Full Details for Intraosseous Infusion

PRE-PROCEDURE

INTRODUCTIONEstablishing vascular access in a critically ill or injured patient can be life saving (see Figure 1). The rapid delivery of fluid, blood, and medication is often the difference between a successful and unsuccessful resuscitation. Although this is true in both children and adults, placing an intravenous (IV) catheter in an ill or injured child can be one of the most challenging and frustrating procedures a clinician can be called upon to perform. Children have small peripheral vessels that collapse during shock, and their increased body fat makes visualization and palpation of peripheral vessels difficult. These factors often result in prolonged attempts and high failure rates.

Peripheral intravenous access can also be difficult in certain adults, including those who are obese, burned, volume depleted, or in shock from any cause.1Intraosseous (IO) access can provide rapid, lifesaving intravascular access in challenging environments and in difficult pediatric and adult patients. The American Heart Association, the American Academy of Pediatrics, and the American College of Surgeons recommend IO access in emergency situations in children when venous access is not immediately possible.2The latest edition of the Advanced Trauma Life Support Manual also notes that IO access using specially designed equipment is also possible in adult trauma patients.3 IO access is as fast as IV access, and the success rate after failed IV attempts is high.

Clinical Pearls: Almost every drug and fluid commonly used in resuscitation has been reported in clinical and preclinical IO studies. 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 infusions.4-6

Clinical Pearls: 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.7,8

INDICATIONSClinical Pearls: When children or adults need immediate resuscitation and intravascular access cannot be rapidly or reliably achieved, the IO route provides a rapid and effective means of administering drugs, fluids, and blood. Once the patient has been stabilized, percutaneous peripheral or central intravascular access may be achieved.

The primary indication for IO access is cardiac arrest in infants and young children. Clinical Pearls: IO access is not commonly used for premature or term infants but is recommended as an alternative for medication and crystalloid administration when venous access is not readily obtained.9

IO infusion is also indicated in adult patients in whom attempts at peripheral and venous access have been unsuccessful. This may include adult patients with burns, trauma, shock, dehydration, or status epilepticus.10,11 IO access serves as a route for fluid administration and can be used to obtain blood specimens for obtaining blood type, crossmatch12and blood chemistry. Electrolyte, blood urea nitrogen (BUN), creatinine, glucose, and calcium levels are very similar to those obtained from serum.13,14 Blood gas values may be an acceptable alternative to judging central acid-base status during CPR.15 A complete blood cell count from a bone marrow aspirate 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 it is placed in a tube that contains heparin.

CONTRAINDICATIONS Relatively few contraindications to IO infusion exist. Osteoporosis and osteogenesis imperfecta are associated with a high fracture potential; therefore, the procedure should be avoided when these diagnoses are known unless absolutely necessary. A fractured bone must be avoided because as fluid is infused, it increases the intramedullary pressure and forces fluid to extravasate at the fracture site (see Figure 2). This may slow the healing process, cause a nonunion of the bone, or lead to a compartment syndrome. Recent prior use of the same bone for IO infusion represents a relative contraindication to IO line placement because extravasation of fluid can occur through recent IO puncture sites placed in the same bone (with the same consequences as fracture). Needle insertion through areas of cellulitis, infection, or burns should be avoided.

EQUIPMENTClinical Pearls: The following is a review of products currently available for intraosseous infusion. There is limited information regarding the use of these products, and there have been few prospective studies comparing IO needles or devices in clinical practice. Until more information becomes available, practitioners are encouraged to review available products and choose those that best meet their needs.

Clinical Pearls: 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 and long enough to reach the marrow cavity. Standard needles for drawing blood or administering medications are not adequate for IO infusions; generally, they are not sturdy enough to penetrate bone and do not have a stylet to prevent bone from plugging the lumen.

