Intraosseous Insertion Gwen Hollaar University of Calgary Outline

Intraosseous Insertion Gwen Hollaar University of Calgary

Outline • • • How does it work Indications and Contraindications Technique Complications Review

How Does It Work • Bone has two components – Bone cortex – Bone marrow • Bone marrow contains – Developing blood cells – Framework for vascular complex of the medulla • Provides blood supply for bone

How Does It Work • Path of fluids into body blood vessels • Fluid enters venous sinusoids in medullary cavity • Fluid drains into central venous channel • Fluid exits bone cortex through nutrient veins

How Does It Work • Intraosseous (IO) infusion – Can deliver fluids as quickly as IV method – Can administer drugs and blood through IO infusion • Onset and peak drug levels are similar to IV administration

Indications and Contraindications • Indications – EMERGENCY VASCULAR ACCESS when usual methods have failed – Initially recommended in children < 6 years – Now also recognized as useful resuscitation technique for adults

Indications and Contraindications • Absolute Contraindication – Fracture near access site • Relative Contraindications – Cellulitis over insertion site – Bacteremia – Osteoporosis

Technique • Sterile Procedure • Equipment – – – – Sterile gloves Drape Alcohol or cleaning solution IO needle holder 12 to 20 gauge needle Gauze Tubing 10 or 20 cc syringe or IV bag

Technique: Intraosseous Needle Holder Designed and made by Richard Near rbn@nearmfg. com

Technique • Choice of needle: – Children • < 18 months – 16, 18, or 20 gauge needle • 18 months to 6 years – 12, 14, 16 gauge needle – Older children and adults • 12 or 14 gauge needle

Technique • Usually use proximal tibia because easy to landmark • Need to be distal to growth plate in children • Landmark – Palpate tibial tuberosity – Move distal 2 cm and slightly medial – Relatively flat area

Technique • Place small towel behind knee • Restrain leg • Use local anesthetic in subcutaneous tissue and periosteum if patient conscious as the procedure is painful • Put on gloves / Drape area / Sterile technique • Load needle onto IO needle holder

Technique foot knee • Landmark and insert needle angled to 10 -15º caudally -- to avoid injury to growth plate • Insert through skin until you feel bone • Begin to twist and push - Keep index finger down on IO holder to prevent plunging in • You will feel a ‘pop’ when you reach marrow • Immediately flush small amount of sterile fluid through needle to dislodge ‘bone plug’

Technique • Confirm proper location of needle before starting infusion – – – • Needle should stand on its own without support if it is through bone cortex Aspirate blood or marrow 5 -10 ml bolus should enter with little resistance and with no extravasation If you make a hole in the cortex, do not put another hole in the cortex of the same bone as this will result in possible fluid extravasation into the soft tissue

Technique • Attach stopcock or syringe or IV tubing • Tape gauze pads around needle to stabilize it • Should use IO access for resuscitation and replace with conventional IV line when resuscitation is completed – IO lines should not be used for a prolonged period of time to minimize risk of osteomyelitis

Technique • Use syringe to give fluid bolus – If needle is attached to IV tubing, you need pressure bag or pump to infuse at a rapid rate • Use isotonic solution (normal saline) • For resuscitation in children: 20 ml / kg

Possible Complication • Extravasation of fluid into subcutaneous tissue – Most common complication – Caused by: • Misplaced needle • Multiple attempts (put other holes in bone) • Enlargement of IO hole from needle movement – May result in: • Subcutaneous tissue or muscle necrosis • Compartment syndrome

Possible Complications • Osteomyelitis – Incidence in children is 0. 6% – Risk increased if: • Prolonged use of IO needle • Pre-existing bacteremia • Use of hypertonic saline • Other rare complications – Fracture at IO site – Compartment syndrome – Cellulitis or local abscess

Preparation of IO Holder • Needs to be cleaned and sterilized after each use • Can be used and cleaned like all other surgical instruments because it is stainless steel • Method – Cleaning – Sterilization

Preparation of IO Holder • Cleaning – Use scrub brush – Decreases possible pieces of blood and tissue that prevents heat or chemical sterilization

Preparation of IO Holder • Chemical Sterilization – Undiluted bleach or 1: 1 bleach dilution • Kills bacteria, virus, fungus, TB (not bacterial spores) • Needs 1 hour contact, then rinse with sterile water – 2% glutaraldehyde • Needs 6 -10 hour contact, then rinse with sterile water • Heat Sterilization – Autoclave • Unwrapped at 124ºC for 15 minutes • Kills bacteria, virus, fungus, TB, and bacterial spores – Steam Sterilization • Wrapped at 121ºC for 30 minutes

Review • Important way to gain emergency IV access for resuscitation when other methods have failed • Placement of needle is in flat area medial and distal to tibial tuberosity • Confirm position and stabilize needle • Bolus 20 ml / kg in children • Replace with conventional IV line when resuscitation completed

References • Intraosseous Infusion – Brian La. Rocco, Henry Wang – Prehospital Emergency Care 2003; 7: 280 -285 • Clinical Review: Vascular Access for fluid infusion in children – Nikolaus Haas – Critical Care 2004; 8(6): 478 -484