# Intraosseous Vascular Access

## Overview

This module describes

short-term

short-term

Intraosseous lines should be removed as soon as possible, and within 24 hours.

vascular access via the intraosseous route in the setting of emergency resuscitation or urgent fluid administration, when peripheral venous access has failed.

## Indications

1. Vascular access for administration of fluids and medications if peripheral venous access has failed

2. Urgent vascular access such as resuscitation

3. Giving intraosseous contrast agents

## Contraindications

1. Fracture of the target bone

2. A previous attempt at intraosseous access in that bone in the past 48 hours

3. Recent orthopaedic surgery in the target bone

4. Osteogenesis imperfecta or severe osteoporosis

5. Burn or infection of the overlying skin

6. Osteomyelitis of the target bone

## Patient information & consent

This procedure is often performed in critically ill patients in an emergency setting, so consent is generally implied. However, check for “Do Not Resuscitate” (DNR) orders, “Not For Max” orders, or living wills that specify that no resuscitation may be performed. In awake patients, seek informed consent.

### How do I explain this procedure?

“I need to place a needle into the marrow of a long bone so that we can give you fluids or medication. This route works the same as for a drip in your arm, but is much faster in urgent situations.”

### What can my patient expect?

“I’m going to clean the area where the needle will go in and give you an injection so that you will not feel pain. Then I will pierce the bone using a special device. The needle will stay in your bone only for as long as it is absolutely necessary, definitely less than a day. I will connect tubing to the needle so that we can give you medications and fluids.”

### What is my patient’s role?

“Let me know if you have any bone diseases like osteoporosis. Fearing blood or needles is normal, but tell me if you have fainted from it. Stay still when I insert the needle, and let me know if at any point you have severe pain or any strange sensations.”

## Preparation

### Documentation

1. Patient notes

### Equipment

1. Non-sterile gloves

2. Alcohol swabs

3. Intraosseous needle
   Intraosseous needle

   Pink needles are used for patients up to 40 kg, blue for most patients over 40 kg, and yellow for very large patients or for the humeral site.

4. Intraosseous needle insertion device
   Intraosseous needle insertion device

   In contrast with automatic drills, manual devices require you to screw in the needle.

5. 3-way tap

6. Two 10 ml syringes

7. IV fluid and giving set

8. Umbilical cord clamp

9. Surgical tape

10. Towel or pillow to support site

11. Gauze

12. For awake patients, have two syringes of 2% lignocaine, one with a needle attached.

## Site & Positioning

The proximal tibia is the

site of choice

site of choice

Other potential sites include:
1. The humeral head (arm inwardly rotated with hand placed on abdomen), 2 cm above the surgical neck
2. The sternum 1 cm below the sternal notch
3. The distal femur 1 cm proximal and 1-2 cm medial to the patella with the leg straightened
4. The distal tibia 2 cm proximal to the medial malleolus on the flat portion of the tibia

Not all devices may be used to access all these sites. Check the device manual.

in most patients, particularly paediatric patients. Position the leg slightly bent, supported by a towel roll. Palpate the tibial tuberosity and insert the needle 1-2 finger-breadths distal, perpendicular to the flat aspect of the tibia.

## Procedure

Follow medical asepsis with non-sterile gloves. In non-emergency settings, use medical asepsis with sterile gloves.

1. Perform hand hygiene. Don gloves.

2. Run IV fluid through the giving set. Flush the three-way tap with IV fluid and attach the giving set to a port.

3. Expose, support and identify the site.

4. Clean the site with an alcohol swab.

5. Anaesthetise the skin and periosteum in awake patients with 2% lignocaine.

6. Insert
   Insert

   Insert at a 90° angle to the bone.

   the needle into the skin until you have firm contact with the cortex.

7. For manual devices: use a corkscrew motion to insert the needle until you feel give.

8. For

   automatic
   automatic

   The needle usually attaches to a drill-like device magnetically. Activate the device by squeezing the trigger and let go once you feel give.

   devices: apply steady downward pressure. Activate the device until you feel give.

9. Hold
   Hold

   Don't let go as the needle is easily dislodged.

   the needle by the base and remove the stylet.

10. Attach an empty syringe to the needle and

    aspirate
    aspirate

    This confirms that the needle is in place. You can also use this aspirate for a group and crossmatch for the blood bank if necessary

    for bone marrow.

11. In awake patients , slowly inject ± 2 ml of lignocaine to prevent infusion pain.

12. Attach the three-way tap to the needle.

13. Secure the needle with a commercial securing device OR use a

    cord clamp, gauze and tape
    cord clamp, gauze and tape

    Wrap a roll of gauze around the base of the needle to protect the skin. Clamp the needle with the cord clamp above the gauze in line with the tibia, and then strap the clamp down with two lengths of tape across the leg, but not circumferentially.

    . In urgent situations, you can start administering boluses of fluid earlier, holding the needle in place while securing it.

14. Attach a syringe to the three-way tap, turn the tap to fill it with IV fluid, then turn the tap again to inject a bolus of

    3-10ml
    3-10ml

    3-5 ml for paediatric patients and 5-10 ml for adults

    of IV fluid.

15. See 3-way tap positions

    here
    here

    .

16. While injecting, palpate the area to detect

    extravasation
    extravasation

    This may feel like tensing or swelling of the calf as you inject.

    .

17. Note that despite local anaesthesia, this procedure may be painful for awake patients.

18. Dispose of medical waste safely.

19. Document completion of the procedure in patient notes.

20. Remove the intraosseous needle as soon as possible, once other intravascular access has been established. Remove the needle with a clockwise twisting motion and cover the site with a sterile dressing.

## Troubleshooting

I have a paediatric patient. There is no intraosseous needle or device.

Use a paediatric spinal needle. Hold the needle with your finger and thumb along the shaft, and the hub resting against your palm for good traction. Insert using a corkscrewing motion.

I can’t aspirate any bone marrow.

Replace the stylet. If you are too shallow, advance a few mm and try to aspirate. If you have inserted almost up to the hub of the needle, you may need to withdraw a few mm. Remove the stylet and try aspirating again.

The drill doesn’t want to activate.

Keep the drill attached and use it as a grip to corkscrew the needle into the bone until you feel give.

## Risks

1. Fluid extravasation and compartment syndrome of the leg

2. Paediatric epiphyseal plate necrosis if placed in the epiphyseal plate

3. Fracture

4. Cellulitis

5. Osteomyelitis

6. Fat embolism

7. Inability to remove a bent needle—requires surgery

## References

1. Dornhofer P, Kellar JZ. Intraosseous Vascular Access. [Updated 2021 Jul 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554373/