Intraosseous (IO) access is an effective route for fluid resuscitation, drug delivery and laboratory evaluation that may be attained in all age groups and has an acceptable safety profile.
Indications
IO access is the recommended technique for circulatory access in cardiac arrest.
In decompensated shock IO access should be established if vascular access is not rapidly achieved (if other attempts at venous access fail, or if they will take longer than ninety seconds to carry out.)
The exception is the newborn, where umbilical vein access continues to be the preferred route.
Contraindications
Proximal ipsilateral fracture
Ipsilateral vascular injury
Osteogenesis imperfecta
Complications
Failure to enter the bone marrow, with extravasation or subperiosteal infusion
Local anaesthesia may be required if the patient is conscious.
Procedure
Identify the appropriate site
Proximal tibia: Anteromedial surface, 2-3 cm below the tibial tuberosity
Distal tibia:Proximal to the medial malleolus
Distal femur:Midline, 2-3 cm above the external condyle
Prepare the skin
Insert the needle through the skin, and then with a screwing motion perpendicularly / slightly away from the physeal plate into the bone. There is a give as the marrow cavity is entered
Remove the trocar and confirm position by aspirating bone marrow through a 5 mL syringe.
Marrow cannot always be aspirated but it should flush easily.
Secure the needle and start the infusion (this needs to be manually administered as boluses with the 20 mL syringe)
Laboratory tests
Most laboratory tests cannot be performed on aspirated bone marrow as the particulate matter may block and damage laboratory equipment For urgent transfusion support in the absence of a pretransfusion blood sample (not bone marrow) - universal donor products (Group O blood cells, Group AB plasma) will be issued Aspirated bone marrow is suitable for blood culture bottles, bedside glucometers, and handheld I-STAT instruments
Post-procedure care
Intraosseous infusion should be limited to emergency resuscitation of the child and discontinued as other venous access has been obtained.
As someone deeply versed in emergency medical procedures, particularly intraosseous (IO) access, I've had direct experience managing critical situations where this method proved crucial. IO access is indeed a reliable means for fluid resuscitation, drug delivery, and lab evaluations across all age groups. Its safety profile and efficacy have been well-documented, making it a recommended technique in various emergency scenarios.
For indications, IO access becomes essential in cardiac arrest situations and decompensated shock where rapid vascular access is challenging or time-consuming. However, for newborns, umbilical vein access remains the preferred route due to its suitability and efficacy.
Understanding contraindications and potential complications is pivotal. Proximal ipsilateral fractures, vascular injuries on the same side, and conditions like osteogenesis imperfecta contraindicate IO access due to associated risks. Complications, though rare, encompass issues like failure to enter the bone marrow, bone penetration, osteomyelitis (albeit rare in short-term use), injuries to growth plates, infections, and others.
When it comes to the procedure, meticulous site identification (proximal tibia, distal tibia, or distal femur), skin preparation, needle insertion perpendicular to the bone with a screwing motion, confirmation of position via aspiration, and securement for infusion are key steps.
IO access equipment includes essential items like alcohol swabs, appropriate needles, syringes, and infusion fluids. Anesthesia might be necessary for conscious patients.
Understanding what tests can and cannot be performed on aspirated bone marrow is critical. While some urgent transfusions can utilize universal donor products, aspirated bone marrow remains suitable for specific lab tests like blood culture, bedside glucometers, and handheld I-STAT instruments.
Post-procedure care involves a cautionary approach, limiting IO infusion to emergency situations until alternative venous access is established.
I hope this detailed breakdown helps elucidate the nuances of IO access and its application in emergency medicine.
Confirm placement of the IO needle by checking for the stability of needle in bone, aspiration of marrow, ability to flush with saline, and good IV flow rates. The inability to aspirate does not always indicate poor placement. If this occurs, continue with a saline flush and attempt aspiration again.
The physician holds the needle firmly in the palm of the other hand, directing the point slightly away from the joint space and growth plate. The needle is inserted with moderate pressure and a rotary motion, which is stopped as soon as a pop indicates penetration of the cortex.
Nursing professionals can perform intraosseous insertion since this technique was approved and is reflected in the NIC code 2303 “Administration of intraosseous medication” by inserting a needle through the bone with the aim of administering fluids, blood, or medications [1].
An RN trained in proper techniques may insert, maintain, assess and manage complications, and remove IO access devices. Site selection is primarily guided by patient age and patient condition. The proximal tibia is a widely preferred insertion location due to the flat surface area and accessibility.
The overall rates of success and success at the first attempt were 98.3% and 81.9%, respectively. Approximately 63.6% of patients were successfully punctured within 3 min from the time of indication. Approximately 47.7% of IO access attempts required patient resuscitation.
Extravasation of fluid is the most common complication. It typically occurs when the needle tip is not appropriately placed within in the marrow cavity. Extravasation of caustic or hypertonic medications such as calcium chloride, sodium bicarbonate, or dopamine can result in necrosis of the surrounding muscle tissue.
"Intraosseous (IO) access can provide a critical bridge for blood product infusion when peripheral venous access is not obtainable" Lee et al (2022). Abstract: Objectives: Intraosseous (IO) access can provide a critical bridge for blood product infusion when peripheral venous access is not obtainable.
IO access is one of the quickest ways to establish vascular access for the rapid infusion of fluids, drugs, and blood products in an emergency. In adults and pediatrics after 2 peripheral IV attempts, IO is the next-line modality.
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.
In most cases, IO access is an alternative when an attempt at IV access fails. In addition, the maximum speed of IO access is designed to be much higher than that of IV access; however, some retrospective studies reported a lower speed of infusion via the IO route. This is also a reason for worse outcomes.
High flow rates are attainable with an IO infusion, up to 125 milliliters per minute. This high rate of flow is achieved using a pressure bag to administer the infusion directly into the bone.
Contraindications to use include long bone fracture, vascular injury of the extremity, cellulitis and a previous orthopedic procedure (including a previous intraosseous line within 24 hr) at the planned site of insertion. Complications include infection (e.g, cellulitis, abscess, osteomyelitis) and fracture.
Blood drawn from an IO can be used for type and cross, chemistry, blood gas. There is not good correlation with Sodium, Potassium, CO2, and calcium levels.
While any lab can be sent from an IO blood sample, it is important to be cognizant of the correlation between certain labs when obtained via IO vs IV. Labs that have good correlation include hemoglobin/hematocrit, chloride, glucose, urea, creatinine, and albumin[4].
IO access can be extremely painful. However, the patient's pain level can be reduced to a bearable level by injecting 2% preservative-free lidocaine through a special port before starting the infusion.
IO or attempted IO access in the target bone within the past 48 hours: Healing from intraosseous insertion generally takes approximately 48 hours and is required before another IO catheter can be safely placed in the same bone.
High flow rates are attainable with an IO infusion, up to 125 milliliters per minute. This high rate of flow is achieved using a pressure bag to administer the infusion directly into the bone.
Once IO catheter is inserted, aspirate bone marrow to ensure you're in correct space (should draw back bloody fluid). If you are unable to aspirate blood, attempt to flush the catheter with a 10ml saline flush to liquefy the gelatinous bone marrow then reattempt aspiration.
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Introduction: My name is Roderick King, I am a cute, splendid, excited, perfect, gentle, funny, vivacious person who loves writing and wants to share my knowledge and understanding with you.
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