Intraosseous Needle Insertion
During the first week of life the umbilical vein is a convenient route for obtaining vascular access during emergencies. The intraosseous (IO) route provides an option for establishing rapid venous access in an emergency after that time. The bone marrow cavity has an extensive virtually non-collapsible vascular network directly communicating with the systemic circulation. Medications or fluids given by the IO route diffuse a few centimetres through the medullary cavity then enter the venous circulation.
The proximal tibia is the preferred site. The entry point is a few centimetres below the tibial tuberosity at the centre of the flat antero-medial surface. The needle is directed caudal away from the upper tibial epiphysis in the line of the shaft.
The distal antero-medial surface of the tibia is an alternate site which can be used in children of all ages.
The distal femur and sternum should not be used.
- sterile gloves and gown
- basic dressing pack
- antiseptic to prepare the skin
- rigid needle with an inner stylet (for patients < 18 months an 18 - 20 lumbar puncture needle can be used)
- syringe with NaCl 0.9% flush
- routine IV line tubing set-up and tape
- observe standard precautions
- immobilize the extremity
- prepare the site with antiseptic
- consider need to use local anaesthetic( 0.5-1 mL 1% lignocaine ) if time permits
- insert the needle
The needle handle is held in the palm of the hand while the thumb and forefinger grip the shaft about a centimetre from the point to stabilize the needle. Firm pressure is applied while using a screwing or rotary action until the bone cortex is traversed. At approximately 1cm or less, below the skin surface, a distinct loss of resistance on entry of the bone marrow is felt.
Three factors should be noted
- a distinctive pop with insertion, or a give or release of resistance is felt
- the needle flushes without significant subcutaneous infiltration and bone marrow is easily aspirated
- the needle stands without support
- unscrew and remove the stylet
- attempt bone marrow aspiration. (bone marrow can be used as a substitute for venous blood for estimation of PCO2, pH, Hb, electrolytes, urea, creatinine, proteins etc)
- flush the needle with 5-10 mL of normal saline to decrease the cellularity of the surrounding marrow, aiding subsequent infusions
- attach IV tubing and commence the infusion of medications or fluids by pump
Recommended intravenous rates for drugs and fluids can be administered via the IO route and reach the central circulation in equivalent times.
Strong alkaline and hypertonic solutions should be diluted before use.
- limb is traumatised
- extravasation of fluid, drugs or air into skin or periosteum. A larger hole is created if a rocking motion is used during insertion of the needle. It may also occur if there has been a previous IO infusion in the same bone
- sub-periosteal infusion may occur when the needle fails to enter the bone marrow
- through and through puncture occurs if the needle is advanced too far
- blockage of the needle may occur if no inner stylet is used
- infection -cellulitis, abscess formation, skin necrosis and osteomyelitis
- tibial fracture
- fat and bone marrow microemboli
Insertion of Cook Intraosseous needle/Emergency intraosseous infusion. A video produced and distributed by Cook Australia, Running time 35 minutes.
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