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 ED staff in the insertion of intraosseous needles in children.

Pre-procedure

  • 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
  • Blood taken from the IO needle can be sent for most laboratory investigations except full blood count
  • It is possible to do group and hold/cross match, blood cultures and blood glucose level
  • Biochemical results may be slightly inaccurate
  • Ensure all blood sent to lab are clearly labelled IO blood sample
  • All medications and fluids which would normally be given intravenously can be given via intraosseous route.

Indications

  • Cardiopulmonary arrest
  • Any critical emergency when a peripheral venous cannulation site is unobtainable within 90 seconds
  • Oral, transmucosal, intramuscular or inhalation routes are not adequate to meet the patients needs for fluids and/or medications.

Contraindications

  • Fractures: do not place an IO below a fracture site, use the other limb
  • Open injury: avoid placement of an IO below any open injury on an extremity, use other limb
  • Infection at potential site: use alternative site.

Equipment

Manual intraosseous needle insertion  Mechanised intraosseous needle insertion 
  • There are a range of commercially IO needles available
  • PCH ED has 3.0 cm in length only
  • Alcohol swabs or Povidone-Iodine solution
  • 10ml syringe for aspiration
  • 10ml syringe with 0.9% saline for flush
  • 3 way extension tap
  • Clean gloves
  • IO insertion device
  • Use the 15mm needle (pink) for 3-40 kg
  • Use the 25mm needle (blue) for > 40 kg patient
  • Alcohol swab or Povidone-Iodine solution
  • 10ml syringe for aspiration
  • 10ml syringe with 0.9% saline for flush
  • 3 way extension tap
  • Clean gloves
  • EZ-Connect connection (comes with needle)

Procedure

Identification of entry site

  • The best site in children is the anteriomedial aspect of the tibia. 2-3cm below the tibia tuberosity, anterior medial leg

Intraosseous access of tibia anatomy

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

Intraosseous access of femur anatomy

    • Distal tibia - above the medial malleolus at the ankle

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, passing deep into the bone via a ‘twisting’ motion
  • A “pop” 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 and proceed with infusion
  • Observe for complications
  • 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 (magnetic attachment). Pierce the skin with the IO needle until it touches the bone surface with a gentle push.
  • Check that at least one black line is visible on the needle. If no black line visible, the needle may 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
  • Detach the needle from the device
  • Remove the inner stylet from the needle
  • Confirm position and proceed with infusion
  • Observe for complications

Post-procedure

Confirm success

  • Aspirating marrow contents
  • Infusing 10ml of 0.9% Saline without significant resistance.

Once the position is confirmed:

  • 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 may need to be infused under pressure or bloused via a 20ml syringe
  • Secure IO in place
  • Observe for complications.

Complications

  • Extravasation of the IO needle
  • Dislodgement
  • Compartment syndrome
  • Bone infections
  • Bone fracture.

Aftercare

  • Do not use IO access for greater than 24 hours
  • To remove IO:
    • remove extension set from needle hub and attach a 5-10ml 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 the needle out
    • maintain 90° angle to the bone
    • Do not rock or bend the needle during removal.

Bibliography

  1. Advanced Paediatric Life Support, Australia & New Zealand: The Practical Approach, 5th Edition Published October 2012
  2. EZ-IO Product Information – available at www.vidacare.com/EZ-IO

Endorsed by:  Director, Emergency Department   Date:  Mar 2018


 Review date:   Jun 2020


This document can be made available in alternative formats on request for a person with a disability.