Back to Basics: Intraosseous Lines

Author: Rahul Gupta, MD

•       Indications

•       Failure to gain IV access in critical patient (burns, shock, resuscitation)

•       Temporizing measure to allow stabilization and to facilitate long-term IV access

•       Contraindications

•       Fractured at or proximal to site or previously penetrated

•       Vascular interruption

•       cellulitis overlying skin

•       Bone disease (OI, osteoporosis)

•       Complications:

•       Long-term use - >24 hours associated with osteomyelitis

•       Fracture, extravasation, compartment syndrome

•       Insertion Site:

•       Proximal tibia (2 finger widths below tibial tuberosity)

•       Distal femur

•       Distal tibia/fibula

•       Proximal humerus - arguably the best due to highest flow rate, but may interfere with resuscitations activities

•       Sternum - best if all limbs are injured

•       Anterior superior iliac spine: best in soft boned pediatric patients

•       Sizes

•       15 mm - pink (3-39kg person), 25 mm - blue (>40kg person), 45 mm - yellow (>40kg with lots of subcutaneous tissue)

•       Yellow is the color of fat

•       Pink is exclusively Peds

•       Confirmation of Line

•       Achieved with aspiration of bone marrow, flushing needle without evidence of extravasation, and clear visualization of needle standing firmly in bone

•       Fluid Infusion

•       Can infuse IV drug or fluid (same dose); flush with 20 mL saline flush

•       Rate: sternum > proximal humerus > tibia

•       Labs

•       Accurate: Hgb/Hct, pH, pCO2, Bicarb, chloride, BUN, creatinine, glucose, serum drug levels, cultures, albumin

•       Inaccurate: WBC, Potassium, Ionized Ca, AST/ALT, Blood oxygenation

References: 

1. Moore GP, Pace SA, Busby W. Comparison of intraosseous, intramuscular, and intravenous administration of succinylcholine. Pediatric Emergency Care. 1989;5(4):209–210.

2. Mittiga MR, Ruddy RM. Procedures. In: Shaw KN, Bachur RG, eds. Fleisher & Ludwig’s Textbook of Pediatric Emergency Medicine. 7th ed. Philadelphia, PA: Wolters Kluwer; 2016:(Ch) 141.

3. Bloch SA, Bloch AJ, Silva P. Adult intraosseous use in academic emergency departments and simulated comparisons of emergency vascular access techniques. Annals of Emergency Medicine. 2010;56(3):S152.

4. Leidel, B.A., Kirchhoff, C., Bogner, V., Stegmaier, J., Mutschler, W., Kanz, KG., & Braunstein, V. (2009). Is the intraosseous route fast and efficacious compared to conventional central venous catheterization in adult patients under resuscitation in the emergency department? A prospective observational pilot study. Patient Safety in Surgery, 3(1), 24-31. doi: 10.1186/1754-9493-3-24