Intraosseous infusion

INTRODUCTION — This topic will discuss intraosseous (IO) infusion in children and adults, including indications, contraindications, and techniques according to device.

Other forms of venous access are discussed separately:

●(See "Vascular (venous) access for pediatric resuscitation and other pediatric emergencies" and "Peripheral venous access in adults".)

●(See "Peripheral venous access in adults".)

●(See "Central venous access in adults: General principles".)

●(See "Basic principles of ultrasound-guided venous access".)

BACKGROUND — Establishment of access to the circulation is a critical component of resuscitation. The preferred venous access site during cardiopulmonary resuscitation (CPR) is the largest, most accessible vein that does not require the interruption of resuscitation. Peripheral venous access is attempted before attempting other forms of vascular access if peripheral veins can be readily seen or palpated. (See "Vascular (venous) access for pediatric resuscitation and other pediatric emergencies" and "Peripheral venous access in adults".)

Intraosseous (IO) infusion, a technique for vascular access, was described first in 1922 and was widely used for drug administration in children in the 1940s [1-6]. It fell out of favor during the 1950s and 1960s, when disposable intravenous catheters were developed and techniques for insertion improved. In the 1980s, after the publication of numerous clinical reports of its effective use in children and animal models [7-10], the practice of IO infusion increased. Use in adults has also grown, especially in the prehospital setting [11,12]. Today, the procedure is reserved for acute, life-threatening or medically necessary situations when standard venous access methods cannot be rapidly achieved and as the first attempt at vascular access in cardiopulmonary arrest or severe shock in selected patients.

ANATOMY — Intraosseous (IO) infusion is possible because of the presence of veins that drain the medullary sinuses in the bone marrow of long bones (figure 1) [13]. These veins, supported by the bony matrix, do not collapse in patients with shock or hypovolemia. The following list provides the site and draining vessels for the most commonly used sites:

●Proximal tibia – Popliteal vein

●Femur – Branches of the femoral vein

●Distal tibia (medial malleolus) – Great saphenous vein

●Proximal humerus – Axillary vein

●Manubrium (upper sternum) – Internal mammary and azygos veins

The anterior inferior iliac spine, clavicle, and distal radius have also been used successfully for IO vascular access as have bones without medullary cavities, including the calcaneus and radial styloid [14-16].

TRAINING — Intraosseous (IO) cannulation is likely to be used by the emergency care provider during resuscitation. The patient’s life may well depend upon the clinician’s ability to secure vascular access. Thus, emergency physicians and others who may need to perform IO cannulation emergently should learn to do so well in advance of the immediate need.

Training can take place on simulation models, animal bones (eg, chicken or turkey legs), or a cadaver. IO placement is taught as part of the Pediatric Advanced Life Support, Advanced Pediatric Advanced Life Support (PALS), and Advanced Trauma Life Support (ACLS) courses. After training, typically consisting of a one-hour lecture followed by a one-hour hands-on experience, novice users have achieved success rates of 93 to 97 percent for manual and battery-powered IO placement in a variety of simulated settings [17-21].

High success rates with battery-powered IO placement have also been shown in field and hospital care after such training:

●Paramedics achieved an 87 percent success rate for field IO placement in infants under two years of age [22].

●Military medics achieved a 97 percent success rate for IO cannulation in children and adults during combat situations [22].

●Physicians achieved a 94 percent success rate for IO placement in 95 children treated in an emergency department [23].

Retention of IO needle insertion skills may wane between biannual PALS/ACLS recertification [24]. More frequent simulations utilizing on-your-own-time and just-in-time kits or training may be beneficial [25].

INDICATIONS — We recommend that infants and children in cardiopulmonary arrest or severe shock who do not have readily available intravenous (IV) access undergo intraosseous (IO) cannulation rather than central venous line placement or surgical venous cutdown.

For adults in cardiopulmonary arrest or severe shock in whom IV access cannot be established, we suggest IO cannulation pending central venous line placement or surgical venous cutdown. However, among adults who have suffered an out-of-hospital cardiac arrest, IO vascular access may be associated with a lower rate of return of spontaneous circulation and neurologically favorable survival. (See "Advanced cardiac life support (ACLS) in adults", section on 'Alternative methods for medication administration'.)

IO cannulation may also be appropriate in emergent or urgent situations where reliable venous access cannot be achieved quickly (eg, patients with shock, sepsis, status epilepticus, extensive burns, multiple trauma) or in patients for whom intravascular access is medically necessary and cannot be achieved by other means despite multiple attempts [26]. In awake patients, analgesia is warranted prior to infusion if the patient’s condition permits. (See 'Analgesia' below.)

IO cannulation allows for intravascular access through which diagnostic studies may be obtained, fluid resuscitation may occur, and a wide variety of medications can be rapidly delivered. (See 'Diagnostic studies' below and 'Drug and fluid administration' below.)

The American Heart Association and the International Committee on Resuscitation endorse the use of IO access as a safe and effective means of vascular access in critically ill children and adults [27,28]. IO cannulation permits rapid intravascular access in critically ill children and adults as demonstrated by the following reports:

●Children

•In a trial comparing success rates and time to insertion between IO and peripheral IV access among children requiring fluid resuscitation for severe dehydration in a hospital setting, the IO route was successful within five minutes for 100 percent of patients, as compared with 67 percent success within five minutes for peripheral IV placement [29].

•In a retrospective series describing attempts by paramedics to establish peripheral IV access for 300 children (0 to 18 years) in the prehospital setting, IV access was successful in two-thirds of all children and in only 49 percent of a subset of children younger than six years of age [30].

•In an observational series describing the use of IO cannulation in patients of all ages in the prehospital setting, the overall success rate was 76 percent, with 85 percent success in children between one and two years of age [31].

