One of the more vivid memories I have from training is the frantic attempts at trying to obtain IV access while a patient circled the drain… 5 tourniquets on each arm and leg, multiple residents and RN’s sticking frantically, spent angiocaths dangling from limbs like ornaments on a christmas tree, while one resident ‘painted’ the groin with betadine and started poking away at the crease of the 300+ pound patient to no avail. Then came US guided peripheral lines, and everyone breathed a sigh of relief… but that too fails (on rare occasion). So I ask, how many sticks does it take before you drop the angiocaths and central line kits altogether and reach for the drill? We are all reluctant, but should we be?
The IO has been around for 80 years. It was initially suggested as a rescue technique for vascular access in children but over the past decade it has been deemed acceptable in adults as well. According to the Emergency Cardiovascular Care Guidelines in 2000, intraosseous access is recommended in all children after 2 failed attempts of intravenous access or during circulatory collapse. In 2005, the American Heart Association recommended intraosseous access if venous access cannot be quickly and reliably established. Studies have shown that IO is faster than central venous access and maybe faster than peripheral access as well… should it be your go to technique when the time comes? Maybe.
But it hurts… maybe not. Insertion pain has been reported by several investigators to have a mean score on the VAS, between 2.5 and 3.5, similar to scores associated with placement of peripheral and central lines. Use a little SQ and periosteal lido and drill away.
All medications and blood products can be safely administered through the intraosseous line, and flow rates, onset of action and peak drug levels are comparable to (or exceed) those of IV administration. Intraosseous needles left in the marrow for longer than 72 hours are at a higher risk of local infection; so, needles should be removed as soon as permanent venous access is established… but for god sakes dont take it out until AFTER you have obtained alternate access.
Contraindications to initiating an intraosseous infusion are few. The only universally accepted contraindication for IO access is a fracture of the bone to be used as an access site. Relative contraindications to IO access include diseases such as osteogenesis imperfecta, severe osteoporosis and cellulitis over the insertion site. In addition, once an IO has been attempted in a bone, further attempts at IO access in that bone are not to be done due to potential leakage from the previous attempt site.
Where should an IO device be placed? The most common: proximal tibia 2 fingerbreaths below the tuberosity. Alternate sites: distal femur, sternum, proximal humerus, pelvis, clavicle, radius… pretty much anywhere there’s bone.
You should always bolus a small amount of preservative free lidocaine (cardiac lido) prior to infusing fluids or medications (0.5 mg/kg (0.05 mL/kg) of preservative-free 1% lidocaine- in an adult this is about 3.5ml) through the intraosseous port before infusion. For more details on weight based dosing of lidocaine: <Click here>
How to Vids
Excuse the cheesy soundtrack
- Intraosseous Infusion: Not Just for Kids Anymore. EMS World. 2005
- Leidel, Bernd A., et al. “Is the intraosseous access route fast and efficacious compared to conventional central venous catheterization in adult patients under resuscitation in the emergency department? A prospective observational pilot study.” Patient Saf Surg 3.1 (2009): 24.
- Ngo, Adeline Su-Yin, et al. “Intraosseous vascular access in adults using the EZ-IO in an emergency department.” International journal of emergency medicine 2.3 (2009): 155-160.
- Leidel, Bernd A., et al. “Comparison of intraosseous versus central venous vascular access in adults under resuscitation in the emergency department with inaccessible peripheral veins.” Resuscitation 83.1 (2012): 40-45.