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Intraosseous (IO) infusion is used for emergency vascular access (fluids and medications) when other access methods have been attempted and cannot be quickly established or have failed. The umbilical vein is the preferred route in a hospital setting, but IO access can be considered if rapid intravenous access is essential and the operator is not experienced in umbilical vein catheter (UVC) placement.


Povidone-iodine solution, 4 × 4 sterile gauze pads, sterile towels, gloves, IO device (devices approved for newborns are available; Table 41–1), syringe with saline flush, IV fluid, and infusion setup.



  1. Contraindications include bone diseases (eg, osteogenesis imperfecta, osteopetrosis), infection of the overlying skin, presence of a fracture, and thermal injury to the overlying skin. There is limited data but IO seems safe in preterm infants.

  2. The proximal tibia (anteromedial surface) is the preferred site in the infant (vs the sternum in adults) and is described here (Figure 41–1). The intramedullary vessel in the tibial marrow empties into the popliteal vein and into the femoral vein. The other 2 most common sites used in newborns are the distal femur and distal tibia.

  3. Select the area in the midline on the flat surface of the anterior tibia, 1–2 cm below the tibial tuberosity. Some recommend inserting a minimum of 10 mm (1 cm) distal to the tibial tuberosity: this avoids epiphyseal growth plate injury, and the thinner cortex here ensures an easier insertion.

  4. Restrain the patient's lower leg and place a small sandbag or IV bag behind the knee for support.

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

  6. Pain management. Lidocaine (0.5–1%) can be injected into the skin, soft tissue, and periosteum, but this is optional as this is ...

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