•IO vascular access was achieved in less than one minute for 85 percent of cases in a prospective report evaluating the time to insertion and success rate of IO cannulation in a variety of prehospital settings [32].

•In an observational study of 95 pediatric emergency department patients receiving IO placement with a battery-driven device, successful insertion and infusion were achieved in 94 percent of individuals. Insertion time was 10 seconds or less in 77 percent of the one-attempt successful cases who had time to insertion reported [23].

●Adults

•In a trial of 182 adults receiving vascular access for cardiac arrest in the prehospital setting, tibial IO placement was associated with a significantly higher frequency of initial vascular access success than peripheral IV placement (91 versus 43 percent, respectively) [33]. Although initial success with humeral IO access was higher than for peripheral IV access (71 versus 49 percent), overall success was not significantly different because of a high rate of IO catheter displacement among patients with humeral IO cannulas. (See 'Sites of placement' below.)

•A trial of IO needle placement using a battery-powered driver or spring-loaded device in 40 adults receiving prehospital care found that vascular access was successfully achieved on the first attempt in 80 to 90 percent of patients, and within two minutes [34].

•A prospective observational study compared IO cannulation using a battery-operated driver device (EZIO) with internal jugular or subclavian central venous access in 10 adult patients, all of whom received both procedures [35]. IO access was achieved on the first attempt more frequently (90 versus 60 percent) and took significantly less time (2 versus 10 minutes) than central venous access.

•In a larger, prospective, observational study of 79 adults undergoing central access placement during inpatient medical resuscitations, IO needle insertion had significantly higher first-pass success than central venous catheter placement (90.3 versus 37.5 percent) and shorter placement times (1.2 versus 10.7 min) [36].

Taken together, these studies suggest that establishing peripheral IV access often is delayed or unsuccessful during resuscitation of critically ill patients, particularly small children. Furthermore, alternative methods of vascular access such as central venous access by percutaneous or surgical venous cutdown takes much longer and are less likely to be successful than IO placement. Finally, all drugs and fluids that might be delivered through peripheral or central venous lines can also be administered through an IO cannula. (See "Vascular (venous) access for pediatric resuscitation and other pediatric emergencies", section on 'Central access' and 'Drug and fluid administration' below.)

In adults, difficult or failed peripheral vascular access is also problematic, especially in the prehospital setting. Alternative approaches to IO cannulation such as ultrasound-guided peripheral IV access and central venous access also achieve high success rates but take longer to perform than IO access. (See "Basic principles of ultrasound-guided venous access" and "Basic principles of ultrasound-guided venous access", section on 'Dynamic ultrasound techniques'.)

IO cannulation by manual insertion becomes progressively more difficult as children age because the cortex of bone becomes thicker and the tibial bone marrow cavity becomes smaller [6,37]. The development of devices such as impact-driven devices and battery-operated handheld drivers has made IO cannulation feasible for patients of all ages [23,27,38]. (See 'Techniques' below.)

Drug and fluid administration — Any IV drug or routine resuscitation fluid can be administered safely by the IO route. Examples include epinephrine, dopamine, dobutamine, adenosine, digitalis, heparin, lidocaine, atropine, sodium bicarbonate, phenytoin, neuromuscular blocking agents, antibiotics, crystalloids, colloids, and blood products [8,10,37,39-44]. Drug and fluid dosing is the same as for IV administration [26,41]. However, for adenosine, the IO route may not be as effective as upper extremity peripheral IV access for the treatment of supraventricular tachycardia in some young infants [45].

●Drugs – When medications are given, the IO cannula should be flushed before and after each medication that is administered. Only compatible drugs may be administered simultaneously through an IO needle or catheter. The IO site and extremity should be monitored frequently for infiltration.

Limited evidence suggests that the onset of action and serum drug concentration after IO infusion during cardiopulmonary resuscitation (CPR) appear comparable to those achieved after IV administration [9,46,47]. In 10 adults receiving CPR, a microbubble marker of drug delivery to the right and left ventricles was approximately 10 seconds shorter using a humeral IO than a brachial IV, although this may not have a significant impact on clinical outcome [48].

Although not directly applicable to humans, studies in animals suggest that the IO route is as effective as the central intravenous route [9,49,50] and may be superior to the peripheral intravenous route during pediatric cardiac arrest [9].

●Rapid fluid administration and viscous drugs – Crystalloid fluids (eg, normal saline) for rapid volume expansion and viscous drugs and solutions should be administered under pressure using an infusion pump, pressure bag, or manual injection through a syringe and stopcock. These approaches overcome the resistance of emissary veins that lead from the intramedullary cavity to the general circulation [51]. The IO site and extremity should be monitored frequently for infiltration during rapid fluid administration.

Infusion rates equivalent to a 21 gauge peripheral intravenous catheter are typically achieved [52]. As an example, in a prospective observational study in 24 adults receiving emergency treatment and in whom peripheral venous access could not be achieved, mean rates of fluid administration under pressure were 165 mL/min at the tibial site and 153 mL/min at the humeral site [53]. Among patients who had placement of an IO at both sites, the rate of fluid administration was not significantly different. In another study performed in 16 fresh cadavers, mean flow rates achieved during IO infusion rates under high pressure (300 mmHg) was highest at the sternal site [54]. However, this rate (94 mL/min) was lower than what has been described in adult patients receiving fluid therapy [53] and suggests that the cadaveric model may not be directly applicable to the clinical setting.

