Chapter 35

1. Indications. Intraosseous infusion can be used for emergency vascular access (for administration of fluids and medications) when other methods of vascular access have been attempted and have failed. Many agents have been infused by this technique in the literature, including intravenous (IV) solutions (eg, Ringer's lactate or normal saline), blood and blood products, and a wide variety of medications. See Table 35–1 for a complete list.

2. Equipment. Needed are povidone-iodine solution, 4 × 4 sterile gauze pads, a syringe, sterile towels, gloves, an 18-gauge disposable iliac bone marrow aspiration needle (preferred), an intraosseous needle, or an 18- to 20-gauge short spinal needle with a stylet, a short (18- to 20-gauge) hypodermic needle or a butterfly (16- to 19-gauge) needle, a sterile drape, and a syringe with saline flush. Specific devices for the newborn are now available (Bone Injection Gun; Waismed, Houston, TX, and the EZ-IO Pediatric; Vidacare, San Antonio, TX), but lack of studies prevents the use in premature infants.

3. Procedure. The proximal tibia is the preferred site and is described here (Figure 35–1). Other sites are the distal tibia and the distal femur.

1. Restrain the patient's lower leg.

1. Place a small sandbag or IV bag behind the knee for support.

1. Select the area in the midline on the flat surface of the anterior tibia, 1–3 cm below the tibial tuberosity.

1. Clean the area with povidone-iodine solution. Sterile drapes can be placed around the area.

1. Lidocaine (0.5–1%) can be used for pain management. Inject into the skin and soft tissue. See Chapter 69 for dosage (optional because this procedure is used for emergency access and time may not allow for pain management).

1. Insert the needle at an angle of 10–15 degrees toward the foot to avoid the growth plate.

1. Advance the needle until a lack of resistance is felt (usually no more than 1 cm is necessary), at which point entry into the marrow space should have occurred.

1. Remove the stylet. (Note: At this point, aspiration of bone marrow for laboratory studies can be done, if needed. Bone marrow aspirates can be sent for blood chemistry values, carbon dioxide level, pH, hemoglobin level, culture and sensitivity, and blood type and cross-match.) Secure the needle to the skin with tape to prevent it from dislodging.

1. Attach the needle to IV fluids. Hypertonic and alkaline solutions should be diluted 1:2 with normal saline.

1. Withdraw the needle, and apply pressure over the puncture site.

1. To avoid the risk of infectious complications, this method of vascular access should optimally be used for <2 h.

4. Complications

1. Fluid infiltration of subcutaneous tissue (most common).

1. Subperiosteal infiltration of fluid.

1. Localized cellulitis/Abscess.

1. Formation of subcutaneous abscesses.

1. Clotting of bone marrow, resulting in loss of vascular access.

1. Osteomyelitis (rare).

1. Fracture of the bone. Radiograph confirmation of the needle should be done to confirm position and rule out fracture.

1. Compartment syndrome.

1. Blasts in the peripheral blood. Blasts in the peripheral blood have been noted after intraosseous infusions in two patients who have no malignant, ...

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