into the marrow. This is
a painful procedure in awake patients, but failure to initially flush the
compartment is a common reason for inadequate flow
A pressurized bag system is suggested if large volumes of fluid are
administered. Flush each dose of medication with 3 to 5 mL of saline
Technical Difficulties Extravasation may be caused by fluids being infused under excessive
pressure and with prolonged use of an IO site
extravasation may also result from incomplete needle penetration or
penetration through the opposite cortex. Even when an IO needle has
been positioned properly, fluid can leak out through holes made by
previous IO attempts or through an insertion site made too large from
“rocking” during insertion or from an improperly secured needle that
becomes loose with movement
the type of needle used does not appear to influence extravasation
rates
Regardless of the cause, if extravasation occurs, remove the needle
quickly and apply pressure to the site
Soft Tissue and Bony
Complications
Infection Although the potential for infection is real, its actual incidence is low
The most common infection is cellulitis at the puncture site, which
usually responds well to antibiotics.
Osteomyelitis is less common but also usually responds well to
antibiotics.
incidence of infection for IO needles placed in emergency conditions
was less than 3%.
In addition to infection, inflammatory reactions of the bone may be
seen. Such reactions are most common when hypertonic or sclerosing
agents are used and may produce an elevation of the periosteum on
plain radiographs or a positive bone scan
One hypertonic sclerosing drug that may be used during cardiac arrest
is sodium bicarbonate
Skin Sloughing Skin sloughing and myonecrosis have been reported secondary to
extravasation of infused fluids and medications
When drugs such as calcium chloride, epinephrine, and sodium
bicarbonate are infused, care should be taken to prevent dislodgment
of the needle and extravasation into tissue
In addition, it is best to infuse such drugs only by gravity because
infusion under pressure increases the risk for extravasation.
Compartment Syndrome may occur when fluids leak out of the bone into a closed compartment
such as the anterior or deep posterior compartment of the lower leg.
The risk for compartment syndrome can be reduced by carefully
placing and securing the IO needle, limiting the number of attempts in
the same bone, and removing the needle once IV access has been
obtained.
it is prudent to check the insertion site frequently, especially when
fluids are being infused under pressure.
Epiphyseal Injuries Injury to the growth plate and subsequent developmental
abnormalities of the bone are ongoing concerns with the IO route.
Regardless, these fears are largely unsupported in the available
literature
there have been no reports of growth plate damage or permanent
abnormalities of the bone
By pointing the needle away from the joint space and using the
previously mentioned landmarks for insertion, the risk for epiphyseal
injury is remote.
Whereas growth plate abnormalities appear to be very rare, tibial
fractures have been reported after IO placement. Hence, it is
appropriate to take follow-up radiographs of patients who have
undergone IO needle attempts or placement
Fat Embolism This condition is rare, however, and has been reported only in adult
patients
Because the marrow in infants and children is primarily
hematopoietic, this potential complication is unlikely to occur in this
population.
Pain with Infusion Most patients undergoing IO infusion will not be in a condition to
sense pain, but infusion into bone marrow can be quite painful.
Infusing 2 to 5 mL of 2% lidocaine before infusion has been suggested
to relieve pain in awake patients
Medications intended to remain in the medullary space, such as local
anesthetics, must be injected very slowly until the desired anesthetic
effect if achieved