Intraosseous access

Disclaimer These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.  Read the full PCH Emergency Department disclaimer.

Aim 

To guide PCH staff in the insertion, care and removal of intraosseous needles in children.

Background

• The intraosseous (IO) space functions as a non-collapsible vein.
• The emissary veins of the IO space absorb all parenteral medication, crystalloid fluids and/or blood products – which move quickly into the central circulation.
• Complications are minor and infrequent.
• Patient weight, anatomy and overlying tissue will determine the appropriate size IO needle set
• Collect marrow from the IO needle prior to flushing and infusing fluids.
• It is possible to do group and hold/cross-match, blood cultures and blood glucose level. Full Blood Count (FBC) from marrow is not available for processing by pathology.
• Do not run sample on blood gas machine as this damages the equipment.
• Ensure all blood tubes sent to lab are clearly labelled “Intraosseous”.
• All medications and fluids which would normally be given intravenously can be given via intraosseous route.
  • Optimal flow rates are achieved by infusing medications and fluids under pressure.

Indications

• Cardiopulmonary arrest in patient without intravenous access
• Any critical emergency where gaining intravenous access cannot be achieved within 60 seconds.
• Oral, transmucosal, intramuscular or inhalation routes are not adequate to meet the patient’s needs for fluids and/or medications when intravenous access is unobtainable. 

Contraindications

• Fractures: do not place an IO below a fracture site, use an alternative site.
• Open injury: avoid placement of an IO below any open injury on an extremity, use an alternative site.
• Infection or burn at potential site: use an alternative site.
• Bone Pathology (osteoporosis, osteogenesis imperfecta).
• Site of previous IO insertion. 

Equipment

Manual intraosseous needle insertion (available in ED and theatre only)

Mechanised intraosseous needle insertion - EZ-IOTM is used at PCH

There are a range of commercially available IO needles: ED have 3.0 cm in length only Theatre stores 3cm, 14G and 18G The EZ-IO can be used manually if required in the event of drill failure Alcohol swabs or Povidone-Iodine solution 10mL syringe for aspiration 10mL syringe with 0.9% Sodium Chloride for flush 3 way extension tap Clean gloves Tape

IO insertion device EZ-IO® (See below for storage and technical consideration) Use the 15mm needle (pink) for 3-39 kg Use the 25mm needle (blue) for > 39 kg patient 45mm needle (yellow) available for obese older patients Alcohol swab or Povidone-Iodine solution 10mL syringe for aspiration 10mL syringe with 0.9% Sodium Chloride for flush 3 way extension tap Clean glove EZ-Connect connection (comes with needle) EZ- stabiliser dressing

Procedure

Identification of entry site

• • The most common and preferred site in children is the proximal tibia: anteriomedial aspect of the tibia. 2-3cm below the tibia tuberosity.

• Alternative sites are:
  • Distal tibia – 2-3cm above the medial malleolus⁴

• Proximal humerus - anterolateral shoulder into greater tubercle

• Distal femur: 2-3cm above the patella, in the midline

Procedure for manual intraosseous needle insertion

Procedure for mechanised intraosseous needle insertion

Use aseptic technique. Clean skin at chosen site, allow to dry. Stabilise the leg. Infiltrate with 1% lignocaine if child is conscious and time permits. Insert the IO at 90° angle to the skin, until bone is felt. Use firm pressure with a “to and fro” twisting motion to insert into the bone corte A “pop” or loss of resistance may be felt as the needle passes through the bone cortex into the marrow cavity. Remove the inner stylet from the needle. Confirm the position by aspirating marrow or flushing (should flush easily if marrow is not aspirated) and collect blood samples. Secure IO in place using tape Proceed with infusion

Use aseptic technique Clean skin at chosen site, allow to dry Stabilise the leg Infiltrate with 1% lignocaine if child is conscious and time permits Attach compatible IO needle to end of device driver (magnetic attachment). Pierce the skin with the IO needle until bone is felt Aim the needle perpendicular to the flat surface of the bone Push the needle tip through the skin until the tip rests on the bone. Check that at least one black line is visible on the needle. If black line is not visible, the needle will not be long enough to reach the medullary space. Squeeze the trigger, guiding the needle into the bone You may feel a “give” as the needle enters the bone marrow cavity - at this point release the trigger Hold the hub and detach the needle from the device Hold the hub and remove the inner stylet from the needle with a counter clockwise rotation Aspirate to confirm position, collect blood samples and proceed with a flush of 10 mL of 0.9% Normal saline (should flush easily if marrow cannot be aspirated) Place EZ-stabiliser dressing over the hub. Connect extension set to the hub.