Diagnostic studies — Based upon comparisons of venous blood and bone marrow samples in children with cancer, bone marrow samples initially obtained from an IO line during placement may be used for a variety of diagnostic studies including glucose, hemoglobin, pH, pCO2, serum bicarbonate, sodium, chloride blood urea nitrogen, creatinine, serum drug levels, and cultures (eg, bacterial, viral, or fungal cultures) [55,56]. By contrast, bone marrow values for blood oxygenation, white blood cell count, platelets, potassium, aspartate aminotransferase, alanine aminotransferase, or ionized calcium may not be accurate. Platelet counts are likely to be lower, while white blood cell counts are generally higher than peripheral blood samples. A waste of 2 mL appears to be sufficient before taking an IO sample [57].

In a study of 28 adult patients, bone marrow aspirates accurately identified blood ABO and Rh type [58]. Thus, bone marrow samples may also be used for type and screen if a standard blood sample is not available.

A canine model suggests that IO drug administration may alter subsequent laboratory measurements [59]. Thus, most experts do not advise using IO access for diagnostic studies once drugs have been administered.

CONTRAINDICATIONS — There are relatively few absolute contraindications to intraosseous (IO) infusions because the technique is primarily indicated in life-threatening emergencies:

●A fractured bone or previously penetrated bone cannot be used because fluids will exit through the fracture or puncture site.

●An extremity with vascular interruption, either from trauma or cutdown attempt, is not suitable for IO infusion because the fluid or drugs administered into the bone marrow will leak through the open blood vessel.

If possible, IO cannulation should be avoided in the following patients:

●Patients with cellulitis, burns, or osteomyelitis involving the cannulation site [49,51].

●Patients with osteogenesis imperfecta or osteopetrosis, who have increased bone fragility. However, successful IO cannulation in a child with osteogenesis imperfecta has been described [49].

●Patients with right-to-left intracardiac shunts (eg, tetralogy of Fallot, pulmonary atresia), who may be at greater risk for cerebral fat or bone-marrow emboli [49,60,61]. (See 'Complications' below.)

PREPARATION — In most instances, intraosseous (IO) cannulation occurs as part of care for a life-threatening emergency. Thus, informed consent is typically implied. In awake patients for whom IO needle placement is necessary, the patient and, in children, the caretaker should receive a detailed explanation of the procedure and provide informed consent. Awake patients should receive local anesthesia prior to IO cannulation attempts. (See "Subcutaneous infiltration of local anesthetics".)

Equipment — The following equipment should be assembled prior to the procedure:

●Chlorhexidine, povidone iodine solution or similar antiseptic

●Surgical mask and eye covering for the clinician performing the procedure

●Sterile latex-free gloves

●10 mL syringe

●Syringe with saline flush

●IO needle and/or device

●In awake patients, small-volume syringe (eg, 3 mL) containing lidocaine 1 percent for infiltration via a small bore needle (eg, 25 gauge needle)

Intraosseous (IO) needles and devices — Commercially available intraosseous cannulation are preferred for IO cannulation as follows [14,26]:

●Manual IO needles – Examples include the Jamshidi (Baxter Healthcare, McGraw Park, IL) and the modified Dieckmann (Cook Critical Care, Bloomington, IN). Important features include a trocar, a short needle length with a handle that provides a resting place for the palm, and an adjustable flange or depth marking to guide placement. (See 'Manual insertion technique' below.)

●Battery-powered driver (EZIO) – The EZIO comes with a lithium powered battery driver and needle sets in three lengths for placement in children and adults. (See 'Battery-powered driver' below.)

●Impact-driven devices (Bone injection gun [BIG], FAST1) – The bone injection gun comes in two sizes that allow IO placement in children and adults. The FAST1 is designed for sternal IO catheter placement in patients ≥12 years of age. (See 'Impact-driven devices' below.)

Other types of needles may be used if an IO needle or device is not available; these include bone marrow needles, styletted needles, and spinal needles [49,62]. Of these, bone marrow needles are best because they are least likely to bend. Standard hypodermic needles should not be used for IO infusion because they often become clogged with bone and bone marrow.

Sites of placement — We recommend that all patients who undergo IO placement for life-threatening illness (eg, cardiac arrest) have the first attempt occur at the proximal tibial site, unless otherwise contraindicated. Preferred alternative sites vary based upon the age and skeletal maturity of the patient (table 1). A battery-powered or impact driven device is typically required to accomplish IO placement in the proximal tibia of patients six years of age or older. If such a device is not available, then the clinician should attempt manual placement at the medial or lateral malleolus in older patients. (See 'Indications' above and 'Contraindications' above.)

In a trial of 183 adults undergoing prehospital vascular access for cardiac arrest, tibial IO placement was significantly more likely to result in successful vascular access when compared to humeral IO or peripheral intravenous (IV) access (91 versus 53 and 41 percent, respectively) [33]. Loss of vascular access during transport was more likely with humeral IO access than either tibial IO or peripheral IV placement. The time to achieve vascular access ranged from five to seven minutes and was similar among the three techniques.

The primary anatomic locations for IO cannulation are as follows (table 1) [41,49]:

●Proximal tibia – Prior to placement, extend the leg. Landmarks for proximal tibia placement depend upon age:

•Infants and children – In infants and children, the suggested proximal tibial site is approximately 1 to 2 cm (one finger breadth) below the tibial tuberosity and up to 1 cm medially on the tibial plateau (figure 2).

In an analysis of tibial radiographs of 190 children from birth to 16 years of age, a distance of one patient's finger breadth below the tibial tuberosity located a site safely away from the growth plate that also corresponded to a wide medullary cavity diameter and a greater chance of proper IO needle placement when compared with a more distal placement as follows [63]:

-Infants (<1 year): 0.5 cm

-Child (1 to 13 years): 1 cm

-Young adolescent (14 to <16 years): 1.5 cm

This study supports locating IO placement at 1 cm below and medial to the tibial tuberosity for most infants and children up to 13 years of age. Given the variability of the position of the growth plate at any given age in children, we do not advocate an IO placement site closer than 1 cm below the tibial tuberosity.

