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Intraosseous (IO) infusion is the infusion of fluids or medications into the bone marrow cavity of a large bone. It is used for emergency vascular access (fluids and medications) when other access methods have been attempted and cannot be quickly established or have failed. In neonates during resuscitation, it is difficult to give medications through a peripheral vein because of insufficient perfusion. The bone medullary cavity does not collapse during circulatory failure or hypovolemia. Some recommend IO access if venous access is not established within 3 attempts or within 90 seconds. The umbilical vein is the preferred route in the delivery room in a hospital setting, but IO access can be considered if rapid intravenous (IV) access is essential and the operator is not experienced in umbilical vein catheter placement. IO access is an acceptable alternative in prehospital settings and emergency rooms. IO infusion of medications and fluids has the same hemodynamic effect as medications and fluids infused by the IV route.


Antiseptic solution, 4 × 4 sterile gauze pads, sterile towels, gloves, IO device (devices approved for newborns are available; Table 45–1), syringe with saline flush, IV fluid, and infusion setup (Luer lock catheter with a 3-way stopcock).


  1. Contraindications include prior unsuccessful attempt in the same bone, bone diseases (eg, osteogenesis imperfecta, osteopetrosis, osteomyelitis), infection of the overlying skin, presence of a fracture, hemophilia or other coagulopathies, and thermal injury to the overlying skin. There are 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 45–1). Benefits include a flat wide surface, less amount of soft tissue to obscure the bony landmark, and that it does not interfere with airway management or chest compressions, if needed. The intramedullary vessel in the tibial marrow empties into the popliteal vein and into the femoral vein. The preferred second site in the infant is the distal femur. Both sites avoid the epiphyseal plates of the bone. In some references the distal tibia is mentioned as an alternative site for infants but in other references it is recommended only for children >1 year. A theoretical alternative intraosseous infusion site that has been suggested is the greater tubercle of the humerus 9.5 to 11.1 mm from the acromion.

  3. Select the area in the midline on the flat surface of the anterior tibia, approximately 2 cm below and 1 to 2 cm medial to the tibial tuberosity (bony bulge below knee cap). This area avoids the epiphyseal growth plate injury, and the thinner cortex here ensures an easier insertion. The mean medullary diameter of the proximal tibia at the site that is recommended is only 7 mm in the neonate and 10 mm in a 1- to 12-month-old infant.


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