Post-Procedure

Once position is confirmed:

• Secure IO in place
• Attach a 3 way extension tap
• Infuse injections through the 3 way tap side port
• Connect IV fluids through the other 3 way port
• IV fluids will need to be infused under pressure or bolused using a 20mL syringe. Gravity is insufficient to drive fluid through an IO.
• Observe for complications I.e, discolouration of limb, swelling, pain, altered sensation in limb, skin temperature change, weak or absent pulses, limb firmness or taut compared to the other limb. Especially in the first half hour.
• Perform hourly neurovascular observation (NVO) on the limb from the time of insertion during the first 24 hours and/or while IO is in situ and/or IO infusion is running.
• After removal of the IO continue 4 hourly NVO for a further 48 hours as per Neurovascular Observation and Assessment Procedure - Clinical Practice Manual (internal WA Health only) and PIVC insertion and Maintenance  - Clinical Practice Manual (internal WA Health only).
• Document insertion date, time and location.

Complications

• Dislodgement
• Extravasation
• Compartment syndrome
• Infections – cellulitis or osteomyelitis
• Bone fracture or growth plate injury
• Pain⁵
• Fat and bone microemboli (rare).

Removal and Aftercare

• Monitor insertion site for extravasation and limb for perfusion. Stop infusion if signs of these and inform treating doctor.
• IO access should not be used for greater than 24 hours. Alternative intravenous access should be obtained as soon as possible.
• IO should be removed once alternative intravenous access is established or signs of infection, extravasation or compartment syndrome.
• The IO should be removed prior transfer to the wards (with the exception of transfer to PCC) if patient has alternative IV access.
• Ambulation should be discouraged until the IO catheter is removed to reduced risk of dislodgement. ⁴
• Consider using other limbs for measurement of clinical vital observations (e.g.; blood pressure) even after removal of intraosseous access.
• To Remove IO:
  • Remove extension set from needle hub and attach a 5 or 10mL sterile syringe with standard luer lock to act as a handle and cap the open IO port.
  • Grasp syringe and continuously rotated clockwise while gently pulling until the needle is removed.
  • Maintain 90° angle to the bone - do not rock or bend the needle during removal.⁴
  • Apply pressure to site as needed; apply occlusive dressing as indicated

• Monitor site 4 hourly for delayed signs of infection, haematoma, extravasation or compartment syndrome ⁴ using age appropriate Neurovascular Observation form (Refer to Neurovascular Observation and Assessment Procedure  - Clinical Practice Manual (internal WA Health only).
• Document removal date and time, along with a description of the site at the time of removal, in the patient notes.
• If patient is to be discharged from PCH prior to 48hr post removal of the IO, provide education on wound care, pain management and monitoring for infection.

References

1. Paxton J.H. Intraosseous Vascular Access: A Review. Trauma; London. Vol 14(3) 195-232. 2012
2. CE Perron. Intraosseous Infusion. UpToDate. Updated June 2021. Available from: https://www.uptodate.com/contents/intraosseous-infusion
3. EZ-IO Product Information – available at www.vidacare.com/EZ-IO
4. ARROW® EZ-IO® Intraosseous Vascular Access System. 2017 Third Edition. The Science and Fundamentals of Intraosseous Vascular Access. Available from: EZ-IO_Science_Fundamentals_MC-003266-Rev1-1.pdf (teleflex.com)
5. Installing an Intraosseous Infusion System (EZ-IO®), Vidacare [Accessed August 2021] Available from: Installing an intraosseous Infusion System (EZ-IO®) (creehealth.org)
6. Advanced Paediatric Life Support, Australia & New Zealand: The Practical Approach, 6th Edition Published February 2016.

Endorsed by:	Co-Director, Surgical Services	Date:	Oct 2021
		Review date:	Oct 2024

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