•Skeletally mature adolescents and adults – In skeletally mature adolescents and adults, the recommended site is 3 cm (two finger breadths) below the inferior tip of the patella and 2 cm medial. The proximal tibial site is rapidly identified and most familiar to emergency clinicians. Furthermore, in patients with cardiac arrest, proximal tibial IO placement avoids interfering with ongoing cardiac compressions. (See 'Manual insertion technique' below and 'Bone injection gun' below.)

●Distal femur – The distal femur site is in the midline approximately 1 to 2 cm above the superior border of the patella with the leg in extension. This site is an alternative site for manual or device-assisted IO placement in infants and young children in whom the IO needle can traverse the tissues of the distal thigh and still reach the marrow cavity (figure 3). (See 'Manual insertion technique' below.)

●Distal tibia or fibula – The malleoli sites are approximately 1 to 2 cm superior to the malleoli in the bone’s axis. The medial malleolus (distal tibia) is preferred to the lateral malleolus (figure 4). These sites are available for manual or device-assisted IO placement in children, adolescents, and adults. (See 'Techniques' below.)

●Proximal humerus – The greater tubercle of the proximal humerus is appropriate for IO placement in skeletally mature adolescents and adults. To identify this site, the clinician should adduct and internally rotate the upper arm (hand on abdomen) to make damage to the medial structures of the axillary plexus unlikely. The greater tubercle of the proximal humerus is located approximately 2 cm below the acromion process. Alternatively, it can be directly palpated from below. (figure 5). This site typically requires a battery-powered driver or spring-loaded impact device for successful IO cannulation. (See 'Battery-powered driver' below and 'Bone injection gun' below.)

●Manubrium – The superior one-third of the sternum may be accessed in adults using a specially designed IO device (FAST1 IO infusion system, PYNG medical, Richmond, British Columbia, Canada) [64]. The device comes with a target patch that is applied along the sternal notch to assist with site identification and placement. (See 'FAST1' below.)

Choice of device — The choice of device (manual, battery-powered, or impact-driven) varies by age as follows:

●Younger than one year of age – We suggest that, in infants under one year of age, clinicians use manual needles or battery-powered devices for IO insertion rather than an impact-driven device. Observational studies suggest that the success rates for manual placement and battery-powered devices in infants are similar, and both techniques have been shown to be easily learned by a variety of health care providers [18,20,22,23]. Manual IO needles are less expensive and are more widely available than other devices. Time to manual IO placement is longer than for a battery-powered device but shorter than for an impact-driven device.

●One year of age and older – We suggest that, in children one year of age or older, adolescents, and adults, clinicians use a battery-powered device for IO placement, if available, rather than a manual needle or impact-driven device. Success rates for patients in these age categories appear to be higher with battery-powered IO placement and time to insertion is shorter.

Available evidence indicates the following success rates and time to IO insertion in children and adults undergoing resuscitation:

•Manual needles: 76 to 100 percent (50 to 67 percent in patients over one year of age) [31,65-67], median time to insertion 38 seconds [66]

•Battery-powered driver: 87 to 97 percent [22,23,68], median time to insertion <10 seconds [23]

•Bone injection gun: 45 to 91 percent [66,69-71], median time to insertion 49 seconds [66]

•FAST1: 72 to 95 percent [66,68,72], median time to insertion 62 seconds [66]

Evidence to guide the choice of IO insertion device is limited to observational studies and small trials that vary according to the setting (eg, prehospital, hospital), clinical provider (eg, paramedic, medic, physician), site of insertion, and patient population (pediatric or adult) and do not allow direct comparisons among all devices available. In order to maximize the chance of successful IO cannulation, proper training is essential prior to use, regardless of which IO insertion technique is chosen. (See 'Training' above.)

Suggested sites of IO placement are discussed separately. (See 'Sites of placement' above.)

Analgesia — In critically ill children and adults who require immediate vascular access (eg, patients in arrest or severe shock), IO placement is performed without analgesia [73]. These patients may receive systemic analgesia (eg, fentanyl intraosseously) or infusion of preservative-free lidocaine, as described below, if they become responsive to pain once the IO is placed and as tolerated by their clinical condition.

In awake patients for whom IO placement is in response to difficulty with peripheral venous access and whose condition is not an emergency, we suggest analgesia for IO placement using local infiltration of anesthetic at the IO site and administration of preservative-free lidocaine through the IO cannula prior to infusion of medications, fluids, or blood products. Infiltration of the periosteum is necessary to achieve analgesia prior to placement (see "Subcutaneous infiltration of local anesthetics", section on 'Direct infiltration'). In one observational study of 1119 patients from the manufacturer database, the pain of EZ-IO insertion in children and adults was less than the pain during infusion (mean pain score 3.4 versus 5.4, respectively) [74]. Thus, local infiltration of the IO insertion site with local anesthetic may not be necessary in adolescents and adults when using a battery-powered driver.

If electing to provide analgesia prior to IO infusion, use preservative-free intravenous lidocaine as follows [73]:

●The usual initial dose is 0.5 mg/kg lidocaine (0.025 mL/kg of 2 percent [20 mg/mL] preservative-free lidocaine formulation for intravenous use, maximum dose: 40 mg [2 mL]). Observe recommended cautions and contraindications for administration of intravenous lidocaine. (See "Major side effects of class I antiarrhythmic drugs", section on 'Lidocaine (intravenous)'.)

