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PLACEMENT OF AN INTRAOSSEOUS NEEDLE
PLACEMENT OF AN INTRAOSSEOUS NEEDLE
THEORY
Intraosseous (IO) access is used in cases where quick, vascular access is needed. It may be used to prevent cardiopulmonary arrest by aggressively treating shock in patients in whom intravenous (IV) line placement has been unsuccessful. It is often difficult it is to place a peripheral IV in cases of shock, where there may be cardiovascular collapse or profound dehydration. Medications will be administered into the bone marrow space and will rapidly proceed to the central circulation. IO placement is for short term only (24 hours), until more secure, long term central venous access can be secured.
PATIENT SELECTION
Indications:
• A child with critical illness or injury in whom peripheral venous access has failed.
Contraindications:
• No absolute contraindications to placing an IO catheter
‣ May even be attempted in patients with Osteogenesis Imperfecta.
• Relative contraindications include:
‣ trauma to the extremity (IO access requires an intact bone marrow cavity and proximal venous system for appropriate function)
‣ cellulitis over the site of potential placement (choose a different location)
‣ recent attempt or placement of an IO line in the same bone
EQUIPMENT
• Intraosseous needle
• Connection tubing
• Saline flush
• Towel roll
• Gloves
• Antiseptic swab
• Syringes and blood specimen containers
• Intraosseous drill
PROCEDURE
1. Choose an appropriately-­‐sized IO needle. • 15 gauge, 15mm in length (for patients between 3 and 39 kg)
• 15 gauge, 25 mm in length (for patients 40kg and above)
tibial
• extra long (>25mm) needle for patients with significant amount of soft tissue, as tuberosity
with an obese patient
2. Select a site. The proximal tibia is most commonly used. It is ideal during a resuscitation because most resuscitation efforts take place near the child’s head and chest. Feel for tibial tuberosity (where patellar tendon inserts into the tibia), then palpate 1-­‐2 cm below tibial tuberosity, and find the medial flat anterior surface of the tibia (Figure 1).
Figure 1: The IO needle should be 3. Preparation. Use Aseptic procedure (similar to IV placement) including wearing placed in the flat part of the proximal gloves and scrubbing site with an antiseptic swab. It is not necessary to drape the tibia, 1-­‐2 cm below the tibial area if one is in an emergency situation. If the child has some degree of tuberosity.
consciousness, give local anesthetic, such as Lidocaine, and infiltrate the skin over the site down to the periosteum.
4. Positioning. Place the leg flat on the bed or support the leg with a towel roll. AVOID placing hand behind the leg as this can result in an accidental needle stick!
5. Insert the IO needle. • Angle the needle perpendicular to the bone, to avoid growth plate.
• Apply pressure and use a boring motion to penetrate the bony cortex (Figure 2). • Will feel a sudden loss of resistance when the needle enters the bone marrow cavity.
• At this point the needle should stand upright and unsupported. Figure 2: The IO needle is used to • Remove the trocar.
6. An IO drill may be used to insert the needle (Figure 3). It is a high-­‐speed drill that penetrate the bony cortex to gain access to the bone marrow space.
easily penetrates bony cortex, making the placement easier and with less CPAP
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PLACEMENT OF AN INTRAOSSEOUS NEEDLE
discomfort, and appearing less traumatic. The IO drill is used with specialized needles that attach to magnetic end of drill. ‣ Gently squeeze the trigger.
Intraosseous
‣ Allow the weight and power of the drill to place the IO catheter through the bone.
Drill
‣ Hold catheter in place while you release the magnet.
7. Draw labs and flush the IO catheter.
• Attempt to aspirate blood and bone marrow. Fluids can be sent to the lab for testing (eg. glucose, chemistries, cultures, type and cross). Note: the peripheral blood count Figure 3: A high-­‐speed IO drill is used with specialized needles.
will not be accurate, as is it drawn from the bone marrow space.
• Finally, attempt to flush the catheter, looking for signs of infiltration anteriorly of posteriorly.
• IO catheter should flush easily, although there will be more resistance than with a peripheral IV, because as the bone marrow cavity is not collapsible, it is also not distensible.
8. Administer medications. Any drug that can be given through a peripheral IV can be given through IO including resuscitation medications, fluids, blood products, and inotropic infusions. All medications administered must be followed with a flush of fluid (5-­‐10mL) to move medications into circulation.
9. Monitor for signs of infiltration. • Anterior infiltration typically happens after the IO has been in place for a while.
‣ Movement of the catheter during use can result in widening of the bore hole allowing medications and fluid to exit out of the hole instead of into the circulation (Figure 4). ‣ Extension tubing is recommended to minimize handling of the IO directly.
• Posterior infiltration results from a needle going through-­‐and-­‐through the Figure 4: Anterior infiltration (top) results bone.
from a widening of the insertion site, and can lead to administered fluids and ‣ Medications and fluids will be infused into the muscle compartment medications exiting out of the hole. posteriorly (Figure 4).
Posterior infiltration (bottom) results from ‣ Recognize early to avoid compartment syndrome, especially if medications the needle going through-­‐and through the like calcium, epinephrine or bicarbonate are infused.
bone, causing medications to be infused 10.Remove the IO catheter. IO is intended to be temporary vascular access for an into the muscle compartment posteriorly.
emergency, and it is recommended to leave an IO in place for no more than 24 hours. There is no special technique for removal. The IO should be pulled from the bone and a dressing applied.
11. Alternate sites for IO placement. Several sites can be used in addition to the proximal tibia.
• Distal Femur (Figure 5a). Large bone but more soft tissue, therefore use a larger needle.
• Distal Tibia (Figure 5b).Find the medial Figure 5: Alternative sites for malleolus, and place the IO needle one IO placement: (a) the distal finger breadth above the medial malleolus
femur (b) the medial malleolus • Humerus (Figure 5c). and (c) the humerus
a
c
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b
PLACEMENT OF AN INTRAOSSEOUS NEEDLE
COMPLICATIONS
• Infection
• Compartment syndrome
• Extravasation of fluids or medications into the surrounding tissues
ASSESSMENT AND MONITORING
• Monitor patient’s skin for signs of infection
• Assess soft tissue near site of intraosseous placement for signs of infiltration
• Monitor for signs of pain while infusing into intraosseous needle
‣ may indicate extravasation of fluid
DOCUMENTATION
•
•
•
•
•
Indication for procedure
Date and time of procedure
Location of intraosseous needle placement
Medications infused in the intraosseous needle
Adverse reactions
REFERENCES
•Fink MP, Abraham E, Vincent J, Kochanek PM (2005). Textbook of critical care medicine. 5th ed. Philadelphia (PA): Elsevier. p. 1912-­‐1913
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in this guideline. OPENPediatrics™ and its affiliations are not responsible or liable for any claim, loss, or damage resulting from the use of this information.
OPENPediatrics™ attempts to keep the information as accurate and up to date as possible. However, as recommendations for care and treatment change,
OPENPediatrics™ does not assume any legal liability or responsibility for the accuracy, completeness or usefulness of any information on this guideline.
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