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 fluid administration. Illinois Sternal/Iliac Aspiration Needle (Monojet, Division of Sherwood Medical, St. Louis, Mo.) This needle was designed for bone marrow aspiration but can be used for IO infusion. The needle is available in both 16- and 18-gauge sizes. It has an adjustable plastic sleeve to prevent the needle from penetrating through the opposite bony cortex. However, its long shaft and poorly designed handle make it prone to dislodgement during transport and other procedures. Jamshidi Disposable Sternal/Iliac Aspiration Needle (Cardinal Health, Dublin, Ohio) (see Figure 3). 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, making it easier to use. It comes in either 15- or 18-gauge sizes and also features an adjustable plastic sleeve to prevent overpenetration. Once inserted, the needle protrudes approximately 2 inches from the skin, increasing the risk for accidental dislodgment. In a study using a turkey-bone model, participants rated the Jamshidi needle easier to use than the Cook IO needle.16 Cook IO Needle (Cook Critical Care, Bloomington, Ind.) (see Figure 4). The Cook IO is specifically designed for IO insertion and infusion. It comes in a variety of sizes from 14- to 18-gauge and can be inserted to a depth of 3 to 4 cm. It has a detachable handle that reduces the risk of it being dislodged and a depth marker to help assure proper placement. Sur-Fast Needle (Cook Critical Care, Inc, Bloomington, Ind.) The 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. In a study by Jun and colleagues, the Sur-Fast IO needle had a similar success rate to a standard bone marrow aspiration needle.17Intraosseous Devices FAST-1 Intraosseous Infusion System (PYNG Medical Corporation, Richmond, B.C., Canada) The FAST-1 Intraosseous Infusion System employs an impact-driven device designed for sternal placement only. The FAST-1 has not been evaluated in the emergency department setting but has been successfully used by both military and pre-hospital care providers.18,19 In one prehospital care study, flow rates of 80 mL/min and 150 mL/min were obtained using gravity and a pressure bag, respectively.20 The device has a series of stabilizing probes that help maintain good contact with the sternum and serve as the depth control mechanism for needle insertion. These probes use the surface of the manubrium rather than the patients skin to ensure the proper depth of insertion. Once the device is positioned against the sternum, additional pressure triggers the release of a hollow needle into the medullary space. The needle comes preconnected to intravenous tubing. The handle is automatically released from the stylet and infusion tubing once the needle has met its pre-set depth. Removal of the needle requires a threaded tool provided with the device. The FAST-1 is larger and heavier than other IO devices and, once triggered, it cannot be reused. Bone Injection Gun (BIG; Waismed; Yokenam, Israel) The Bone Injection Gun is another spring-loaded, impact-driven device that comes in both pediatric and adult sizes. Like the FAST-1 system, this device is designed for single use only. An advantage of the Bone Injection Gun is the ability to adjust the depth of insertion, allowing use in different sites (e.g., tibia, humerus). However, if the device is not carefully stabilized before and during insertion, incorrect placement can easily occur. In addition, there is the potential for operator and patient injury if the device is accidentally triggered or mistargeted.19 EZ-IO Device (Vida-Care, San Antonio, Texas) (see Figure 5). This new handheld, battery-powered device drills an IO needle to the appropriate depth in the intraosseous space. The EZ-IO device allows the operator to control the pressure or force used during insertion.21In one study of 250 prehospital uses, successful placement was achieved in 97% of patients.22The authors of this study strongly recommend flushing the needle to ensure optimal flow. In another study of the EZ-IO device, placement was successful in 118 out of 125 attempts, with an average insertion time of 4.5 seconds.23 TIAX Reusable IO Infusion Device (TIAX LLC, Cambridge, Mass.) TIAX has developed a compact, portable, and reusable IO infusion device for quick vascular access through the sternum of soldiers wounded in battle situations. The device is lightweight (217 g), can be operated with one hand, and uses a driver/depth control system that can be used repeatedly to insert single use IO needles. The device is currently in phase II trials.

ANATOMY Bone anatomy Long bones are richly vascular structures with a dynamic circulation. They are capable of accepting large volumes of fluid and rapidly transporting fluids 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 space, which in turn drain into a central venous channel. 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.24 The medullary cavity functions as a rigid, noncollapsible vein, even in the presence of profound shock or cardiopulmonary arrest.25Radiographic studies have demonstrated that radiopaque dye spreads only a few centimeters in the medullary space before being transported to the venous system.26 The richly vascular red marrow cavity of the long bones is gradually replaced by less vascular yellow marrow after age 5.27 Sites for IO Needle Placement The patients 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 of age, the proximal tibia is the preferred site, followed by the distal tibia and distal femur. Other sites, such as the clavicle and humerus, have been used, but neither has gained popularity. In adults, the distal tibia has been the most common site for IO access. However, with the introduction of spring-loaded and drill devices, IO locations once reserved only for children are now potential sites in adults as well. In addition, the FAST-1 system makes the sternum a simple and effective location for IO access in adults. Locations for IO access18,28,30 Iliac crest Femur (see Figure 6) The distal portion of the femur is occasionally used as an alternate site in children, but because of thick overlying muscle and soft tissue, it is more difficult to palpate bony landmarks. If chosen, the needle should be inserted 2 to 3 cm above the femoral condyles in the mid-line and directed cephalad at an angle of 10 degrees to 15 degrees from the vertical. Proximal tibia (see Figure 7) The tibia is a less desirable location in adults because red marrow is replaced by less vascular yellow marrow or fat by the fifth year of life.31,32 The tibia is a large bone with a thin layer of overlying subcutaneous tissue that allows landmarks to be readily palpated, and insertion here does not interfere with airway management and cardiopulmonary resuscitation. On the proximal tibia, the broad, flat, anteromedial surface is used, with the tibial tuberosity serving 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 from the growth plate to prevent damage but is in an area in which the bone is still soft enough to allow easy penetration of a needle. In adults, penetrating the thick bone in the proximal 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. Distal tibia (see Figure 8) The distal tibia, although a preferred site in adults, may be used as a site 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 degrees to 15 degrees cephalad to avoid the growth plate. Sternum (see Figure 9) The sternum has been advocated as the best site to establish IO access in adults because it is large, flat, and can be readily located.33 The sternums cortical bone is thin (1-2 mm) and the marrow space relatively uniform (6-11 mm).32 In addition, it is less likely to be fractured in major trauma than the long bones. The high proportion of red marrow allows rapid transfer of infused fluids and drugs to the central circulation. The introduction of the FAST-1 system, which allows safe and effective penetration of the sternum, has led to increased utilization and popularity of sternal IO insertion in adults. Other potential sites for IO insertion Radius Clavicle Humerus Calcaneus