●For pediatric and adult patients weighing 40 kg or greater, prime the connection tubing with lidocaine. For the EZ-Connect system, the priming volume is approximately 1.0 mL which corresponds to 20 mg of preservative-free lidocaine 2 percent. After IO placement, attach the tubing to the IO and administer intravenous lidocaine by attaching a syringe containing an additional 20 mg of preservative-free intravenous lidocaine 2 percent. Slowly infuse the lidocaine over two minutes.

●For pediatric patients weighing less than 40 kg, administer intravenous lidocaine after IO placement by carefully attaching the syringe directly to the needle hub. Aspirate the IO needle to remove air and then slowly infuse the intravenous lidocaine by syringe over two minutes. Then connect tubing primed with normal saline to the IO.

●Allow lidocaine to dwell in the IO space for one minute after slow infusion.

●Flush the IO with 5 to 10 mL of normal saline. Some clinicians prefer to flush once with heparinized saline (10 units/mL in infants <10 kg and 100 units/mL in infants and children 10 kg of weight or greater and in adults although no evidence is available to indicate longer patency of the IO catheter when heparin is given.

●The duration of analgesic effect is typically less than one hour [73]. Redosing is accomplished by administering half the initial lidocaine dose IO over 60 seconds.

●Provide systemic pain control (eg, fentanyl intraosseously) to patients with persistent pain during IO infusion despite lidocaine administration.

TECHNIQUES — Intraosseous (IO) needles may be placed manually or with the assistance of specifically designed devices.

Manual insertion technique — Manual insertion in the proximal tibia is generally difficult to perform in patients over six years of age. The distal tibial site is preferred in older patients. A high quality video is available in the reference to assist with learning the manual placement technique [75].

The following step-by-step technique for manual IO cannulation and removal assumes the use of the proximal tibial location (figure 6 and figure 2) [49,76]:

●Placement

•Don a surgical mask, eye protection, and latex-free sterile gloves.

•Prepare the injection site with an antiseptic (eg, chlorhexidine or povidone iodine solution).

•If the child is awake, infiltrate the skin, subcutaneous tissue, and periosteum with 1 percent lidocaine.

•Place the leg with knee extended in neutral position and then slightly externally rotate at the hip to expose the flat part of the tibial surface, and externally rotate the foot.

•Check the needle to ensure that the bevels of the outer needle and the internal stylet are properly aligned.

•Grasp the leg distally and lateral to the insertion site with the palm and fingers of the nondominant hand to brace the leg against the force of IO placement and to prevent distal leg movement during the procedure (figure 7). In infants and young children, the nondominant hand may be placed above the site and wrap around the knee and thigh (figure 6). No portion of the stabilizing hand should rest behind the insertion site because this places the operator at risk for needle-stick injury should the IO needle be inadvertently driven completely through the extremity.

•Palpate the landmarks to identify the flat surface of the tibia approximately 1 to 2 cm below and slightly (up to 1 cm) medial to the tibial tuberosity, and insert the IO needle through the skin (figure 6).

•Direct the IO needle perpendicular to the entry site (figure 7 and figure 6) or, in skeletally immature children, at a slight angle (10 to 15 degrees) from vertical (caudad for the proximal tibia (figure 2); cephalad for the distal tibia or femur (figure 4 and figure 3)).

•Apply pressure with a twisting motion (figure 7). Avoid rocking the needle side to side which may bend it or enlarge the access hole and lead to extravasation of fluid. As the needle passes through the cortex and into the marrow cavity, a "give" or release of resistance is felt. Clinicians not experienced in bone marrow needle insertion should understand that considerable force is needed to introduce the needle into the bone marrow when traditional methods are used (rather than a spring-loaded device or battery-powered driver). A back-and-forth-twisting motion works best to pierce the bony cortex.

•Unscrew the needle cap and remove the stylet. If the needle has an adjustable flange, carefully screw the flange down to the skin surface while stabilizing the needle.

•Aspirate bone marrow to identify correct placement of the IO catheter and, if desired, to obtain a sample for laboratory analysis, using a syringe attached directly to the hub or the manufacturer-provided extension set. The provider may not always be able to aspirate bone marrow despite correct IO position in the medullary cavity. (See 'Confirmation of placement' below.)

•Provide analgesia, as needed and depending upon patient status, by slow administration of 0.5 mg/kg lidocaine (2 percent [20 mg/mL] preservative-free formulation, maximum dose: 40 mg). (See 'Analgesia' above.)

•Once proper placement is confirmed, flush the needle with 10 mL of normal saline and connect it to conventional IV tubing. Some clinicians prefer to flush once with heparinized saline (10 units/mL in infants <10 kg and 100 units/mL in infants and children 10 kg of weight or greater and in adults although no evidence is available to indicate longer patency of the IO catheter when heparin is given.

•Secure the bone marrow needle with tape and a dressing that does not obscure the needle placement site so that infiltration can be rapidly detected (see 'Detection of infiltration' below). IO needles that are properly placed are secure and not easily dislodged.

●Removal – Remove the needle by grasping the shaft and pulling up with a slight rotary motion. Apply pressure to the IO site. Dress the site using aseptic technique.

Technical difficulties with manual IO needle placement usually decrease with experience and familiarity with the procedure. Strategies to improve the success rate of IO needle placement include emphasizing rotary motion, stabilizing the tubing and limb, monitoring continuously for extravasation, and using strong, sharp needles [77].

Battery-powered driver — Battery-powered IO driver and needle sets are available for use in children and adults (EZ-IO, Teleflex, Morrisville, North Carolina).

The proper needle length should be modified by the depth of subcutaneous tissue overlying the bone surface. The weight-based manufacturer recommendations for needle length are provided below but should always be tested at the time that the needle is pushed through the skin and subcutaneous tissue to the bone surface and prior to drilling. The provider should ensure that the black line on the needle is still visible above the skin before drilling; otherwise, the needle will be too short to penetrate into the bone marrow cavity.

The 15-gauge needles come in three lengths as follows:

●15 mm (pink) suggested for placement in patients weighing 3 to 39 kg; however, a 25 mm (blue) needle may be necessary to reach the medullary cavity for children >5 to 10 kg, especially for patients with excessive subcutaneous tissue [63]

●25 mm (blue) suggested for placement in patients ≥40 kg with normal subcutaneous tissue

●45 mm (yellow) suggested for placement in patients ≥40 kg with excessive subcutaneous tissue

A high-quality video is available in the reference to assist with learning the battery-powered driver technique [75]. The needles may be inserted in the proximal or distal tibia, distal femur in infants and children with limited subcutaneous tissue or, in skeletally mature adolescents and adults, the proximal humerus [14,64,78]. (See 'Sites of placement' above.)

Placement and removal of the EZIO is performed as follows:

●Placement

•Identify the placement site based upon anatomic landmarks. (See 'Sites of placement' above.)

•Don appropriate personal protective equipment and prepare the insertion site as for the manual insertion technique. (See 'Manual insertion technique' above.)

•Ensure that the appropriate needle is selected based upon the patient’s weight and the amount of subcutaneous tissue over the selected insertion site.

•Securely seat the needle on the battery-powered driver.

•Remove the needle safety cap.

•Position the driver with the needle at a 90 degree angle to the bone.

•Gently drive or manually press the needle until the tip touches the bone. Ensure that at least 5 mm of the catheter is visible above the skin at this point.

•Squeeze the driver trigger and apply light but steady downward pressure to penetrate the bone. Insufficient pressure may result in the needle not penetrating the bone.

•Release the trigger to stop insertion when a sudden decrease in resistance is felt ("give" or "pop") or when the appropriate depth, as indicated on the needle, is reached.

•Wait for the driver to stop spinning. Then, while holding the catheter in place, remove the driver by pulling straight up from the catheter and unscrew the needle stylet by rotating it counter-clockwise.

•Aspirate bone marrow to identify correct placement of the IO catheter and, if desired, to obtain a sample for laboratory analysis using a syringe attached directly to the hub or the manufacturer-provided extension set. The provider may not always be able to aspirate bone marrow despite correct IO position in the medullary cavity. (See 'Confirmation of placement' below and 'Diagnostic studies' above.)

•Provide analgesia, as needed and depending upon patient status, by slow administration of 0.5 mg/kg lidocaine (2 percent [20 mg/mL] preservative-free formulation, maximum dose: 40 mg). (See 'Analgesia' above.)

•Once proper placement is confirmed, secure the needle using tape and gauze or manufacturer supplied fixation dressings (EZ Stabilizer Dressing, VidaCare Corporation, Shavano Park, Texas, United States); ensure that the dressing does not obscure the needle placement site so that infiltration can be rapidly detected. (See 'Detection of infiltration' below.)

•Flush the needle with 10 mL of normal saline using the manufacturer supplied IV connector tubing. Some clinicians prefer to flush once with heparinized saline (10 units/mL in infants <10 kg and 100 units/mL in infants and children 10 kg of weight or greater and in adults although no evidence is available to indicate longer patency of the IO catheter when heparin is given.

●Removal – Attach a Luer lock syringe to the catheter hub. While stabilizing the extremity, rotate the catheter and syringe clockwise while pulling straight back. Apply pressure to the IO site. Dress the site using aseptic technique.

Impact-driven devices — The impact-driven devices consist of the bone injection gun (BIG, PerSys Medical, Houston, Texas, United States) and the FAST1 (Pyng Medical Corporation, Richmond, British Columbia, Canada).

Bone injection gun — The spring-loaded bone injection gun is available in sizes and automated insertion depths suitable for patients over 12 years of age (blue casing, 15 gauge needle, insertion depth 2.5 cm) and children from term newborn to 12 years of age (red casing, 18 gauge needle, adjustable insertion depth 0.5 to 1.5 cm) [14,64,79].

A training video is available in the reference [79].

IO cannulation of the proximal tibia (all patients) or proximal humerus (skeletally mature adolescents and adults) and removal is accomplished as follows:

●Placement

•Identify the placement site based upon anatomic landmarks. (See 'Sites of placement' above.)

•Don appropriate personal protective equipment and prepare the insertion site as for the manual insertion technique. (See 'Manual insertion technique' above.)

•Choose the appropriate size bone injection gun (over 12 years of age: adult, term infant to 12 years of age: pediatric). In children, set the insertion depth using the marker located on the device as follows:

-0 to 3 years: 0.5 to 1 cm

-3 to 6 years: 1 to 1.5 cm

-6 to 12 years: 1.5 cm

•Place the device over the insertion site by holding the barrel at a 90 degree angle using the nondominant hand.

•Squeeze the sides of the orange safety latch and remove it from the device using the dominant hand. Save the safety latch for later use.

•While firmly holding the device in place with the nondominant hand, use the dominant hand to deploy the needle by grasping under the wings of the device with two fingers and steadily and gently pressing the palm against the top of the device. A "pop" will be heard when the needle is successfully deployed.

•Remove the housing of the bone injection gun by pulling upward while rocking it gently from side to side.

•Remove the stylet from the cannula.

•Place the safety latch around the cannula and tape it down to provide support. The dressing should not obscure the needle placement site so that infiltration can be rapidly detected. (See 'Detection of infiltration' below.)

•Aspirate bone marrow to identify correct placement of the IO catheter and, if desired, to obtain a sample for laboratory analysis using a syringe attached directly to the hub or the manufacturer provided extension set. The provider may not always be able to aspirate bone marrow despite correct IO position in the medullary cavity. (See 'Confirmation of placement' below and 'Diagnostic studies' above.)