PROCEDURE Positioning Place the patient supine with the insertion site accessible. To prepare the proximal tibia or distal femur for IO insertion, a small support such as a towel roll should be placed behind the knee. Choose an appropriate site for IO needle insertion. Observe universal precautions. **UNIVERSAL PRECAUTIONS** Site Preparation Cleanse the insertion site with chlorhexidine or povidone-iodine (see Figure 10). **STERILE TECHNIQUE** For patients with severe shock, dehydration, or cardiopulmonary arrest, local anesthesia may be considered, but is not necessary. If the patient is conscious, anesthetize the skin and periosteum. See Local Anesthesia for further details. Manual Needle Insertion Prior to insertion, use your free hand (i.e., the hand not holding the IO needle) to stabilize the site and act as a guide for identification of landmarks (see Figure 11). For example, during proximal tibial insertion, use the thumb and index finger of the free hand to stabilize the proximal tibia and identify (palpate) the tibial tuberosity (the main bony landmark for proximal tibial insertion). During insertion, avoid puncturing your free hand by keeping it out of the plane of insertion and clear of the puncture site. Direct the IO needle perpendicular (90 degrees) to the bones long axis or slightly caudad (60-75 degrees). Directing the needle slightly caudad will help avoid penetration of the growth plate (see Figure 12). Advance the needle using a twisting or rotating motion, driving it into the bone and puncturing the cortex. Once the cortex is penetrated, there will be a sudden decrease in bony resistance and a crunchy feeling as the needle enters the marrow cavity. Penetration of the inner cortex usually occurs at approximately 1 cm. Aspirate blood and/or marrow contents to confirm correct placement (see Figure 13). Other signs of correct placement include the needles ability to remain upright without support and free-flowing fluid without signs of extravasation into surrounding tissue. Clinical Pearls: If available, ultrasound imaging or a miniature C-arm device has also been shown to reliably confirm IO placement.34-37

FAST-1 device This device was designed specifically to penetrate the sternum and has been gaining popularity for both pre-hospital and military applications where rapid, simple, and reliable intraosseous access is required.18,38 The FAST-1 device is prepackaged with alcohol and iodine and comes with a protective dressing that holds the device in place and a threaded tip remover for easy removal of the metal tip and infusion tubing. Disinfect the skin site on the sternum, then 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. Next, 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 the proper needle depth. Once in position over the target zone, 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 pre-connected to plastic infusion tubing. After release, the central IO needle advances 5 mm beyond the circular cluster of needles stopping at the bony cortex and positioning the metal tip at the cortex-medullary junction. At this point, withdraw the handle, leaving only the plastic infusion tube protruding from the insertion site. Aspirate marrow and note rapid flow of fluid to verify position. Attach the plastic dome to the target patch via Velcro fasteners to secure the tubing in place. To remove the infusion tube, use the included threaded-tip remover. The tube can also be removed by direct pulling; however, the metal tip is sometimes left behind and must be extracted through a small incision.18 Bone Injection Gun (BIG) The 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 counter-clockwise to reduce or increase needle depth, respectively. Place the BIG firmly against the skin perpendicular to the long axis of the bone (or slightly caudad) and fire the gun by applying palmar force on the back of the unit while pulling on the flanges with the middle and ring fingers. Aspirate marrow, then flush with the same syringe, and note flow through the IV tubing to confirm placement. Slide the slotted safety pin into the needle to maintain stability. To remove the needle, rotate it back and forth using the small clamps provided with the unit. Dress the site as deemed appropriate. EZ-IO Needle This battery-operated drill can drive the IO needle through even thick bone with relative ease. The EZ-IO kit comes with the battery-operated drill and an IO needle with a stylet; the EZ-IO AD comes with a 15-gauge, 25-km IO needle for use in patients >40 kg while the EZ-IO PD comes with a 15-gauge, 15-mm needle for use in patients