•Provide analgesia, as needed and depending upon patient status, by instillation of 0.5 mg/kg lidocaine (2 percent [20 mg/mL] preservative-free formulation, maximum dose: 40 mg). (See 'Analgesia' above.)

•Once placement is confirmed, flush the IO catheter with 10 to 20 mL of normal saline through an intravenous catheter connection set. Some clinicians prefer to flush once with heparinized saline (10 units/mL in infants <10 kg and 100 units/mL in infants, children, and adults 10 kg of weight or greater) although no evidence is available to indicate longer patency of the IO catheter when heparin is given.

●Removal – Place the safety latch so that the IO catheter hub is seated in the square notch. If the safety latch is not available, attach a Luer lock syringe. Pull upward with a slight rotary motion. Apply pressure to the IO site. Dress the site using aseptic technique.

FAST1 — The FAST1 is an impact-driven device designed for placement of an IO catheter (14 gauge and 155 mm in length) at a depth of 6 mm into the manubrium of patients ≥12 years of age through the use of manual pressure [64,80].

IO catheter placement and removal in the sternum is performed as follows:

●Placement

•Expose the upper sternum and ensure that there is no evidence of trauma to it.

•Don appropriate personal protective equipment and prepare the insertion site as for the manual insertion technique using chlorhexidine or iodine and isopropyl alcohol provided in the device package. (See 'Manual insertion technique' above.)

•Remove the target patch from the package and remove the first backing (labeled "1").

•Identify the sternal notch and place a finger perpendicular to the notch. Apply the patch notches against the finger while maintaining alignment of the patch with the sternal notch.

•Remove the bottom half of the backing (labeled "2") and secure the patch to the patient’s sternum and chest.

•Ensure that the clear "target zone" is centered over the manubrium (upper sternum).

•Remove the sharps plug and introducer from the package.

•Remove the clear sharps cap from the introducer.

•Confirm alignment of the target patch and then, while firmly holding the introducer perpendicular to the manubrium, place the bone probe needles into the circular target zone.

•Push down on the introducer steadily while maintaining perpendicular force to the manubrium until the handle separates from the assembly with a "pop."

•Remove the introducer assembly with bone probe needles and use the sharps plug and clear sharps cap to secure the sharps safely.

•Remove the blue cap from the IO catheter and connect the infusion tube to the friction connector on the tubing attached to the target patch.

•Remove the white cap from the Luer fitting of the target patch infusion tubing.

•Aspirate bone marrow to identify correct placement of the IO catheter and, if desired, obtain a sample for laboratory analysis. (See 'Confirmation of placement' below and 'Diagnostic studies' above.)

•Provide analgesia, as needed and depending upon patient status, by instillation of 0.5 mg/kg lidocaine (2 percent [20 mg/mL] preservative-free formulation, maximum dose: 40 mg). (See 'Analgesia' above.)

•Flush the IO catheter with 10 to 20 mL of normal saline through an intravenous catheter connection set. Some clinicians prefer to flush once with heparinized saline (10 units/mL in infants <10 kg and 100 units/mL in infants, children, and adults 10 kg of weight or greater) although no evidence is available to indicate longer patency of the IO catheter when heparin is given.

•Secure the protector dome directly over the target patch.

●Removal – While holding the target patch against the skin, peel away the protector dome. Disconnect the infusion tube. Grasp the infusion tube close to the skin with fingers or a hemostat and pull upwards perpendicular to the manubrium until the infusion tube, including the metal tip is removed from the chest. Remove the target patch and apply pressure to the infusion site. Dress the site using aseptic technique.

Confirmation of placement — The following findings indicate correct placement of the IO cannula:

●The needle or catheter stands firmly on its own within the bone.

●Bone marrow is obtained with aspiration of the needle or catheter, although this may not always occur even with a properly placed IO needle or catheter.

●Flushing of the needle or catheter occurs without evidence of extravasation. Resistance to flushing is expected because, unlike a vein, the bone marrow cavity is not distensible.

Correct placement in the bone marrow cavity can also be confirmed radiologically using a mini C-arm fluoroscopic imaging device or bedside Doppler ultrasound [81,82]. Doppler ultrasound can also identify incorrect positioning indicated by extravasation of fluid around the IO needle or catheter.

Detection of infiltration — During infusion of fluids or medications, the provider should frequently check for swelling around the insertion site and, for sites other than the manubrium, swelling posterior to the site (eg, posterior calf in patients with an IO placed in the tibia). Because fluid administration requires the use of a pressure bag or pump, infiltration can occur rapidly during fluid resuscitation. If present, then the IO should be removed and replaced at a site in a different extremity.

DURATION OF USE — Intraosseous (IO) cannulation provides rapid temporary vascular access. An IO needle should be replaced with a venous line as soon as possible. In one retrospective series describing 58 IO placements in children requiring critical care transport, IO needles were left in place for a mean of 5.2 hours (range 10 minutes to 36 hours) [65]. The only reported complications were local edema and infiltration, occurring in 12 percent of patients. Prolonged IO infusions beyond 24 hours are associated with an increased risk of osteomyelitis [83].

COMPLICATIONS — Intraosseous (IO) cannulation is considered to be relatively safe, with a rate of serious complications of less than 1 percent [5,84]. Potential problems include tibial fracture, compartment syndrome, skin necrosis, osteomyelitis, and subcutaneous abscess. Theoretical long-term complications include damage to the bone marrow and disturbance in growth of the bone, as well as fat embolism.

●Bilateral tibial fractures have been described in a single case of a three-month-old infant for whom attempts at IO cannulation using a large bore needle were unsuccessful [84].

●Infusion of fluids into the subcutaneous tissue has caused compartment syndrome and resulted in amputation of an extremity [85]. Osteomyelitis is a rare complication. A review of the publications describing 4270 IO infusions found only 27 cases (0.6 percent) of osteomyelitis [83]. Most reported infections occurred when the needle remained in place for more than 24 hours. One observational study from 1940 suggested an increased risk of osteomyelitis with infusion of hypertonic fluids, but this association has not been subsequently validated [4].

●No long-term effects on tibial growth were found in a prospective study of 23 children with mean follow-up of 29 months [86]. A smaller study had similar results [87]. Follow-up studies of bone and bone marrow after IO infusions in experimental models also have shown only short-term periostitis and no or minimal long-term sequelae on bone marrow or bone growth [88-90]. The metaphyseal changes after insertion of a bone marrow needle resolve by three weeks [89].

●Microscopic fat and bone marrow emboli were found in the pulmonary autopsy specimens of two children who received IO infusion during resuscitation attempts and in 100 percent of study subjects in several animal studies of IO infusion [60,61]. However, the clinical relevance of these emboli is not clear. No significant alterations in arterial oxygenation were noted, nor any intrapulmonary shunting, during a four-hour study period, despite the universal finding of fat and bone marrow emboli [60].

●The only reported deaths resulting from IO infusions were associated with the sternal approach using a manual technique. These deaths were from mediastinitis, hydrothorax, and cardiac or great vessel injury [91].

ADDITIONAL RESOURCES — Videos are available in the reference to assist with learning techniques for intraosseous cannulation:

●Manual placement [75]

●Battery-powered driver technique [75]

●Bone injection gun [79]

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Basic and advanced cardiac life support in children".)

SUMMARY AND RECOMMENDATIONS

●Anatomy – Intraosseous (IO) cannulation provides intravascular access via the medullary sinuses in the bone marrow of long bones (figure 1). These veins, supported by the bony matrix, do not collapse in patients with shock or hypovolemia. (See 'Anatomy' above.)

●Indications – We recommend that infants and children in cardiopulmonary arrest or severe shock who do not have readily available intravenous access undergo IO cannulation for medication administration, fluid therapy, and diagnostic studies rather than percutaneous central venous line placement or surgical venous cutdown (Grade 1A).

For adults in cardiopulmonary arrest or with severe shock in whom peripheral venous access cannot be obtained, we suggest placement of an IO cannula for medication administration, fluid therapy, and diagnostic studies pending percutaneous central venous line placement or surgical venous cutdown (Grade 2B). We emphasize that an IO needle be flushed before and after medication administration if fluids are not already infusing. (See 'Indications' above.)

IO cannulation may also be appropriate in patients with emergency conditions in whom reliable venous access cannot be achieved quickly (eg, shock, sepsis, status epilepticus, extensive burns, multiple trauma) or in patients for whom intravascular access is medically necessary and cannot be achieved by other means.

●Contraindications – IO cannulation should not be performed in fractured bones, bones with a prior failed IO placement attempt, or in extremities with vascular disruption. IO access also should be avoided in patients with osteogenesis imperfecta, osteopetrosis, right to left congenital cardiac shunts, or those with burns or infection near the access site. (See 'Contraindications' above.)

●Placement site – We recommend that all patients who undergo IO placement for life-threatening illnesses (eg, cardiac arrest) have the first attempt made at the proximal tibial site, unless otherwise contraindicated (Grade 1B):

•In infants and children, the suggested proximal tibial site is approximately 1 to 2 cm (one finger breadth) below the tibial tuberosity and up to 1 cm medially on the tibial plateau (figure 2).

•In skeletally mature adolescents and adults, the recommended site is 3 cm (two finger breadths) below the inferior tip of the patella and 2 cm medial.

Alternative IO placement sites vary based upon the age and skeletal maturity of the patient (table 1). A battery-powered or impact driven device is typically required to accomplish IO placement in the proximal tibia of patients >6 years of age. If such a device is not available, the clinician should attempt manual placement at the medial or lateral malleolus. (See 'Sites of placement' above.)

●Choice of device – We suggest that, in infants under one year of age, clinicians use manual needles or battery-powered devices for IO insertion rather than an impact-driven device (Grade 2C). (See 'Choice of device' above and 'Techniques' above.)

We suggest that, in children ≥1 year of age, adolescents, and adults, clinicians use a battery-powered device for IO placement, if available, rather than a manual needle or impact-driven device (Grade 2B). (See 'Choice of device' above and 'Techniques' above.)

●Analgesia – In critically ill children and adults who require immediate vascular access (eg, patients in arrest or severe shock), IO placement is performed without analgesia. These patients may receive systemic analgesia (eg, fentanyl intraosseously) or infusion of preservative-free lidocaine, if they become responsive to pain once the IO is placed and as tolerated by their clinical condition. (See 'Analgesia' above.)

In awake patients for whom IO placement is in response to difficulty with peripheral venous access and whose condition is not an emergency, we suggest analgesia for IO placement be provided by local infiltration of anesthetic at the IO site and administration of preservative-free lidocaine (0.5 mg/kg preservative-free lidocaine 2 percent [20 mg/mL, maximum dose: 40 mg] given over one minute) through the IO cannula prior to infusion of medications, fluids, or blood products (Grade 2C). Local infiltration of anesthetic at the IO insertion site may not be necessary in adolescents and adults when using a battery-powered driver. (See 'Analgesia' above.)

●Techniques – The technique for manual insertion, battery-powered driver, and impact-driven devices is provided above. Videos are available in the references to assist with learning techniques for manual, battery-powered driver, and bone injection gun IO cannulation. (See 'Additional resources' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Pamela Bailey, MD, who contributed to earlier versions of this topic review.